The document discusses various causes of central vertigo including: 1. Wallenberg syndrome which is caused by occlusion of the posterior inferior cerebellar artery and presents with nausea, vomiting, nystagmus, ataxia and other neurological signs. 2. Brainstem or cerebellar infarcts which present with abrupt vertigo and accompanying neurological symptoms depending on location and size of infarct. 3. Cerebellar hemorrhage which is a neurosurgical emergency that can cause sudden onset headache, vertigo and vomiting. 4. Other causes discussed include multiple sclerosis, central nervous system tumors, acoustic neuromas, neurodegenerative disorders, epilepsy, familial atax

1. CENTRAL VERTIGO

2. Central vertigo
• caused by dysfunction of central structures that process sensory input
from the inner ear.

3. CASE SCENARIO
A 60 yr old gentleman was brought to the casualty with complaints of
• sudden onset of dizziness with him feeling the perception of the
surroundings revolving about him of two hours duration
• nausea and vomiting at the time of onset
• had difficulty in sitting up in the bed and had to be given support to
go to the bathroom
• He is a known hypertensive and diabetic

4. • On examination he had :-
• Nystagmus
• Motor ataxia – Towards the right side
• Right palate, pharynx and laryngeal paresis
• loss of pain and temperature on right half of the face and left half
of the body

8. Wallenberg Syndrome
• Occlusion of posterior inferior cerebellar artery
• Relatively common cause of central vertigo
• Associated Symptoms:
• nausea
• Vomiting
• Nystagmus
• ataxia
• Horner syndrome
• palate, pharynx and laryngeal paresis
• loss of pain and temperature on ipsilateral face and contralateral body
8

9. 9

12. • The brainstem, cerebellum, and peripheral labyrinths - all supplied by
the vertebrobasilar arterial system.
• Central and peripheral ischemic vertigo syndromes may
overlap

18. Brainstem/cerebellar infarct
• Abrupt onset
>24hrs vs minutes
Brainstem ischemia
• accompanied by other neurological signs and symptoms
• motor and sensory pathways are in close proximity to vestibular
pathways.

19. Cerebellar Ischemia
• vertigo as the most prominent or only symptom
• Acute-onset vertigo - MRI study to rule out cerebellar infarction.

20. • Oculomotor testing can show:
1- Pure unidirectional nystagmus
2- Direction-changing gaze evoked nystagmus
3- Impaired smooth pursuit
4- Overshooting saccades

23. Management
Thrombolysis
Antiplatelets
Physiotherapy
Occupational
therapy

24. Cerebellar Hemorrhage
• Neurosurgical emergency
• Suspected in any patient with sudden onset headache, vertigo, vomiting and
ataxia
• May have gaze preference
• Motor-sensory exam usually normal
• Gait disturbance often not recognized because patient appears too ill to
move
24

26. Patients who are at risk for deterioration
• Admission systolic blood pressure greater than 200 mm Hg
• Pinpoint pupils and abnormal corneal and oculocephalic reflexes
• Hemorrhage extending into the cerebellar vermis
• Hematoma diameter greater than 30 mm
• Brainstem distortion
• Intraventricular hemorrhage
• Acute hydrocephalus

27. • Emergency management
• Oxygen support – Endotracheal intubation if necessary
• Atropine – bradycardia 2° to Cushing’s Reflex
• Surgical management

28. Sub-clavian Steal Syndrome
• Rare, but treatable
• Arm exercise on side of stenotic subclavian artery usually causes symptoms of
intermittent claudication
• Blood is shunted into the ipsilateral upper limb by the vertebral artery into the
subclavian artery from the opposite vertebral artery and basilar artery.
• Hence the brainstem suffers from ischaemia
28

29. Multiple Sclerosis
• Subacute onset
• Duration - Minutes-wks
• 5% of patients with MS report vertigo as an initial symptom.
• Vertigo may be rotatory with a positional component
• Diplopia, facial paraesthesia and weakness may co-exist
• 0ccasionally patients show typical peripheral vestibular nystagmus
- The lesion affects the root entry zone of the vestibular nerve.

