Vertigo, dizziness, and imbalance are among the most frequent presenting symptoms in primary care and in the emergency department (ED). The clinical diagnosis is based on a structured patient history and bedside examination of the vestibular system and the ocular motor system, looking especially for central ocular motor signs. Recent guidelines, such as the GRACE-3 guideline on acute vertigo and dizziness, the increasing availability of bedside diagnostic algorithms, and the use of quantitative vestibular and ocular motor testing in both the ED-setting and in the outpatient center have facilitated and standardized the approach to the dizzy patient. Here we review recent developments in neuro-otology and neuro-ophthalmology, covering the period after the latest neuro-otology update was published in this journal in 2023. Both new-onset acute, episodic and chronic vestibular conditions are discussed separately, highlighting advancements in disease characterization, diagnostic criteria, and treatment strategies. While major progress has been made in terms of the pathophysiology, etiology, genetics, and diagnostic criteria of peripheral, central, and functional vestibular diseases as well as ocular motor disorders, this knowledge has to be transferred into clinical practice. Systematic teaching of doctors to increase knowledge and to improve skills in applying the different tests in clinical practice on a high level are identified challenges. In terms of treatment, there is still a very great need for state-of-the art clinical trials applying approved therapies.

Throughout the history of medicine, successive scientific advances have led to the abandonment of certain previously established statements or clinical practices. Otoneurology has been no exception, and this has resulted in substantial changes in the traditional approach to these topics. These facts are reflected in the following paper, where, based on concepts previously published in the literature and selected in accordance with the PRISMA guidelines, we examine the objective data that would make it necessary to discard them in favour of a better clinical practice.

Falcotentorial meningiomas (FTMs) account for a small proportion of intracranial meningiomas. They originate from the falcotentorial junction, a region where critical venous structures and deep brain regions intersect, making surgical resection challenging. Current literature on FTM consists mainly of isolated case reports and small case series, focusing primarily on surgical techniques. This systematic review aims to consolidate and analyze the clinical characteristics, surgical approaches, and outcomes of FTM cases to offer evidence-based insights that can guide clinicians in managing this rare type of meningioma more effectively. A comprehensive literature search was conducted using PubMed, Scopus, and Web of Science databases to identify case reports and case series on FTM. Articles were included if they provided detailed clinical, surgical, and outcome data. The primary outcome was the incidence of postoperative visual field defects across different surgical approaches. Secondary outcomes included systemic complications, tumor recurrence, and mortality. The analysis included 127 patients (mean age 55 years, 51.3% male). The most common presenting symptom was headache (81.8%), followed by gait disturbances (21.1%) and dizziness (19.5%). About 49.4% of tumors were grade I, while grade II tumors were present in 5.2% of cases. The occipital interhemispheric transtentorial approach was used in 36.4% of cases. Postoperative visual field defects were observed in 12.3% of cases, with the occipital interhemispheric transtentorial being the most associated with higher rates of visual complications ( p  < 0.001). Recurrence occurred in 8.4% of patients, while the overall mortality rate was 1.3%. FTMs pose significant challenges due to their complex location and proximity to critical structures. This study highlights the need for further research to refine surgical techniques and improve long-term outcomes for patients diagnosed with FTM.

Lhermitte-Duclos disease (LDD), or dysplastic cerebellar gangliocytoma, is a rare benign cerebellar lesion that may present with atypical imaging and histopathological features, resulting in diagnostic uncertainty and potential overtreatment. We report a 32-year-old woman who presented with progressive headache, vomiting, vertigo, and right-sided cerebellar ataxia. Magnetic resonance imaging revealed a large right cerebellar lesion extending into the vermis, middle cerebellar peduncle, and hemipons, with inhomogeneous contrast enhancement and diffusion restriction, closely mimicking a malignant posterior fossa tumor. The patient underwent suboccipital craniotomy and decompression. Histopathology demonstrated distorted cerebellar folia with depletion of the Purkinje cell layer and expansion of the granular layer by neurocytic cells, raising a diagnostic dilemma with medulloblastoma. Immunohistochemistry showed NeuN and synaptophysin positivity with a very low K i -67 index, supporting LDD. Postoperative imaging demonstrated subtotal resection, and the patient had an uneventful recovery. This case highlights the importance of recognizing atypical presentations of LDD and the critical role of immunohistochemistry in establishing the diagnosis.

