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Modern concept of vascular vertigo

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Among the various causes of acute vestibular vertigo, vascular factors are of particular importance. Numerous studies show that the diagnosis of vascular vertigo remains inadequate, often leading to overdiagnosis of stroke and transient ischemic attacks in patients with peripheral vestibular disorders and vestibular migraine, on the one hand, and underestimation of the importance of cerebrovascular pathology, especially in patients with the first attack of persistent vestibular vertigo, on the other.

The International Barany Society has developed and published diagnostic criteria for vascular vertigo. These criteria are intended to facilitate the identification of vascular causes of acute vestibular syndrome. Particular emphasis is placed on clinical signs because imaging techniques often do not allow detection of foci small in volume and area, especially in cases when stroke is manifested by an isolated vestibular syndrome. Key clinical signs to analyze when a vascular etiology of acute vestibular syndrome is suspected include nystagmus, corrective saccades on the Halmagyi test, smooth visual pursuit, visual saccades, severity of trunk ataxia, and hearing loss.

About the Authors

D. V. Zhiznevskiy
Department of Neurology with a course of reflexology and manual therapy, Russian Medical Academy of Continuing Professional Education, Ministry of Health of Russia
Russian Federation

Dmitriy Vladimirovich Zhiznevskiy

2/1, Barrikadnaya St., Build. 1, Moscow 125993

M. V. Zamergrad
Department of Neurology with a course of reflexology and manual therapy, Russian Medical Academy of Continuing Professional Education, Ministry of Health of Russia; Russian Clinical and Research Center of Gerontology, N.I. Pirogov Russian National Research Medical University, Ministry of Health of Russia
Russian Federation

2/1, Barrikadnaya St., Build. 1, Moscow 125993

16, 1st Leonova St., Moscow 129226

S. P. Grachev
Department of Cardiology, A.I. Evdokimov Moscow State University of Medicine and Dentistry, Ministry of Health of Russia
Russian Federation

20, Delegatskaya St., Build. 1, Moscow 127473


1. Parfenov VA. Vestibular neuronitis. Meditsinskiy sovet = Medical Council. 2021;(2):31-6. doi: 10.21518/2079-701X-20212-31-36 (In Russ.)].

2. Zamergrad MV, Parfenov VA, Yakhno NN, et al. The diagnosis of systemic vertigo in outpatient practice. Nevrologicheskiy zhurnal = Neurological Journal. 2014;(2):23-9 (In Russ.)].

3. Zamergrad MV, Parfenov VA, Kosivtsova OV. Differential diagnosis and treatment of vestibular dizziness. Meditsinskiy sovet = Medical Council. 2012;(4):48-53 (In Russ.)].

4. Kulesh AA, Emelin AYu, Bogolepova AN, et al. Clinical manifestations and issues of diagnosis of chronic cerebrovascular disease (chronic cerebral ischemia) at an early (predementia) stage. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2021;13(1):4-12. doi: 10.14412/2074-2711-2021-1-4-12 (In Russ.)].

5. Choi KD, Kim JS. Vascular vertigo: updates. J Neurol. 2019 Aug;266(8):1835-43. doi: 10.1007/s00415-018-9040-3.Epub 2018 Sep 5.

6. Goeldlin M, Gaschen J, Kammer C, et al. Frequency, aetiology, and impact of vestibular symptoms in the emergency department: a neglected red flag. J Neurol. 2019 Dec;266(12):3076-86. doi: 10.1007/s00415019-09525-4. Epub 2019 Sep 17.

7. Suslina ZA, Gulevskaia TS, Maksimova MYu, Morgunov VA. Narusheniia mozgovogo krovoobrashcheniia: diagnostika, lechenie, profilaktika [Cerebral circulation disorders: diagnosis, treatment, prevention]. Moscow: MEDpress-inform; 2016 (In Russ.)].

8. Lee SH, Kim JS. Differential diagnosis of acute vascular vertigo. Curr Opin Neurol. 2020 Feb;33(1):142-9. doi: 10.1097/WCO.0000000000000776

9. Searls DE, Pazdera L, Korbel E, et al. Symptoms and signs of posterior circulation ischemia in the new England medical center posterior circulation registry. Arch Neurol. 2012 Mar;69(3):346-51. doi: 10.1001/archneurol.2011.2083. Epub 2011 Nov 14.

