eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Vertigo & Dizziness

CNS Causes of Vertigo: Differential Diagnoses & Workup

Author: Marcelo B Antunes, MD, Resident Physician, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System
Coauthor(s): Michael J Ruckenstein, MD, MSc, FACS, FRCSC, Professor, Residency Program Director, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System
Contributor Information and Disclosures

Updated: Sep 10, 2009

Workup

Laboratory Studies

Few laboratory studies facilitate the diagnosis of the CNS causes of vertigo.

If vertigo is accompanied by prolonged nausea and vomiting in elderly patients, monitoring and replacing fluids and electrolytes is prudent.

In the rare case of suspected Lyme neuroborreliosis, serology for Lyme disease with enzyme-linked immunosorbent assay (ELISA), Western blot analysis, and lymphocyte antigen stimulation assay are indicated. Obtain cerebrospinal fluid for Lyme antibody tests and polymerase chain reaction analysis to evaluate for Borrelia burgdorferi DNA.

Imaging Studies

Imaging studies are indicated when the symptoms are suspected to result from ischemia. MRI and MR angiography are the most helpful studies in assessing posterior circulation disorders and acute infarction. Diffusion-weighted MRI is sensitive and specific for early detection and differentiation between vasogenic and cytotoxic edema in patients with acute neurologic deficits.

Other Tests

Electronystagmography (ENG) is the most used vestibular test. When combined with the patient’s history and examination, the results of the ENG can be used to support a diagnosis of a peripheral or central etiology.1,2 Nystagmus patterns may be spontaneous or may be elicited by a change in gaze, head position, or head shake. Patterns of central and peripheral nystagmus were discussed in the Clinical section. Abnormalities in smooth pursuit or saccades are typically central in origin.

Electrode montage for electronystagmography (ENG)...

Electrode montage for electronystagmography (ENG) testing.

[ CLOSE WINDOW ]
Electrode montage for electronystagmography (ENG)...

Electrode montage for electronystagmography (ENG) testing.


Formal evaluation with vestibular testing is indicated if the diagnosis is not apparent after obtaining a history and performing a physical examination. Vestibular testing can facilitate distinction between central, peripheral, and mixed causes of imbalance and vertigo. The test battery assesses labyrinthine function with caloric testing, rotational chair testing, and vestibular evoked myogenic potential. Oculomotor integrity is evaluated with eye tracking during smooth pursuit, saccades, and optokinetic stimulation. The evaluation of spontaneous and gaze-evoked nystagmus can provide critical clues to central pathology.

Abnormalities found by oculomotor testing that suggest a central balance problem include saccade inaccuracy and smooth pursuit dysmetria. Failure to suppress nystagmus with visual fixation is often a sign of disease that affects the cerebellar flocculus or neural connections between the flocculus and the vestibular nuclei.

Positional testing with infrared oculography can be used to reveal nystagmus and to clearly define nystagmus patterns. Multidirectional nystagmus, spontaneous nystagmus, or positional nystagmus that is downbeat, torsional, or dissociated suggests a central lesion.

If symptoms suggest hypoperfusion, embolic events, or arrhythmia as the cause, perform a complete cardiac and peripheral vascular examination, including ECG, Holter monitoring, echocardiography, and carotid and vertebral Doppler ultrasonography.

More on CNS Causes of Vertigo

Overview: CNS Causes of Vertigo
Differential Diagnoses & Workup: CNS Causes of Vertigo
Treatment & Medication: CNS Causes of Vertigo
Follow-up: CNS Causes of Vertigo
Multimedia: CNS Causes of Vertigo
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Solomon D. Distinguishing and treating causes of central vertigo. Otolaryngol Clin North Am. Jun 2000;33(3):579-601. [Medline].

  2. Rubin AM, Zafar SS. The assessment and management of the dizzy patient. Otolaryngol Clin North Am. Apr 2002;35(2):255-73. [Medline].

  3. Baloh RW, Harker LA. Central vestibular system disorders. In: Cummings CW, ed. Otolaryngology-Head and Neck Surgery,. 2nd ed. St. Louis, MO: Mosby; 1993:3177-3198.

  4. Chang CYJ, Gadre AK. Central Vestibulopathy. In: Bailey BJ, ed. Head and Neck Surgery- Otolaryngology. 4th ed. Philadelphia, PA: Lippincont; 2006:2303-2316.

  5. Serra A, Leigh RJ. Diagnostic value of nystagmus: spontaneous and induced ocular oscillations. J Neurol Neurosurg Psychiatry. Dec 2002;73(6):615-8. [Medline].

  6. Buttner U, Helmchen C, Brandt T. Diagnostic criteria for central versus peripheral positioning nystagmus and vertigo: a review. Acta Otolaryngol. Jan 1999;119(1):1-5. [Medline].

  7. Lipton RB, Stewart WF. Prevalence and impact of migraine. Neurol Clin. Feb 1997;15(1):1-13. [Medline].

  8. Waters WE, O'Connor PJ. Prevalence of migraine. J Neurol Neurosurg Psychiatry. Jun 1975;38(6):613-6. [Medline].

  9. Lempert T, Neuhauser H. Migrainous vertigo. Neurol Clin. Aug 2005;23(3):715-30, vi. [Medline].

  10. Koehler B. Benign paroxysmal vertigo of childhood: a migraine equivalent. Eur J Pediatr. Aug 1980;134(2):149-51. [Medline].

