What symptoms are consistent with central vertigo?

Symptoms Consistent with Central Vertigo

Central vertigo is characterized by neurological symptoms including gait disturbances, speech abnormalities, and autonomic dysfunction, which distinguish it from peripheral vertigo causes. 1

Key Clinical Features of Central Vertigo

Neurological Symptoms and Signs

• Gait and speech abnormalities - cerebellar ataxia, dysarthria 2, 1
• Autonomic dysfunction - may be more pronounced than in peripheral causes 2
• Additional neurological deficits - limb ataxia, cranial nerve abnormalities 3
• Headache and vomiting - particularly occipital headache may suggest vertebrobasilar insufficiency 1, 3

Nystagmus Characteristics

• Direction-changing gaze-evoked nystagmus - a key component of the HINTS examination 1
• Positional downbeat nystagmus - present in approximately 69% of central positional vertigo cases 4
• Apogeotropic horizontal nystagmus - seen in about 42% of cases 4
• Multiplanar nystagmus - observed in approximately 23% of cases 4
• Nystagmus that doesn't fatigue - lack of habituation with repeated testing 4

Positional Testing Abnormalities

• Atypical response to Dix-Hallpike maneuver - nystagmus inconsistent with BPPV patterns 5
• Failed response to repositioning maneuvers - persistent symptoms despite appropriate treatment for presumed BPPV 3
• Abnormal HINTS test - particularly important in acute vestibular syndrome 1

Red Flags Suggesting Central Vertigo

• Isolated positional downbeat nystagmus 3
• Apogeotropic horizontal nystagmus on supine roll test without typical BPPV features 3
• Persistent symptoms after appropriate BPPV treatment 2
• Associated auditory or neurological symptoms 2
• Symptoms that don't follow the typical brief, positional pattern of BPPV 4

Diagnostic Considerations

Central vertigo can masquerade as BPPV in approximately 12-20% of positional vertigo cases 5. The HINTS examination (Head-Impulse, Nystagmus, Test of Skew) is particularly valuable for differentiating central from peripheral causes, with abnormal results suggesting central pathology 1.

Common Central Causes of Vertigo

• Posterior circulation stroke/TIA
• Cerebellar tumors
• Cerebellopontine angle tumors
• Multiple sclerosis
• Vascular loops
• Cerebral venous thrombosis
• Obstructive hydrocephalus 3, 5

Clinical Pitfalls to Avoid

1. Misdiagnosing central vertigo as BPPV - Strokes presenting with dizziness-vertigo are frequently misdiagnosed in emergency settings 6
2. Failing to recognize "red flag" nystagmus patterns - Apogeotropic horizontal and isolated positional downbeat nystagmus should raise suspicion for central pathology 3
3. Assuming treatment failure is due to persistent BPPV - Central nervous system disorders explain approximately 3% of BPPV treatment failures 2
4. Overlooking subtle neurological signs - Even mild neurological symptoms or signs warrant further investigation 3

When patients present with symptoms consistent with BPPV but do not respond to appropriate repositioning maneuvers after 2-3 attempts, or describe associated auditory or neurological symptoms, they should undergo thorough neurological examination and brain MRI to identify possible central pathology 2.