10. Akhtar N, Kamran SI, Deleu D, et al.Ischaemic posterior circulation stroke in State of Qatar. Eur J Neurol. 2009 Sep;16(9):1004-9. doi: 10.1111/j.1468-1331.2009.02709.x. Epub 2009 Jun 15.

11. Francis DA, Bronstein AM, Rudge P, du Boulay EP. The site of brainstem lesions causing semicircular canal paresis: an MRI study. J Neurol Neurosurg Psychiatry. 1992 Jun;55(6):446-9. doi: 10.1136/jnnp.55.6.446

12. Thömke F, Hopf HC. Pontine lesions mimicking acute peripheral vestibulopathy. J Neurol Neurosurg Psychiatry. 1999 Mar;66(3):340-9. doi: 10.1136/jnnp.66.3.340

13. Kim HJ, Lee SH, Park JH, et al. Isolatedvestibular nuclear infarction: report of two cases and review of the literature. J Neurol. 2014 Jan;261(1):121-9. doi: 10.1007/s00415-0137139-0. Epub 2013 Oct 27.

14. Lee SU, Park SH, Park JJ, et al. DorsalMedullary Infarction: Distinct Syndrome of Isolated Central Vestibulopathy. Stroke. 2015 Nov;46(11):3081-7. doi: 10.1161/STROKEAHA.115.010972. Epub 2015 Oct 13. Erratum in: Stroke. 2015 Dec;46(12):e261.

15. Thömke F, Mars JJ, Iannetti GD, et al. A topodiagnostic investigation on body lateropulsion in medullary infarcts. Neurology. 2005 Feb 22;64(4):716-8. doi: 10.1212/01.WNL.0000152040.27264.1A

16. Felice KJ, Keilson GR, Schwartz WJ. 'Rural' gait ataxia. Neurology. 1990 Jun;40(6):1004-5. doi: 10.1212/wnl.40.6.1004-a

17. Yi HA, Kim HA, Lee H, Baloh RW. Body lateropulsion as an isolated or predominant symptom of a pontine infarction. J Neurol Neurosurg Psychiatry. 2007 Apr;78(4):372-4. doi: 10.1136/jnnp.2006.106237. Epub 2006 Nov 21.

18. Zwergal A, Möhwald K, Salazar Lopez E, et al. A Prospective Analysis of LegionSymptom Relationships in Acute Vestibular and Ocular Motor Stroke. Front Neurol. 2020 Aug 6;11:822. doi: 10.3389/fneur.2020.00822

19. Choi JH, Seo JD, Choi YR, et al. Inferiorcerebellar peduncular lesion causes a distinct vestibular syndrome. Eur J Neurol. 2015 Jul;22(7):1062-7. doi: 10.1111/ene.12705. Epub 2015 Apr 6.

20. Lee SU, Bae HJ, Kim JS. Ipsilesional limbataxia and truncal ipsipulsion in isolated infarction of the superior cerebellar peduncle. J Neurol Sci. 2015 Feb 15;349(1-2):251-3. doi: 10.1016/j.jns.2015.01.006. Epub 2015 Jan 10.

21. Saber Tehrani AS, Kattah JC, Mantokoudis G, et al. Small strokes causing severe vertigo: frequency of false-negative MRIs and nonlacunar mechanisms. Neurology. 2014 Jul 8;83(2):169-73. doi: 10.1212/WNL.0000000000000573. Epub 2014 Jun 11.

22. Choi JH, Kim HW, Choi KD, et al. Isolatedvestibular syndrome in posterior circulation stroke: Frequency and involved structures. Neurol Clin Pract. 2014 Oct;4(5):410-8. doi: 10.1212/CPJ.0000000000000028

23. Lee H, Cho YW. A case of isolated nodulusinfarction presenting as a vestibular neuritis. J Neurol Sci. 2004 Jun 15;221(1-2):117-9. doi: 10.1016/j.jns.2004.03.022

24. Moon IS, Kim JS, Choi KD, et al. Isolated nodular infarction. Stroke. 2009 Feb;40(2):487-91. doi: 10.1161/STROKEAHA.108.527762. Epub 2008 Dec 24.

