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Dizziness

Central Vertigo

Central Vertigo · H81.4

Central vertigo is dizziness caused by abnormalities in the vestibular processing structures of the central nervous system, such as the brainstem, cerebellum, and thalamus. It includes causes such as stroke, cerebellar tumor, and multiple sclerosis that can be life-threatening or leave neurological sequelae, so rapid differentiation from peripheral vertigo is clinically very important.

AT A GLANCE

At a glance

Approximately 10-15% of patients with dizziness have central causes, and among these, stroke is the most dangerous cause. Central vertigo is differentiated from peripheral vertigo by accompanying neurological symptoms (double vision, dysarthria, limb weakness), severe gait instability, and specific nystagmus patterns (vertical nystagmus, directional nystagmus). The HINTS test (Head Impulse test, Nystagmus, Test of Skew) is known to have higher sensitivity than MRI in diagnosing stroke in patients with acute dizziness. In emergency situations, brain imaging is required immediately.

Definition and Overview

Central vertigo is dizziness caused by abnormalities in the central nervous system structures involved in vestibular processing (brainstem vestibular nuclei, cerebellum, thalamus, vestibular cortex, etc.). Although it accounts for approximately 10-15% of all dizziness patients, it is of high clinical importance because it includes life-threatening causes such as stroke.

The causes of central dizziness are diverse, including ischemic or hemorrhagic stroke, cerebellar tumor or metastatic cancer, demyelinating lesions in multiple sclerosis, basilar artery migraine, Wallenberg syndrome, progressive cerebellar atrophy, central nervous system infection, and drug toxicity. Stroke is the most clinically important and frequent cause.

Distinguish between peripheral and central

The key to emergency treatment is to quickly distinguish between peripheral (vestibular system, vestibular nerve abnormalities) and central (brain stem, cerebellum abnormalities) dizziness.

Nystagmus characteristics are an important distinguishing point. Nystagmus in peripheral vertigo is typically a mixed horizontal-rotational type, has a fixed direction (unidirectional), and has a fast image directed to the opposite side of the lesion. Even if you change the direction of gaze, the direction of nystagmus does not change. Nystagmus in central vertigo appears as pure vertical nystagmus or direction-changing nystagmus, which changes direction depending on the direction of gaze.

In the head impulse test (HIT), peripheral vertigo shows corrective saccades, whereas central vertigo (especially brainstem and cerebellum lesions) shows normal results. In a skew deviation test, vertical skew deviation, which is a difference in the height of both eyes, strongly suggests centrality.

HINTS Inspection

The HINTS (Head Impulse, Nystagmus, Test of Skew) test is a bedside test to rule out central causes in patients with acute vestibular syndrome. A central cause is ruled out with low confidence only when all three tests show a peripheral pattern. If any central pattern appears, brain imaging is required immediately.

In one study, the HINTS test was reported to have a sensitivity of over 96% and a specificity of 96% for diagnosing stroke in patients with acute vestibular syndrome, making it superior to initial MRI (sensitivity 72-80%).

Cerebellar infarction and isolated dizziness

Approximately 10-20% of cerebellar cerebral infarctions present only isolated dizziness and nausea/vomiting as initial symptoms, which can be confused with vestibular neuritis or BPPV. Severe dizziness that occurs suddenly in patients with stroke risk factors such as old age, high blood pressure, diabetes, smoking, and atrial fibrillation must be considered as a possibility of cerebellar cerebral infarction.

In about 70% of patients with cerebellar cerebral infarction, the head impulse test is normal (central finding in HINTS), so this test is helpful in differentiation.

Wallenberg syndrome

Wallenberg syndrome (lateral medullary infarction) is a representative case of central dizziness. It occurs due to occlusion of the posterior inferior cerebellar artery (PICA) or vertebral artery, and is accompanied by dizziness, nausea, and vomiting along with the following symptoms: decreased facial sensation on the ipsilateral side of the lesion, decreased temperature and pain sensation in the extremity on the contralateral side (crossed sensory loss), dysphagia, hoarseness, Horner syndrome (ipsilateral ptosis, miosis, anhidrosis), and cerebellar ataxia.

brain imaging tests

Brain MRI, especially diffusion-weighted imaging (DWI), is the gold standard for diagnosing acute ischemic stroke. However, cerebellar/brainstem infarction within 24 to 48 hours of onset may show no abnormalities even on DWI, so clinical judgment is important. Even if the initial MRI is normal, if there is a strong clinical suspicion of stroke, a follow-up MRI is performed 24 to 48 hours later.

CT is useful for ruling out hemorrhagic lesions and confirming large infarctions, but cerebellum and brainstem lesions are difficult to see on CT due to shadowing of the skull.

QUESTIONS

Frequently asked questions

Q01What is central dizziness?

Dizziness is most often caused by ear problems (peripheral), but it can also be caused by abnormalities in the brain (brainstem, cerebellum). Dizziness caused by brain problems is called central dizziness. It can be caused by stroke, cerebellar tumor, multiple sclerosis, and brainstem tumor, so it is often more dangerous than peripheral vertigo. If you have neurological symptoms along with dizziness, you should visit a hospital immediately.

Q02How to distinguish between central and peripheral dizziness?

They can be distinguished by several characteristics. Central vertigo is often accompanied by neurological symptoms such as double vision (objects appearing double), slurred speech, loss of strength in one limb, and facial paresthesia. The pattern of eye movement (nystagmus) is different; vertical nystagmus or nystagmus that changes direction when the head is turned suggests centrality. Severe gait disturbances that make it difficult to even stand on one's own are also suspicious for centrality. If you have any of these symptoms, you should seek emergency medical care immediately.

Q03Can dizziness be a symptom of a stroke?

Yes, there are cases where the first symptom of a stroke is dizziness. In particular, approximately 10-20% of cerebellar infarctions may initially cause only dizziness. If you have sudden severe dizziness, balance problems that prevent you from walking, are accompanied by headaches, or have stroke risk factors such as high blood pressure, diabetes, or atrial fibrillation, you should immediately seek emergency medical treatment to rule out the possibility of stroke.

Q04Is MRI absolutely necessary to diagnose central dizziness?

When in doubt, a brain MRI (especially a DWI sequence) is indicated, but even MRI may miss abnormalities early in the acute episode. For this reason, in clinical practice, bedside neurological tests such as the HINTS test (head impulse test, nystagmus pattern, and heterophoria test) are important in diagnosing stroke. Studies have shown that the HINTS test has a higher sensitivity for stroke diagnosis than initial MRI in acute vestibular syndrome. Utilizes a combination of clinical judgment and imaging studies.

Q05When should I go to the emergency room immediately if I have dizziness?

If you have any of the following symptoms, you should go to the emergency room right away: These include double vision, drooping of one eye, slurred speech or difficulty swallowing, sudden weakness or numbness in one limb, balance problems that make walking impossible, sudden and very severe headaches, and blurred consciousness. If you have stroke risk factors (high blood pressure, diabetes, atrial fibrillation, etc.), you should be more careful.

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This article provides general medical information and does not replace an individual diagnosis or treatment plan. Please seek a medical assessment if symptoms persist.

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