Which finding most strongly suggests a central vestibular disorder rather than a peripheral problem?

• A. Vertical or direction-changing nystagmus
• B. Fatigable horizontal nystagmus with head movement
• C. Nystagmus that disappears with fixation
• D. Normal gait with vertigo

Answer: (A)

A central vestibular problem is most suggested by nystagmus that is vertical or changes direction with gaze. Vertical or gaze-evoked nystagmus points to involvement of brainstem or cerebellar circuits, which regulate eye movements in multiple planes and can produce vertical components or opposite fast phases depending on where you look. Peripheral vestibular issues, by contrast, typically cause a horizontal, unidirectional nystagmus that fatigues with time and is suppressed by visual fixation.

The other findings lean toward a peripheral source: fatigue and horizontal orientation of nystagmus with head movement fits a canal- or vestibular nerve lesion on one side; nystagmus that disappears with fixation is classic for peripheral nystagmus (fixation suppresses it); and a vertigo patient who walks normally could occur with either type, but central causes usually show additional gait or balance abnormalities.