25. Lee SH, Park SH, Kim JS, et al. Isolatedunilateral infarction of the cerebellar tonsil: ocular motor findings. Ann Neurol. 2014 Mar;75(3):429-34. doi: 10.1002/ana.24094

26. Yacovino DA, Ally MP, Luis L, Zee DS.The Floccular Syndrome: Dynamic Changes in Eye Movements and Vestibulo-ocular Reflex in Isolated Infarction of the Cerebellar Flocculus. Cerebellum. 2018 Apr;17(2):122-31. doi: 10.1007/s12311-017-0878-1

27. Amarenco P, Hauw JJ. Cerebellar infarctionin the territory of the anterior and inferior cerebellar artery. A clinicopathological study of 20 cases. Brain. 1990 Feb;113 ( Pt 1):139-55. doi: 10.1093/brain/113.1.139

28. Choi SY, Park JH, Kim HJ, Kim JS.Vestibulocochlear nerve infarction documented with diffusion-weighted MRI. J Neurol. 2015 May;262(5):1363-5. doi: 10.1007/s00415-0157715-6. Epub 2015 Mar 26.

29. Kim JS, Lopez I, DiPatre PL, et al. Internalauditory artery infarction: clinicopathologic correlation. Neurology. 1999 Jan 1;52(1):40-4. doi: 10.1212/wnl.52.1.40

30. Liqun Z, Park KH, Kim HJ, et al. Acute Unilateral Audio vestibulopathy due to Embolic Labyrinthine Infarction. Front Neurol. 2018 May 2;9:311. doi: 10.3389/fneur.2018.00311

31. Mazzoni A. The vascular anatomy of thevestibular labyrinth in man. Acta Otolaryngol Suppl. 1990;472:1-83. doi: 10.3109/00016489009121137

32. Monak AA, Kaileva NA, Kulesh AA, et al. Labyrinthine infarction as a cause of acute cochleovestibular syndrome. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2023;15(1):716. doi: 10.14412/2074-2711-2023-1-71-76 (In Russ.)].

33. Lee H, Kim JS, Chung EJ, et al. Infarctionin the territory of anterior inferior cerebellar artery: spectrum of audiovestibular loss. Stroke. 2009 Dec;40(12):3745-51. doi: 10.1161/STROKEAHA.109.564682. Epub 2009 Sep 24.

34. Lee H. Audiovestibular loss in anterior inferior cerebellar artery territory infarction: a window to early detection? J Neurol Sci. 2012 Feb 15;313(1-2):153-9. doi: 10.1016/j.jns.2011.08.039. Epub 2011 Oct 13.

35. Vivas EX, Panella NJ, Baugnon KL. Spontaneous Labyrinthine Hemorrhage: A Case Series. Otolaryngol Head Neck Surg. 2018 Nov;159(5):908-13. doi: 10.1177/0194599818785900. Epub 2018 Jul 3.

36. Kim HA, Lee H. Isolated vestibular nucleusinfarction mimicking acute peripheral vestibulopathy. Stroke. 2010 Jul;41(7):1558-60. doi: 10.1161/STROKEAHA.110.582783. Epub 2010 May 20.

37. Von Brevern M, Süsmilch S, Zeise D. Acute vertigo due to hemispheric stroke: a case report and comprehensive review of the literature. J Neurol Sci. 2014 Apr 15;339(1-2):153-6. doi: 10.1016/j.jns.2014.02.005. Epub 2014 Feb 14.

38. Artem'ev DV, Levin OS, Vestibular vertigo in hemispheric strokes. Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova. 2017;117(82):27-31. doi: 10.17116/jnevro20171178227-31 (In Russ.)].

39. Man Chan Y, Wong Y, Khalid N, et al.Prevalence of acute dizziness and vertigo in cortical stroke. Eur J Neurol. 2021 Sep;28(9):3177-81. doi: 10.1111/ene.14964. Epub 2021 Jul 2.

