The direction of nystagmus is
named by the fast(cortical)
component.Vertigo with anyCNS
symptoms or findings?
Assume central cause!Central vertigo is classically
ill defined and constant with
associated vertical nystagmus.
Peripheral vertigo is classically
dramatic and sudden with
rotatory—vertical or horizontal
nystagmus.■ Vertebral artery dissection
■ Wallenberg syndrome (lateral medullary infarction of brainstem)
■ Multiple sclerosis
■ Migraine
SYMPTOMS/EXAM
■ Onset may be sudden or gradual
■ Symptoms are often ill defined and constant
■ Vertical nystagmus
■ Associated with other CNS symptoms/findings indicating posterior fossa
pathology—dipolopia, dysarthria, visual changes
DIAGNOSIS/TREATMENT
MRI is imaging of choice to visualize the posterior fossa, though CT scan may
identify cerebellar mass, hemorrhage, or infarct.
Peripheral Vertigo
CAUSES
Caused by disorders affecting VIII CN and the vestibular apparatus (see
Table 15.12)
SYMPTOMS/EXAM
■ Most commonly a dramatic and suddenonset of intense paroxysmal vertigo
■ Nausea and vomiting
■ Often aggravated by position
■ Rotatory-vertical or horizontal nystagmus
■ Hearing loss (not with BPPV, vestibular neuronitis)
■ No central findings
DIAGNOSIS
■ Primarily a clinical diagnosis
■ Dix-Hallpike test confirms posterior canal BPPV.
■ MRI to visualize CN VIII lesions
TREATMENT
■ Depends on underlying etiology (eg, d/c ototoxic agents in ototoxicity, Epley
maneuver for posterior canal BPPV)
■ Symptomatic treatment with antihistamines or antiemetics
A 50-year-old male is brought in by ambulance with a possible stroke.
The patient has history of hypertension and BP 180/100 upon arrival.
The findings reveal a left-sided facial droop that includes the forehead.
There is no arm or leg weakness. Should this patient be worked up for
a CVA?
No. This patient has isolated facial droop with forehead includedwhich is
consistent with a peripheral (not central) 7th nerve palsy.NEUROLOGY