Can an isolated cerebellar stroke present with only a positive Romberg sign?

Can Cerebellar Stroke Present with Only a Positive Romberg Sign?

No, an isolated positive Romberg sign alone is extremely unlikely to be the sole manifestation of cerebellar stroke. While cerebellar infarction can produce truncal ataxia that may be detected by Romberg testing, isolated cerebellar stroke virtually always presents with additional neurological symptoms or signs that should be identifiable on careful examination.

Typical Presentation of Cerebellar Stroke

The most common presenting symptoms of cerebellar infarction are vertigo (87%) and lateropulsion (82%), not isolated balance abnormalities. 1 In fact, isolated vertigo or lateropulsion without any other symptoms was present in 38% of patients with cerebellar infarction, demonstrating that even "isolated" presentations typically include recognizable vestibular symptoms. 1

Core Clinical Features to Assess

• Dizziness, vertigo, and vomiting are the most common initial complaints in cerebellar infarction according to the American Heart Association. 2
• Unsteady gait and difficulty with coordination are common symptoms that should be actively assessed. 2
• Nausea is a frequent accompanying symptom, particularly when the posterior inferior cerebellar artery (PICA) territory is involved. 2
• Truncal ataxia is commonly missed during bedside examination, highlighting the need for careful assessment beyond just Romberg testing. 2

Why Isolated Romberg Positivity Is Insufficient

Limb ataxia was a presenting symptom in 40% of patients with isolated cerebellar infarctions, meaning that careful examination of limb coordination should reveal abnormalities in many cases. 1 A truly isolated positive Romberg without any detectable limb ataxia, gait abnormality, nystagmus, dysarthria, or vestibular symptoms would be highly atypical for cerebellar stroke.

Critical Examination Components Often Overlooked

• Abnormal eye movements require detailed examination in suspected cerebellar infarction. 2 Nystagmus was associated with specific cerebellar lobule involvement (pyramis lobule) in stroke patients. 1
• Speech disturbances (dysarthria) are observed in cerebellar infarction, particularly with anterior paravermis lesions. 2, 1
• Impaired coordination and gait abnormalities require careful assessment beyond simple Romberg testing. 2

The Diagnostic Challenge: Pseudo-Peripheral Vestibulopathy

Approximately 11% of patients with isolated cerebellar infarction can simulate acute peripheral vestibulopathy (pseudo-APV), most commonly with medial PICA territory infarction. 3 However, even these "isolated" presentations include vertigo and vestibular symptoms—not just a positive Romberg sign. 4, 3

Key Distinguishing Features

• A normal head impulse test can differentiate acute medial PICA infarction from true peripheral vestibulopathy. 4, 3 This is a critical examination maneuver that should be performed in any patient with acute vestibular symptoms.
• The HINTS examination (Head Impulse, Nystagmus, Test of Skew) has 100% sensitivity for detecting stroke when performed by trained practitioners, far exceeding early MRI sensitivity of 46%. 5

Common Diagnostic Pitfalls to Avoid

Truncal ataxia is frequently missed during bedside examination in cerebellar stroke patients. 2 This means that while a positive Romberg may be present, it should not be the only finding if a thorough examination is performed. The absence of other cerebellar signs should prompt consideration of alternative diagnoses.

What to Look For Beyond Romberg

• Lateropulsion (tendency to fall to one side) is present in 82% of cerebellar infarctions and is associated with posterior paravermis or nodulus lesions. 1
• Vertigo is present in 87% of cases and is more common with caudal vermis lesions. 1
• Nystagmus patterns: Direction-changing, vertical, or gaze-evoked nystagmus suggests central pathology. 5
• Dysarthria is associated with anterior paravermis involvement. 1

When to Image Despite "Isolated" Findings

Initial CT can be normal in as many as 25% of patients with cerebellar infarction, highlighting the need for MRI when clinical suspicion exists. 2 However, the clinical suspicion should be based on more than just a positive Romberg sign.

Red Flags Requiring Urgent MRI

• Decreased level of consciousness is the most reliable clinical symptom of tissue swelling in cerebellar stroke. 2
• New severe headache accompanying any balance disturbance mandates immediate imaging. 5
• High vascular risk patients (age >50, hypertension, diabetes, prior stroke) with acute vestibular syndrome require MRI even with normal neurologic examination, as 11-25% may have posterior circulation stroke. 5

Alternative Diagnoses to Consider

If a patient truly has only a positive Romberg sign without vertigo, nystagmus, limb ataxia, dysarthria, or other cerebellar signs, consider:

• Sensory ataxia from peripheral neuropathy or posterior column dysfunction (as seen in CANVAS syndrome, which presents with positive Romberg, sensory neuropathy, and vestibular areflexia). 6
• Vestibular disorders that may not be immediately apparent without specialized testing.
• Medication effects, particularly vestibular suppressants, antihypertensives, or sedatives. 2

In summary, while cerebellar stroke can cause truncal ataxia detectable by Romberg testing, an isolated positive Romberg without any accompanying vertigo, nystagmus, limb ataxia, dysarthria, or other cerebellar signs is not a typical presentation and should prompt consideration of alternative diagnoses or more thorough neurological examination. 1, 7