1599-5453 Contact Us KO
Dizziness

Central Vertigo

Central Vertigo · H81.4

Central vertigo is dizziness caused by abnormalities in vestibular processing structures of the central nervous system, including the brainstem, cerebellum, and thalamus. Because it encompasses potentially life-threatening or neurologically disabling conditions such as stroke, cerebellar tumors, and multiple sclerosis, rapid differentiation from peripheral vertigo is clinically critical.

2026-03-28

At a Glance

Approximately 10-15% of dizzy patients have a central cause, with stroke being the most dangerous etiology. Central vertigo is differentiated from peripheral vertigo by accompanying neurological symptoms (diplopia, dysarthria, limb weakness), severe gait instability, and specific nystagmus patterns (vertical nystagmus, direction-changing nystagmus). The HINTS examination (Head Impulse test, Nystagmus, Test of Skew) is reported to have higher sensitivity than MRI for identifying stroke in acute vertigo patients. In emergency situations, immediate brain imaging is required.

Definition and Overview

Central vertigo is dizziness caused by abnormalities in central nervous system structures involved in vestibular processing (vestibular nuclei of the brainstem, cerebellum, thalamus, vestibular cortex, etc.). Although it accounts for only approximately 10-15% of all dizzy patients, its clinical significance is high because it includes life-threatening causes such as stroke [2].

The causes of central vertigo are diverse, including ischemic or hemorrhagic stroke, cerebellar tumors or metastases, demyelinating lesions of multiple sclerosis, basilar migraine, Wallenberg syndrome, progressive cerebellar atrophy, central nervous system infections, and drug toxicity. Stroke is the most clinically important and frequent cause.

Differentiating Peripheral from Central Vertigo

Rapidly distinguishing between peripheral vertigo (vestibular organ or nerve abnormality) and central vertigo (brainstem or cerebellar abnormality) is the cornerstone of emergency management [4].

Nystagmus characteristics are a key differentiating feature. Peripheral vertigo typically presents with mixed horizontal-torsional nystagmus that is unidirectional, with the fast phase directed away from the lesion side. The nystagmus direction does not change with gaze direction. Central vertigo nystagmus may be purely vertical or exhibit direction-changing nystagmus that reverses direction with changes in gaze direction [5].

On the head impulse test (HIT), peripheral vertigo produces corrective saccades, whereas central vertigo (particularly brainstem and cerebellar lesions) shows normal results [1]. On skew deviation testing, vertical skew deviation (misalignment of the eyes in the vertical plane) strongly suggests a central cause [1].

HINTS 검사

The HINTS (Head Impulse, Nystagmus, Test of Skew) examination is a bedside assessment for ruling out central causes in patients with acute vestibular syndrome [1]. A central cause can only be excluded with low confidence when all three tests show peripheral patterns. If any test shows a central pattern, immediate brain imaging is required.

In one study, the HINTS examination demonstrated a sensitivity of over 96% and specificity of 96% for diagnosing stroke in acute vestibular syndrome patients, outperforming initial MRI (sensitivity 72-80%) [1].

Cerebellar Infarction and Isolated Vertigo

Approximately 10-20% of cerebellar infarctions present with isolated vertigo and nausea/vomiting as the initial symptoms, which can be confused with vestibular neuritis or BPPV [3]. In patients with stroke risk factors such as advanced age, hypertension, diabetes, smoking, and atrial fibrillation, sudden onset of severe vertigo must prompt consideration of cerebellar infarction [3].

Approximately 70% of cerebellar infarction patients show normal results on the head impulse test (a central finding on HINTS), making this test helpful in differentiation [3].

Wallenberg Syndrome

Wallenberg syndrome (lateral medullary infarction) is a classic example of central vertigo. It results from occlusion of the posterior inferior cerebellar artery (PICA) or vertebral artery, presenting with vertigo, nausea, and vomiting along with the following symptoms: ipsilateral facial sensory loss, contralateral limb temperature and pain sensory loss (crossed sensory deficit), dysphagia, hoarseness, Horner syndrome (ipsilateral ptosis, miosis, anhidrosis), and cerebellar ataxia.

