Disorders · Introduction
Central causes of vertigo
Most vertigo comes from the inner ear. The minority that comes from the brain — a posterior-circulation stroke, a demyelinating plaque, a posterior-fossa tumour — is the part you cannot afford to miss. This chapter is about recognising it.
What “central” means here
Vertigo is the false sense that you or the room is moving. Usually the problem is in the balance organ of the ear. But the same feeling can come from the brain — from the brainstem and cerebellum at the back of the head, where the balance signals are processed. When it does, there are often other warning signs: double vision, slurred speech, weakness, or being unable to walk at all.
Central vertigo arises from the central vestibular structures — the vestibular nuclei, brainstem, cerebellum, thalamus and cortex — rather than the labyrinth or vestibular nerve. The three conditions that dominate this chapter are posterior-circulation stroke, multiple sclerosis and posterior-fossa tumours.1,4
The clinical problem is asymmetric risk. A peripheral vestibulopathy is unpleasant but benign; a cerebellar or brainstem stroke that looks identical at first glance is a neurological emergency. Up to a third of cerebellar infarcts are initially mislabelled as peripheral, and a normal early MRI does not exclude one.2,3 The whole chapter is therefore organised around one discipline: in the right patient, assume central until you have actively excluded it.5
Central vertigo by the numbers
Central causes are uncommon among all-comers with dizziness, but they are over-represented among the dangerous outcomes — and easy to miss when vertigo is the only complaint.
The signal that something is central
No single feature is decisive, but a cluster should raise the alarm — and any one of them in a patient with acute vestibular syndrome is enough to image:
- Vertical or direction-changing nystagmus that does not suppress with fixation.
- A normal head-impulse test in a patient who is genuinely vertiginous.
- Gait failure out of proportion to the vertigo — unable to stand or walk unaided.
- Any focal sign: diplopia, dysarthria, dysphagia, facial numbness, limb weakness, Horner’s.
- Vascular risk factors and age > 50, or a young adult with prior demyelinating events.
These threads come together in the differential-diagnosis page, which includes an interactive HINTS interpreter and a side-by-side stroke-versus-MS comparison.
How this chapter is organised
- Posterior-circulation stroke — vascular territories, the acute vestibular syndrome that mimics neuritis, diagnosis and time-critical management.
- Multiple sclerosis — demyelination of the vestibular pathways, internuclear ophthalmoplegia, the McDonald criteria, and relapse and disease-modifying therapy.
- Tumours & other central causes — posterior-fossa and cerebellopontine-angle masses, and a note on paraneoplastic and other rarer central causes.
- Differential diagnosis & HINTS — central versus peripheral, stroke versus MS, the interactive HINTS interpreter, diagnostic pitfalls and future directions.
- Clinical cases — worked vignettes with shared clinical pearls.
Key points
- Central vertigo arises from brainstem, cerebellum or their pathways — not the labyrinth.
- It is uncommon but high-stakes: a cerebellar stroke can be indistinguishable from neuritis at the bedside.
- Stroke, multiple sclerosis and posterior-fossa tumours are the conditions to know.
- Bedside oculomotor examination — especially HINTS — outperforms early MRI for stroke in acute vestibular syndrome.
- In the at-risk patient, assume central until actively excluded.