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The dizzy patient: don't forget disorders of the central vestibular system

  • Review Article
  • Published:

From Nature Reviews Neurology

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Key Points

  • About 13% of neurological patients in emergency units complain of vertigo or dizziness; a diagnosis of a central vestibular disorder is established in about 25% of all outpatients who visit dizziness units

  • Vestibular migraine, the most frequent form of spontaneous episodic vertigo, must be differentiated from attacks of Ménière disease

  • Central and peripheral acute vestibular syndromes can be quickly distinguished by the head impulse test and a search for spontaneous nystagmus, gaze-evoked nystagmus, ocular skew deviation, and deficits in smooth pursuit and saccadic eye movements

  • Sustained rotational vertigo usually occurs in unilateral peripheral labyrinth, vestibular nerve or vestibular nuclei disorders, but rarely with lesions of vestibular structures in the upper brainstem, thalamus or cortex

  • Disorders of higher vestibular function affect multisensory modalities and cognition; examples include hemispatial neglect, the room tilt illusion, pusher syndrome, and bilateral vestibular loss with spatial disorientation

  • A European network for vertigo and balance research, known as DIZZYNET, was founded in 2014 to establish clinical and educational standards for the management of dizzy patients

Abstract

Vertigo and dizziness are among the most common complaints in neurology clinics, and they account for about 13% of the patients entering emergency units. In this Review, we focus on central vestibular disorders, which are mostly attributable to acute unilateral lesions of the bilateral vestibular circuitry in the brain. In a tertiary interdisciplinary outpatient dizziness unit, central vestibular disorders, including vestibular migraine, comprise about 25% of the established diagnoses. The signs and symptoms of these disorders can mimic those of peripheral vestibular disorders with sustained rotational vertigo. Bedside examinations, such as the head impulse test and ocular motor testing to determine spontaneous and gaze-evoked nystagmus or skew deviation, reliably differentiate central from peripheral syndromes. We also consider disorders of 'higher vestibular functions', which involve more than one sensory modality as well as cognitive domains (for example, orientation, spatial memory and navigation). These disorders include hemispatial neglect, the room tilt illusion, pusher syndrome, and impairment of spatial memory and navigation associated with hippocampal atrophy in cases of peripheral bilateral vestibular loss.

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Figure 1: Frequency of vertigo and dizziness syndromes.
Figure 2: Common peripheral vestibular disorders.
Figure 3: The central vestibular system.
Figure 4: Brainstem lesions and acute central vestibular syndrome.
Figure 5: Vestibular lesions manifesting with ocular tilt reaction.
Figure 6: Central vestibular syndromes and disorders of higher vestibular function.

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Acknowledgements

The authors thank Judy Benson for copyediting the manuscript. The authors' work is supported by the Federal Ministry for Education and Science of Germany (BMBF 01 EO 0901), the Hertie Foundation, the German Research Foundation (SyNergy — Munich Center for Systems Neurology), and the German Foundation for Neurology.

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Authors and Affiliations

  1. German Center for Vertigo and Balance Disorders, Klinikum Grosshadern, Ludwig-Maximilians University Munich,

    Thomas Brandt & Marianne Dieterich

  2. Department of Neurology, Ludwig-Maximilians University Munich, Marchioninistrasse 15, Munich, D-81377, Germany

    Marianne Dieterich

  3. SyNergy — Munich Center for Systems Neurology, Feodor-Lynen-Strasse 17, Munich, D-81377, Germany

    Marianne Dieterich

Authors
  1. Thomas Brandt
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  2. Marianne Dieterich
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Both authors contributed equally to all aspects of manuscript preparation.

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Correspondence to Thomas Brandt.

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PowerPoint slides

Glossary

Head impulse test

(HIT). A test that determines the function of the vestibulo-ocular reflex by eliciting passive, rapid head movements in the planes of the semicircular canals.

Spontaneous nystagmus

Involuntary oscillatory eye movements with quick and slow phases that are elicited by an acute vestibular dysfunction.

Roll planes

The three major planes of action of the vestibular system, namely, the horizontal yaw plane and the two vertical planes — the sagittal pitch plane and the frontal roll plane.

Body lateropulsion

Direction-specific tilts or falls of the body due to a vestibular tone imbalance.

Endolymphatic hydrops

Enlargement of the endolymphatic space of the inner ear.

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Brandt, T., Dieterich, M. The dizzy patient: don't forget disorders of the central vestibular system. Nat Rev Neurol 13, 352–362 (2017). https://doi.org/10.1038/nrneurol.2017.58

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