About Central Vertigo.

1. VERTIGO
-Dr Saumya H Mittal

2. Vertigo denotes a hallucinatory sensation of movement caused by
mismatch of sensory information received from vestibular system ,
visual system , proprioceptive system.

3. • Vertigo can be caused by
lesion in any of the
following systems
– Peripheral - A disordered
generation of the nerve
impulses by vestibule.
– Intermediate- Faulty
transmission of impulses
along the VIII th cranial
nerve (vestibulo cochlear
nerve)
– Central- Misinterpretation
of impulses by vestibular
nuclei in brain.

4. • Causes of Peripheral
Vertigo-
– BPPV
– Meniere’s disease
– Labyrinthitis
– Vestibular paroxysmia
– Perilymph fistula
– Sudden hearing loss
• Causes of Intermediate
Vertigo-
– Vestibular neuronitis
– Acoustic neuroma
– Drugs- so-called ‘ototoxic‘
drugs eg antibiotics such as
Streptomycin, Kanamycin,
Neomycin.
• Causes of Central Vertigo-
– Stroke/TIA esp
Vertebrobasilar insufficiency
– Multiple Sclerosis
– Neurodegenrative disorders
– Migraine
– Familial Ataxia Syndromes
– Brain tumors
– Epilepsy

5. Sign/Symptom Peripheral Central
Direction of Nystagmus Unidirectional Bi/Unidirectional
Fast phase opposite to lesion
Purely Horizontal Nystagmus Uncommon Common
without torsional component
Vertical or Purely Never Present May be Present
Torsional Nystagmus
Visual Fixation Inhibits vertigo and Nystagmus No change
Severity of Vertigo Marked Often Mild
Direction of Spin Towards fast phase Varied
Direction of Fall Towards slow phase Varied
Duration of Symptoms Finite, Recurrent episodes Chronic usually
Tinnitus/Deafness Often present Usually absent
Central Abnormalities None Common

6. CASE 1

7. • 65 year old female presented to the hospital
with sudden onset of vertigo.
• Associated with headache, vomiting, swaying
of gait, blurred vision, diplopia.
• K/C/O Hypertension.
• O/E- Deviation of mouth.
– Cerebellar signs present.
– Left plantar extensor.

8. CT showed

9. CASE 2

10. • 60/M
• C/O sudden onset
vertigo.
• Associated symptoms
of
– Left hemiparesis
– Imbalance on walking
• O/E
– (L) hemiparesis- UL- 4/5,
LL- 3/5
– (L) facial palsy
– (L) plantar extensor

11. MRI showed

12. Brainstem or Cerebellar
Ischemia/Infarction
• Ischemia affecting vestibular pathways within the brainstem or
cerebellum often causes vertigo. Brainstem ischemia is normally
accompanied by other neurological signs and symptoms, because
motor and sensory pathways are in close proximity to vestibular
pathways.
• Vertigo is the most common
symptom with Wallenberg
syndrome.
• Other neurological symptoms
and signs are invariably
present.
– diplopia,
– facial numbness,
– Horner syndrome
• Ischemia of the cerebellum
– vertigo as the most
prominent or only
symptom
– Dilemma?
• whether the patient with
acute-onset vertigo needs
MRI- (CT scans of the
posterior fossa are not a
sensitive test).
Reports of Pontine infarct causing vertigo are known.

13. • Abnormal ocular motor findings in patients
with brainstem or cerebellar strokes include:
– spontaneous nystagmus that is purely vertical or
torsional,
– direction-changing gaze-evoked nystagmus
(patient looks to the left and has left-beating
nystagmus, looks to the right and has right-
beating nystagmus),
– impairment of smooth pursuit, and
– overshooting saccades.

14. Central causes of nystagmus can sometimes
closely mimic the peripheral vestibular pattern
of spontaneous nystagmus. In these cases, a
negative head-thrust test (i.e., no corrective
saccade) or a skew deviation could be the key
indicators of a central rather than a peripheral
vestibular lesion.