Orthostatic tremor (OT) is traditionally classified using tremor frequency and the presence of associated neurological signs. However, increasing reports of overlapping frequencies, fluctuating electrophysiological profiles, and diverse clinical associations indicate that current classification systems may not fully capture the clinical heterogeneity of OT.

Patients in rural communities face significant health disparities including disparities in many subspecialties of medicine. Hawai'i Island is a largely rural island and is the second most populous island in the state of Hawai'i. Of the identified physician shortages across the state, neurology ranks among the highest on Hawai'i Island. Given this shortage, this study sought to assess Hawai'i Island primary care physicians' perceptions and experiences with accessing and delivering neurological care. Physicians practicing on Hawai'i Island were sent an anonymous online survey between April 2025 and September 2025 assessing need for neurology care. To ensure that only primary care physician responses were recorded, eligibility for the survey was determined by whether respondents indicated they were a currently practicing primary care physician on Hawai'i Island in the first question. Of the 28 eligible respondents, 19 (68%) reported that 10-50% of their patients have neurological complaints or diagnoses. Twenty respondents (71%) reported that they may decline to refer to a neurologist due to difficulties accessing neurological care. Respondents varied in their comfort with managing neurological conditions, preferring to refer to a neurologist for neuromuscular and movement disorders, epilepsy/seizures, and multiple sclerosis, while preferring to self-manage back pain, headaches/migraines, and dizziness/vertigo. Neurological patients comprise a large percentage of the patients that Hawai'i Island primary care physicians see and, because of shortages, patients may not be receiving necessary neurological care. Long-term efforts should be focused on increasing accessibility to neurological care on Hawai'i Island.

Oncocytic (Hurthle cell) carcinoma is an uncommon thyroid malignancy that tends to spread through the bloodstream and often concentrates radioactive iodine poorly. Spread to the brain is rare, and a solitary cerebellar deposit is rarer still. We describe a 44-year-old man who presented with neck swelling and was found to have a widely invasive oncocytic carcinoma with extensive vascular invasion and a minor classic papillary component (5%). He underwent total thyroidectomy with central neck dissection followed by radioactive iodine ablation with 150 mCi of iodine-131. The post-therapy scan showed uptake confined to the thyroid bed. Over the next 18 months, his serum thyroglobulin climbed steadily from 1.5 µg/L to 11.6 µg/L even though the thyroid-stimulating hormone (TSH)-stimulated diagnostic whole-body iodine scan remained negative. Fluorodeoxyglucose positron emission tomography/computed tomography then showed multiple hypermetabolic bilateral pulmonary nodules suspicious for metastases. Roughly 22 months after thyroidectomy, he developed progressive dizziness and headache. Magnetic resonance imaging (MRI) revealed a 3.3 × 3.2 × 3.1 cm mixed cystic and solid left cerebellar mass with surrounding vasogenic edema and mass effect on the brainstem. The mass was resected through a left suboccipital craniotomy. Histology showed a malignant epithelioid neoplasm with nested and trabecular growth, abundant granular eosinophilic cytoplasm, prominent nucleoli, scattered bizarre giant nuclei, and 8 mitoses per 2 mm[2] without necrosis. The tumor cells expressed cytokeratin AE1/AE3, CK7, TTF-1, and PAX-8 and were negative for CK20, CDX-2, synaptophysin, chromogranin, and S100, confirming thyroid origin. The metastasis fulfilled criteria for high-grade differentiated thyroid carcinoma with oncocytic features. His symptoms resolved after surgery, and stereotactic radiosurgery for the resection cavity was recommended. A rising thyroglobulin with negative iodine imaging represents a biochemical incomplete response and should prompt a search for structural disease recurrence. Because the brain lesion in our patient came to light only when symptoms appeared, brain MRI may be worth considering in patients with radiodiodine-refractory distant metastases.