Definition

Vertigo is a clinical condition where an individual experiences hallucinations or incorrect perceptions of movement or the surrounding environment while in a stationary position. The sensations can be of spinning, swaying, floating, or feeling unbalanced. Vertigo is divided into peripheral vertigo and central vertigo.

The vestibular system is a system in the ear and brain that processes information related to body balance and eye movement. Peripheral vertigo is caused by disturbances in the peripheral vestibular system within the ear, while central vertigo is caused by disturbances arising in the vestibular nuclei in the central nervous system.

Typically, the sensation experienced with vertigo is dizziness with a spinning sensation. However, it's not uncommon for some to complain of a one-sided headache instead of spinning dizziness, which occurs in 12% of adults.

Since the cause of central vertigo is a disturbance in the central nervous system, doctors usually conduct examinations to identify the underlying disease causing the disturbance.

Causes

Dysfunction or disturbance in the vestibular system of the central nervous system is the primary cause of central vertigo. Ischemic stroke is often mentioned as one of the causes of vertigo. Below are some diseases that can cause central vertigo:

• Cerebrovascular disease: Blockage or insufficiency of arterial blood vessels supplying the brain area responsible for balance can cause recurrent episodes of spontaneous vertigo.
• Tumors in the vestibular system of the brain: Such as meningioma, acoustic neuroma, brainstem glioma, medulloblastoma, neurofibromatosis.
• Vestibular migraine
• Nerve damage in the vestibular system due to multiple sclerosis
• Metabolic disorders
• Degenerative diseases
• Toxicity from anticonvulsant drugs
• Head injury

Risk factor

A study conducted in the emergency department of a hospital found an increased risk of stroke later in patients diagnosed with "peripheral vertigo." The risk of stroke increases within the first 30 days after the patient is discharged from the ER. This indicates that acute ischemic attacks or strokes are sometimes misdiagnosed as "peripheral vertigo," whereas the cause of vertigo itself originates from abnormalities in the central nervous system. Stroke itself is a vascular disease with many risk factors such as smoking, uncontrolled high blood pressure, and a history of other diseases like diabetes and high cholesterol.

Apart from cerebrovascular diseases, risk factors such as multiple sclerosis or tumors also need to be considered.

Symptoms

Spinning dizziness is the main symptom of vertigo, usually occurring spontaneously and continuously. Spinning dizziness can be accompanied by nausea and vomiting. Since the cause of central vertigo is a disturbance in the vestibular nucleus of the central nervous system, patients may also show neurological deficit symptoms such as numbness or weakness in limbs, double vision (diplopia), slurred speech, or balance disorders visible from the patient's gait.

Doctors usually inquire about the onset and duration of vertigo. If spinning dizziness is accompanied by hearing disturbances, and if the patient has a history of cerebrovascular diseases, these factors are considered.

A clear symptom of central vertigo is nystagmus. Nystagmus is a rapid eye movement in a specific direction. Nystagmus in central vertigo usually shows vertically, torsionally, or in changing directions and does not disappear when the patient focuses their gaze.

Diagnosis

Doctors perform physical examinations to differentiate between peripheral and central vertigo. One such test is the head impulse test to observe the direction of nystagmus or eye movements. As mentioned above, nystagmus in central vertigo patients is usually vertical or torsional. Apart from ENT physical examinations, neurological examinations are also performed, especially if the patient's vertigo symptoms are accompanied by neurological deficits. The doctor also examines the patient's gait, sometimes visible when the patient enters the healthcare facility.

When physical examination results lead to a diagnosis of central vertigo and further investigation is needed, the patient is usually hospitalized for in-depth evaluation. Laboratory tests and radiological examinations such as CT scans or MRI are conducted to check for conditions like stroke, tumors, or multiple sclerosis. CT angiogram and MR angiogram tests can also be performed to identify blockages in the brain's vestibular system blood vessels. Patients are usually referred to a neurologist.

Management

Treatment is aimed at addressing the underlying disease causing central vertigo. Patients are given antiemetic drugs to alleviate the spinning sensation. The underlying disease could be brain tissue bleeding, brain edema, brainstem compression, vestibular nerve destruction, or brain tissue ischemia. For instance, if the underlying cause of central vertigo is ischemic stroke, patients typically receive thrombolytic therapy or thrombectomy, depending on the doctor's decision regarding the patient's condition and medical history. In multiple sclerosis patients, intravenous corticosteroids may be administered.

If patients have risk factors such as hypertension, lifestyle changes are necessary, such as limiting high-salt foods to control blood pressure. Patients can also be taught eye movement and balance stabilization exercises to resume normal activities quickly.

Complications

The patient's outcome with central vertigo depends on the underlying disease causing the symptoms. The most common complication is acute lateral medullary syndrome, caused by a blockage in the vertebral artery or the posterior inferior cerebellar artery. Adequate therapy provides a good outcome for patients. However, multiple sclerosis with brainstem relapses usually has a poorer outcome compared to multiple sclerosis without brainstem damage.

Prevention

There is no definite prevention for central vertigo since the underlying cause is another disorder in the vestibular system in the brain area. However, preventing these other diseases is possible by avoiding controllable risk factors, such as maintaining normal blood pressure, quitting smoking, and following a healthy diet to stabilize blood sugar levels. Regular exercise for at least 30 minutes a day, 3-4 times a week, helps maintain overall body fitness.

When to see a doctor?

Recognize the warning signs of this disease. Spontaneous and continuous spinning dizziness without a clear trigger is typical of central vertigo. If the spinning sensation is accompanied by neurological symptoms, it is likely not ordinary vertigo and indicates another disorder in the brain area. Immediate medical attention is necessary to prevent severe complications.