Brain Imaging

Brain MRI, particularly diffusion-weighted imaging (DWI), is the standard for diagnosing acute ischemic stroke. However, cerebellar and brainstem infarctions within 24-48 hours of onset may show no abnormalities on DWI, making clinical judgment essential [4]. Even if the initial MRI is normal, follow-up MRI at 24-48 hours should be performed when stroke is strongly suspected clinically.

CT is useful for excluding hemorrhagic lesions and identifying large infarctions, but cerebellar and brainstem lesions are often poorly visualized on CT due to skull base artifacts.

Frequently Asked Questions

While dizziness most commonly results from ear problems (peripheral causes), it can also be caused by abnormalities in the brain (brainstem, cerebellum). Dizziness caused by brain problems is called central vertigo. Stroke, cerebellar tumors, multiple sclerosis, and brainstem tumors can all be causes, making it often more dangerous than peripheral vertigo. If you experience dizziness accompanied by neurological symptoms, you should visit the hospital immediately.

They can be differentiated by several features. Central vertigo is often accompanied by neurological symptoms such as diplopia (double vision), slurred speech, unilateral limb weakness, and facial sensory abnormalities. The pattern of eye movements (nystagmus) differs -- vertical nystagmus or nystagmus that changes direction with head turning suggests a central cause. Severe gait disturbance where the patient cannot even stand alone also raises suspicion for central vertigo. If you have these symptoms, you should seek emergency medical care immediately.

Yes, stroke can present with dizziness as the only initial symptom. In particular, approximately 10-20% of cerebellar infarctions may initially present with dizziness alone. If you experience sudden onset of severe dizziness, balance impairment preventing walking, accompanying headache, or have stroke risk factors such as hypertension, diabetes, or atrial fibrillation, you should seek emergency medical care immediately to rule out stroke.

When central vertigo is suspected, brain MRI (particularly DWI sequences) is needed, but in the early acute phase, MRI can sometimes miss abnormalities. For this reason, bedside neurological examinations such as the HINTS test (head impulse test, nystagmus type, skew deviation test) are critically used in clinical practice to differentiate stroke. Studies show that the HINTS examination has higher sensitivity for stroke diagnosis than initial MRI in acute vestibular syndrome. Clinical judgment and imaging studies are used together.

You should visit the emergency room immediately if you experience any of the following: double vision or drooping of one eye, slurred speech or difficulty swallowing, sudden weakness or numbness in one arm or leg, balance impairment severe enough to prevent walking, sudden onset of very severe headache, or altered consciousness. Extra caution is warranted if you have stroke risk factors such as hypertension, diabetes, or atrial fibrillation.

References

  1. [1] Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE (2009). "HINTS to diagnose stroke in the acute vestibular syndrome." Stroke, 40: 3504-3510. DOI PubMed
  2. [2] Newman-Toker DE, Hsieh YH, Camargo CA, Pelletier AJ, Butchy GT, Edlow JA (2008). "Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample." Mayo Clinic Proceedings, 83: 765-775. DOI PubMed
  3. [3] Lee H, Sohn SI, Cho YW, Lee SR, Ahn BH, Park BR, et al. (2006). "Cerebellar infarction presenting isolated vertigo: frequency and vascular topographical patterns." Neurology, 67: 1178-1183. DOI PubMed
  4. [4] Tarnutzer AA, Berkowitz AL, Robinson KA, Hsieh YH, Newman-Toker DE (2011). "Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome." CMAJ, 183: E571-592. DOI PubMed
  5. [5] Edlow JA, Newman-Toker D (2016). "Using the physical examination to diagnose patients with acute dizziness and vertigo." Journal of Emergency Medicine, 50: 617-628. DOI PubMed

Related Articles

Vestibular Migraine
Central VertigoCentral VertigoStroke-Related DizzinessCerebellar VertigoBrainstem VertigoDangerous Dizziness

This content is provided for medical information purposes only and cannot replace professional medical advice. If you have symptoms, please consult a specialist.

Are you concerned about related symptoms?

Get an accurate diagnosis at OSANG Neurosurgery.

02-514-8887 Contact Us