Central vertigo vs Peripheral vertigo
How to tell Central vertigo and Peripheral vertigo apart when a board question makes them look alike.
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HINTS examination showing direction-changing or vertical nystagmus.
Side by side
Continuous vertigo with vertical or direction-changing nystagmus, severe gait ataxia, or focal neurologic deficits suggests central vertigo.
Episodic vertigo with horizontal unidirectional fatigable nystagmus and no focal deficits suggests peripheral vestibular disease.
Brainstem or cerebellar pathology disrupts central vestibular processing.
Inner-ear or vestibular nerve dysfunction distorts peripheral motion signaling.
HINTS pattern of normal head impulse, direction-changing nystagmus, or skew deviation suggests central lesion; MRI diffusion imaging may confirm posterior circulation stroke.
Abnormal corrective saccade on head impulse with unidirectional nystagmus and no skew favors peripheral vestibulopathy.
The trap
A normal head CT does not exclude posterior circulation stroke. In acute vestibular syndrome with central HINTS findings, treat as stroke and escalate urgently.
The repair move
Next best step: perform focused bedside neurologic and HINTS evaluation in acute vestibular syndrome, activate stroke protocol for central signs, and obtain urgent MRI with diffusion-weighted imaging when posterior stroke is suspected.
Try a free question
CoreA 60-year-old man has constant vertigo for 12 hours. Exam shows vertical nystagmus and severe truncal ataxia. What is the most likely diagnosis?
Show answer and explanation
Answer: B. Central vertigo. Vertical nystagmus and severe ataxia are central findings until proven otherwise.
Why the other choices are tempting
- A. Incorrect because peripheral causes usually produce unidirectional horizontal nystagmus without severe focal neurologic signs.
- C. Incorrect because BPPV is brief positional vertigo, not continuous severe syndrome with central signs.
- D. Incorrect because Meniere disease includes auditory symptoms and peripheral exam pattern.
- E. Incorrect because panic does not produce objective direction-changing or vertical nystagmus.
Flashcards
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Which nystagmus pattern strongly favors central vertigo?
Vertical or direction-changing gaze-evoked nystagmus.
What head impulse finding is expected in many peripheral vestibular lesions?
Corrective saccade indicating abnormal vestibulo-ocular reflex.
Quick answers
What is the fastest way to tell Central vertigo from Peripheral vertigo?
HINTS examination showing direction-changing or vertical nystagmus.
What is the key clue for Central vertigo?
Continuous vertigo with vertical or direction-changing nystagmus, severe gait ataxia, or focal neurologic deficits suggests central vertigo.
What is the key clue for Peripheral vertigo?
Episodic vertigo with horizontal unidirectional fatigable nystagmus and no focal deficits suggests peripheral vestibular disease.
What is the common trap with Central vertigo vs Peripheral vertigo?
A normal head CT does not exclude posterior circulation stroke. In acute vestibular syndrome with central HINTS findings, treat as stroke and escalate urgently.