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Inventis - June 2023

Overview of Central Vestibular Disorders

Vishal Pawar

November 27, 2023
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Central vestibular disorders (CVDs) are caused by dysfunction of the central vestibular pathways in the brainstem, cerebellum and cerebrum. Approximately 10-12% of patients experiencing vestibular symptoms may have a central origin. Understanding the differential diagnosis is crucial as certain CVDs can lead to severe consequences. Some of the common CVDs leading to vestibular symptoms are vestibular migraine, stroke, multiple sclerosis, nutritional deficiency, and tumors. Differentiating central disorders from peripheral ones can be achieved through careful consideration of the patient's history, observation of eye movement abnormalities, identification of other neurological signs. Sometimes the symptoms and signs of CVDs can be similar to those of peripheral vestibular disorders, making it challenging to differentiate between the two. The dictum in identification of CVD’s is ‘Central signs are always central and Peripheral signs can be central or peripheral. Apart from imaging, vestibular testing with the help of Video-nystagmography (VNG) and Video-head impulse test (vHITs) can be of great help in this context. Understanding the detailed anatomy, physiology, function and clinical signs of dysfuction of central vestibular structures is crucial for a vestibular practitioner.

 

AudiologyOnline: How prevalent are the vestibular disorders?

Vishal Pawar: Vertigo and associated dizziness are pervasive health issues that often go under-recognized. According to large-scale epidemiological studies, these symptoms affect an estimated 15% to 20% of adults annually1. When we extrapolate these figures to the population of Dubai, where I practice, which is approximately 9.3 million, we find that nearly 1.4 to 1.8 million adults in the city are likely to experience some form of vertigo or dizziness each year.

The etiologies of vertigo can range from benign conditions such as benign paroxysmal positional vertigo (BPPV) to more severe, life-threatening conditions like stroke or brain tumors2. Despite the high prevalence, the condition is often not diagnosed or managed effectively, leading to a reduced quality of life for the affected individuals3.

Given the significant impact on public health, it is crucial for healthcare providers to be well-versed in the diagnosis and management of vertigo and related disorders. Timely intervention can not only alleviate symptoms but also mitigate the risk of complications, thereby enhancing the overall well-being of the population.

References

  1. Neuhauser HK, Radtke A, von Brevern M, Lezius F, Feldmann M, Lempert T. "Burden of Dizziness and Vertigo in the Community," Archives of Internal Medicine, 2008; 168(19):2118–2124. [PubMed](https://pubmed.ncbi.nlm.nih.gov/18955640/).
  2. Kim AS, Fullerton HJ, Johnston SC. "Risk of Vascular Events in Emergency Department Patients Discharged Home with Diagnosis of Dizziness or Vertigo," Annals of Emergency Medicine, 2011; 57(1): 34–41. [PubMed](https://pubmed.ncbi.nlm.nih.gov/20828863/).
  3. Yardley L, Owen N, Nazareth I, Luxon L. "Prevalence and Presentation of Dizziness in a General Practice Community Sample of Working Age People," The British Journal of General Practice, 1998; 48(429): 1131–1135. [PubMed](https://pubmed.ncbi.nlm.nih.gov/9624762/)

AudiologyOnline: What are the symptoms of vestibular disorders?

Vishal Pawar: Patients with vertigo and vestibular disorders often present with a constellation of symptoms that can significantly impact their daily lives. Understanding these symptoms is crucial for accurate diagnosis and effective management.

  1. Vertigo: This is characterized by a sensation of spinning or movement, often described as whirling, tilting, or rotating1.
  2. Dizziness: Patients may experience a disoriented sense of spatial awareness, affecting their balance and stability2.
  3. Visual Disturbances: Despite having normal eye examinations, patients may experience:
  • Oscillations or shaking of the visual field (External Vertigo).
  • Blurring or lagging of vision post head movement.
  • Difficulty in navigating digital screens like mobile phones and computers3.
  1. Postural Instability: This symptom is particularly noticeable when the patient is in an upright position and may include:
  • A sense of imbalance or veering in a specific direction.
  • Feelings of being pushed or a fear of falling.
  • Actual falls due to balance issues4.

