Review Finds MS Is an Underrecognized Cause of Acute Vertigo

Vertigo, dizziness, and imbalance are underrecognized manifestations of multiple sclerosis (MS) relapses, and bedside tests used in the emergency setting cannot distinguish an acute demyelinating attack from a stroke, according to a mini review published in Frontiers in Neurology.¹

The authors, from the Department of Neurology at Eginition Hospital, National and Kapodistrian University of Athens, Greece, wrote that motor, sensory, and visual deficits are widely recognized features of relapsing-remitting MS, whereas vestibular symptoms receive comparatively less attention. They noted that research on central causes of acute vertigo over the past 2 decades has focused largely on ischemic stroke.

A prospective study of 170 acute vestibular syndrome presentations evaluated from 1999 to 2011 found that 4% (n = 7) were caused by demyelinating disease, including 3 first demyelinating events. All patients had central oculomotor signs, lesions were located from the medulla to the midbrain, and all improved with steroids.²

Lesion Locations and Ocular Motor Findings

The authors compiled 123 published cases of MS-related vertigo or dizziness, 64 of which reported the lesion location. The pons was the most frequent site (n = 25), followed by the middle cerebellar peduncle (n = 12), medulla (n = 10), inferior cerebellar peduncle (n = 6), superior cerebellar peduncle and cerebellar hemisphere (n = 4 each), and midbrain (n = 3). The authors attributed the involvement of large white matter tracts to the demyelinating nature of the disease.¹

According to the review, most eye movement abnormalities caused by brainstem or cerebellar plaques are nonspecific, but several are considered highly characteristic of MS. Bilateral internuclear ophthalmoplegia (INO), caused by lesions of the medial longitudinal fasciculus, is particularly characteristic of MS, especially in younger patients, whereas ischemic INO is typically unilateral. The authors also identified wall-eyed bilateral INO and acquired pendular nystagmus, which may result from a brainstem-cerebellar lesion combined with prior optic neuritis, as suggestive findings. A plaque at the vestibular nerve root entry zone can mimic peripheral vestibular neuritis.

The review also addresses benign paroxysmal positional vertigo (BPPV), whose posterior canal form has a lifetime prevalence of 2.4%. Some case series suggest BPPV is the most common cause of acute vertigo in MS. The authors wrote that recognizing BPPV in the emergency department avoids unnecessary costs, tests, and treatments, as it can be treated on site with repositioning maneuvers. BPPV must be distinguished from central positional nystagmus, which has been linked to plaques a few millimeters in size.

Limitations of the HINTS Exam

The Head-Impulse, Nystagmus, Test-of-Skew (HINTS) exam is designed for continuous acute vestibular syndrome with spontaneous nystagmus, the authors noted. It can indicate a central cause but cannot differentiate stroke from an MS exacerbation. According to the authors, this may delay intravenous corticosteroids for an MS relapse or lead to high-dose steroids being given to a patient with MS who is having an ischemic stroke.

Researchers recommended combining ocular motor examination with thin-slice infratentorial MRI and, where available, perfusion imaging and MS imaging markers such as the central vein sign and paramagnetic rim lesions. They noted that these imaging methods have limited availability in emergency settings and require prospective validation. Additionally, the review concluded that improving emergency triage of these patients depends on pairing a detailed neurological examination with advanced neuroimaging.

References

1. Anagnostou E, Kouvli M. Multiple sclerosis as an under-recognized cause of acute vertigo: clinical and pathophysiologic insights. Front Neurol. 2026;17:1888822. doi:10.3389/fneur.2026.1888822
2. Pula JH, Newman-Toker DE, Kattah JC. Multiple sclerosis as a cause of the acute vestibular syndrome. J Neurol. 2013;260(6):1649-1654. doi:10.1007/s00415-013-6850-1