[The VeSFADS structural classification of vestibular disorders]

The issuing of International Classification of Vestibular Disorders（ICVD） by Brny society（2015） greatly facilitates the progress of vestibular medicine. The syndromic classification of vestibular disorders by ICVD enable the physician to narrow the spectrum of differential diagnosis for the vestibular disorder in clinical practice. However, the division of vestibular pathway, especially the central vestibular system, has not be classified yet in the ICVD（2015）. Central vertigo, being a group of heterogeneous disorders, may present diverse clinical spectrums. The misdiagnosis of central vestibular as well as peripheral vestibular disorders have been reported in the clinic practice. Therefore, the author by review study proposes a structural classification of vestibular disorders combined the Vestibular System Functional Anatomy Division with Syndromes（VeSFADS）. The VeSFADS classification of vestibular disorders could help the physician in clinical practice to narrow the spectrum of vestibular disorders, in addition to the syndromic classification, by the clinical feature of vestibular disorders from different division of vestibular system. And the VeSFADS classification of vestibular disorders may facilitate to clarify the clinical features of vestibular disorders at different Division of vestibular pathway.

Hemodynamic orthostatic dizziness/vertigo: Diagnostic criteria

This paper presents the diagnostic criteria for hemodynamic orthostatic dizziness/vertigo to be included in the International Classification of Vestibular Disorders (ICVD). The aim of defining diagnostic criteria of hemodynamic orthostatic dizziness/vertigo is to help clinicians to understand the terminology related to orthostatic dizziness/vertigo and to distinguish orthostatic dizziness/vertigo due to global brain hypoperfusion from that caused by other etiologies. Diagnosis of hemodynamic orthostatic dizziness/vertigo requires: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) orthostatic hypotension, postural tachycardia syndrome or syncope documented on standing or during head-up tilt test; and C) not better accounted for by another disease or disorder. Probable hemodynamic orthostatic dizziness/vertigo is defined as follows: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) at least one of the following accompanying symptoms: generalized weakness/tiredness, difficulty in thinking/concentrating, blurred vision, and tachycardia/palpitations; and C) not better accounted for by another disease or disorder. These diagnostic criteria have been derived by expert consensus from an extensive review of 90 years of research on hemodynamic orthostatic dizziness/vertigo, postural hypotension or tachycardia, and autonomic dizziness. Measurements of orthostatic blood pressure and heart rate are important for the screening and documentation of orthostatic hypotension or postural tachycardia syndrome to establish the diagnosis of hemodynamic orthostatic dizziness/vertigo.

[The significance of directional preponderance in the evaluation of vestibular function in patients with vertigo]

Objective: To analyze the relationship between directional preponderance (DP), spontaneous nystagmus(SN) and vestibular disorders, and to investigate the significance of DP in directing peripheral vestibular function in patients with vertigo. Methods: This was a retrospective analysis of 394 cases diagnosed with peripheral vestibular disease accompanied by vertigo from March 2012 to June 2014 in the Outpatient Department of the Eye & ENT Hospital of Fudan University. Results of static and dynamic posture equilibrium tests, SN, unilateral weakness(UW), and DP in videonystagmography(VNG) were analyzed and compared. Results: The mean interval time between the last vertigo attack and examination in patients with SN or DP in caloric test were 4.4 d and 7.3 d respectively, and those without SN or DP were 18.3 d and 17.5 d respectively. The patients were divided into two groups according to DP results of caloric test. DP-normal group had 203 cases and DP-abnormal group had 191 cases. Spontaneous nystagmus was presented in 44 cases in the DP-normal group (21.67%) and four in the DP-abnormal group (2.09%). A significant difference was found between the two groups (χ²=35.27, P=0.000). Deficiency of vestibular function was noted in 165 cases in the DP-normal group (81.28%) and 123 (64.40%) in the DP-abnormal group in static and dynamic posture equilibrium tests. The difference between the two groups was statistically significant (χ²=14.26, P=0.000). Conclusion: Compared with DP-normal patients, DP-abnormal patients are more likely to have spontaneous nystagmus and balance disorders due to vestibular dysfunction.

