What does the direction of nystagmus indicate about peripheral versus central vestibular pathology?

Direction of Nystagmus in Peripheral vs Central Vestibular Pathology

Key Distinguishing Principle

The direction of nystagmus provides critical diagnostic information: peripheral vestibular lesions typically produce unidirectional horizontal or horizontal-torsional nystagmus that follows predictable patterns based on canal involvement, while central lesions characteristically produce purely vertical (especially downbeat), direction-changing nystagmus without positional triggers, or baseline nystagmus without provocative maneuvers. 1, 2

Peripheral Vestibular Nystagmus Patterns

Posterior Canal BPPV (Most Common)

• Torsional upbeating nystagmus is the hallmark finding during Dix-Hallpike maneuver, with the fast phase beating toward the forehead and rotating toward the affected ear 1, 2
• Demonstrates a latency period of 5-20 seconds between completing the maneuver and nystagmus onset 1
• Shows crescendo-decrescendo pattern that resolves within 60 seconds from onset 1
• Fatigues with repeated testing, a key peripheral feature 1

Lateral Canal BPPV

• Produces horizontal direction-changing positional nystagmus during supine roll test 1, 2
• Geotropic variant (most common): nystagmus beats toward the ground on both sides, with stronger nystagmus indicating the affected ear 1, 2
• Apogeotropic variant: nystagmus beats away from the ground on both sides, with the side opposite the strongest nystagmus being affected 1, 2
• Both variants change direction only with changes in head position, not spontaneously 1

Other Peripheral Patterns

• Acute unilateral vestibulopathy produces unidirectional horizontal nystagmus beating away from the affected side 3
• Peripheral vestibular nystagmus is suppressed by visual fixation, unlike central lesions 4

Central Vestibular Nystagmus Patterns

Red Flag Central Patterns

• Downbeat nystagmus strongly suggests bilateral floccular lesion or cervicomedullary junction pathology 1, 2, 5, 3, 6
• Purely vertical nystagmus (upbeat or downbeat) without torsional component indicates brainstem or cerebellar lesion 3, 6
• Direction-changing nystagmus occurring without changes in head position (periodic alternating nystagmus) 1
• Baseline nystagmus present in primary position without provocative maneuvers 1, 2

Anatomical Localization

• Downbeat nystagmus: bilateral floccular dysfunction 3, 6
• Upbeat nystagmus: midbrain or medullary lesion 3, 6
• Gaze-evoked nystagmus in all directions: cerebellar dysfunction 3, 6
• Purely vertical gaze-evoked nystagmus: midbrain lesion 6
• Purely horizontal gaze-evoked nystagmus: pontomedullary lesion 6

Critical Central Features

• Central nystagmus does not fatigue with repeated testing 1
• Not easily suppressed by visual fixation, unlike peripheral lesions 1, 4
• Often accompanied by other neurological signs: ataxia, dysmetria, dysdiadochokinesia 2

Direction-Changing Nystagmus: A Nuanced Finding

When It Suggests Peripheral Disease

• Direction-changing positional nystagmus triggered by specific head position changes is characteristic of lateral canal BPPV 1, 2
• Research shows that 30% of direction-changing positional nystagmus cases have peripheral vestibular disease, and 48% have no definite diagnosis 4
• The key is that direction changes occur only with positional maneuvers, not spontaneously 1

When It Suggests Central Disease

• Direction-changing nystagmus without positional triggers (periodic alternating nystagmus) indicates central pathology 1
• Only 22% of direction-changing positional nystagmus cases have confirmed central neurologic disease 4
• Lack of suppression with visual fixation suggests central lesion even with direction-changing pattern 4

Diagnostic Algorithm

Step 1: Assess Baseline Eye Position

• Check for spontaneous nystagmus in primary position without head movement 2
• If present, this suggests central pathology or acute peripheral vestibulopathy 1, 3

Step 2: Perform Dix-Hallpike Maneuver

• Look for torsional upbeating nystagmus with latency (peripheral posterior canal BPPV) 1, 2
• Downbeat nystagmus without torsional component indicates central cause requiring urgent neuroimaging 2, 5

Step 3: Perform Supine Roll Test

• Essential to identify lateral canal BPPV, which accounts for up to 30% of BPPV cases 1, 7
• Assess whether nystagmus is geotropic or apogeotropic 1, 2

Step 4: Assess Fixation Suppression

• Peripheral vestibular nystagmus suppresses with visual fixation 4
• Central nystagmus persists despite fixation 1, 4

When to Obtain Urgent Neuroimaging

Absolute Indications for MRI

• Downbeat nystagmus identified on examination 2, 5
• Direction-changing nystagmus without positional triggers 1, 2
• Baseline nystagmus in primary position 1, 2
• Associated cerebellar signs (ataxia, dysmetria) 2
• Failure to respond to appropriate BPPV treatment after 2-4 attempts 7

Imaging Modality

• MRI of the brain is the preferred modality for suspected central pathology 2, 5
• CT scans are inadequate for visualizing posterior fossa structures 5, 7

Common Diagnostic Pitfalls

• Misdiagnosing central positional nystagmus as BPPV occurs when proper attention is not paid to nystagmus characteristics (purely vertical, no latency, no fatigue) 2, 7
• Failing to perform both Dix-Hallpike and supine roll testing misses lateral canal BPPV in up to 30% of cases 7
• Assuming all direction-changing nystagmus is central: the pattern is typical for lateral canal BPPV when triggered by position changes 1, 4
• Relying solely on patient description rather than objective nystagmus characteristics leads to diagnostic errors 7