CNS Causes of Vertigo Workup

  • Author: Marcelo B Antunes, MD; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Apr 2, 2012
 

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.

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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.

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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.[4, 5] 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.

See the image below.

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.[26] 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.

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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, Professor, Department of Otorhinolaryngology Head and Neck Surgery, University of Pennsylvania Health System

Michael J Ruckenstein 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.

Specialty Editor Board

B Viswanatha, MBBS, MS, DLO  Professor of Otolaryngology (ENT), Chief of ENT III Unit, Sri Venkateshwara ENT Institute, Victoria Hospital, Bangalore Medical College and Research Institute; PG and UG Examiner, Manipal University, India and Annamalai University, 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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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; Advanced Bionics Honoraria Board membership; Cochlear Corp Honoraria Board membership; Med El Corp travel grants Consulting; Foresight Consulting fee Consulting

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, 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 of Otolaryngology, Dentistry, and Engineering, 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 Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Medvoy Ownership interest Management position; Cerescan Imaging Consulting; Headwatersmb Consulting fee Consulting; Venturequest Royalty Consulting

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Electrode montage for electronystagmography (ENG) testing.
 
 
 
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