[Vertigo/dizziness and syncope from a neurological perspective]

Vertigo/dizziness and syncope are among the most frequent clinical entities encountered in neurology. In patients with presumed syncope, it is important to distinguish it from neurological and psychiatric diseases causing a transient loss of consciousness due to another etiology. Moreover, central nervous disorders of autonomic blood pressure regulation as well as affections of the peripheral autonomic nerves can be responsible for the onset of real syncope. This is particularly relevant in recurrent syncope. Vertigo occurs in the context of temporary disorders, relatively harmless diseases associated with chronic impairment, as well as in acute life-threatening states. Patient history and clinical examination play an important role in classifying these symptoms. It is of crucial importance in this context, e.g., to establish whether the patient is experiencing an initial manifestation or whether such episodes have been known to occur recurrently over a longer period of time, as well as how long the episodes last. Clinical investigations include a differential examination of the oculomotor system with particular regard to nystagmus. The present article outlines the main underlying neurological diseases associated with syncope and vertigo, their relevant differential diagnoses as well as practical approaches to their treatment.

[Peripheral vertigo versus central vertigo. Application of the HINTS protocol]

INTRODUCTION

One of the most important dilemmas concerning vertigo in emergency departments is its differential diagnosis. There are highly sensitive warning signs in the examination that can put us on the path towards finding ourselves before a case of central vertigo.

AIM

To determine how effective the application of the HINTS protocol is in the diagnosis of cerebrovascular accidents that mimics peripheral vertigo.

PATIENTS AND METHODS

We conducted a descriptive observation-based study on patients admitted to hospital with a diagnosis of acute vestibular syndrome in the emergency department. All the patients were monitored on a day-to-day basis until their symptoms improved, with information about nystagmus, the oculocephalic manoeuvre and the skew test. The results from the magnetic resonance imaging study were compared with the alteration of any of those three signs during the time the patient was hospitalised.

RESULTS

Altogether 91 patients were examined, with a mean age of 55.8 years. A cerebrovascular accident was observed in eight cases. Of these (mean age: 71 years), in seven of them there were alterations in some of the HINTS signs, and in one case the study was normal (sensitivity: 0.88; specificity: 0.96). All of them had some vascular risk factor.

CONCLUSIONS

Faced with a patient who visits the emergency department with an acute vestibular syndrome, a suitably directed examination is essential to be able to establish the differential diagnosis between peripheral and central pathology, since some cerebrovascular accidents can present with the appearance of acute vertigo. Applying a protocol like HINTS makes it possible to suspect the central pathology with a high degree of sensitivity and specificity.

[Comparison of anxiety and depression state among patients with different type of vestibular peripheral vertigo]

OBJECTIVE

To investigate and analyze the status of anxiety and depression among patients with four types of peripheral vertigo.

METHOD

The clinical data of patients with one of the four types of peripheral vertigo, namely benign paroxysmal positional vertigo (BPPV), vestibular migraine (VM), Menière's disease (MD), and vestibular neuritis (VN), were collected. Thorough otological and neuro-otological examinations were performed on these patients, and their status of anxiety and depression were assessed using self-rating anxiety scale (SAS) and self-rating depression scale (SDS).

RESULT

A total of 129 patients with one of the four types of peripheral vertigo(49 cases of BPPV, 37 cases of VM, 28 cases of MD and 15 cases of VN) were included in the study. The scores of SAS and SDS were higher in the patients with VM or MD than those with BPPV or VN (P < 0.05), and the incidence of anxiety (VM = 45.9% MD = 50.0%) and depression (VM = 27.0% MD = 28.6%) were higher in the patients with VM or MD than those with BPPV or VN (P < 0.05). Paired comparisons showed the differences between the incidences of BPPV and MV groups, BPPV and MD groups, and MD and VN groups were statistically significant (P < 0.05).

