Central Vertigo

Central Vertigo Basics - Brain's Dizzy Dance

• Pathophysiology: Dysfunction of central vestibular pathways.
• Onset: Often gradual; can be sudden (e.g., stroke, hemorrhage).
• Vertigo Character:
  • Less intense, more ill-defined than peripheral.
  • Often constant, may feel like imbalance.
• Nystagmus:
  • Pure vertical, torsional, or horizontal.
  • May change direction with gaze.
  • Not suppressed by visual fixation.
• Associated Features: Neurological deficits common (diplopia, dysarthria, ataxia).
• Hearing Loss/Tinnitus: Typically absent.
• Autonomic Symptoms (nausea/vomiting): Less severe.

⭐ Central vertigo originates from lesions within the brainstem or cerebellum.

Etiology Unmasked - Central Culprit Hunt

• Vascular (Most Common):
  • Brainstem Ischemia/Infarction (e.g., pons, medulla)
  • Cerebellar Ischemia/Infarction/Hemorrhage
  • Vertebrobasilar Insufficiency (VBI): Transient symptoms
  • Wallenberg Syndrome (Lateral Medullary Syndrome - PICA occlusion)
  • Subclavian Steal Syndrome
• Demyelinating Disease:
  • Multiple Sclerosis (MS): Plaques in brainstem or cerebellar pathways
• Neoplastic:
  • Posterior Fossa Tumors:
    • Cerebellar (e.g., medulloblastoma, astrocytoma, hemangioblastoma)
    • Brainstem (e.g., glioma)
    • Metastases
• Migraine:
  • Vestibular Migraine: Episodic vertigo with migrainous features
• Infectious/Inflammatory:
  • Brainstem Encephalitis (e.g., viral, Listeria)
  • Cerebellitis
  • Tuberculoma, Neurocysticercosis (NCC) in posterior fossa
• Traumatic Brain Injury (TBI):
  • Brainstem or cerebellar contusions/hematomas
• Degenerative Disorders:
  • Spinocerebellar Ataxias (SCAs)
  • Paraneoplastic Cerebellar Degeneration
• Medication/Toxin-Induced (Rarely isolated central):
  • Anticonvulsants (e.g., phenytoin), alcohol, chemotherapy agents

⭐ Vertebrobasilar insufficiency is a common vascular cause of central vertigo, especially in elderly patients.

Symptoms & Signs - Decoding Dizziness Clues

• Vertigo Characteristics: Often persistent, may be less intense than peripheral but continuous; not always position-dependent.
• Nystagmus (Key Central Features):
  • Purely vertical (upbeating/downbeating) or purely torsional.
  • Direction-changing gaze-evoked nystagmus (changes direction with gaze).
  • Often not suppressed by visual fixation.
• Associated Neurological Deficits (The "5 Ds + A"):
  • Diplopia, Dysarthria, Dysphagia, Dysmetria (ataxia, incoordination), motor/sensory Deficits.
  • Altered consciousness (less common, but ominous).
• Hearing Loss/Tinnitus: Typically ABSENT (key differentiator from many peripheral causes).
• Gait: Severe ataxia, often unable to stand or walk unassisted, even with eyes open.
• 📌 HINTS Exam (Head Impulse, Nystagmus, Test of Skew): Crucial for differentiating central (e.g., stroke) from peripheral causes in acute vestibular syndrome.
  • Head Impulse: Normal (Vestibulo-Ocular Reflex intact) often points to central.
  • Nystagmus: Central type (see above).
  • Test of Skew: Skew deviation present suggests central.
  • (Recall 📌 INFARCT: Impulse Normal, Fast-phase Alternating nystagmus, Refixation on Cover Test)

⭐ Purely vertical or purely torsional nystagmus, or direction-changing gaze-evoked nystagmus, strongly suggests a central cause.

Diagnosis & Care - Navigating Neuro-Vertigo

• Clinical Evaluation:
  • History: Focus on 📌 "4 Ds" (Dizziness, Diplopia, Dysarthria, Dysphagia), headache, weakness.
  • Neuro Exam: Cranial nerves, cerebellar signs (ataxia, dysmetria); nystagmus (vertical, pure torsional, direction-changing, non-fatigable).
• Investigations:
  • MRI Brain (with DWI): Essential for posterior fossa pathology.
  • CT Brain: Acute setting if MRI delayed/contraindicated.
  • Audiometry: Usually normal. VNG may show central patterns.
• Management Strategy:
  • Treat Etiology: Ischemia (stroke care), tumor (surgery/RT), MS (DMTs).
  • Symptomatic Relief: Antiemetics (e.g., ondansetron), limited vestibular suppressants (e.g., diazepam).
  • Vestibular Rehabilitation (VRT): For chronic imbalance.
  • Specialist Referral: Neurologist.

⭐ MRI of the brain is the gold standard investigation for suspected central vertigo to identify structural lesions.

High‑Yield Points - ⚡ Biggest Takeaways

• Central vertigo originates from brainstem or cerebellar pathology.
• Nystagmus is typically vertical, bidirectional, or purely torsional, and not suppressed by visual fixation.
• Hearing loss and tinnitus are generally absent; if present, suspect other causes.
• Prominent neurological signs (e.g., ataxia, dysarthria, diplopia, weakness) are key differentiators.
• Vertigo is often milder but more constant and disabling than peripheral types.
• Key causes include posterior circulation stroke/TIA, multiple sclerosis, cerebellar tumors, and vestibular migraine.