Central Causes of Vertigo

Aka: Central Causes of Vertigo, Vertigo due to Central Causes, Non-peripheral Vertigo Causes

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II. Findings: Suggestive of central causes

  1. Nystagmus
    1. Vertical or torsional Nystagmus (pure Horizontal Nystagmus may occur with either peripheral or central cause)
    2. No Nystagmus on Horizontal Head Impulse Test
    3. Persists <6 seconds after Dix-Hallpike Maneuver
    4. Fixation of eyes on object does not inhibit Nystagmus
    5. Requires weeks to months to resolve
  2. Episodes last hours to days
  3. Severe imbalance impairs standing and walking
  4. No Hearing Loss or Tinnitus in most central cases
  5. Acute Vestibular Syndrome (Posterior Circulation in 25% of cases)
    1. Rapid onset (<1 hour) of acute, persistent, continuous Vertigo or Dizziness
    2. Associated with Nystagmus, Nausea or Vomiting, head motion intolerance, and gait unsteadiness
  6. Positive HiNTs Exam Criteria (at least 1 of 3 positive) are suggestive of Cerebellar CVA or Brainstem CVA (100% sensitive, 96% specific)
    1. Normal Horizontal Head Impulse Test (no saccade/correction on head rotation) OR
    2. Nystagmus that changes direction (or Vertical Nystagmus or torsional Nystagmus) OR
    3. Skew Deviation on Alternate Eye Cover Test in which uncovered eye demonstrates quick vertical gaze corrections
  7. Risk Factors
    1. Cardiovascular Risk Factors (e.g. Diabetes Mellitus, Hypertension, Hyperlipidemia)
    2. Atrial Fibrillation

III. Causes: Central Vertigo

  1. Non-Vascular Central Causes of Vertigo (CN 8 or CNS)
    1. Tumor
      1. Acoustic Neuroma (Vestibular Schwannoma)
      2. Infratentorial ependymoma
      3. Brainstem glioma
      4. Medulloblastoma
      5. Neurofibromatosis
    2. Migraine Headache
    3. Multiple Sclerosis
    4. Degenerative Ataxia Disorders or Cerebellar Syndromes
      1. See Ataxia
      2. Multiple System Atrophy
      3. Friedreich's Ataxia
      4. Parkinsonism-Plus Syndrome (PPS, Atypical Parkinsonism)
  2. Vascular disease related transient cerebral anoxia or CVA
    1. Dizziness Causes not vertebrobasilar specific
      1. Postural Hypotension
      2. Syncope
    2. Specific anoxia to vertebrobasilar system
      1. Vessel specific
        1. Brainstem Infarct (associated with Hearing Loss)
          1. Anterior Inferior Cerebellar Artery Infarction
          2. Anterior Vestibular Artery Infarction
        2. Brainstem Infarct (no Hearing Loss)
          1. Posterior Inferior Cerebellar Artery infarction
          2. Labyrinthine Artery Infarction
      2. Precipitating conditions
        1. Arteriosclerosis
        2. Hypertension
        3. Anemia
        4. Atrial Fibrillation

IV. Imaging

  1. MRI Brain (preferred)
    1. Consider repeating MRI at 3-7 days if posterior CVA is suspected but negative on initial MRI
    2. Initial MRI in first 48 hours misses 15% of posterior strokes
  2. CT Head
    1. Cannot reliably exclude posterior CVA (high False Negative Rate)

V. References

  1. Baloh (1999) Postgrad Med 105(2):161-72 [PubMed]
  2. Knox (1997) Am Fam Physician 55(4):1185-90 [PubMed]
  3. Labuguen (2006) Am Fam Physician 73:244-51 [PubMed]
  4. Tusa (2005) Neurol Clin 23:655-673 [PubMed]
  5. Tusa (2003) Med Clin N Am 87:609-41 [PubMed]

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Related Studies

Ontology: Central Nervous System Origin Vertigo (C0155503)

Concepts Disease or Syndrome (T047)
MSH D014717
ICD9 386.2
ICD10 H81.4 , H81.49
SnomedCT 194362009, 38403006, 20425006
Italian Vertigine originante dal sistema nervoso centrale, Vertigine di origine centrale
Dutch vertigo van centrale oorsprong, centraal; vertigo, vertigo; centraal, Vertigo van centrale oorsprong, vertigo van CZS oorsprong
German Vertigo zentralen Ursprungs, Schwindel zentralen Ursprungs, Vertigo ZNS-bedingt
English Vertigo of central origin NOS, VERTIGO CNS ORIGIN, vertigo of central origin (diagnosis), vertigo of central origin, Vertigo CNS origin, Vertigo, Central Nervous System Origin, Central Origin Vertigo, Vertigo, Central Origin, Central origin vertigo, Vertigo of central origin, unspecified ear, central origin vertigo, labrynthitis, Vertigo of central origin NOS (disorder), CNS Origin Vertigos, Origin Vertigos, Central, Origin Vertigo, CNS, Central Origin Vertigos, Vertigos, Central Origin, CNS Origin Vertigo, Vertigo, CNS Origin, Vertigos, CNS Origin, Origin Vertigo, Central, Origin Vertigos, CNS, Vertigo of central origin, Central vestibular vertigo, Vertigo of central origin (disorder), central; vertigo, vertigo; central, Central Nervous System Origin Vertigo, Vertigo central nervous system origin
Portuguese Vertigem de origem central, Vertigem com origem no SNC
Spanish Vértigo de origen central, vértigo de origen central, SAI, vértigo de origen central, SAI (trastorno), vértigo de origen central (trastorno), vértigo de origen central, Vértigo de origen en el SNC
Japanese 中枢神経系に起因する回転性めまい, 中枢性回転性めまい, ﾁｭｳｽｳｾｲｶｲﾃﾝｾｲﾒﾏｲ, ﾁｭｳｽｳｼﾝｹｲｹｲﾆｷｲﾝｽﾙｶｲﾃﾝｾｲﾒﾏｲ
French Vertige d'origine centrale, Vertige central
Czech Vertigo centrálního původu, Vertigo CNS původu, centrální vertigo
Korean 중추기원의 현기증
Hungarian Centralis eredetű vertigo, KIR eredetű vertigo
Norwegian Sentral vertigo, Sentralnervesystemforårsaket vertigo, Vertigo, sentralnervesystem, Vertigo som skyldes skade på sentralnervesystemet
Derived from the NIH UMLS (Unified Medical Language System)

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