Early 60's guy with no PMH, non-smoker comes in with family and complains of dizziness with marked nausea and vomiting since yesterday morning. Denies headache, neck pain, etc... his only complaints are the imbalance, dizziness and the vomiting and they are all reproduced and worsened with change in head position. On exam, has a normal neuro exam with no cerebellar signs and has a positive dix-hallpike with horizontal nystagmus induced. Non-contrast CT head is negative (per wife, he may have hit his head yesterday). I tried the epley maneuver twice without resolution of symptoms. He got meclizine and zofran and was much better post meds. Upon further questioning it was discovered he had a year long history of tinnitus. So i'm thinking either BPPV or Meniere's and discuss this with the family and talk about follow up care. They mention they're not completely comfortable and then someone in the family brings up that he's had double vision with this. I rexamined him and his visual fields had no evidence of deficit, no rotary or vertical nystagmus, etc...all normal. After thinking about it for too long, I finally decided to get an MRI/MRA of the head...and sure enough he had a large left cerebellar infarct. It was humbling to say the least. Definitely a near miss on my part but I guess the diplopia was enough to make me feel something wasn't right. Anyway, I thought it was an interesting case that really highlights the difficulty in distinguishing peripheral vs central vertigo.