Surreal illustration of dizziness related to cerebellar stroke

Unusual Dizziness? How a Tiny Stroke in Your Brain Could Be the Cause

Beau Callahan in Health & Wellness June 2025 • 4 min read.

"Isolated cerebellar nodulus strokes can cause positional vertigo, often mistaken for more common conditions. Learn how to spot the signs and why early brain imaging is crucial."

Positional vertigo, a frequent complaint, requires careful evaluation to pinpoint its origin. While benign paroxysmal positional vertigo (BPPV), triggered by displaced otolithic debris within the semicircular canals, is the most prevalent cause, central etiologies stemming from brain-related issues should not be overlooked.

Brain-related positional vertigo often involves lesions in the posterior fossa, particularly affecting the fourth ventricle and cerebellum. Notably, even minimal damage to the lower cerebellar vermis and the nodulus can manifest as positional vertigo.

In cases of nodulus involvement, positional vertigo may occur without accompanying neurological deficits and may only last for hours to days. Therefore, prompt brain imaging is essential for accurate diagnosis. Here, we explore three cases of cerebellar nodulus stroke identified through magnetic resonance imaging (MRI).

Decoding the Link Between Nodulus Stroke and Vertigo: What the Cases Reveal

Surreal illustration of dizziness related to cerebellar stroke

Researchers reported three cases where patients experienced positional vertigo due to a stroke affecting the cerebellar nodulus. Each case highlighted a unique presentation, underscoring the subtle yet significant role this brain region plays in balance and spatial orientation. Symptoms lasted only a few days in each patient, which made proper diagnosis harder to get.

The cases shared several key features:

Sudden Onset: All patients experienced a rapid onset of intense positional vertigo.
Absence of Other Neurological Symptoms: Initially, vertigo was the only noticeable symptom in these patients. This absence of other signs complicated the diagnostic process.
Apogeotropic Nystagmus: Two patients exhibited apogeotropic horizontal positional nystagmus, a specific type of eye movement associated with certain types of vertigo.
Short Duration: The vertigo episodes resolved within a few days in all cases.
MRI Confirmation: Brain MRI was crucial in identifying small lacunar infarcts (small strokes) in the cerebellar nodulus.

These cases underscore the importance of considering cerebellar nodulus stroke in patients presenting with acute positional vertigo, even when other neurological signs are absent.

Don't Dismiss That Dizziness: The Takeaway Message

While positional vertigo is often benign, this report serves as a crucial reminder that stroke, even in a small area of the brain, can be the underlying cause. Early recognition and brain imaging are vital for accurate diagnosis and appropriate management. If you experience sudden, intense vertigo, especially without other apparent causes, seek immediate medical attention and discuss the possibility of brain imaging with your healthcare provider.

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Everything You Need To Know

What exactly is the cerebellar nodulus, and why is a stroke there so problematic?

The cerebellar nodulus is a small but significant part of the brain, specifically within the cerebellum. A stroke in this area can disrupt balance and spatial orientation, leading to positional vertigo. This is important because the nodulus plays a key role in processing signals related to balance and eye movements. Damage, even if minimal, can cause noticeable symptoms like vertigo. Because of its involvement in balance, spatial orientation and eye movements a stroke can manifest as vertigo. The unusual aspect is that it may present without other neurological symptoms.

What is positional vertigo, and how does a stroke relate to it?

Positional vertigo is a type of dizziness triggered by changes in head position. While often caused by benign conditions like BPPV (benign paroxysmal positional vertigo), which involves displaced crystals in the inner ear, it can also stem from brain-related issues, such as a stroke affecting the cerebellum. It's important to differentiate between these causes because the treatments differ significantly; BPPV is treated with physical maneuvers, while stroke requires immediate medical intervention.

What is apogeotropic nystagmus and how does it relate to positional vertigo?

Apogeotropic nystagmus refers to a specific type of involuntary eye movement that can occur with certain types of positional vertigo. In the context of cerebellar nodulus stroke, the presence of apogeotropic nystagmus can be a clue that the vertigo is originating from a central (brain-related) cause rather than a peripheral (inner ear) cause. This is significant because it helps doctors narrow down the possible causes of vertigo and determine if further investigation, such as brain imaging, is needed.

Why is brain imaging so important when someone has sudden, intense vertigo?

Brain imaging, particularly MRI (magnetic resonance imaging), is crucial because it can visualize the brain and identify even small strokes in areas like the cerebellar nodulus. Without brain imaging, a nodulus stroke might be missed, as its symptoms can mimic more common types of vertigo. MRI's ability to detect small lacunar infarcts (small strokes) in the nodulus makes it invaluable for accurate diagnosis and appropriate management. Early detection through MRI can help prevent further complications associated with stroke.

When should I be really concerned about positional vertigo and seek immediate medical attention?

While positional vertigo is often benign and resolves on its own or with simple treatments like the Epley maneuver for BPPV, it's vital to seek immediate medical attention if you experience sudden, intense vertigo, especially if there are no obvious triggers or if it's accompanied by other neurological symptoms. This is because, in rare cases, it could be a sign of a stroke in the cerebellar nodulus or another part of the brain. Early diagnosis and treatment of stroke are essential to minimize brain damage and improve outcomes. Discuss the possibility of brain imaging with your healthcare provider to rule out serious underlying causes.