15. Vertebro Basilar Insufficiency
• Vertebrobasilar insufficiency or TIA of the vertebrobasilar system
patients experience symptoms that symptoms resolve within 24
hours.
• A common cause of vertigo in elderly, 29% of patients suffer from at
least one episode of vertigo. 33% patients have vertigo as the only
feature.
• Symptoms last from minutes to hours (average 8 minutes).
• Patients who present with other features eg paresis, blindness, or
altered consciousness should be evaluated urgently for impending
stroke
• MRA is a non invasive method to evaluate vertebrobasilar
haemodynamics.
• Treatment includes antiplatelets, anticoagulation, possible
thrombolysis and percutaneous transluminal angioplasty.

16. Although this disease should always be in the
differential, several months of recurrent vertigo
unaccompanied by other neurological signs suggests
another disorder. Patients suffering a vertebrobasilar
TIA are likely to progress to stroke more quickly than
those experiencing TIAs in the anterior territory. The
likelihood of immediate stroke is less in patients
presenting with only episodic vertigo.

17. Multiple Sclerosis
• Dizziness is a common symptom in patients with multiple sclerosis.
Vertigo is the initial symptom in about 5% of patients with MS.
• A typical MS attack has a gradual onset, reaching its peak within a
few days. Milder spontaneous episodes of vertigo, not characteristic
of a new attack, and positional vertigo lasting seconds are also
common in MS patients.
• The key to the diagnosis is to find lesions disseminated in time and
space within the nervous system. Nearly all varieties of central
spontaneous and positional nystagmus occur with MS, and
occasionally patients show typical peripheral vestibular nystagmus
when the lesion affects the root entry zone of the vestibular nerve.
• MRI of the brain identifies white matter lesions in about 95% of MS
patients, although similar lesions are sometimes seen in patients
without the clinical criteria for the diagnosis of MS.

18. CASE 3

19. • 30/M
• C/O-
– Vertigo, increased on getting up after prolonged sitting for
3 years, increased for1 year.
• Associated complaints
– Imbalance and swaying on walking for 3 years, increased
for 1 year.
– neck pain increased on bending the neck.
• O/E-
– Gaze evoked nystagmus +
– Downbeat nystagmus +
– Gag reflex Normal.
– Power- Norma
– Reflexes- Normal
– Cerebellar signs- Tandem walking abnormal

20. MRI shows

21. Posterior Fossa Structural
Abnormalities
• Any structural lesion of the posterior fossa can
cause dizziness.
• With the CHIARI MALFORMATION, the brainstem and cerebellum are
elongated downward into the cervical canal, causing pressure on both the
caudal midline cerebellum and the cervicomedullary junction.
• Symptoms include
– Slowly progressive unsteadiness of gait described as dizziness (most common)
– Vertigo and hearing loss (in about 10% of patients)
– Ocular motor abnormalities (e.g., spontaneous or positional downbeat
nystagmus, impaired smooth pursuit)
– Dysphagia, hoarseness, and dysarthria (stretching of lower cranial nerves)
– Obstructive hydrocephalus (occlusion of the basilar cisterns).
• MRI is the procedure of choice for identifying Chiari malformations; midline
sagittal sections clearly show the level of the cerebellar tonsils.

22. • CNS TUMORS in the
posterior fossa
• Ocular motor dysfunction
(impaired smooth pursuit,
overshooting saccades),
impaired coordination, or
other central findings occur
in these patients.
• An early finding of patients
with cerebellar tumors can
be central positional
nystagmus.
• Most common
– gliomas in adults and
– medulloblastoma in children.
• VASCULAR
MALFORMATIONS
• can similarly cause dizziness
but generally are
asymptomatic until bleeding
occurs.
– arteriovenous malformations
– cavernous hemangiomas

23. Migraine
• Dizziness has long been
known- benign recurrent
vertigo is usually a migraine
equivalent.
– no other signs or symptoms
develop over time,
– typical migraine visual aura or
other focal neurological
symptoms
– the neurological exam remains
normal,
– a family or personal history of
migraine headaches is common
– typical migraine triggers are
apparent.
• Migraine-associated dizziness
may present with new onset
motion intolerance.
• Other types of dizziness are
also common in migraine
including
– nonspecific dizziness and
– positional vertigo.
• The cause of vertigo in
migraine patients is not yet
known.
• Heterogeneous genetic disorder*.
• Characterized by headaches and many other neurological
symptoms. Up to 38% migraineurs have episodic vertigo.

24. • Interestingly, some patients with benign
recurrent vertigo also report auditory
symptoms similar to patients with Meniere
disease, and a mild hearing loss may also be
seen on the audiogram. *
• The key distinguishing factor between
migraine and Meniere disease is the lack of
progressive unilateral hearing loss in patients
with migraine.

