Acute vestibulopathy

1. Vestibular neuritis
2. Labyrinthitis
3. Stroke affecting peripheral or central vestibular structures
4. Traumatic vestibulopathy
5. Demyelinating disease with vestibular involvement
6. Drug intoxication (anticonvulsants, lithium)
7. Antidepressant discontinuation syndrome
8. Carbon monoxide intoxication
9. Thiamine deficiency (Wernicke encephalopathy)

Differential Diagnosis

1. Rotational vertebral artery occlusion syndrome: if attacks are associated with turning of the head.
2. Superior canal dehiscence syndrome : if attacks are associated with intracranial change in pressure, or change in pressure in the ear canal.
3. Meniere’s disease: duration of the attacks from 20 min to 12 hours, low- to medium-frequency sensorineural hearing loss (>30 dB, <2000 Hz).
4. Vestibular drop attacks. These sudden falls are usually not accompanied by vertigo, and occur most often in patients with known Meniere’s disease, typically while standing, whereas in vestibular paroxysmia the attacks occur in any body positions.
5. Vertebrobasilar transient ischemic attacks: vertigo frequently occurs in isolation in this condition.
6. Vestibular migraine: short spells of vertigo may be induced by changes of head or body position when patients are motion sensitive during an episode of vestibular migraine.
7. Episodic ataxia type 2: the duration of the attacks varies from several minutes to hours and more than 90% of the patients have cerebellar signs, in particular gaze-evoked nystagmus and downbeat nystagmus. The onset of manifestations after the age of 20 is unusual.
8. Epilepsy with vestibular aura:

A useful approach to the causes of vertigo is to separate episodic from persistent¹:

 

A clinical syndrome of transient vertigo, dizziness, or unsteadiness lasting seconds to hours, occasionally days, and generally including features suggestive of temporary, short-lived vestibular system dysfunction (eg, nausea, nystagmus, sudden falls). There may also be symptoms or signs suggesting cochlear or central nervous system dysfunction. Episodic vestibular syndrome usually has the history of multiple, recurrent attacks caused by an episodic disorder with repeated spells (triggered or spontaneous), but may initially present after the first attack².

I Labyrinth/vestibulo-cochlear nerve
 Meniere’s disease
 Vestibular paroxysmia
 Superior canal dehiscence syndrome (induced by coughing, pressing, or loud sounds of a specific frequency, i.e. a Tullio phenomenon)
 Benign paroxysmal positioning vertigo (only during changes of head position relative to gravity)
 Cogan’s syndrome
 Cysts or tumors of the cerebellopontine angle

II Central vestibular system
 Transient vertebrobasilar ischemia
 Rotational vertebral artery occlusion syndrome
 Vestibular epilepsy
 ‘Room-tilt illusion’
 Paroxysmal ataxia/dysarthrophonia (multiple sclerosis)
 Episodic ataxia types 1 and 2
 Paroxysmal ‘ocular tilt reaction’

III Peripheral and/or central vestibular system
 Basilar/vestibular migraine
 Benign paroxysmal vertigo of childhood
 Vertebrobasilar transient ischemia (eg, AICA)

A clinical syndrome of chronic vertigo, dizziness, or unsteadiness lasting months to years and generally including features of persistent vestibular system dysfunction (eg, oscillopsia, nystagmus, gait unsteadiness). There may also be symptoms or signs suggesting cochlear or central nervous system dysfunction. Chronic vestibular syndrome often has a progressive, deteriorating course, but may sometimes reflects a stable, incomplete recovery after an acute vestibular event, or persistent, lingering symptoms between episodic vestibular attacks. It may be difficult to distinguish chronic vestibular syndrome from episodic conditions. Chronic conditions are usually structural¹.

1. Long-standing bilateral and unilateral peripheral lesions¹

• Bilateral vestibulopathy
• Unilateral vestibulopathy
• Presbyvestibulopathy

2. Central disorders

• Cerebellar disorders (SCA, MSA-C, CANVAS) (Cerebellar degeneration)
• Downbeat Nystagmus Syndrome
• Movement disorders: PSP, Parkinson’s disease
• Orthostatic Tremor
• Normal Pressure Hydrocephalus
• Vascular disease
• Sequelae after stroke
• Posterior fossa neoplasms

3.  Functional disorders

• PPPD (Persistent Postural Perceptual Dizziness)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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