  11. Neuhauser H, Leopold M, von Brevern M, Arnold G, Lempert T. The interrelations of migraine, vertigo, and migrainous vertigo. Neurology. Feb 27 2001;56(4):436-41. [Medline].

  12. Reploeg MD, Goebel JA. Migraine-associated dizziness: patient characteristics and management options. Otol Neurotol. May 2002;23(3):364-71. [Medline].

  13. Lempert T, Neuhauser H, Daroff RB. Vertigo as a symptom of migraine. Ann N Y Acad Sci. May 2009;1164:242-51. [Medline].

  14. Savitz SI, Caplan LR. Vertebrobasilar disease. N Engl J Med. Jun 23 2005;352(25):2618-26. [Medline].

  15. Sacco RL, Freddo L, Bello JA, Odel JG, Onesti ST, Mohr JP. Wallenberg's lateral medullary syndrome. Clinical-magnetic resonance imaging correlations. Arch Neurol. Jun 1993;50(6):609-14. [Medline].

  16. Amarenco P, Rosengart A, DeWitt LD, Pessin MS, Caplan LR. Anterior inferior cerebellar artery territory infarcts. Mechanisms and clinical features. Arch Neurol. Feb 1993;50(2):154-61. [Medline].

  17. Keim RJ. William F. House Lecture. Neurotologic manifestations of microvascular hypoperfusion. Am J Otol. Jan 1995;16(1):34-8. [Medline].

  18. Paul KS, Lye RH, Strang FA, Dutton J. Arnold-Chiari malformation. Review of 71 cases. J Neurosurg. Feb 1983;58(2):183-7. [Medline].

  19. Longridge NS, Mallinson AI. Arnold-Chiari malformation and the otolaryngologist: place of magnetic resonance imaging and electronystagmography. Laryngoscope. Mar 1985;95(3):335-9. [Medline].

  20. Williams NP, Roland PS, Yellin W. Vestibular evaluation in patients with early multiple sclerosis. Am J Otol. Jan 1997;18(1):93-100. [Medline].

  21. [Guideline] Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. May 27 2008;70(22):2067-74. [Medline].

  22. [Guideline] Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. Nov 2008;139(5 Suppl 4):S47-81. [Medline].

[ CLOSE WINDOW ]

Further Reading

Clinical guidelines

Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, Hain TC, Herdman S, Morrow MJ, Gronseth GS, Quality Standards Subcommittee, American Academy of Neurology. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008 May 27;70(22):2067-74. 21

Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, Chalian AA, Desmond AL, Earll JM, Fife TD, Fuller DC, Judge JO, Mann NR, Rosenfeld RM, Schuring LT, Steiner RW, Whitney SL, Haidari J, American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2008 Nov;139(5 Suppl 4):S47-81. 22

Turski PA, Seidenwurm DJ, Davis PC, Brunberg JA, De La Paz RL, Dormont PD, Hackney DB, Jordan JE, Karis JP, Mukherji SK, Wippold FJ II, Zimmerman RD, McDermott MW, Sloan MA, Expert Panel on Neurologic Imaging. Vertigo and hearing loss. [online publication]. Reston (VA): American College of Radiology (ACR); 2006. 8 p.

[ CLOSE WINDOW ]

Keywords

CNS causes of vertigo, vertigo, dizziness, imbalance, disequilibrium, migraine-associated vertigo, presyncopal, vertebrobasilar artery insufficiency, vestibular function, VBA insufficiency, posterior fossa cerebrovascular disease, cerebellar tumors, temporal lobe tumors, brainstem lesions, cerebellopontine angle tumors, CPA tumors, multiple sclerosis, posttraumatic vertigo, familial periodic ataxia syndromes, Lyme neuroborreliosis, psychogenic vertigo, migraine-associated vertigo, migraine, migraine headache, nystagmus

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Marcelo B Antunes, MD, Resident Physician, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System
Disclosure: Nothing to disclose.

Coauthor(s)

Michael J Ruckenstein, MD, MSc, FACS, FRCSC, Professor, Residency Program Director, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System
Michael J Ruckenstein, MD, MSc, FACS, FRCSC is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Medical Editor

B Viswanatha, MBBS, MS, DLO, Professor of ENT, Sri Venkateshwara ENT Institute, Victoria Hospital, Bangalore Medical College and Research Institute, India
B Viswanatha, MBBS, MS, DLO is a member of the following medical societies: Association of Otolaryngologists of India, Indian Medical Association, and Indian Society of Otology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Peter S Roland, MD, Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director of Clinical Center for Auditory, Vestibular and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Adjunct Professor of Communicative Disorders, University of Texas School of Human Development
Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American Laryngological Rhinological and Otological Society, American Neurotology Society, American Otological Society, North American Skull Base Society, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Alcon labs Honoraria Speaking and teaching; GSK Honoraria Speaking and teaching; Advanced Bionics Honoraria Board membership; Cochlear corp Honoraria Board membership; Med El corp travel grants Consulting

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.