{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T05:18:46Z","timestamp":1787635126168,"version":"build-2736575974"},"reference-count":33,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T00:00:00Z","timestamp":1787616000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Neurol."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Acute vestibular syndrome (AVS) is characterized by sudden, persistent vertigo or dizziness with nausea, vomiting, postural instability, and spontaneous nystagmus. Differentiating peripheral vestibular disorders from posterior circulation stroke remains a major diagnostic challenge in emergency neurology, as vestibulo-cerebellar infarcts may present as \u201ccentral pseudo-neuritis,\u201d mimicking peripheral vestibular disease. Although the HINTS examination is a valuable bedside tool, its reliability depends on the presence and characterization of nystagmus and is reduced in patients without spontaneous nystagmus.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objective<\/jats:title>\n                    <jats:p>To characterize nystagmus phenotypes in posterior circulation stroke using videooculography (VOG) and to identify features that improve recognition of central vestibular pathology in patients with AVS.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>Retrospective single-center descriptive cohort study of 34 patients with posterior circulation stroke confirmed by neuroimaging, who underwent VOG between 2014 and 2026. Eye movements were assessed using VOG and nystagmus features (direction, gaze dependence, fixation suppression, head-shaking responses) were correlated with lesion location.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Thirty-four patients were included; nystagmus was present in 70% (24\/35). Of these, 50% showed multiple nystagmus phenotypes and 50% a single pattern. Spontaneous nystagmus (horizontal or vertical) and Head-shaking nystagmus (HSN) both occurred in 62%, while gaze-evoked nystagmus was rare (12%). There was a non-significant trend toward a higher prevalence of HSN in PICA infarctions (OR 4.81) and HSN showed cross-coupled or direction changing features in 80% of patients. No clear correlation was found between the side of the lesion and the direction of nystagmus, nor between fixation and the slow-phase velocity (SPV) of nystagmus.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Nystagmus is a frequent clinical feature of posterior circulation stroke with heterogenous phenotypes. Lesion laterality did not correlate with nystagmus direction, and fixation did not consistently alter SPV. HSN was a frequent sign of central vestibular dysfunction. Performance of the head shaking test may improve detection of central vestibular pathology and complement the HINTS examination in acute vertigo.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fneur.2026.1916451","type":"journal-article","created":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T04:23:39Z","timestamp":1787631819000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Nystagmus phenotypes in posterior circulation stroke"],"prefix":"10.3389","volume":"17","author":[{"given":"F. K.","family":"Schwarz","sequence":"first","affiliation":[{"name":"Department of Neurology, Medical University of Vienna","place":["Vienna, Austria"]},{"name":"Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna","place":["Vienna, Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"P.","family":"Rommer","sequence":"additional","affiliation":[{"name":"Department of Neurology, Medical University of Vienna","place":["Vienna, Austria"]},{"name":"Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna","place":["Vienna, Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"U.","family":"Schwarz-Nemec","sequence":"additional","affiliation":[{"name":"Department of Biomedical Imaging and Image-guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna","place":["Vienna, Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"S.","family":"Greisenegger","sequence":"additional","affiliation":[{"name":"Department of Neurology, Medical University of Vienna","place":["Vienna, Austria"]},{"name":"Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna","place":["Vienna, Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"G.","family":"Wiest","sequence":"additional","affiliation":[{"name":"Department of Neurology, Medical University of Vienna","place":["Vienna, Austria"]},{"name":"Comprehensive Center for Clinical Neurosciences and Mental Health, Medical University of Vienna","place":["Vienna, Austria"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,8,25]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"205","DOI":"10.3233\/VES-210169","article-title":"Vascular vertigo and