References

  1. Strupp M, Brandt T. "Diagnosis and Treatment of Vertigo and Dizziness," Deutsches Ärzteblatt International, 2008; 105(10): 173–180. [PubMed](https://pubmed.ncbi.nlm.nih.gov/18385548/)
  2. Newman-Toker DE, Cannon LM, Stofferahn ME, Rothman RE, Hsieh YH, Zee DS. "Imprecision in Patient Reports of Dizziness Symptom Quality: A Cross-sectional Study Conducted in an Acute Care Setting," Mayo Clinic Proceedings, 2007; 82(11): 1329–1340. [PubMed](https://pubmed.ncbi.nlm.nih.gov/17976352/)
  3. Bronstein AM. "Vision and Vertigo: Some Visual Aspects of Vestibular Disorders," Journal of Neurology, 2004; 251(4): 381–387. [PubMed](https://pubmed.ncbi.nlm.nih.gov/15083277/)
  4. Whitney SL, Marchetti GF, Morris LO, Sparto PJ. "The Reliability and Validity of the Four Square Step Test for People With Balance Deficits Secondary to a Vestibular Disorder," Archives of Physical Medicine and Rehabilitation, 2007; 88(1): 99–104. [PubMed](https://pubmed.ncbi.nlm.nih.gov/17207680/)

AudiologyOnline: What are the additional symptoms in patients with vestibular disorders beyond vertigo and dizziness?

Vishal Pawar: Vestibular disorders often manifest with a range of symptoms beyond the commonly recognized vertigo and dizziness. These additional symptoms can be equally debilitating and may include:

  1. Cognitive impairment: Patients frequently report difficulties in focusing and concentration, affecting their daily activities1.
  2. Autonomic symptoms: Lighth headedness, faintness, blackouts, and sweating are often reported, indicating an autonomic nervous system involvement2.
  3. Loss of consciousness: Though rare, some patients may experience brief episodes of unconsciousness3.
  4. Motor symptoms: Involuntary movements of hands and legs, often described as fits, can occur in some cases4.
  5. Mental confusion: Patients may experience transient episodes of confusion, affecting their orientation and decision-making5.
  6. General fatigue: A pervasive sense of fatigue and generalized weakness is commonly reported, impacting the quality of life6.
  7. Ill-defined dizziness: A subset of patients finds it challenging to articulate their symptoms, often described as "ill-defined dizziness"7.

Given the multifaceted nature of vestibular disorders, a comprehensive clinical evaluation is essential for accurate diagnosis and effective management.

References

  1. Yardley L, Masson E, Verschuur C, Haacke N, Luxon L. "Symptoms, Anxiety and Handicap in Dizzy Patients: Development of the Vertigo Symptom Scale," Journal of Psychosomatic Research, 1992; 36(8): 731–741. [PubMed](https://pubmed.ncbi.nlm.nih.gov/1484171/).
  2. Staab JP, Ruckenstein MJ. "Which Comes First? Psychogenic Dizziness Versus Otogenic Anxiety," The Laryngoscope, 2003; 113(10): 1714–1718 [PubMed](https://pubmed.ncbi.nlm.nih.gov/14520092/)
  3. Drachman DA. "A 69-Year-Old Man with Chronic Dizziness," JAMA, 1998; 280(24): 2111–2118. [PubMed](https://pubmed.ncbi.nlm.nih.gov/9875877/)
  4. Furman JM, Jacob RG. "A Clinical Taxonomy of Dizziness and Anxiety in the Otoneurological Setting," Journal of Anxiety Disorders, 2001; 15(1-2): 9–26. [PubMed](https://pubmed.ncbi.nlm.nih.gov/11388352/)
  5. Balaban CD, Thayer JF. "Neurological Bases for Balance-Anxiety Links," Journal of Anxiety Disorders, 2001; 15(1-2): 53–79. [PubMed](https://pubmed.ncbi.nlm.nih.gov/11388355/)
  6. Jacob RG, Furman JM, Durrant JD, Turner SM. "Panic, Agoraphobia, and Vestibular Dysfunction," The American Journal of Psychiatry, 1996; 153(4): 503–512. [PubMed](https://pubmed.ncbi.nlm.nih.gov/8599398/)
  7. Staab JP, Ruckenstein MJ. "Expanding the Differential Diagnosis of Chronic Dizziness," Archives of Otolaryngology–Head & Neck Surgery, 2007; 133(2): 170–176. [PubMed](https://pubmed.ncbi.nlm.nih.gov/17309982/)

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vishal pawar

Vishal Pawar

Dr. Vishal Pawar is a highly skilled specialist neurologist with over a decade of experience in neurology and oto-neurology. He completed his MBBS, DNB in Medicine, and DNB in Neurology in India and has been a valuable member of the Aster Gardens specialty clinic in Dubai for seven years. Dr. Pawar's expertise lies in vestibular medicine and headache disorders, and he has actively contributed to patient care, academics, and research in these areas. He has earned recognition as a Fellow of the European Board of Neurology and has established a dedicated vertigo clinic.



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