Vestibular manifestations as the initial presentation of multiple sclerosis: a case series

Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system that can initially present with diverse neurological symptoms. Vestibular dysfunction may be an early manifestation, and can mimic common peripheral vestibular disorders, creating a diagnostic challenge.

To characterize vestibular symptoms and clinical signs in patients with MS presenting initially with vestibular dysfunction.

This retrospective observational case series included ten patients evaluated between 2019 and 2024 whose first clinical manifestation of MS was vestibular dysfunction. Clinical and neuro-otologic assessment, vHIT, and VNG were performed, and brain MRI was obtained when central vestibular involvement was suspected.

Four main presentations were identified: acute vestibular syndrome (n = 2), imbalance (n = 4), recurrent vertigo (n = 2), and positional vertigo (n = 2). Nine of ten patients had at least one finding suggestive of central vestibular involvement, whereas one patient had a normal vestibular examination. Brain MRI demonstrated lesions fulfilling the radiological criteria for MS in all ten patients.

Central vestibular signs in young adults presenting with vestibular symptoms should raise suspicion of an underlying central lesion and possible MS. Recognition of these signs, together with appropriate neuroimaging when clinically indicated, may facilitate earlier diagnosis during the clinically isolated syndrome stage.