Neurological update: dizziness

Abstract

The diagnosis and management of vertigo remains a challenge for clinicians, including general neurology. In recent years there have been advances in the understanding of established vestibular syndromes, and the development of treatments for existing vestibular diagnoses. In this 'update' I will review how our understanding of previously "unexplained" dizziness in the elderly is changing, explore novel insights into the pathophysiology of vestibular migraine, and its relationship to the newly coined term 'persistent postural perceptual dizziness', and finally discuss how a simple bedside oculomotor assessment may help identify vestibular presentations of stroke.

Keywords: Dizziness; Persistent postural perceptual dizziness (PPPD); Small vessel disease cerebral; Vestibular; Vestibular migraine.

Fig. 1

Schematic representation of the additional deleterious effects of postural blood pressure hypotension in cerebral small vessel disease associated dizziness in addition to cortico-subcortical (1), and cortico-cortical (2) disconnectivity. Localized oxidative stress processes damage the cerebral vasculature, leading to endothelial dysfunction and promoting neurodegenerative alterations in the brain tissue through reactive oxidative species (ROS). Microvascular endothelial dysfunction in turn disrupts cerebral autoregulation—which in healthy states maintains adequate and stable cerebral blood flow when blood pressure drops (3). This leads to intra-cerebral orthostatic hypotension and perfusion, manifest as postural light-headedness and imbalance. From Kaski et al. [10] with permission