Vertigo – from a neurologist’s
point of view
Tung-Hua Chiang M.D.
Department of Neurology
Cheng-Ching General Hospital
Dizziness and other sensations of imbalance are,
along with headache, back pain, the most frequent
complaints among medical outpatients (Kroenke
For the most part they are benign, but always there
is the possibility that they signal the presence of an
important neurologic disorder.
Diagnosis of the underlying disease demands that
the complaint of dizziness be analyzed correctly -
the nature of the disturbance of function being
determined first, and then its anatomic localization
“Vertigo” should be correctly defined
“Dizziness” : a feeling of rotation or whirling as
well as nonrotatory swaying, weakness, faintness,
light-headedness, or unsteadiness.
“Vertigo” : subjective and objective illusions of
Mechanisms responsible for the
maintenance of a balanced posture
Continuous afferent impulses from the eyes,
labyrinths, muscles, and joints
The adaptive movements necessary to maintain
equilibrium are carried out - at a reflex level.
Afferent impulses (1)
Visual impulses from the retinas and possibly
proprioceptive impulses from the ocular muscles.
Afferent impulses (2)
Impulses from the labyrinths, the three
semicircular canals sense angular acceleration of
the head, and the saccular and utricular maculae
sense linear acceleration and gravity
Vestibulo-ocular reflex - stabilizes the eyes
Vestibulo-spinal reflex - stabilizes the position of
the head and body
All connected with cerebellum and certain
ganglionic centers and pathways in the brainstem,
particularly the vestibular nuclei, and, via the
medial longitudinal fasciculi, with the red and
ocular motor nuclei.
Any disease that disrupts these neural mechanisms
may give rise to vertigo
Cerebral cortical lesion
vertigo may constitute the aura of an epileptic
electrical stimulation of the cerebral cortex
(posterolateral aspects of the temporal lobe,
inferior parietal lobule, adjacent to the sylvian
fissure) may evoke intense vertigo
Vertiginous epilepsy vs Vestibulogenic seizures
Vestibulogenic seizures : an excessive vestibular
discharge serves as the stimulus for a seizure - a
rare form of reflex epilepsy
Ocular motor disorders
abrupt onset of ophthalmoplegia with diplopia - a
source of spatial disorientation and brief sensations
of vertigo (maximal : when looks in the direction
of action of the paralyzed muscle; receipt of two
conflicting visual images)
depend on which part of this structure is involved
large, destructive processes in the cerebellar
hemispheres and vermis may cause no vertigo
lesions involving the territory of the medial branch
of the PICA may cause intense vertigo,
indistinguishable from that due to labyrinthine
Infarction extended to the midline and involved the
flocculonodular lobe : falling toward the side of
the lesion; nystagmus was present on gaze to each
side but was more prominent on gaze to the side of
unidirectional nystagmus to the side opposite the
impaired labyrinth and swaying or falling toward
the involved side, direction of the nystagmus is
opposite to that of the falling and past pointing
Biemond and DeJong
originating in the upper cervical roots and the muscles and
ligaments that they innervate
Spasm of the cervical muscles, trauma to the neck, and
irritation of the upper cervical sensory roots are said to
produce asymmetrical spinovestibular stimulation and
thus to evoke nystagmus and prolonged vertigo, and
Downbeat nystagmus, vertigo and postural
instability have been observed with paramedian
lesions at the craniocervical junction.
Upbeat nystagmus with oscillopsia and vertigo has
been traced to two separate brainstem lesions : one
in the perihypoglossal nuclei and the other in the
pontomesencephalic tegmentum (Brandt)
Cervical vertigo has also been attributed to VBI
Occasionally, vertigo lasting a few minutes occurs
as a prelude to a basilar migraine headache (Grad
Recurrent attacks of vertigo associated with
fluctuating tinnitus and deafness.
