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central vertigo

Central vertigo is less common than peripheral vertigo & generally occurs with other symptoms of central nervous system dysfunction. Etiology: 1) vertebrobasilar insufficiency - transient ichemic attack, vertebrobasilar stroke - cerebellar stroke or brainstem infarction - lateral medullary infarction (Wallenberg's syndrome) 2) CNS neoplasms 3) multiple sclerosis 5) migraine headaches (vestibular migraine) 6) vestibular paroxysmia * acoustic neuroma is classfied as causing peripheral vertigo Clinical manifestations: 1) general - nausea/vomiting 2) distinguishing features from peripheral vertigo a) 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 b) visual fixation does NOT inhibit nystagmus or vertigo c) severity of vertigo is often mild - stroke may present as acute onset of severe vertigo [4] d) direction of spin is variable e) direction of fall is variable f) duration of symptoms may be chronic g) tinnitus &/or hearing loss is generally absent h) hearing loss is generally absent, but often unilateral when present i) 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 [3] Radiology: - magnetic resonance imaging with angiography within 12 hours of symptom onset to rule out stroke - MRI may miss small brainstem strokes [4] - repeat MRI may be indicated [4] - computed tomography provides faster, lower cost evaluation for hemorrhagic stroke [4] Management: 1) medical emergency if acute onset [3] - neurosurgery consult 2) depends upon etiology 3) vestibular paroxysmia generally responds to carbamazepine 4) prognosis: - 87% of patients with vestibular migraine remain symptomatic for at least 9 years [2]

Related

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

Specific

cervicogenic vertigo vestibular paroxysmia

General

vertigo

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1013-15
  2. Radtke A et al. Vestibular migraine: Long-term follow-up of clinical symptoms and vestibulo-cochlear findings. Neurology 2012 Oct 9; 79:1607. PMID: 23019266
  3. Medical Knowledge Self Assessment Program (MKSAP) 16, 18, 19. American College of Physicians, Philadelphia 2012, 2018, 2021.
  4. Saber Tehrani AS et al. Small strokes causing severe vertigo: Frequency of false- negative MRIs and nonlacunar mechanisms. Neurology 2014 Jun 11 PMID: 24920847 http://www.neurology.org/content/83/2/169