VERTIGO:
it’s primarily an issue due to following areas
Inner Ear
Vestibular nerve
Medullo-Pontine Junction
Cerebellum
First two are labelled as Periphrral while later two are Central vertigo.
Features suggestive of Central causes are important to remember so that we don’t miss a serious pathology: those clues are as follow;
1.Vertigo with Nystagmus is almost always central unless proven otherwise
2.vertigo which is persistent at the same intensity for hours or days is central ( as peripheral vertigo gets less & less with time due to fatigue of vestibular apparatus & nerve).
3. Vertigo with any neurological sign like cerebellar signs or cranial nerve involvement or sensory / motor deficit or gaze problem etc is always central.
4.vertigo without Tinnitus/ hearing loss/ ear symptoms should be taken as central unless its clearly BPPV ( usually positive Hall-pike & worsened in lying position on turning in bed& not seen in other positions).
5. If not sure, take it as Central unless you are an experienced & competent physician or Neurologist. Get MRI to exclude central causes.
6.Vertigo can still be central even if a patient has inner ear problem due to Co-existent pathology especially in those at risk of central vertigo e.g, old age, vasculopath like DM HTN AF previous stroke IHD etc, patients with malignancy, patients with transplant & immunocompromised, patients with organ failures etc etc.
Periphrral causes are simple & easy for ENT surgeons like Menier’s disease, vestibulopathy/neuritis, inner ear infection, BPPV etc. ENT assessment is helpful. Menier’s. affect both vestibular & cochlear functions in episodic fashion with good response to treatment. Vestibular neuritis doesn’t affect cochlear functions & usually lasts a few days. BPPV is positional & gets better with Epiley’s maneuver.
Middle ear infections with involvement of inner ear should be apparent on examination. More detail by ENT colleagues.
Central causes are brain stem ( Medullo-Pontine junction) /cerebellar causes including
Vascular events, tumours/space occupying lesions,MS,infections etc.
MRI brain is very imp to exclude organic central causes.
This is a topic where I have seen Neurologists to have uncertainty many times so unless sure we should not take risk of missing central cause.