Abstract

The bedside examination of dizzy patients should include a systematic evaluation of spontaneous and triggered nystagmus, and evaluation of the ocular motilities including saccades, smooth pursuit, optokinetic nystagmus, and the vestibulo-ocular reflex (VOR). Bedside evaluation of the VOR function includes head impulse test, visual enhancement of the VOR, and visual cancellation of the VOR. Examination of the balance and coordination function may disclose dysfunction of the cerebellar system. In contrast to the nystagmus of peripheral origin, the central nystagmus may show various patterns. Usually pure vertical and torsional nystagmus, direction-changing nystagmus, and nystagmus not suppressed by fixation indicates a central pathology. In case of positioning/positional nystagmus which does not follow the characteristic patterns of benign paroxysmal positional vertigo and does not respond to repeated canalith repositioning maneuvers, a possibility of central positional vertigo should be considered. Head impulse test is mostly negative in the central vestibulopathies, even in the presence of vertigo and spontaneous nystagmus. Disorders of ocular motility and coordination, and severe imbalance also suggest central lesions. Careful bedside evaluation provides valuable information on the underlying pathology of dizziness.