CONCLUSION

Among patients with different types of peripheral vertigo, anxiety/depression is more common in patients with VM or MD. This may be due to the different mechanisms involved in different types of vertigo, as well as differences in the prevention and self-control of the patients against the vertigo.

[Vertigo from the practitioner's standpoint]

One third of the population suffer from vertigo at some stage of their life. Some of its causes are harmless, some life-threatening, some will resolve spontaneously and some never. Vertigo is divided into four main types: vertigo, syncope, disturbance of balance and nonspecific vertigo. Medical history is the most important method of examination and leads to diagnosis in two out of three cases. Attempts are always made to provoke the sensation of vertigo and the possible nystagmus during the consultation. The success of the specific treatment in accordance with the primary cause determines the patient's prognosis.

The nervous system: conditions involving the nervous system can present in many different ways

Vertigo is a fairly common complaint encountered by medics. It is very upsetting and unpleasant for the patient, but it is usually benign and resolves on its own. However, it is vital that the medic be able to differentiate between common vertigo and a more serious condition like stroke. Careful attention to history and physical exam will allow medics to make the right determinations.

Unsteadiness and drunkenness sensations as a new sub-type of BPPV

AIM

Benign Paroxysmal Positional Vertigo (BPPV) represents at least 35% of vertigo cases and perhaps much more. The aim of this study was to review a proposed new type of BPPV which may be detected by using a mechanical assistance in BPPV diagnostic and therapeutic maneuvers. MATERIELS AND METHODS: The prospective study extracted subjects from 465 patients who presented with some positional vertigo or unsteadiness. Only 152 dizzy patients, who presented with positional nystagmus but no true vertigo, were included. The TRV armchair permits rotation of patients wearing infrared video goggles in all semi-circular planes. Treatment effectiveness was defined as absence of symptoms or findings 3 days after the therapy sessions. If not initially successful, repeat therapeutic sessions were performed or patients underwent further vestibular examination and sometime MRI.

RESULTS

One hundred nine of the 152 patients demonstrated a low level canalithiasis showing nystagmus. Unusual data were collected: Ninety seven had a lateral canal and 12 had posterior canal conditions. The average of the patients was 62 and they had an average of 1.6 mechanical therapeutic maneuvres to reach the success end-point.

CONCLUSION

Some patients have persistent unsteadiness or drunkenness sensations after being treated by conventional maneuvers for BPPV. Often considered a post-BPPV otolithic syndrome an alternative possibility is BPPV with a very few otoliths in the lateral canal. The therapeutic technique using the mechanical chair permits to improved diagnosis of canalithiasis, especially that involving the horizontal canals. Some mild dizziness, which may be disabling and chronic can be better investigated and treated with mechanical assistance.

Nystagmus parameters and subtypes of benign paroxysmal positional vertigo

CONCLUSION

Although computational models suggest the existence of canalithiasis and cupulolithiasis subtypes of benign paroxysmal positional vertigo (BPPV), these subtypes cannot be distinguished from each other based on characteristics of nystagmus. Therefore, although the subtypes probably exist more information is needed from each patient than is available without invasive procedures. Also, some patients may have clinical syndromes that include both canalithiasis and cupulolithiasis subtypes.

OBJECTIVE

To determine if the parameters of nystagmus provide sufficient information to determine the subtype of nystagmus in a patient with BPPV.

METHODS

Patients (n = 118) had unilateral BPPV of the posterior canal; 15 patients also had BPPV of the lateral canal. The main outcome measures were parameters of nystagmus in response to the Dix-Hallpike maneuver: latency to onset of nystagmus, maximum slow phase velocity, and maximum duration.

RESULTS

Correlations between pairs of variables showed minimal or no relationships. Also, cluster analyses showed no significant subtypes. The contralateral eye moved significantly faster than the ipsilateral eye.