dizziness: diagnostic criteria","volume":"32","author":"Kim","year":"2022","journal-title":"J Vestib Res"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"3504","DOI":"10.1161\/STROKEAHA.109.551234","article-title":"HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging","volume":"40","author":"Kattah","year":"2009","journal-title":"Stroke"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"173","DOI":"10.1007\/s00415-026-13720-5","article-title":"The epidemiology and clinical presentation of acute vestibular syndromes: a systematic review of the literature","volume":"273","author":"Coban","year":"2026","journal-title":"J Neurol"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"680","DOI":"10.1056\/NEJM199809033391007","article-title":"Acute vestibular syndrome","volume":"339","author":"Hotson","year":"1998","journal-title":"N Engl J Med"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"550","DOI":"10.1016\/S1474-4422(11)70069-2","article-title":"Atypical presentations of acute cerebrovascular syndromes","volume":"10","author":"Edlow","year":"2011","journal-title":"Lancet Neurol"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"632","DOI":"10.1007\/s00415-022-11202-y","article-title":"Capturing nystagmus in the emergency room: posterior circulation stroke versus acute vestibular neuritis","volume":"270","author":"Nham","year":"2023","journal-title":"J Neurol"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"120451","DOI":"10.1016\/j.jns.2022.120451","article-title":"Diagnosing and localizing the acute vestibular syndrome - beyond the HINTS exam","volume":"442","author":"Fracica","year":"2022","journal-title":"J Neurol Sci"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"3662","DOI":"10.1093\/brain\/awr269","article-title":"Patterns of spontaneous and head-shaking nystagmus in cerebellar infarction: imaging correlations","volume":"134","author":"Huh","year":"2011","journal-title":"Brain J Neurol"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"1178","DOI":"10.1212\/01.wnl.0000238500.02302.b4","article-title":"Cerebellar infarction presenting isolated vertigo: frequency and vascular topographical patterns","volume":"67","author":"Lee","year":"2006","journal-title":"Neurology"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"338","DOI":"10.1111\/j.1749-6632.2008.03737.x","article-title":"Head-shaking nystagmus in central vestibulopathies","volume":"1164","author":"Choi","year":"2009","journal-title":"Ann N Y Acad Sci"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"1869","DOI":"10.1212\/WNL.0000000000002141","article-title":"Stroke risk stratification in acute dizziness presentations: a prospective imaging-based study","volume":"85","author":"Kerber","year":"2015","journal-title":"Neurology"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"55","DOI":"10.3390\/brainsci15010055","article-title":"Diagnostic errors in the acutely dizzy patient-lessons learned","volume":"15","author":"Tarnutzer","year":"2025","journal-title":"Brain Sci"},{"key":"ref13","doi-asserted-by":"crossref","DOI":"10.1093\/med\/9780199969289.001.0001","volume-title":"The Neurology of Eye Movements","author":"Leigh","year":"2015"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"87","DOI":"10.1097\/WNO.0000000000000456","article-title":"Cerebellar control of eye movements","volume":"37","author":"Beh","year":"2017","journal-title":"J Neuroophthalmol"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"1296","DOI":"10.1111\/ene.14161","article-title":"Clinical implications of head-shaking nystagmus in central and peripheral vestibular disorders: is perverted head-shaking nystagmus specific for central vestibular pathology?","volume":"27","author":"Yang","year":"2020","journal-title":"Eur J Neurol"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"161","DOI":"10.3988\/jcn.2025.0105","article-title":"Usefulness of nystagmus patterns in distinguishing peripheral from central acute vestibular syndromes at the bedside: a critical review","volume":"21","author":"Lee","year":"2025","journal-title":"J Clin Neurol"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"51","DOI":"10.1111\/j.1749-6632.2009.04461.x","article-title":"Parallel ascending vestibular pathways: anatomical localization and functional specialization","volume":"1164","author":"Zwergal","year":"2009","journal-title":"Ann N Y Acad Sci"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"292","DOI":"10.1002\/ana.410330311","article-title":"Ocular torsion and tilt of subjective visual vertical are sensitive brainstem signs","volume":"33","author":"Dieterich","year":"1993","journal-title":"Ann Neurol"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"781","DOI":"10.1007\/s12311-015-0745-x","article-title":"Recent