Vertigo and balance in children--diagnostic approach and insights from imaging

Common causes of vertigo and dizziness in childhood are vestibular migraine and associated syndromes (benign paroxysmal vertigo), unilateral vestibular failure due to labyrinthitis, positioning vertigo, and somatoform syndromes. Although the same spectrum of diseases as in adults can be found, the frequency differs widely. Further, balance disorders not related to vestibular function, like cerebral palsy, can present with dizziness. Vestibular function can reliably be addressed at the bedside by head impulses to test vestibulo-ocular reflex function, ocular motor testing of the central vestibular system, and balance tests for vestibulo-spinal function. Vestibulo-ocular reflex function can now be quantified by recording eye and head movements with high resolution video-oculography (256 Hz) and inertial sensors. Posturographic measures using artificial neuronal networks are used to classify dysbalance. Quantitative gait analysis further helps to distinguish balance disorders caused by e.g. sensory dysfunction or supraspinal disturbances. Recently, functional neuroimaging opened a view to the brain network for the control of posture and locomotion. From frontal cortex the locomotor signal is conveyed via the basal ganglia to the centers for locomotion and postural control in the brainstem tegmentum. The cerebellum is involved in sensory integration and rhythm generation during postural demands. To summarize, most syndromes causing dizziness, vertigo and imbalance can be diagnosed based on history and clinical tests. However, new data from neurophysiology and imaging help to understand the pathophysiology and the therapeutic principles in these disorders.