30. Eye signs in MS patients with vertigo :-
• Nystagmus
• Internuclear ophthalmoplegia is characteristic
• Abnormal saccades
• Impaired pursuit
• Impaired convergence

33. Treatment
Chronic
Disease:-
• Interferon β-1α
• Glatrimer Acetate
• Mitoxantrone
• Fingolamide
Acute attacks :-
• High dose
corticosteroids –
Methyl
prednisolone
• Plasmapharesis

34. Cranio Vertebral Junction Anomalies
I. Bony Anomalies
A. Major Anomalies
1. Platybasia
2. Occipitalization
3. Basilar Invagination
4. Dens Dysplasia
5. Atlanto- axial dis.
B. Minor Anomalies
1. Dysplasia of Atlas
2. Dysplasia of
occipital condyles,
clivus, etc.
II. Soft Tissue anomalies
1. Arnold-Chiari Malformation
2. Syringomyelia/ Syringobulbia

35. Chiari malformation
• The brainstem and cerebellum are elongated downward into the
cervical canal - pressure on both the caudal midline cerebellum and
the cervicomedullary junction.
• Spontaneous or positional downbeat nystagmus
• central nystagmus can also occur.

36. • Dysphagia, hoarseness, and dysarthria - stretching of the lower
cranial nerves
• obstructive hydrocephalus - occlusion of the basilar cisterns.

37. • Sagittal and coronal MRI images of Chiari type I malformation.
• descent of cerebellar tonsils (T) below the level of foramen magnum (white line) down to the level of C1 posterior arch (asterisk).

38. Management
Duraplasty with pericranial graft
• The duraplasty - additional room for
cerebellar tonsils at the craniocervical
junction, while achieving closure of
dura and prevention of cerebrospinal
fluid leak.

40. Central Nervous System Tumors
• The most common -gliomas in adults and medulloblastoma in
children.
• Ocular motor dysfunction (impaired smooth pursuit, overshooting
saccades), impaired coordination, and other central nervous system
• An early finding - central positional nystagmus.

41. Acoustic Neuroma
• Peripheral Vertigo With Central Manifestations
• Tumor Of The Schwann Cells Around The 8th Cn
• Vertigo With Hearing Loss And Tinnitus
• Earliest Sign Is Decreased Corneal Reflex
• Later Truncal Ataxia
41

42. Neurodegenerative disorder
• Onset - Spontaneous or positionally triggered
• Parkinsonism
• Progressive supranuclear palsy
• Multi-system atrophy
• spinocerebellar ataxia involving cerebellum and brainstem.

43. Epilepsy
• Vestibular symptoms are common with focal seizures, particularly those
originating from the temporal and parietal lobes.
• The key to differentiate vertigo with seizures from other causes of vertigo -
association of seizures with an altered level of consciousness.
• Episodic vertigo as an isolated manifestation of a focal seizure is a rarity, if
it occurs at all.

44. Familial ataxia syndromes
• Onset - Acute-subacute, episodic type with stress, exercise
• Duration - hours
• Vestibular symptoms and signs –
• spinocerebellar ataxia types 1, 2, 3, 6, and 7
• Friedreich's ataxia
• Refsum's disease
• episodic ataxia (EA) types 2, 3, 4, and 5

45. • The positional vertigo and nystagmus can be the initial symptom
• the symptoms are slowly progressive, with the cerebellar ataxia and
incoordination later overshadowing the vestibular symptoms.
• Attacks of vertigo may occur in up to half of patients with SCA6 many
of which are positionally triggered
• Persistent down-beating nystagmus often is seen in patients placed in
the head-hanging position

47. Management
• no known cure for spinocerebellar ataxia
• directed towards alleviating symptoms
• Physical therapy

48. Basilar Migraine
• heterogeneous genetic disorder characterized by headaches in addition to many other
neurological symptoms
• Benign recurrent vertigo may be considered as a migraine equivalent
• Onset - With typical migraine triggers
• Duration from hours to days
• + family history
• Normal neurological exam
• No progressive hearing loss

49. • Some patients - auditory symptoms similar to Meniere's disease, and
a mild hearing loss also may be evident on the audiogram
• The key factor distinguishing between migraine and Meniere's disease
is the lack of progressive unilateral hearing loss
• Positional vertigo also may occur in patients with migraine
• diagnosis of migraine-associated dizziness remains one of exclusion

50. References
1. Bradley: Neurology in Clinical Practice, 5th ed.
2. Adams and Victors Priniciples of Neurology , 9th ed.
3. Harrison's Principles of Internal Medicine, 18th ed.
4. Practical Neurology, 3rd Edition