central vertigo

Introduction

Central vertigo is less common than peripheral vertigo & generally occurs with other symptoms of central nervous system dysfunction.

Etiology

• vertebrobasilar insufficiency
  • transient ichemic attack, vertebrobasilar stroke
  • cerebellar stroke or brainstem infarction
    • lateral medullary infarction (Wallenberg's syndrome)
• CNS neoplasms
• multiple sclerosis
• migraine headaches (vestibular migraine)
• vestibular paroxysmia

* acoustic neuroma is classfied as causing peripheral vertigo

Clinical manifestations

• general
  • nausea/vomiting
• distinguishing features from peripheral vertigo
  • nystagmus
    • may be unidirectional, bidirectional &/or change directions
    • purely horizontal nystagmus without torsional component is common
    • vertical nystagmus or purely torsional nystagmus may be present
  • visual fixation does NOT inhibit nystagmus or vertigo
  • severity of vertigo is often mild
    • stroke may present as acute onset of severe vertigo
  • direction of spin is variable
  • direction of fall is variable
  • duration of symptoms may be chronic
  • tinnitus &/or hearing loss is generally absent
  • hearing loss is generally absent, but often unilateral when present
  • associated CNS abnormalities are generally present
    • cranial nerve palsies are often present
      • trigeminal nerve (CN 5)
      • abducens nerve (CN 6)
      • facial nerve (CN 7)
    • vertebrobasilar stroke associated with
      • dysarthria
      • dysphagia
      • diplopia
      • weakness or numbness
      • 20% of patients present with isolated vertigo

Radiology

• magnetic resonance imaging with angiography within 12 hours of symptom onset to rule out stroke
  • MRI may miss small brainstem strokes
  • repeat MRI may be indicated
• computed tomography provides faster, lower cost evaluation for hemorrhagic stroke

Management

• medical emergency if acute onset
  • neurosurgery consult
• depends upon etiology
• vestibular paroxysmia generally responds to carbamazepine
• prognosis:
  • 87% of patients with vestibular migraine remain symptomatic for at least 9 years

More general terms

• vertigo

More specific terms

• cervicogenic vertigo
• vestibular paroxysmia

Additional terms

• migraine headache
• multiple sclerosis (MS); includes clinically isolated syndrome
• vertebrobasilar disease
• vestibular schwannoma (acoustic neuroma)