advances in cerebellar ischemic stroke syndromes causing Vertigo and hearing loss","volume":"15","author":"Kim","year":"2016","journal-title":"Cerebellum"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"1558","DOI":"10.1161\/STROKEAHA.110.582783","article-title":"Isolated vestibular nucleus infarction mimicking acute peripheral vestibulopathy","volume":"41","author":"Kim","year":"2010","journal-title":"Stroke"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"1837","DOI":"10.1007\/s00415-015-7773-9","article-title":"Gaze holding deficits discriminate early from late onset cerebellar degeneration","volume":"262","author":"Tarnutzer","year":"2015","journal-title":"J Neurol"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"361","DOI":"10.1212\/WNL.0b013e318208f4c3","article-title":"Incidence and anatomy of gaze-evoked nystagmus in patients with cerebellar lesions","volume":"76","author":"Baier","year":"2011","journal-title":"Neurology"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"542","DOI":"10.1007\/s00415-014-7385-9","article-title":"Central ocular motor disorders, including gaze palsy and nystagmus","volume":"261","author":"Strupp","year":"2014","journal-title":"J Neurol"},{"key":"ref24","first-page":"199","article-title":"The vascular territories in the cerebellum and brainstem: CT and MR study","volume":"8","author":"Savoiardo","year":"1987","journal-title":"AJNR Am J Neuroradiol"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"95","DOI":"10.1007\/s12311-016-0772-2","article-title":"Impaired tilt suppression of post-rotatory nystagmus and cross-coupled head-shaking nystagmus in cerebellar lesions: image mapping study","volume":"16","author":"Lee","year":"2017","journal-title":"Cerebellum"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"575","DOI":"10.1212\/01.WNL.0000150729.87682.79","article-title":"Isolated perverted head-shaking nystagmus in focal cerebellar infarction","volume":"64","author":"Kim","year":"2005","journal-title":"Neurology"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"2865","DOI":"10.1007\/s00415-020-09891-4","article-title":"Upbeat vertical nystagmus after brain stem cavernoma resection: a rare case of nucleus intercalatus\/nucleus of roller injury","volume":"267","author":"Meling","year":"2020","journal-title":"J Neurol"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"148","DOI":"10.1007\/s12311-022-01376-6","article-title":"Upbeat nystagmus with an unusual velocity-decreasing and increasing waveform: a sign of gaze-holding dysfunction in the Paramedian tracts in the medulla?","volume":"22","author":"Tian","year":"2023","journal-title":"Cerebellum"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"182","DOI":"10.1007\/s12311-015-0688-2","article-title":"Failure of fixation suppression of spontaneous nystagmus in cerebellar infarction: frequency, pattern, and a possible structure","volume":"15","author":"Kim","year":"2016","journal-title":"Cerebellum"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"e42","DOI":"10.1212\/WNL.0000000000012176","article-title":"Stroke prediction based on the spontaneous nystagmus suppression test in dizzy patients: a diagnostic accuracy study","volume":"97","author":"Mantokoudis","year":"2021","journal-title":"Neurology"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"390","DOI":"10.3389\/fneur.2020.00390","article-title":"Vestibular and ocular motor properties in lateral medullary stroke critically depend on the level of the medullary lesion","volume":"11","author":"Lee","year":"2020","journal-title":"Front Neurol"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"420","DOI":"10.1097\/MOO.0b013e32833de71f","article-title":"Mechanisms of vestibular compensation: recent advances","volume":"18","author":"Dutia","year":"2010","journal-title":"Curr Opin Otolaryngol Head Neck Surg"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"446","DOI":"10.1136\/jnnp-2012-303177","article-title":"Nystagmus in SCA territory cerebellar infarction: pattern and a possible mechanism","volume":"84","author":"Lee","year":"2013","journal-title":"J Neurol Neurosurg Psychiatry"}],"container-title":["Frontiers in Neurology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2026.1916451\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,25]],"date-time":"2026-08-25T04:23:40Z","timestamp":1787631820000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fneur.2026.1916451\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,25]]},"references-count":33,"alternative-id":["10.3389\/fneur.2026.1916451"],"URL":"https:\/\/doi.org\/10.3389\/fneur.2026.1916451","relation":{},"ISSN":["1664-2295"],"issn-type":[{"value":"1664-2295","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,25]]},"article-number":"1916451"}}