CENTRAL VERTIGO

Central vertigo

• caused by dysfunction of central structures that process sensory input

from the inner ear.

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

• 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

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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

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• The brainstem, cerebellum, and peripheral labyrinths - all supplied by

the vertebrobasilar arterial system.

• Central and peripheral ischemic vertigo syndromes may

overlap

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.

Cerebellar Ischemia

• vertigo as the most prominent or only symptom

• Acute-onset vertigo - MRI study to rule out cerebellar infarction.

• Oculomotor testing can show:

1- Pure unidirectional nystagmus

2- Direction-changing gaze evoked nystagmus

3- Impaired smooth pursuit

4- Overshooting saccades

ManagementThrombolysis

Antiplatelets

Physiotherapy

Occupational therapy

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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

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

• Emergency management

• Oxygen support – Endotracheal intubation if necessary

• Atropine – bradycardia 2° to Cushing’s Reflex

• Surgical management

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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

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.

Eye signs in MS patients with vertigo :-

• Nystagmus

• Internuclear ophthalmoplegia is characteristic

• Abnormal saccades

• Impaired pursuit

• Impaired convergence

Treatment

Chronic Disease:-• Interferon β-1α• Glatrimer Acetate• Mitoxantrone• Fingolamide

Acute attacks :-• High dose

corticosteroids – Methyl prednisolone

• Plasmapharesis

Cranio Vertebral Junction Anomalies

I. Bony AnomaliesA. Major Anomalies

1. Platybasia2. Occipitalization3. Basilar Invagination4. Dens Dysplasia5. Atlanto- axial dis.

B. Minor Anomalies1. Dysplasia of Atlas2. Dysplasia of

occipital condyles, clivus, etc.

II. Soft Tissue anomalies1. Arnold-Chiari Malformation2. Syringomyelia/ Syringobulbia

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.

• Dysphagia, hoarseness, and dysarthria - stretching of the lower cranial

nerves

• obstructive hydrocephalus - occlusion of the basilar cisterns.

• 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).

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.

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.

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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

Neurodegenerative disorder

• Onset - Spontaneous or positionally triggered

• Parkinsonism

• Progressive supranuclear palsy

• Multi-system atrophy

• spinocerebellar ataxia involving cerebellum and brainstem.

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.

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

• 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

Management

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

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

• 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

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