Painless vertebral artery dissection mimicking benign paroxysmal positional vertigo: a case report

Acute positional vertigo is a common neurological presentation, which is often assumed to be due to benign peripheral vestibular causes. This paper presents the case of a woman in her late 30s who presented with brief, recurrent, position-triggered vertigo. She had no headache, neck pain, trauma history, or vascular risk factors. The clinical history closely resembled benign paroxysmal positional vertigo. However, neurological examination revealed subtle central signs: internuclear ophthalmoplegia and cerebellar ataxia. Brain imaging demonstrated infarction in the left cerebellar hemisphere. Brainstem imaging showed no corresponding abnormalities. Vascular imaging revealed extracranial left vertebral artery dissection. The patient condition was managed conservatively with antiplatelet therapy and a statin. Her symptoms resolved spontaneously, with no recurrence of vertigo on follow-up. This case illustrates that vertebral artery dissection may present without pain and highlights the importance of careful neurological examination in patients with acute vertigo.