June 20, 2019
Vertigo implies an abnormal sensation of movement or rotation of the patient or his or her environment. Some patients with central disease may complain of disequilibrium, imbalance, or difficulty maintaining an upright posture.
Central Positional Vertigo (CPV) is a dangerous and abnormal benign positional paroxysmal vertigo (BPPV) which is often caused by disease in the brain stem or cerebellum.
Diseases such as tumors, sudden bleeds and strokes, or conditions such as Multiple Sclerosis (MS) can result in CPV. Rarer causes include degenerative conditions of the cerebellum, cancer elsewhere in the body poisoning the brain and generalised brain failure.
It is important to be able to identify between the commonplace benign positional paroxysmal vertigo (BPPV) and rare dangerous Central Positional Vertigo (CPV).
Diagnosis is based on a detailed history of the complaint. The clinician will look for typical and unusual features before carrying out a two part examination.
Part 1 – A careful neurological examination with a focus on eye movements.
Part 2 – manipulation of the head into certain classic positions in an attempt to provoke classical eye movements which are associated with the various forms of BPPV.
Patients with both BPPV and CPV report a sensation of spinning when their head is in a certain position.
In classical BPPV the typical experience of “morning vertigo” is a sudden sensation of spinning, either when turning over in bed, bending over or looking up. Although it lasts for only lasts a few seconds, it is quite disturbing.
Patients often feel sick and unsteady for many hours after the attack, however, it doesn’t affect hearing or cause any ringing sounds in the ears.
There are no abnormal neurological findings and manipulation of the head generates eye movements which fit with specific types of BPPV.
In Central Positional Vertigo (CPV) the patient may have abnormal findings in neurological examination such as ataxia, saccadic pursuit, gaze evoked nystagmus, down beat nystagmus and impaired fixation suppression of the vestibular ocular reflex; all of which are never found in BPPV.
In CPV the first initial manipulation of the head into the classic BPPV head position frequently provokes marked nausea and vomiting. This is linked with a lack of rapid eye movement, referred to clinically as nystagmus.
The type of eye movements provoked by the initial manipulation of the head are inconsistent with types of BPPV e.g. rotating eye movement when it should be horizontal ( as seen in horizontal canal BPPV) or up beat nystagmus, rotatory or combined rotatory/horizontal movement ( as in posterior canal BPPV).
Treatment depends on what the cause of the condition is found to be.
If you are concerned about symptoms associated with this article please contact Mr Paul Montgomery, London Ear Nose and Throat Doctor with a specialist interest in vertigo, dizziness and balance problems to arrange a consultation.