CNS Causes of Vertigo

Updated: May 06, 2020
  • Author: Marcelo B Antunes, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Overview

Practice Essentials

Dizziness is a vague and nonspecific symptom. It refers to an abnormal sensation in relation to space and position. Vertigo is a specific type of dizziness that is defined as a spinning or rotatory sensation. Patients with vertigo report that things are rotating around them or that they are rotating around things. Vertigo could be either from a peripheral (labyrinth and vestibular nerve) or a central disorder (central nervous system). Central vertigo is usually a result of an abnormal processing of the vestibular sensory input by the central nervous system. Medical treatment for vertigo includes supportive care with fluid replacement and vestibular suppressants for intractable vertigo with nausea and vomiting.

See the image below.

Electrode montage for electronystagmography (ENG) Electrode montage for electronystagmography (ENG) testing.

Symptoms of vertigo

Patient history is of critical importance in determining if vertigo is from a peripheral or central origin because usually physical findings and vestibular testing can only provide supportive information. Peripheral vertigo can be positional, lasting for seconds to a few minutes (such as in benign paroxysmal positional vertigo); recurrent, lasting for hours and associated with hearing loss, aural fullness, and tinnitus (such as in Ménière syndrome); [1] or a single episode lasting days without associated auditory or neurologic symptoms (such as in vestibular neuronitis).

Central vertigo should be considered when the patient’s history is not consistent with any of the well-defined peripheral syndromes. The history could be acute or chronic vertigo, usually associated with neurologic symptoms. The presence of neurologic symptoms such as headaches, aura, or visual, sensory, or motor symptoms is more suggestive of a central disorder. [2, 3, 4]

Workup in vertigo

Imaging studies are indicated when the symptoms are suspected to result from ischemia. Magnetic resonance imaging (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.

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. [2, 3]

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. [5] The evaluation of spontaneous and gaze-evoked nystagmus can provide critical clues to central pathology.

Management of vertigo

Medical treatment includes supportive care with fluid replacement and vestibular suppressants for intractable vertigo with nausea and vomiting.

Treatment of migraine-associated vertigo includes analgesics and vestibular suppressants. Drugs useful in the treatment of migraines include sumatriptan, propranolol, imipramine, amitriptyline, nortriptyline, and the vestibular suppressants diazepam and alprazolam.

Surgical treatment of central vertigo is limited to urgent posterior fossa decompression of cerebellar and brainstem edema that complicates the infarction.

Cerebellopontine angle (CPA) tumors, which affect the vestibular nerve or root entry zone, are surgically removed on an elective basis. If a medical contraindication exists, radiotherapy for tumor control is an option.

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Pathophysiology

The sensation of balance is the result of appropriate information detected by the vestibular, ocular, and proprioceptive sensory receptors that is then properly integrated within the cerebellum and brain stem. Proper gait, posture, and visual focus during head movement all depend on an intact sense of balance. Loss of sensory information, central integration, and output control mechanisms all result in a sense of imbalance.

Central causes of vertigo result from either a disruption of central integrators (ie, brain stem, cerebellum) or a sensory information mismatch (ie, from the cortex). Lesions that affect the vestibular nerve or root entry zone (ie, cerebellopontine angle [CPA] lesions) result in imbalance by affecting primary vestibular sensory information.

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Epidemiology

Race

No racial predilection exists for CNS causes of vertigo.

Sex

Men and women are affected differently by different causes of CNS vertigo. Vestibular migraine (migraine-related vertigo, or migrainous vertigo), for example, shows a predilection for women.

Age

CNS causes of vertigo typically affect older population groups because of the associated risk factors of vascular causes of vertigo, such as hypertension, atherosclerosis, and diabetes mellitus. [6]

Younger population groups are more commonly affected by migraine headaches and multiple sclerosis (MS). [7] Cerebellar tumors affect a bimodal population of children and adults. CPA tumors typically affect people in the fifth to eighth decades of life.

A study by Teggi et al involving 252 patients with vestibular migraine found the ages of onset for migraine and vertigo to be 23 years and 38 years, respectively, in this group. Onset of migraine tended to occur at a lower age in patients with a family history of migraine, while the age of vertigo onset tended to be lower in patients with a childhood history of benign paroxysmal vertigo, benign paroxysmal torticollis, and motion sickness. [8]

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