Meniere disease affects the sexes about equally
and has its onset most frequently in the fifth
decade of life, although it may begin earlier or
Usually sporadic, but rare hereditary forms, both
The main pathologic change : increase in the
volume of endolymph and distention of the
endolymphatic system (endolymphatic hydrops)
Paroxysmal attacks of vertigo : ruptures of the
membranous labyrinth and a dumping of
potassium-containing endolymph into the
perilymph, which has a paralyzing effect on
vestibular nerve fibers and leads to degeneration of
the delicate cochlear hair cells
A small proportion of patients with Meniere
disease experience sudden, violent falling attacks :
"otolithic catastrophe of Tumarkin," : deformation
of the otolithic membrane of the utricle and
saccule. Consciousness is not lost
An initial attack must be distinguished from other
types of drop attacks, occurrence of more typical
vertiginous attacks with deafness and tinnitus,
clarify the diagnosis.
The hearing loss in Meniere disease usually
precedes the first attack of vertigo
There is frequently a decrement in hearing with
each attack; hearing may improve after a few
hours, but later the loss becomes irreversible
Early : low tones; Later : high tones
The attacks of vertigo usually cease when the
hearing loss is complete.
Sensorineural type of deafness
During an acute attack of Meniere disease, rest in
bed is the most effective treatment
Destruction of the labyrinth should be considered
only in patients with strictly unilateral disease and
complete or nearly complete loss of hearing.
Bilateral disease or significant retention of hearing,
the vestibular portion of the eighth nerve can be
sectioned or decompressed (by separating the
nerve from an aberrant vessel).
Endolymphatic-subarachnoid shunt is the
operation favored by some surgeons
Vestibular Neuronitis (Neuropathy)
Originally by Dix and Hallpike
Disturbance of vestibular function, paroxysmal
and usually single attack of vertigo and absence of
tinnitus and deafness.
Mainly in young to middle-aged adults, equal sex.
Examination discloses vestibular paresis on one
Nystagmus (quick component) and sense of body
motion are to the opposite side, whereas falling
and past pointing are to the side of the lesion.
Auditory function is normal.
A benign disorder.
The severe vertigo subside in several days, but
lesser degrees of these symptoms, made worse by
rapid movements of the head, may persist for
In some patients there has been a recurrence
months or years later.
Primarily affected the superior part of the
vestibular nerve trunk, which was observed to
show degenerative changes
The cause is uncertain, may be a viral infection,
many neurologists prefer the term vestibular
Other Paroxysmal Vertigo
A single abrupt attack of severe vertigo, nausea,
and vomiting without tinnitus or hearing loss, with
permanent ablation of labyrinthine function on one
side -> suggested occlusion of the labyrinthine
division of the internal auditory artery;
Labyrinthine hemorrhage has been demonstrated
by MRI in some of these patients.
In childhood : good health, sudden onset of brief vertigo,
pallor, sweating, and immobility, and occasionally
vomiting and nystagmus.
Recurrent but tend to cease spontaneously after a period of
several months or years
Impairment or loss of vestibular function, bilateral or
unilateral, frequently persisting after the attacks have
ceased. Cochlear function is unimpaired.
Unknown pathologic basis
Young adults in which a nonsyphilitic interstitial keratitis
is associated with vertigo, tinnitus, nystagmus, and rapidly
The prognosis for vision is good, but the deafness and loss
of vestibular function are usually permanent.
Unknown cause and pathogenesis
Half of the patients later develop aortic insufficiency or a
systemic vasculitis that resembles polyarteritis nodosa.
There are many other causes of aural vertigo, such
as purulent labyrinthitis complicating meningitis,
serous labyrinthitis due to infection of the middle
ear, "toxic labyrinthitis" due to intoxication with
alcohol, quinine, or salicylates, motion sickness,
and hemorrhage into the inner ear.
Head trauma, cerebral concussion or whiplash
injury, vertigo due to loosening or dislodgement of
the otoconia in the otoliths.