Clinical Features

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The conditions that cause vertigo are summarized in (Tab!e,,22.3-1). Vertigo is typically subdivided into peripheral and central causes. Unfortunately, clinical abilities to distinguish the severity of vertigo are limited since there is no measurement scale for vertigo. While the discussion below does classify vertigo somewhat by severity, the clinician must also use information such as age, comorbidity, and vascular disease to stratify the probability of central versus peripheral vertigo. Peripheral vertigo is caused by disorders affecting the vestibular apparatus and the eighth cranial nerve, while central vertigo is caused by disorders affecting central structures, such as the brainstem and the cerebellum. The characteristics distinguishing peripheral and central vertigo are found in Tabblle, ,22.3-2. Ei.g.ure.,2.2.3.,-2 shows how the nystagmus pattern itself may help to differentiate peripheral and central vertigo.

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TABLE 223-1 An Etiologic Classification of Vertigo

TABLE 223-2 Classification of Vertigo

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FIG. 223-2. Schematic drawing of peripheral and central vestibular nystagmus with and without visual fixation. The direction of the arrows indicates the horizontal direction of the fast phase of the nystagmus (a torsional component is not shown). The thickness of the arrows represents the relative intensity of the nystagmus. Panel A shows findings typical of peripheral nystagmus, which remains in the same direction when the direction of gaze changes, and central nystagmus, which changes direction when the direction of gaze changes. Removal of visual fixation increases the intensity of peripheral nystagmus but not of central nystagmus. Panel B illustrates how removal of fixation helps to differentiate peripheral from central nystagmus when the nystagmus is predominantly in one direction of gaze during fixation. With removal of fixation, peripheral nystagmus may increase in intensity and become apparent in more than one direction of gaze. (Reprinted by permission.)

Although disorders causing peripheral vertigo tend to produce more distressing symptoms, they are seldom life-threatening. Disorders causing central vertigo may produce less distressing symptoms and have a slower onset than those due to peripheral vertigo, but they are generally of a more serious nature, requiring urgent or semiurgent diagnostic imaging or consultation with a neurologist or neurosurgeon. Unfortunately, these clinical features of vertigo are not always sufficient or specific enough to clearly classify the disorder as central or peripheral.

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