Probable vestibular paroxysmia mimicking benign paroxysmal positional vertigo of the superior semicircular canal in the presence of a neurovascular conflict: a case report and review of the literature

Positional vertigo is a frequent complaint in otology and vestibular physiotherapy, arising from functional or structural causes affecting the peripheral or central vestibular systems. Although benign paroxysmal positional vertigo (BPPV) is the most common form, other etiologies such as vestibular paroxysmia (VP), central positional vertigo, or vertebrobasilar insufficiency should be considered. Recognizing the specific features and differential diagnosis of these conditions is crucial for accurate assessment. We describe the case of a 52-year-old French woman presenting with positional vertigo initially diagnosed as a BPPV of the right superior semicircular canal. Despite multiple repositioning maneuvers, symptoms persisted. The positional downbeat and right torsional nystagmus observed in the right Dix–Hallpike test (illustrated in video) and the lack of response to treatment raised suspicion of an atypical etiology. MRI re-evaluation revealed a neurovascular conflict between the right anterior inferior cerebellar artery and the right vestibulocochlear nerve, supporting the diagnosis of probable vestibular paroxysmia mimicking a superior canal BPPV. Positional vertigo resembling BPPV that is refractory to repositioning maneuvers or atypical should prompt reconsideration of the diagnosis. In particular, suspected superior canal BPPV requires heightened diagnostic caution and a comprehensive clinical assessment.