Central Vestibular Disorders

Vestibular diseases cause four different clinical syndromes. Each can be due to either a peripheral vestibular problem in the inner ear or vestibular nerve, or a central vestibular problem in the brain. Here we consider diseases involving the central vestibular system. These four syndromes are: (1) Acute vestibular syndrome (AVS) in which the patient has an attack of vertigo or imbalance or both, accompanied by nausea and vomiting. Common central causes are posterior circulation stroke and vestibular migraine which need to be distinguished from common peripheral causes such as acute vestibular neuritis and Meniere’s disease. (2) Recurrent spontaneous vertigo, commonly due to vestibular migraine, rarely due to posterior circulation transient ischemic attacks. This needs to be distinguished from Meniere’s disease. (3) Positional vertigo, commonly due to peripheral disorders, cupulolithiasis, or canalolithiasis, but can be due to central problems such as tumors or encephalitis effecting predominantly the midline cerebellum. (4) Subacute or chronic imbalance which is sometimes due to bilateral peripheral vestibular loss but more often due to central causes such as cerebellar, extrapyramidal parkinsonian or spinal cord diseases. This chapter aims to help the busy otolaryngologist decide quickly if a patient has a central neurological rather than a peripheral otologic cause for their presenting vestibular syndrome and if so refer the patient to an appropriate neurologist.