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Updated: Dec 17 2021

Central vs. Peripheral Vertigo

  • Snapshot
    • A 26-year-old man presents to his primary care physician due to dizziness. He said his symptoms began 2 weeks prior to presentation, are recurrent, and last a few seconds. He notices that his symptoms worsen with head movement; however, he denies any ear ringing or hearing loss. The Dix-Hallpike maneuver was performed, which showed horizontal nystagmus that is delayed in onset and fatigable. (Benign paroxysmal positional vertigo)
  • Introduction
    • "Dizziness" is a term used by patients that can mean many things such as
      • vertigo
        • the patient reporting a spinning sensation of movement (illusion of movement)
      • light-headedness
      • unsteadiness
    • Vertigo
      • this illusion of movement is caused by
        • lesions affecting anywhere in the vestibular pathway
          • e.g., labrynth, vestibular nerve, vestibular nuclei, and cerebellum
      • can be divided into
        • peripheral vertigo
        • central vertigo
    • Peripheral vertigo
      • describes vertigo caused by lesions affecting the
        • inner ear and cranial nerve VIII (vestibulocochlear nerve)
      • etiologies include
        • benign paroxysmal positional vertigo (BPPV)
        • vestibular neuritis
        • Meniere's disease
        • acoustic neuroma
        • aminoglycoside toxicity
        • semicircular canal dehiscence syndrome
        • perilymphatic fistula
        • herpes zoster oticus (Ramsay Hunt syndrome)
    • Central vertigo
      • describes vertigo caused by lesions affecting the
        • brainstem and cerebellum
      • etiologies
        • vestibular migraine
        • brainstem stroke
        • multiple sclerosis
        • ischemic or hemorrhagic damage to the cerebellum
        • cerebral edema
          • high altitude cerebral edema
    • Physical exam maneuvers
      • Dix-Hallpike (or Nylen-Barany) maneuver
        • can help in distinguishing perpheral from central causes of vertigo
        • maneuver
          • the patient sites on the examining table
          • the examiner supports the patient's head and
            • lies the patient back with their head rotated and extended over the edge of the table
          • the examiner looks for nyastagmus
            • peripheral vertigo nystagmus is
              • delyed in onset
              • horizontal or rotatory and unidirectional
              • fatigable
            • central vertigo nystagmus is
              • delayed or immediate in onset
              • horizonal or rotatory; however,
                • vertical nystagmus, nystagmus that changes direction, and prominent nystagmus in the absence of vertigo are
                  • highly suggestive of a central lesion
      • Summary of Peripheral Vs. Central Vertigo
      • Vertigo Type
      • Etiology
      • Differential
      • Symptoms
      • Peripheral vertigo
      • Lesion affecting the:
      • vestibular apparatus (in the inner ear)
      • cranial nerve VIII
      • Benign paroxysmal positional vertigo (BPPV)
      • Vestibular neuritis
      • labrynthitis presents similarly but with otological findings (e.g., tinnitus or hearing loss)
      • treat with steroids and meclizine for symptoms.
      •  Meniere's disease
      •  Acoustic neuroma
      • Aminoglycoside toxicity
      • Semicircular canal dehiscence syndrome
      • Perilymphatic fistula
      • Herpes zoster oticus (Ramsay Hunt syndrome)
      • Intermittent and positional vertigo
      • Can be associated with tinnitus as well as:
      • hearing loss
      • postural unsteadiness
      •  Nyastagmus is:
      • delayed in onset
      • rotatory or horizontal
      • prominent if vertigo is present
      • adaptive
      •   Vertigo stops with visual fixation 
      • Central vertigo
      • Lesion affecting the
      • brainstem nuclei
      • cerebellum
      • Vestibular migraine
      • Brainstem stroke
      • Multiple sclerosis
      • Ischemic or hemorrhagic damage to the cerebellum
      • high altitude cerebral edema (HACE)
      • Non-positional vertigo
      • May accompany other cranial nerve injuries such as:
      • facial droop
      • dysarthria
      •   Nystagmus is:
      • immediate or delayed in onset
      • rotatory, horizontal, or vertical
      • not adaptive
      •   Vertigo does not stop with visual fixation
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