40. Chalela JA, Kidwell CS, Nentwich LM, et al. Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison. Lancet. 2007 Jan 27;369(9558):293-8. doi: 10.1016/S0140-6736(07)60151-2

41. Saber Tehrani AS, Kattah JC, Kerber KA,et al. Diagnosing stroke in acute dizziness and vertigo: pitfalls and pearls. Stroke. 2018;49:788-95. doi: 10.1161/STROKEAHA.117.016979

42. Kattah JC, Talkad AV, Wang DZ, et al.HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009 Nov;40(11):3504-10. doi: 10.1161/STROKEAHA.109.551234. Epub 2009 Sep 17.

43. Kerber KA, Meurer WJ, Brown DL, et al.Stroke risk stratification in acute dizziness presentations: A prospective imaging-based study. Neurology. 2015 Nov 24;85(21):1869-78. doi: 10.1212/WNL.0000000000002141. Epub 2015 Oct 28.

44. Newman-Toker DE, Kerber KA, Hsieh YH, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med. 2013 Oct;20(10):986-96. doi: 10.1111/acem.12223

45. Newman-Toker DE, Curthoys IS, Halmagyi GM. Diagnosing Stroke in Acute Vertigo: The HINTS Family of Eye Movement Tests and the Future of the “Eye ECG”. Semin Neurol. 2015 Oct;35(5):506-21. doi: 10.1055/s0035-1564298. Epub 2015 Oct 6.

46. Carmona S, Martinez C, Zalazar G, et al. The Diagnostic Accuracy of Trance Taxi and HINTS as Cardinal Signs for Acute Vestibular Syndrome. Front Neurol. 2016 Aug 8;7:125. doi: 10.3389/fneur.2016.00125

47. Choi JH, Park MG, Choi SY, et al. AcuteTransient Vestibular Syndrome: Prevalence of Stroke and Efficacy of Bedside Evaluation. Stroke. 2017 Mar;48(3):556-62. doi: 10.1161/STROKEAHA.116.015507. Epub 2017 Jan 18.

48. Parfenov VA, Kulesh AA, Demin DA, et al. Vestibular vertigo in stroke and vestibular neuronitis. Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova. 2021;121(12-2):41-9. doi: 10.17116/jnevro202112112241 (In Russ.)].

49. Parfenov VA. Meniere's disease and chronic cerebrovascular diseases. Meditsinskiy sovet = Medical Council. 2021;(19):35-40. doi: 10.21518/2079-701X-2021-19-35-40 (In Russ.)].

50. Antonenko LM, Parfenov VA. Vestibular vertigo. Zhurnal nevrologii i psikhiatrii imeni S.S. Korsakova. 2020;120(6):125-30. doi: 10.17116/jnevro2020120061125 (In Russ.)].

51. Kulesh AA, Parfenov VA. Vestibular migraine: epidemiology, pathogenesis, clinical picture, diagnosis and treatment. Nevrologiya, neiropsikhiatriya, psikhosomatika = Neurology, Neuropsychiatry, Psychosomatics. 2022;14(6):411. doi: 10.14412/2074-2711-2022-6-4-11 (In Russ.)].

52. Antonenko LM. Drug and non-drug treatments of vertigo. Meditsinskiy sovet = Medical Council. 2021;(2):39-44. doi: 10.21518/2079701X-2021-2-39-44 (In Russ.)].

53. Wang W, Zhang Y, Pan Q, et al. Centralnystagmus plus ABCD2 identifying stroke in acute dizziness presentations. Acad Emerg Med. 2021 Oct;28(10):1118-23. doi: 10.1111/acem.14295. Epub 2021 Jun 9.

54. Kim JS, Newman-Toker DE, Kerber KA, et al. Vascular vertigo and dizziness: Diagnostic criteria. J Vestib Res. 2022;32(3):205-22. doi: 10.3233/VES-210169

55. Choi KD, Choi JH, Kim JS, et al.Rotational vertebral artery occlusion: mechanisms and long-term outcome. Stroke. 2013 Jul;44(7):1817-24. doi: 10.1161/STROKEAHA.113.001219. Epub 2013 May 21.

