Identifying central positional vertigo to prevent diagnostic pitfalls: A case series and review of literature

This case series highlights the critical role of radiological imaging in patients presenting with positional vertigo initially suggestive of benign paroxysmal positional vertigo (BPPV) but ultimately attributable to central nervous system pathology. The objective is to raise awareness among clinicians and paramedical professionals regarding the importance of early imaging when atypical clinical features are present. We report 6 cases of central positional vertigo in patients aged 18-85 years (3 men and 3 women) initially referred for physiotherapy with a presumed diagnosis of BPPV. Detailed clinical analysis revealed red flags prompting neurological evaluation and neuroimaging. Magnetic resonance imaging (MRI) played a decisive role in all cases, enabling accurate etiological diagnosis. Imaging protocols included brain MRI with T1- and T2-weighted, FLAIR, diffusion-weighted imaging with apparent diffusion coefficient mapping, susceptibility-weighted imaging when indicated, and postcontrast T1 sequences following gadolinium administration. Additional sequences such as constructive interference in steady state (CISS/FIESTA) were used when neurovascular conflict was suspected. Identified etiologies included cerebellar hemangioblastoma, vestibular migraine with radiologic findings, neurovascular compression syndrome, cerebellar atrophy, cerebellar meningioma, and midbrain ischemic stroke. MRI findings were essential for differentiating central from peripheral causes of positional vertigo and for guiding urgent management, particularly in vascular and tumoral conditions. In all cases, imaging corrected the initial misdiagnosis of peripheral vertigo and prevented inappropriate repositioning maneuvers. This case series underscores the importance of integrating clinical examination with early neuroimaging when positional vertigo presents with central warning signs. Brain MRI remains the gold standard for identifying central causes and improving patient outcomes.