Vascular Vertigo

Vascular Vertigo and Dizziness Diagnostic Criteria

By Megan Clark, MWC

The Committee for the Classification of Vestibular Disorders of the Bárány Society recently released diagnostic criteria for vascular vertigo and dizziness. Classifying the type of vascular vertigo/dizziness can help identify the underlying cause and appropriate treatment.

Patients with vascular vertigo/dizziness typically present with acute vestibular syndrome (AVS), which is a sudden onset of vertigo or dizziness with nausea or vomiting, head-motion intolerance, and unsteadiness. The diagnostic criteria classify vascular vertigo/dizziness based on presentation, particularly the amount of time since symptom onset. Acute prolonged vascular vertigo/dizziness refers to symptoms lasting at least 24 hours. When a patient presents with a previous episode of vertigo/dizziness of less than 24 hours, the term transient vascular vertigo/dizziness may be used. In addition, acute vascular vertigo/dizziness in evolution may be applied when a patient with acute vertigo/dizziness is being evaluated within 24 hours from symptom onset.

Diagnostic Criteria

Acute prolonged vascular vertigo/dizziness

1. Acute vertigo, dizziness, or unsteadiness lasting for 24 hours or more
2. Imaging evidence of ischemia or hemorrhage in the brain or inner ear, which corresponds to the symptoms, signs and findings
3. Not better accounted for by another disease or disorder

Probable acute prolonged vascular vertigo/dizziness

1. Acute vertigo, dizziness or unsteadiness lasting for 24 hours or more
2. At least one of the following:
   1. Focal central neurological symptoms and signs (such as sensory loss, difficulty speaking or swallowing, postural instability)
   2. At least one component of central HINTS (normal head impulse test, direction-changing gaze-evoked nystagmus, or pronounced skew deviation)
   3. Other central ocular motor abnormalities (abnormal eye movements)
   4. Increased risk for vascular events
3. Not better accounted for by another disease or disorder

Transient vascular vertigo/dizziness or acute vascular vertigo/dizziness in evolution

1. Acute spontaneous vertigo, dizziness, or unsteadiness lasting less than 24 hours
2. Imaging evidence of ischemia or hemorrhage in the brain or inner ear, which corresponds to the symptoms, signs and findings
3. Not better accounted for by another disease or disorder

Probable acute vascular vertigo/dizziness in evolution

1. Acute spontaneous vertigo, dizziness, or unsteadiness for more than 3 hours, but less than 24 hours when seen
2. At least one of the following:
   1. Local central neurological symptoms and signs, or severe postural instability
   2. At least one component of central HINTS (normal head impulse tests, direction-changing gaze-evoked nystagmus, or pronounced skew deviation)
   3. Other central ocular motor abnormalities (abnormal eye movements)
   4. New onset of moderate to severe craniocervical pain
   5. Increased risk for vascular events
   6. Significant (> 50%) narrowing of an artery of the vertebrobasilar system
3. Not better accounted for by another disease or disorder

Probable transient vascular vertigo/dizziness

1. Acute spontaneous vertigo, dizziness, or unsteadiness lasting less than 24 hours
2. At least one of the following:
   1. Focal central neurological symptoms or severe postural instability during the attack
   2. New onset of moderate to severe craniocervical pain during the attack
   3. Increased risk for vascular events
   4. Significant (> 50%) narrowing of an artery of the vertebrobasilar system
3. Not better accounted for by another disease or disorder

The criteria also include vertigo/dizziness due to vertebral artery compression syndrome (VACS). The diagnosis requires symptoms provoked by a sustained eccentric neck position in combination with imaging or sonographic documentation of vertebral artery compression or decreased blood flow in the posterior circulation.

Determining the characteristics of vestibular symptoms, associated central symptoms, and vascular risk factors are the first steps in establishing a diagnosis of vascular vertigo/dizziness. Identifying its origin is critical for selecting the proper treatment.

Source: Kim JS, Newman-Toker DE, Kerber KA, et al. Vascular vertigo and dizziness: Diagnostic criteria. Journal of Vestibular Research. 2022;32(3):205-222. doi:10.3233/VES-210169