Combined peripheral and central vestibulopathy.

Diagnosis of central vestibulopathy remains a challenge when it is associated with peripheral vestibular dysfunction because neurotological findings from peripheral vestibulopathy may overshadow those from central vestibular involvements. To define the characteristics of disorders involving both peripheral and central vestibular structures, we classified the combined vestibulopathies into four types according to their vestibular manifestations, and describe a typical case in each subtype. Infarction involving the territory of anterior inferior cerebellar artery is the most common cause of acute unilateral cases, whereas tumors involving the cerebellopontine angle should be of prime suspicion in patients with chronic unilateral ones. Wernicke encephalopathy was most common in patients with acute bilateral combined vestibulopathy while degenerative disorders should be considered in chronic bilateral ones. Since the head impulse test (HIT) is mostly positive in combined vestibulopathy, signs of central vestibular dysfunction other than negative HIT should be sought carefully even in patients with obvious clinical or laboratory features of peripheral vestibulopathy.