Neurology 1 - topic 30 - Characteristic appearance of harmonic and disharmonic vestibular syndromes


Dizziness, imbalance, vertigo, tinnitus, hearing loss, brain fog, vision impairment, cognitive changes

Which are the vestibular symptoms?

Frenzel's glasses / goggles

Dix-Hallpike maneuver

Halm�gyi head impulse test

Alternating cover test

B�r�ny test

P: unidirectional (quick component to the contralateral side of the lesion)
C: both uni - and bidirectional

Peripheral nystagmus - central nystagmus: uni or bi-directional

P: no (?), but if the pt looks in the direction of the quick component the amplitude might increase
C: Changing the direction of the gaze might influence the direction of the nystagmus. + The gaze-evoked nystagmus is often central

Peripheral nystagmus - central nystagmus: does changing the gaze affect the nystagmus?

P: accompanied by severe vertigo or emesis
C: can be accompanied by milder vegetative symptoms

Peripheral nystagmus - central nystagmus: accompanying symptoms

P: can have multi-components (horizontal, rotatory or vertical)
C: usually pure-vertical or pure-rotatory

Peripheral nystagmus - central nystagmus: horizontal, rotatory or vertical?

P: yes
C: no

Peripheral nystagmus - central nystagmus: reduced by fixation

Peripheral vestibular syndrome

Harmonic vestibular syndrome

Central vestibular syndrome

Disharmonic vestibular syndrome

Nystagmus is contralateral to the side of the lesion
B�r�ny, Romberg and Blind Walking test is directed towards the slow component
No central symptoms

Clinical symptoms of Harmonic vestibular syndrome

Nystagmus is ipsilateral to the side of the lesion
B�r�ny, Romberg and Blind Walking test is directed towards the quick component
Central symptoms may be present: cerebellar, pyramidal or brainstem lesions

Clinical symptoms of Disharmonic vestibular syndrome

Blood supply of the cerebellum

-Gradually developing spinning-like vertigo
-Harmonic vestibular symptoms
-85% Halm�gyi positive
-Skew deviation and direction-changing nystagmus is never present
-No hearing impairment

Vestibular neuronitis symptoms

-Mixture of peripheral and central symptoms
-98% vertigo
-96% central eye movement symptoms
-100% one of: skew deviation, neg Halm�gyi, direction-changing nystagmus
-50% hearing impairment + positive Halmg�gyi + no skew deviation

AICA infarction

-Acute disharmonic vestibular syndrome
-Sudden onset of vertigo
-Leaning towards any side
-Neg Halmg�gyi
-Spontaneous nystagmus which is either direction changing or gaze-evoked
-Severe postural instability
-20% skew deviation
-30% accompanying brainstem

PICA infarction

-Sudden onset severe gait and limb ataxia
-Slurred speech
-50% dizziness
-Nausea without dizziness may sometimes be the first symptom
-40% headache
-50% brainstem symptoms
-70% limb ataxia
-50% direction-changing nystagmus
-100% one of: skew deviation, ne

SCA infarction

-Spinning-like vertigo, paroxysmal provoked by sudden movement of the head or change in posture
-Positive Dix-Hallpike and Halm�gyi
-Neg alternating cover test
-No hearing disturbance
-Nystagmus + significant vegetative symptoms
-Symptoms begin after chan