The borderland of epilepsy: clinical and molecular features of phenomena that mimic epileptic seizures

Paroxysmal losses of consciousness and other episodic neurological symptoms have many causes. Distinguishing epileptic from non-epileptic disorders is fundamental to diagnosis, but even this basic dichotomy is often challenging and is certainly not new. In 1907, the British neurologist William Richard Gowers published his book The Border-land of Epilepsy in which he discussed paroxysmal conditions "in the border-land of epilepsy-near it, but not of it" and their clinical differentiation from epilepsy itself. Now, a century later, we revisit the epilepsy borderland, focusing on syncope, migraine, vertigo, parasomnias, and some rarer paroxysmal disorders. For each condition, we review the clinical distinction from epileptic seizures. We then integrate current understanding of the molecular pathophysiology of these disorders into this clinical framework. This analysis shows that, although the clinical manifestations of paroxysmal disorders are highly heterogeneous, striking similarities in molecular pathophysiology are seen among many epileptic and non-epileptic paroxysmal phenomena.

On machine learning classification of otoneurological data

A dataset including cases of six otoneurological diseases was analysed using machine learning methods to investigate the classification problem of these diseases and to compare the effectiveness of different methods for this data. Linear discriminant analysis was the best method and next multilayer perceptron neural networks provided that the data was input into a network in the form of principal components. Nearest neighbour searching, k-means clustering and Kohonen neural networks achieved almost as good results as the former, but decision trees slightly worse. Thus, these methods fared well, but Naïve Bayes rule could not be used since some data matrices were singular. Otoneurological cases subject to the six diseases given can be reliably distinguished.

[Vertigo in children]

Vertigo is uncommon in children, but it is usually underecognized and it has not been well referenced in the medical literature until the 1980s. It is defined as a subjective sensation of movement of the body or the surrounding, and it is a symptom that may have multiple causes. This paper reviews the different types of vertigo in children, emphasizing their clinical features that may be useful in establishing the diagnosis. Of particular relevance is an accurate clinical history and a complete otologic and neurologic examination. More common causes of pediatric vertigo are otitis media and migraine variants, particularly benign paroxysmal vertigo. An appropriate approach to the child with vertigo begins with the clinical suspicion, based on a detailed clinical history and examination, and specific tests. Diagnosis should be followed by adequate symptomatic treatment and management of the underlying specific causes.

Rezidivierende Tiefton-Hörverluste ohne Schwindel – ein eigenes Krankheitsbild?

BACKGROUND

Besides the typical attacks of dizziness, recurrent low-frequency sensory hearing loss--together with mostly low-frequency tinnitus--is also a characteristic sign of Menière's disease. It is therefore often assumed to be a prodromal sign of Menière's disease, even without dizziness.

METHODS

During our longitudinal study, which was started in 1995, we reported that there were 81 patients with recurrent low-frequency hearing loss with no initial vertigo in the first suspense year of 1999. After a further 6 years, we investigated 46 (57%) of these original 81 patients in the second suspense year, 2005, for new components of vertigo, with the questions of development of Menière's disease and further development of the patients' hearing ability and psychic situation in mind.

RESULTS

In all, 12 (26%) of the 81 former patients suffered from vertigo, but only 4 (9%) had developed the typical signs of full-blown Menière's disease with the typical labyrinthine vertigo. Of the 12 patients who suffered from vertigo, 6 (13% of the 81 with vertigo) were diagnosed with psychogenic vertigo, 1 (1%) suffered from benign and treatable paroxysmal positional vertigo and 1 (1%) had developed vertigo after acoustic neurinoma surgery.

CONCLUSIONS

We conclude from our observations that, although almost every patient with Menière's disease suffers from recurrent low-frequency hearing loss, only a few patients with recurrent hearing loss develop Menière's disease. However, many patients with low-frequency sensory hearing loss develop anxiety leading to psychogenic dizziness in fearful expectation of "imminent" Menière's disease. We found that 26% of the patients had persisting bilateral normacusis in the low-frequency ranges, while 34% had unilateral hearing loss that was sufficiently severe to affect their lives and 39%, bilateral hearing loss; however, none of the patients became completely deaf.

