Central Neurogenic

Vertigo

Vertigo in Neuro Clinic

June

99 to May 2000
Total no of Neuro cases seen:
Total no of vertigo cases seen:
Male : Female 150: 106
< 10 years
6
10 20 years
4
20 40 years
112
40 60 years
74
> 60 years
48

2456
248

Is It Central Vertigo?
Associated symptoms
Central

: diplopia, dysarthria, dysphagia,

perioral numbness, one sided weakness

or ataxia, headache (occipital)
Peripheral:

Hearing loss, tinnitus,

Vertigo Central/peripheral ?
Symptom

Peripheral

Central

Hallucination Definite
of movement
Onset
Paroxysmal

Less definite

Intensity

Severe

Moderate

Duration

Short

Long

Postural

frequent

Seldom

Acute

Vertigo Central/peripheral?
Symptoms
Nystagmus
ANS
Tinnitus
Deafness
Consciousness
Neurologic
sign

Peripheral
Present
Frequent
Frequent
Frequent
Preserved
Absent

Central
May present
Less frequent
Seldom
Seldom
May loss
Present

Vertigo in Childhood
Neurological deficit

Tumor

Epilepsy

Isolated

Migraine

Migraine and Vertigo

Most

common cause of vertigo in children 34.7%

Basilar migraine and Migraine equivalents as
benign paroxysmal vertigo
Migraine and benign positional vertigo may
coexist (migraine 3 times in BPV) 32%
Miigraineurs had higher prevalence central and
peripheral vestibular dysfunction compared to
non-migraineurs
Respond to anti migraine medication

Basilar migraine
Bickerstaff in

1961

Vertigo

with brain stem symptoms

followed by headache

Due

to basilar artery vasoconstriction

followed by vasodilatation

Recently

central mechanism postulated

Benign paroxysmal vertigo in

childhood.
Vertigo

of sudden onset lasting a few

minutes and in extreme cases several
hours or even up to 2 days.
Autonomic symptoms
nystagmus
Consciousness is not impaired.
Frequency varies weeks to months

Episodic vertigo related to migraine

vestibular migraine?

Onset : at any age, peak

fourth decade in men and a
"plateau" between the third
and fifth decades in women.
Duration: Few seconds to
several hours
78% Mono-symptomatic
Vertigo
16% audio-vestibular
32% not associated with
headache

In the symptom-free interval

66% of the patients showed

mild central ocular motor

signs such as vertical (48%)
and/or horizontal (22%)
saccadic pursuit, gaze-evoked
nystagmus (27%), moderate
positional nystagmus (11%),
and spontaneous nystagmus
(11%).

52% with other migraine

Nervenarzt 1993
Feb;64(2):121-6

Epileptic vertigo
Vertigo is common as aura of an
epileptic attack
Isolated recurrent vertigo is rare
Usually last for few seconds
EEG shows temporal spikes

Vertigo in Adult
Isolated

Hearing loss

Labyrinthitis
Meniere's

CA Mass

Vestibular
Neuronitis
Benign
Positional

CP angle tumor
Rarely

present solely with episodic vertigo.

Vertigo occurs in approximately 20%, but a
symptom of imbalance or dis-equilibration
is more common
The most common symptoms associated
progressive hearing loss and tinnitus.
Look for neurological signs such as a
depressed corneal reflex.

The diagnostic value of imaging the

patient with dizziness. A Bayesian
approach.
Dizziness

: 0.0004 or 1 in 2500
Isolated dizziness without hearing loss: .000107
or 1 in 9307
Dizziness with asymmetric hearing loss:
0.00156 or 1 in 638
Clin Otolaryngol 1996 Feb;21(1):80-3

Imaging in Dizziness for CAM

Progressive hearing loss with
abnormal speech reception
thresholds probably warrants
a magnetic resonance imaging
scan of the internal auditory
canals.

Bilateral loss of vestibular function:

clinical findings in 53 patients.

39% had associated

neurological disease
13% had a progressive
cerebellar syndrome
9% cranial or peripheral
neuropathies with hearing loss
11% had hearing loss
secondary to meningitis
6% had other neurological
disorders.
17% had Gentamicin
ototoxicity

9% autoimmune disease
13% Otological or
neoplastic disease
21% Idiopathic BVF characterised by paroxysmal
vertigo and/or oscillopsia,
but no abnormal clinical
signs.

J Laryngol Otol 1998

Feb;112(2):193-5

Vertigo in Elderly

Neurological deficit

Vascular

Isolated

Cervicogenic

Vascular Vertigo

Vertebrobasilar Insufficiency

Wallenbergs syndrome

AICA syndrome

Cerebellar infarction

Cerebellar hemorrhage

Lateral medullary syndrome

Complete

syndrome: Vertigo with

dysphagia, dysarthria, ipsilateral ataxia and
facial anesthesia, Horner's syndrome and
contralateral body anesthesia
Incomplete syndrome may present with
vertigo followed by subtle Horner. Facial
and body hypoesthesia. Needs careful
examination.

Small Cerebellar infarction

Vertigo,

unsteadiness and
unidirectional nystagmus
Vestibular neuritis
Vertigo with tinnitus and hearing
disturbance Meniere's disease
Paroxysmal positional vertigo
BPV

Clue to small cerebellar

infarction
Transient

headache and blurred vision

Vertigo

may disappear but ataxia may

progress

Electronystagmography

peripheral apparatus

show normal

VBI and Vertigo

Vertigo is common in VBI

Isolated vertigo was thought to rule out VBI in elderly
Recently many papers have emphasized isolated recurrent
vertigo as symptom of VBI
Ischemia of vestibule by AICA and medial cerebellum by
PICA
MRA, Angiography BAER may help
In elderly patients with no laboratory evidence of
peripheral vestibulopathy or systemic disease, episodic
disequilibration or dizziness may be due to vertebrobasilar
disease

Cervicogenic Vertigo
Abnormal

cervical proprioceptive impulse

to vestibular apparatus
Associated neck pain and tender points and
limitation of neck movements
Improves with limitation of neck
movements and aggravated by neck
movements
Cervical spondylosis, cervical trauma

Clinical significance of cervical

arthropathy in patients with vertigo .
102 Patient examined with 20 Control with vestibular
symptoms
No relationship was observed between the degree of
cervical spondylosis and vestibular abnormalities
an age dependent microvascular damage may be
more likely as an etiological factor for vestibular
symptoms in the elderly.
Rev Med Chil 1990 Jun;118(6):657-61

Isolated Vertigo 99-2000

Epilepsy

02
Migraine 10
Cervical spondylosis 30
Peripheral unclassified 122
Meniere's 01
BPV
01
CPA Mass00
VBI
00

Thank you