Labyrinthine hemorrhage: practical lessons from a rare cause of acute vestibular syndrome.

Abstract: Labyrinthine hemorrhage (LH) is a rare cause of sudden sensorineural hearing loss (SNHL) and acute vestibular syndrome (AVS), which may mimic both peripheral and central etiologies. We report a case of a 76-year-old male on edoxaban therapy presenting with sudden right-sided SNHL and vertigo. Brain magnetic resonance imaging (MRI) performed 2 weeks later showed T1 and fluid-attenuated inversion recovery (FLAIR) hyperintensity of the right inner ear, consistent with LH. Evaluation of AVS in the emergency setting remains challenging, as LH may present as a rare stroke mimic, often indistinguishable from isolated labyrinthine stroke or labyrinthitis. Proper application and interpretation of vestibular assessment protocols, such as HINTS-plus, are critical in such cases. When bedside vestibular testing suggests central-type findings, but initial neuroimaging is normal, high-resolution brain MRI focused on the inner ear might be essential to rule out LH. Awareness of this rare entity may help prevent misdiagnosis, inappropriate thrombolysis, and delayed recognition, although stroke management should still be prioritized when HINTS-plus suggests a central pattern. This case highlights the diagnostic complexity of AVS and its potential pitfalls in bedside and imaging assessment, raising awareness of LH as a rare but clinically relevant stroke mimic.