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