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A previously healthy 58-year-old man developed vertigo, imbalance, nausea, and vomiting shortly after smoking cocaine. He denied hearing loss, double vision, limb weakness, or sensory loss. Examination showed left-beating horizontal nystagmus with a torsional component, skew deviation, and positive right-sided head-impulse test. His urine tested positive for cocaine. Autoimmune workup, lipid panel, and echocardiography were unremarkable. MRI revealed acute right medial vestibular nucleus (VN) infarction (figure, A and B) and subcortical T2 hyperintensities (figure, C). Cerebral angiography was unremarkable. Presenting symptoms responded to meclizine and ondansetron, resolving by the third day.
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