25. The diagnosis of migraine should be entertained
in any patient with chronic recurrent attacks of
dizziness of unknown cause. Though the
diagnosis of migraine-associated dizziness
remains one of exclusion, little else can cause
recurrent episodes without any other symptoms
over a long period of time.

26. • Once the diagnosis of Migraine-associated dizziness
has been reached, numerous therapies are available
for treatment.
• Initial management- avoidance of triggers through
lifestyle modification.
• For those who fail to find relief with lifestyle
modification alone, medical treatment may be
necessary.
– Prophylactic treatment.
– Acute attacks-
• antiemetics
• anti-vertiginous medications,
• triptans.
• non-steroidal anti-inflammatory drugs.

27. Central Positional Vertigo
• Rare cause of positional vertigo.
• It’s especially common due to structural lesions in the cerebellum,
especially the cerebellar nodulus and uvula (especially in tumors
like medulloblastoma).
• Also somewhat common in the
– Arnold-Chiari malformation
– disorder of basilar invagination,
– strokes
– tumors
– multiple-sclerosis lesions
– cerebellar degenerations.
• Ordinarily this diagnosis is made by noting a positional vertigo,
finding that it does not respond to exercises for BPPV, and then
further investigation.
involving the brainstem or cerebellum area.

28. Epilepsy
• It is a rare cortical vertigo syndrome secondary to focal epileptic
discharges in chiefly the temporal lobes or the parietal association
cortex.
• They are simple or complex partial seizures with predominant
symptom being vertigo.
• There’s a sudden dysequilibrium with rotational or linear vertigo
– lasting seconds to minutes
– associated with body, head or eye rotation with or without nystagmus
– may be associated nausea
– skew deviation of eyes with nystagmus during attacks may occur
– tinnitus, contralateral paesthesia, olfactory or gustatory sensations
may precede the episode
This suggests lateral and
superior rather than temporal
and basal temporal location.

29. • Vertigo here is not due to functional loss, but due
to focal discharges.
• Electrical stimulation of thalamus during
stereotactic neurosurgical procedures induced
sensations of movements in space, most
frequently described as horizontal or vertical
rotation or sensations of fall or rising. These
sensations were similar to those induced by
stimulation of vestibular cortex.
• Other epileptic focus has been reported in frontal
lobe seizures.

30. • Vestibular seizures are considered to respond
well to anti-epileptic medication. In the oldest
series, over half of the patients had complete
remission with phenytoin or carbamazepine
with a considerable reduction in the
frequency and severity of attacks .

31. CASE 4

32. • 28/M
• C/O Vertigo since 3 days
– Frequent episodes+
• Associated C/O-
– Nausea
– Dull headache
• No other symptom.
• Had H/O some surgery on Left side 3 years ago- no records
were available as to why/what.
• No nystagmus was observed and his symptoms were not
evoked by the hyperventilation manoeuvre.
• The patient showed bilaterally symmetrical saccade and
smooth pursuit.
• A cerebellar function test was normal and a caloric test and
audiometry showed normal responses.

33. • Brain MRI revealed the
presence of an osteoplastic
craniotomy scar in the left
lateral convexity.
• A diagnosis of vestibular
epilepsy was considered.
• Video EEG for 24 hours was
requested which showed no
ictal phenomenon during
clinical phenomenon.
The patient improved after psychological counselling
and has had no further symptoms without medications.

34. Non Neurogenic Causes
Ocular vertigo
Anemia
Cardiac and valvular- arrhythmias, heart failure, valvular heart d/s
Carotid sinus hypersensitivity
Orthostatic hypotension
Hypo and Hyperglycemia
Hyperventilation
Psychogenic- anxiety, phobia, depression
Medications and Toxins- Alcohol, Sedative-hypnotics, Anticonvulsants
eg Phenytoin, Lithim, Amiodarone, Lead, Mercury, Thallium

35. CASE 5

36. • 50/M
• C/O Vertigo when walking for 6months.
• Associated C/O
– Imbalance when walking for 6 months.
• O/E-
– No Nystagmus
– Power- Normal, (R) EHL weak
– Romberg’s positive
– Vibration Impaired

37. MRI
showed-

38. Was found to have
TSH- 176.9
FT3-0.963
FT4-0.023
Improved after Thyroid
replacement.

39. Balance Tests
• Romberg Test
• Unterberger Test
• Babinski Weill Test
• Barany Pointing Test

40. Eye Movement-Nystamus
Vertigo of peripheral
origin generally
manifests by
• horizontal,
• rotatory, or
• absent nystagmus
Horizontal nystagmus
is not a specific sign of
peripheral vertigo.

