Cell Biochem Biophys (2011) 59:109112

DOI 10.1007/s12013-010-9120-1

ORIGINAL RESEARCH

A Clinical Epidemiological Study in 187 Patients with Vertigo

Yan Zhang Xu Chen Xiaoting Wang
Limei Cao Zhiqiang Dong Jia Zhen
Gang Li Zhongxin Zhao

Published online: 26 October 2010

Springer Science+Business Media, LLC 2010

Abstract A retrospective study to investigate the clinical

epidemiological characteristics of vertigo was carried out on
187 patients with vertigo. A clinical history for each patient
was recorded precisely about the attack, frequency, and
development of vertigo, its duration, intensity, and the
accompanied symptoms including the risk factors for cerebrovascular disease, etc. All the patients were subjected to
physical examination with special attention to neurologic
systems and Dix-Hallpike maneuver, computed tomography/computed tomographyangiography (CT/CTA) and
MRI scan were performed when necessary. Majority of the
patients in this study suffered with posterior circulation
ischemia (59.89%) and benign paroxysmal positional vertigo (16.04%). Other ailments that affected these patients
included migraine, Menieres disease (1.6%), sudden hearing loss (1.07%), vestibular neuronitis, multiple sclerosis,
acute viral encephalitis, meningioma, neurosis, posttraumatic vertigo, acute myocardial infarction (0.53%), and
neurosis (14.97%). It appeared that in comparison to

Yan Zhang and Xu Chen should be regarded as joint first authors.

Y. Zhang
X. Chen (&)
X. Wang
L. Cao
Z. Dong

J. Zhen
G. Li
Department of Neurology, The 8th Peoples Hospital,
Shanghai 200235, China
e-mail: CXWP65@163.com
Z. Zhao (&)
Department of Neurology, Changzheng Hospital, Second
Military Medical University, Shanghai 200003, China
e-mail: zhaozx@medmail.com.cn

younger patients the elderly population is likely to be more

susceptible to vertigo. Vertigo attacks patients with various
diseases, which pre-dispose the patients to this disease.
Presentation of vertigo can be clinically diagnosed in most
cases of patients suffering from posterior circulation
ischemia.
Keywords Vertigo
Brain ischemia
Computed
tomographyangiography

Introduction
Vertigo is a subjective symptom, a sense of whirling of the
environment or the body, and a motor illusion. Even
though dizziness and vertigo are common causes of patient
visits to hospital emergency room, there is very little
clinical-based epidemiological information available on
this condition. In order to establish guidelines for the
effective management of this pathological condition in
suffering patients, it is necessary to have the epidemiological data and the associated disorders [1]. Vertigo is one
of the common symptoms of different neurological disorders, with high incidence and complicated causes, which
make it difficult in its diagnosis and differential diagnosis.
It has been suggested recently [2, 3] that peripheral vestibular disordersvestibular neuritis, benign paroxysmal
positional vertigo (BPPV), and Menieres diseasemay be
the underlying causes of majority of the vertigo and dizziness presentations and thus a clear understanding of these
vestibular disorders is necessary for the evaluation and
management of vertigo. The present study surveyed 187
vertigo patients retrospectively, analyze their clinical
characteristics and causes, to help clinical work and
improve treatment and diagnosis of vertigo.

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Materials and Methods

Patients
Relevant clinical data of 187 in-patients in the Neurology
Department of our hospital admitted between 1 Jan and 31
Dec in 2008 were collected. Patients age ranged from 16
to 91 years, with an average of 72 years and 71 of them are
male while 116 are female. All the patients presented with
the chief complaint of vertigo.
Methods
All the patients presenting with vertigo were examined by
neurologists. Medical histories of the patients were collected including gender, age, possible inducing factors,
duration and frequency of episode, relationship to the head
and body position, course and concomitant symptoms, risk
factors of stroke, detailed past histories, systematic physical and neurological examination, Dix-Hallpike test, CT,
MRI, and CTA examination.
Diagnostic Criteria
Posterior circulation ischemia (PCI) was diagnosed
according to the criteria mentioned in the New England
Medical Center Posterior Circulation Registry (LouisR
et al.). Benign paroxysmal positional vertigo (BPPV) is
diagnosed according to the clinical practice guidelines by
Bhattacharyya et al [4]. These criteria included (AD have
to be fulfilled): (A) Recurrent vestibular vertigo, (B)
Duration of an attack always \1 min, (C) Symptoms
invariably provoked by the following changes of head
position: lying down or turning over in the supine position
or at least two of the following maneuvers: redlining the
head or rising up from supine position or bending forward
and (D) Not attributable to another disorder.
Statistics
The causes and clinical features of vertigo are summarized
and analyzed statistically. Statistical analysis was done
using v2 test with the Graphpad Prism 4 and Excel software. Differences are considered significant if P \ 0.01.

