On 26 September 2010 a hypertensive, 66 year old male presented with an acute vestibular syndrome and headache of 4-h duration. Exam showed a crossed left face/right body hypoanalgesia and mild right axial lateropulsion. Initial brain magnetic resonance imaging (MRI) the same day showed acute infarction of the left cerebellar tonsil, gracile, and biventral lobe and of the caudal lateral medulla. He improved, but on 10 October 2010 developed worsening imbalance and could not sit without support due to severe right axial lateropulsion. On exam the next day, he had a right ocular tilt reaction (OTR), with a 3-prism-diopter hypotropic, excyclotropic right eye and low amplitude gaze evoked left-beat nystagmus. His subjective visual vertical (SVV) deviated 16° to the right. He had a normal head impulse test.
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