56. Sakaguchi M, Kitagawa K, Hougaku H, et al. Mechanical compression of the extracranial vertebral artery during neck rotation. Neurology. 2003 Sep 23;61(6):845-7. doi: 10.1212/

57. Trattnig S, Schwaighofer B, Hübsch P, et al. Color-coded Doppler sonography of vertebral arteries. J Ultrasound Med. 1991 Apr;10(4):221-6. doi: 10.7863/jum.1991.10.4.221

58. Seidel E, Eicke BM, Tettenborn B,Krummenauer F. Reference values for vertebral artery flow volume by duplex sonography in young and elderly adults. Stroke. 1999 Dec;30(12):2692-6. doi: 10.1161/01.str.30.12.2692

59. Jeng JS, Yip PK. Evaluation of vertebralartery hypoplasia and asymmetry by colorcoded duplex ultrasonography. Ultrasound Med Biol. 2004 May;30(5):605-9. doi: 10.1016/j.ultrasmedbio.2004.03.004

60. Hong JM, Chung CS, Bang OY, et al.Vertebral artery dominance contributes to basilar artery curvature and peri-vertebrobasilar junctional infarcts. J Neurol Neurosurg Psychiatry. 2009 Oct;80(10):1087-92. doi: 10.1136/jnnp.2008.169805. Epub 2009 May 3.

61. Chen YY, Chao AC, Hsu HY, et al.Vertebral artery hypoplasia is associated with a decrease in net vertebral flow volume. Ultrasound Med Biol. 2010 Jan;36(1):38-43. doi: 10.1016/j.ultrasmedbio.2009.08.012

62. Hu XY, Li ZX, Liu HQ, et al. Relationshipbetween vertebral artery hypoplasia and posterior circulation stroke in Chinese patients. Neuroradiology. 2013 Feb;55(3):291-5. doi: 10.1007/s00234-012-1112-y. Epub 2012 Nov 2.

63. Chuang YM, Hwang YC, Lin CP, Liu CY. Toward a further elucidation: role of vertebral artery hypoplasia in migraine with aura. Eur Neurol. 2008;59(3-4):148-51. doi: 10.1159/000111878. Epub 2007 Nov 30.

64. Kosla KN, Majos M, Podgorski M, et al.Anomalous course and diameter of left-sided vertebral arteries – significance and predisposing factors in clinical practice. Ann Anat. 2014 Sep;196(5):360-4. doi: 10.1016/j.aanat.2014.04.005. Epub 2014 May 4.

65. Chuang YM, Chan L, Wu HM, et al. The clinical relevance of vertebral artery hypoplasia. Acta Neurol Taiwan. 2012;21:1-7.

66. Katsanos AH, Kosmidou M, Kyritsis AP,Giannopoulos S. Is vertebral artery hypoplasia a predisposing factor for posterior circulation cerebral ischemic events? A comprehensive review. Eur Neurol. 2013;70(1-2):78-83. doi: 10.1159/000351786. Epub 2013 Jun 26.

67. Park JH, Kim JM, Roh JK. Hypoplasticvertebral artery: frequency and associations with ischaemic stroke territory. J Neurol Neurosurg Psychiatry. 2007 Sep;78(9):954-8. doi: 10.1136/jnnp.2006.105767. Epub 2006 Nov 10.

68. Perren F, Poglia D, Landis T, Sztajzel R.Vertebral artery hypoplasia: a predisposing factor for posterior circulation stroke? Neurology. 2007 Jan 2;68(1):65-7. doi: 10.1212/01.wnl.0000250258.76706.98

69. Thierfelder KM, Baumann AB, Sommer WH, et al. Vertebral artery hypoplasia: frequency and effect on cerebellar blood flow characteristics. Stroke. 2014 May;45(5):1363-8. doi: 10.1161/STROKEAHA.113.004188. Epub 2014 Apr 3.

70. Chuang YM, Huang YC, Hu HH, Yang CY. Toward a further elucidation: role of vertebral artery hypoplasia in acute ischemic stroke. Eur Neurol. 2006;55(4):193-7. doi: 10.1159/000093868. Epub 2006 Jun 13.


For citations:

Zhiznevskiy D.V., Zamergrad M.V., Grachev S.P. Modern concept of vascular vertigo. Neurology, Neuropsychiatry, Psychosomatics. 2023;15(4):4-11. (In Russ.)

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