This case report describes a 40-year-old male presenting with recurrent episodes of vertigo, mild tinnitus, nausea, and vomiting, with associated unilateral hearing loss. MRI imaging revealed an aberrant anterior inferior cerebellar artery (AICA), which may be contributing to his symptoms. The report discusses the clinical presentation, diagnostic findings, and potential management strategies for this condition.

Vertigo is a common symptom with a wide range of etiologies, including peripheral vestibular disorders, central nervous system pathologies, and vascular abnormalities. The anterior inferior cerebellar artery (AICA) supplies the inner ear and brainstem, and its aberrant course can lead to neurovascular compression, resulting in vertigo, tinnitus, and other vestibular symptoms. This case highlights the importance of considering vascular anomalies in the differential diagnosis of recurrent vertigo.

A 40-year-old male presented with a 6-month history of recurrent vertiginous attacks lasting minutes to hours, accompanied by mild tinnitus, nausea, and vomiting. The episodes occurred without warning and were associated with unilateral hearing impairment. The patient denied any history of head trauma, migraines, or recent infections.

Neurological examination revealed no focal deficits, and otoscopic examination was normal. Pure-tone audiometry showed normal hearing thresholds in left ear and moderate hearing loss in right ear. MRI of the brain with contrast demonstrated an aberrant course of the AICA, with the vessel looping close to the vestibulocochlear nerve (CN VIII) at the cerebellopontine angle. No other structural abnormalities or signs of infarction were noted. 

The patient’s symptoms are consistent with a vestibular disorder, likely related to neurovascular compression of the vestibulocochlear nerve by the aberrant AICA. The AICA supplies the inner ear and brainstem, and its abnormal course can lead to episodic vertigo, tinnitus, and other vestibular symptoms, even in the absence of hearing loss bilaterally. This condition is often referred to as AICA loop syndrome or vascular loop syndrome.

Differential diagnoses for recurrent vertigo include:

1. Meniere’s disease (unlikely in this case due to the absence of progressive hearing loss and ear fullness).

2. Vestibular migraine (less likely given the lack of migraine history).

3. Benign paroxysmal positional vertigo (BPPV) (unlikely as symptoms are not positional).

4. Vestibular neuritis (unlikely due to the recurrent nature of symptoms).

The MRI findings of an aberrant AICA provide a plausible explanation for the patient’s symptoms. Neurovascular compression syndromes are increasingly recognized as a cause of vertigo and tinnitus, particularly when other causes have been excluded. 

Management:

1. Medical Management:

• Vestibular suppressants (e.g., meclizine or betahistine) for acute symptom relief.
• Anti-emetics (e.g., ondansetron) for nausea and vomiting.
• Consideration of prophylactic medications (e.g., low-dose tricyclic antidepressants or calcium channel blockers) to reduce the frequency of attacks.

2. Surgical Management:

• In refractory cases, surgical decompression of the AICA loop may be considered, though this is reserved for severe, disabling symptoms.

3. Rehabilitation:

• Vestibular rehabilitation therapy (VRT) to improve balance and reduce the impact of vertigo on daily activities. 

This case highlights the importance of considering vascular anomalies, such as an aberrant AICA, in the differential diagnosis of recurrent vertigo. MRI imaging is a valuable tool for identifying neurovascular compression syndromes. A multidisciplinary approach involving neurology, otolaryngology, and radiology is essential for accurate diagnosis and management.