What are the causes of central vertigo?

Causes of Central Vertigo

Central vertigo arises from pathology in the brainstem, cerebellum, or central vestibular pathways, with posterior circulation stroke being the most critical cause to exclude, followed by multiple sclerosis, vestibular migraine, cerebellar hemorrhage, and posterior fossa tumors. 1

Vascular Causes (Most Life-Threatening)

Posterior circulation stroke (brainstem or cerebellar infarction) is the most worrisome central cause and accounts for approximately 25% of acute vestibular syndrome presentations, rising to 75% in high-risk vascular cohorts. 1 Critically, 75-80% of stroke-related acute vestibular syndrome patients present without focal neurologic deficits, making stroke easy to miss on initial examination. 1, 2

• Vertebrobasilar insufficiency produces episodes typically lasting less than 30 minutes without accompanying hearing loss, and may precede a completed stroke by weeks to months. 3, 2
• Cerebellar hemorrhage is a rare but life-threatening cause that requires urgent recognition. 1
• Approximately 10% of cerebellar strokes present identically to benign peripheral vestibular disorders. 2, 4

Demyelinating Disease

Multiple sclerosis involving the brainstem or cerebellar peduncles accounts for approximately 4% of acute vestibular syndrome cases. 1 Nearly all MS patients with vertigo have additional abnormal neurologic findings suggesting a central lesion, which helps distinguish them from peripheral causes. 1

Vestibular Migraine

Vestibular migraine has a lifetime prevalence of 3.2% and accounts for up to 14% of all vertigo cases, making it extremely common. 3, 2, 4 Episodes last 5 minutes to 72 hours and are accompanied by migraine features including photophobia, phonophobia, or visual aura. 3, 2 Unlike Ménière's disease, hearing loss is typically stable or absent rather than fluctuating. 3

Structural Lesions

• Posterior fossa tumors including vestibular schwannomas, cerebellar tumors, and fourth ventricle lesions can produce central vertigo. 3, 5
• Lesions near the fourth ventricle can rarely cause positional vertigo that mimics benign paroxysmal positional vertigo. 6

Infectious and Inflammatory Causes

Autoimmune, infectious, and metabolic conditions affecting the brainstem or cerebellum are rare causes of isolated acute vestibular syndrome. 1 CNS infections can produce central vertigo and require imaging for diagnosis. 5

Key Clinical Distinguishing Features

Central vertigo is characterized by specific nystagmus patterns that differ fundamentally from peripheral causes:

• Pure vertical nystagmus (upbeating or downbeating) without torsional component 1, 3
• Direction-changing nystagmus without changes in head position (periodic alternating nystagmus) 3, 2
• Gaze-evoked nystagmus that changes direction with eccentric gaze 3, 4
• Baseline nystagmus present without provocative maneuvers 3, 2
• Nystagmus that does not fatigue with repeated testing and is not suppressed by visual fixation 1, 3

Additional central features include:

• Severe postural instability with falling that is disproportionate to the vertigo 3, 2
• Associated neurologic symptoms: dysarthria, dysmetria, dysphagia, sensory or motor deficits, diplopia, or Horner's syndrome 1, 3
• Failure to respond to canalith repositioning procedures or vestibular rehabilitation 3, 2, 4

Critical Pitfalls to Avoid

The most dangerous pitfall is assuming that absence of focal neurologic deficits excludes stroke—one-third to two-thirds of posterior circulation strokes present without focal findings. 1 In one study, 11% of patients with acute persistent vertigo but no focal neurologic symptoms had acute infarct on imaging. 1

Downbeating nystagmus on Dix-Hallpike maneuver without torsional component is a red flag that mandates urgent MRI with diffusion-weighted imaging, as it indicates central pathology rather than benign positional vertigo. 3, 2

Clinicians must recognize that multiple vestibular disorders can coexist (e.g., BPPV with Ménière's disease or vestibular neuritis), which can complicate the clinical picture. 3

Imaging Approach

MRI brain with diffusion-weighted imaging is mandatory when any red-flag features are present and is essential to exclude posterior fossa pathology. 3 CT head has limited utility, with a diagnostic yield of less than 1% in isolated dizziness, though it can detect cerebellar hemorrhage acutely. 1, 3 MRI is superior for detecting acute ischemia, MS plaques, and structural lesions. 5