Symptoms and signs of central and peripheral vestibular lesion

1. Big picture

Vertigo is a false sensation of movement, usually rotation or tilting, caused by mismatch between vestibular, visual, and proprioceptive/deep sensory input. In the exam, the key task is not only to say “the patient is dizzy,” but to decide:

Is this peripheral vestibular disease, or is this a dangerous central brainstem/cerebellar lesion?

This distinction is high-yield because peripheral vertigo is usually unpleasant but not immediately life-threatening, while central vertigo may be posterior circulation stroke, cerebellar hemorrhage, multiple sclerosis, or posterior fossa tumor.

The examiner wants you to know the difference between:

• Peripheral vestibular lesion = inner ear / labyrinth / vestibular nerve.

• Central vestibular lesion = vestibular nuclei, brainstem, cerebellum, vestibular pathways.

The most important clinical clues are type of nystagmus, associated neurological signs, head impulse test, skew deviation, severity of autonomic symptoms, gait/ataxia, and hearing symptoms.