Central vertigo

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1. CENTRAL VERTIGO

2. Central vertigo caused by dysfunction of central structures that process sensory input from the inner ear.

3. CASE SCENARIO A 60 yr old gentleman was brought to the casualty with complaints of sudden onset of dizziness with him feeling the perception of the surroundings revolving about him of two hours duration nausea and vomiting at the time of onset had difficulty in sitting up in the bed and had to be given support to go to the bathroom He is a known hypertensive and diabetic

4. On examination he had :- Nystagmus Motor ataxia – Towards the right side Right palate , pharynx and laryngeal paresis loss of pain and temperature on right half of the face and left half of the body

5. Wallenberg Syndrome Occlusion of posterior inferior cerebellar artery Relatively common cause of central vertigo Associated Symptoms: nausea Vomiting Nystagmus ataxia Horner syndrome palate, pharynx and laryngeal paresis loss of pain and temperature on ipsilateral face and contralateral body 8

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7. The brainstem, cerebellum, and peripheral labyrinths - all supplied by the vertebrobasilar arterial system. Central and peripheral ischemic vertigo syndromes may overlap

8. Brainstem/cerebellar infarct Abrupt onset >24hrs vs minutes Brainstem ischemia accompanied by other neurological signs and symptoms motor and sensory pathways are in close proximity to vestibular pathways.

9. Cerebellar Ischemia vertigo as the most prominent or only symptom Acute-onset vertigo - MRI study to rule out cerebellar infarction.

10. Oculomotor testing can show: 1- Pure unidirectional nystagmus 2- Direction-changing gaze evoked nystagmus 3- Impaired smooth pursuit 4- Overshooting saccades

11. Management

12. Cerebellar Hemorrhage Neurosurgical emergency Suspected in any patient with sudden onset headache, vertigo, vomiting and ataxia May have gaze preference Motor-sensory exam usually normal Gait disturbance often not recognized because patient appears too ill to move 24

13. Patients who are at risk for deterioration Admission systolic blood pressure greater than 200 mm Hg Pinpoint pupils and abnormal corneal and oculocephalic reflexes Hemorrhage extending into the cerebellar vermis Hematoma diameter greater than 30 mm Brainstem distortion Intraventricular hemorrhage Acute hydrocephalus

14. Emergency management Oxygen support – Endotracheal intubation if necessary Atropine – bradycardia 2 ° to Cushing’s Reflex Surgical management

15. Sub- clavian Steal Syndrome Rare, but treatable Arm exercise on side of stenotic subclavian artery usually causes symptoms of intermittent claudication Blood is shunted into the ipsilateral upper limb by the vertebral artery into the subclavian artery from the opposite vertebral artery and basilar artery. Hence the brainstem suffers from ischaemia 28

16. Multiple Sclerosis Subacute onset Duration - Minutes- wks 5 % of patients with MS report vertigo as an initial symptom . Vertigo may be rotatory with a positional component Diplopia, facial paraesthesia and weakness may co-exist 0ccasionally patients show typical peripheral vestibular nystagmus - The lesion affects the root entry zone of the vestibular nerve.

17. Eye signs in MS patients with vertigo :- Nystagmus Internuclear ophthalmoplegia is characteristic Abnormal saccades Impaired pursuit Impaired convergence

18. Treatment

19. Cranio Vertebral Junction Anomalies Bony Anomalies Major Anomalies 1. Platybasia 2. Occipitalization 3. Basilar Invagination 4. Dens Dysplasia 5. Atlanto - axial dis. B. Minor Anomalies Dysplasia of Atlas Dysplasia of occipital condyles , clivus , etc. II. Soft Tissue anomalies Arnold- Chiari Malformation Syringomyelia / Syringobulbia

20. Chiari malformation The brainstem and cerebellum are elongated downward into the cervical canal - pressure on both the caudal midline cerebellum and the cervicomedullary junction. Spontaneous or positional downbeat nystagmus central nystagmus can also occur.

21. Dysphagia, hoarseness, and dysarthria - stretching of the lower cranial nerves obstructive hydrocephalus - occlusion of the basilar cisterns.

22. Sagittal and coronal MRI images of Chiari type I malformation . descent of cerebellar tonsils (T) below the level of foramen magnum (white line) down to the level of C1 posterior arch (asterisk).

23. Management Duraplasty with pericranial graft The duraplasty - additional room for cerebellar tonsils at the craniocervical junction, while achieving closure of dura and prevention of cerebrospinal fluid leak.

24. Central Nervous System Tumors The most common - gliomas in adults and medulloblastoma in children. Ocular motor dysfunction (impaired smooth pursuit, overshooting saccades), impaired coordination, and other central nervous system An early finding - central positional nystagmus .

25. Acoustic Neuroma Peripheral Vertigo With Central Manifestations Tumor Of The Schwann Cells Around The 8 th Cn Vertigo With Hearing Loss And Tinnitus Earliest Sign Is Decreased Corneal Reflex Later Truncal Ataxia 41

26. Neurodegenerative disorder Onset - Spontaneous or positionally triggered Parkinsonism Progressive supranuclear palsy Multi-system atrophy spinocerebellar ataxia involving cerebellum and brainstem.

27. Epilepsy Vestibular symptoms are common with focal seizures, particularly those originating from the temporal and parietal lobes. The key to differentiate vertigo with seizures from other causes of vertigo - association of seizures with an altered level of consciousness. Episodic vertigo as an isolated manifestation of a focal seizure is a rarity, if it occurs at all.

28. Familial ataxia syndromes Onset - Acute- subacute , episodic type with stress, exercise Duration - hours Vestibular symptoms and signs – spinocerebellar ataxia types 1, 2, 3, 6, and 7 Friedreich's ataxia Refsum's disease episodic ataxia (EA) types 2, 3, 4, and 5

29. The positional vertigo and nystagmus can be the initial symptom the symptoms are slowly progressive, with the cerebellar ataxia and incoordination later overshadowing the vestibular symptoms. Attacks of vertigo may occur in up to half of patients with SCA6 many of which are positionally triggered Persistent down-beating nystagmus often is seen in patients placed in the head-hanging position

30. Management no known cure for spinocerebellar ataxia directed towards alleviating symptoms Physical therapy

31. Basilar Migraine heterogeneous genetic disorder characterized by headaches in addition to many other neurological symptoms Benign recurrent vertigo may be considered as a migraine equivalent Onset - With typical migraine triggers Duration from hours to days + family history Normal neurological exam No progressive hearing loss

32. Some patients - auditory symptoms similar to Meniere's disease, and a mild hearing loss also may be evident on the audiogram The key factor distinguishing between migraine and Meniere's disease is the lack of progressive unilateral hearing loss Positional vertigo also may occur in patients with migraine diagnosis of migraine-associated dizziness remains one of exclusion

33. References Bradley: Neurology in Clinical Practice, 5th ed. Adams and Victors Priniciples of Neurology , 9th ed. Harrison's Principles of Internal Medicine , 18th ed. Practical Neurology, 3rd Edition