41. • A horizontal nystagmus is the most common type of
nystagmus observed in patients with cerebellar infarction.
• A vertical nystagmus is considered specific for central
vertigo.
• Nystagmus of central origin characteristically is worsened
by fixation of gaze, while peripheral nystagmus may be
ameliorated.
• Central nystagmus may be unidirectional or
multidirectional and may change direction with an
alteration in the direction of gaze (ie, gaze evoked), while
peripheral nystagmus is unidirectional.
• The direction of the nystagmus in c-PPV can be
– downbeat in the head-hanging position,
– counterclockwise in the right-hanging position,
– downbeat and left beating in the left-hanging position,
– upbeat in the supine position, or
– torsional with positioning.

42. Head Thrust
• The head-thrust test is a test of vestibular function that
can be easily done during the bedside examination.
• This maneuver tests the vestibulo-ocular reflex.
• The patient sits in front of the examiner and the
examiner holds the patient’s head steady in the
midline. The patient is instructed to maintain gaze on
the nose of the examiner. The examiner then quickly
turns the patient’s head about 10–15 degrees to one
side and observes the ability of the patient to keep the
eyes locked on the examiner’s nose.

43. If the patient’s eyes
move with the head and
then the patient makes a
voluntary eye movement
back to the examiner’s
nose (i.e., corrective
saccade), then this
indicates a lesion of the
peripheral vestibular
system and not the
central nervous system.

44. • If the patient’s eyes stay
locked on the examiner’s
nose (i.e., no corrective
saccade), then the
peripheral vestibular
system is assumed to be
intact.
• Thus, when a patient
presents with the acute
vestibular syndrome, the
test result would suggest
a CNS lesion (because the
VOR is intact).

45. Treatment Options
• Central causes of vertigo require urgent institutionalization
for specific treatment.
• Symptomatic treatment includes
– Antihistamines eg Meclizine, Dimenhydrinate, Promethazine.
– Anticholinergics eg Scopolamine.
– Benzodiazepines eg Diazepam and Lorazepam
– Phenothiazines eg Prochlorperazine
– Benzamide eg Metoclopramide.
• Trials lack that could predict the drugs or combination of
drugs that will be effective in individual patients.
• These medicines are not specific to vestibular system, so
side effects are common.

46. • Anticholinergic or antihistamine drugs are usually
effective in treating patients with mild to moderate
vertigo, and sedation is minimal.
• If the patient is particularly bothered by nausea, the
antiemetics prochlorperazine and metoclopramide can
be effective and combined with other antivertiginous
medications.
• For severe vertigo, sedation is often desirable, and
drugs such as promethazine and diazepam are
particularly useful, though prolonged use is not
recommended.

47. Patientia(Patience)- Brit Mus: No. 1891,1015.3 By-
Sebald Beham (1500–50)
Winged female figure in antique-style dress seated
with her eyes closed on the base of a column in the
foreground, her legs crossed and on her lap a sheep.
On the right a demonic creature with warts looking
up at the two putti who are hovering in clouds and
holding up a laurel wreath over the head of the
female figure. Leaning against the column an
inscribed tablet. 1540 Engraving

48. THANK YOU
• Vincent Van Gogh – Artist.
• Janet Jackson – Singer.
• Nicholas Cage – Actor.
• Kristin Chenoweth – Actress.
• Katie Leclerc- Actress.
• George Clinton – Musician.
• Ryan Adams – Musician.
• Peggy Lee- Songwriter, Actor,
Composer, Singer.
• Richard Lugar – Politician.
• David Duval – Golfer.
• Alain Robert – Climber.
• Nick Esasky- Major League
Baseball player.
• LeBron James – Basketball Player.
• Philip K. Dick- Author.
• Emily Dickinson- Poet, Writer.
• Alan Shepard- NASA astronaut.
Famous Personalities
who shared the
symptom of Vertigo