Results

Cell Biochem Biophys (2011) 59:109112

Table 1 The causative factors of vertigo and their contribution
Causes

Number of patients

PCI

112

59.89

30

16.04

1.60

BPPV
Migraine

Percentage

Brain stem hemorrhage

1.60

Meniere

1.60

Sudden deafness

1.07

Vestibular neuritis

0.53

MS

0.53

Viral encephalitis

0.53

Meningioma

0.53

Post traumatic vertigo

Myocardial infarction

1
1

0.53
0.53

Neurosis
Total

28
187

14.97
100

maximally to vertigo in our patient population. Nearly 60%

of the patients had PCI and among these 99 patients had
vertebro basilar transient ischemic attack (TIA), 9 patients
suffered from brain stem infarction (2 of 9 are Wallenberg
syndrome) and 4 with cerebellar infarction. Approximately
16% of the vertigo patients suffered from BPPV and neurosis afflicted almost 15% of the patients. The distribution
of male patients to female patients among the PCIs (43
males; 69 females) and the BPPVs (11 males; 19 females)
is about the same as in the original patient population.
The Incidence Characteristics of Vertigo
Analysis of age distribution of the vertigo patients (Fig. 1)
revealed that the incidence of vertigo increases with age,
and peaks at about 70 years of age, and there are no gender-related differences. Incidence of PCI among our patient
population was noticed after 50 years of age, peaking at
70 years (Fig. 2). However, BPPV started at much earlier
age, by 30 years and did not show any age-dependent
increase in comparison to PCI. Most of the vertigo patients
who suffered from BPPV are from 5060 years old
(Fig. 2).
The PCI and BPPV are the two most common diseases
among these vertigo patients. Figure 3 shows the numbers
of patients at different age period of each disease. In the
two age groups, the number of patients with BPPV is
significantly lower (P \ 0.0001) than those with PCI.

Analysis of Causative Factors of Vertigo

Discussion
The causes and their contribution to the incidence of vertigo in the patient population analyzed are shown in
Table 1. By far, PCI and BPPV appear to contribute

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It has been reported earlier that migraine is strongly associated with the incidence of vertigo [3, 5, 6]. In this study

Cell Biochem Biophys (2011) 59:109112

Fig. 1 Age distribution of vertigo patients

Fig. 2 Age distribution of PCI and BPPV patients

Fig. 3 Number of patients at different age period of BPPV and PCI

with the 187 in-patients admitted in our hospital, the most

common cause of vertigo is PCI, followed by BPPV, as
these two conditions are most predominant in our patients.
Even though this is different from the studies else where,
similar results were reported earlier in other Chinese
patients, by Wang et al. [7], that PCI being the causative
factor in nearly 60% of the vertigo patients. This difference
may be attributed to the following two reasons: (1) The

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patients in this sample are all in-patients, who are admitted

to hospital because of the extent and duration of vertigo
and (2) The patients in this study are older, and most of
them have risk factors of stroke. There is at least one risk
factor in the history of this sample of patients.
The posterior circulation is also called the vertebrobasilar artery system. It consists of the vertebral artery, the
basilar artery, and the posterior cerebral artery, mainly
irrigating the brain stem, cerebellar, thalamus, occipital
lobe, part of temporal lobe, and the upper spinal cord. PCI
includes post-circulation TIA, cerebellar infarction and
brain stem infarction. The most frequently seen symptoms
of PCI are dizzy/vertigo, extremity/head and facial numbness, extremity weakness, headache, nausea, vomiting,
diplopia, transient loss of consciousness, visual disorder,
and lack of balance while walking or falling. Signs are
conscious disturbance, oculomotor nerve palsy, extremity
paralysis, paresthesia, walking/extremity ataxia, dysarthria/
dysphagia, and visual field defect [8]. PCI usually manifests as a series of symptoms whereas, signs related to the
ischemia part, merely cause a single symptom [9]. In the
PCI Registration Study of the New England Medical
Centre [9], it was reported that less than 1% of the PCI
patients show a single specific symptom or sign. Similarly,
in the present studied group of 112 PCI patients, besides
vertigo, most of them have nystagmus, nausea, vomiting,
balance disturbance, head and extremity numbness, dysarthria or dysphagia. Other concomitant symptoms in these
patients include transient conscious disturbance in 6 of
them, Horner sign in 2 patients, peripheral facial paralysis
in 2 patients, ataxia in 6 of them, diplopia in 2 of them,
recurrent visual disturbance in 5 of them, and transient
amnesia in one patient. Only in 2 patients of PCI, a single
symptom of vertigo and vomiting was noticed.
Benign paroxysmal positional vertigo is an internal ear
disease, in which transient vertigo attacks when the head is
moved to a certain position [10]. The fall of the calcium
carbonate otolith from the macula of the utricle into one of
the semicircular canals leads to BPPV. These otoliths,
because of their higher density, move in response to gravity
and cause ampullary nerve excitation in the affected canal,
which in turn, triggers a burst of vertigo that is associated
with nystagmus unique to the affected canal [10]. Vertigo
of BPPV is latent, rotating, transient, and exhaustible. The
average age for the onset of BPPV is 54 years is similar to
the average vertigo onset age, 58.4 years, for the present
sample of patients. Surprisingly, none of the present studied patients was diagnosed with BPPV before their
admission to hospital and this could be due to the lack of
related history or Dix-Hallpike test.
Age distribution analysis of the vertigo patients studied
presently shows that a majority of the BPPV affected
patients fall in the age group of 3059 years in comparison

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to the group of older patients. However, PCI afflicted

vertigo patients are predominantly more than 60 years old
(Fig. 2, Table 1). This suggests that age is one of the factors that should be taken into consideration when diagnosing vertigo.
In this sample of patients 76% are elderly people.
Morphological studies and functional evaluation of the
vestibular system as a function of patients age showed that
this system degenerates with the increasing age [11]. This
degeneration process thus makes the elderly people to be
more vulnerable to vertigo, especially the central vertigo
[12]. This also has an impact on society as because of the
increasing aging population, the number of the elderly
vertigo patients is also on the rise.
Our present epidemiological study on the hospitalizedvertigo patients suggests that vertigo is a symptom for
which there are several causative factors. Also, vertigo is a
major manifestation of PCI, but PCI is not the only cause
of vertigo.

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