Acute thrombosis of the carotid artery associated with positional nystagmus at multiple planes

OBJECTIVE: An acute onset central pathology without any clear neurological symptoms may mimic peripheral vestibular problem in an emergency setting. A 54-year-old man suddenly developed dizziness without any cranial nerve symptoms, paresis, cerebellar signs or sensory disturbances except upbeat positional nystagmus at multiple provoked positions which alerted for a possible acute central pathology. FINDINGS: An instantaneous magnetic resonance imaging and angiography studies further showed obstruction of the left internal carotid artery above the bifurcation. The patient’s subsequent prognosis was consistent with good recovery following anti-coagulant therapy. A follow-up MRI and angiography showed resolution of thrombosis. CONCLUSION: It should be kept in mind that positional nystagmus is likely to occur in central pathologies. Differentiation between benign paroxysmal positional vertigo and central positioning nystagmus is critical.