What is the true incidence of horizontal semicircular canal benign paroxysmal positional vertigo?

OBJECTIVE

To assess the correct incidence of horizontal semicircular canal (H-SCC) benign paroxysmal positional vertigo (BPPV).

STUDY DESIGN

Retrospective assessment of patients with BPPV.

METHODS

All patients with BPPV were included and the rates of involvement of posterior, horizontal, and anterior SCCs were determined.

RESULTS

One hundred sixty-nine patients with the diagnosis of BPPV were evaluated. One hundred forty-four patients (85.2%) were found to have posterior SCC (P-SCC) involvement, and there were 20 patients (11.8%) with horizontal SCC (H-SCC) and 2 patients (1.2%) with anterior SCC (A-SCC) involvement. Three patients (1.8%) had simultaneous H-SCC and P-SCC BPPV ipsilaterally. Geotropic nystagmus was seen in 17 out of 23 patients (73.9%) in roll test, and ageotropic nystagmus was seen in the remaining 6 patients (26.1%).

CONCLUSION

H-SCC constitutes 13.6% of all BPPV cases. H-SCC BPPV with geotropic nystagmus is more common. H-SCC BPPV can coexist with ipsilateral P-SCC BPPV. However, in some cases of H-SCC BPPV, Dix-Hallpike maneuver can cause vertigo and horizontal nystagmus. This may be confused with P-SCC BPPV. Therefore, the roll test must be performed in all cases in addition to Dix-Hallpike maneuver and both ears must be evaluated with respect to all SCCs for BPPV.

EBM RATING

C-4.

Initial evaluation of vertigo

Dizziness is one of the most common reasons patients visit their physicians. Balance control depends on receiving afferent sensory information from several sensory systems: vestibular, optical and proprioceptive. Bioelectric signals, generated by body movements in the semicircular canals and in the otolithic apparatus, are transported via the vestibular nerve to the vestibular nucleus. All four vestibular nuclei, located bilaterally in medial longitudinal fasciculus, are linked with central nervous system structures. These central nervous system structures are involved in maintaining visual stability, spatial orientation and balance control. Nystagmus is a result of afferent signals balance disorders. Nystagmus due to peripheral lesions is conjugate nystagmus, because there is a bilateral central connection. Lesions above the vestibular nuclei induce deficits in synchronization and conjugation of eye movements, thus the nystagmus is dissociated. This paper shows that in peripheral vestibular disorders spontaneous nystagmus is rhythmic, associated, horizontal-rotatory or horizontal, with subjective sensation of dizziness which decreases with time and harmonic signs whose direction coincides with the slow phase of nystagmus and it is associated with mild disorders during pendular stimulation with statistically significant vestibular hypofunction. Spontaneous nystagmus in central vestibular lesions is severe, dissociated, horizontal, rotatory or vertical, without changes related to optical suppression; if vestibular symptoms are present, they are non-harmonic. In central disorders, findings after thermal stimulation are either normal or pathological, with dysrhythmias and inhibition in pendular stimulation. This paper deals with differential diagnosis of vertigo based on anamnesis and clinical examination, as well as objective diagnostic tests. .

[True or false vertigo: a true or false question?]

Some practitioners ask on which criteria vertigo can be considered as "true" or "false". The goal of this paper is to explain why such a concept is misleading. Vertigo and imbalance are subjective symptoms caused by many possible factors, somatic or psychologic, which may cause, in turn, psychological distress in some patients. In all cases, the complain is "true", even in case of psychological disorder. To evaluate patients suffering from vertigo, knowledge in anatomy and physiology are necessary as well as knowledge of the interface between neuro-totologic and psychiatric conditions.

[Vertigo and pathology of the cerebellospinal system]

Central vertigo is most often expressed by a feeling of dizziness, non or badly systematized, but it can also appear, more seldom, like an isolated acute vertigo or associated to other neurological signs. A precise clinical exam can lead to evidence essential clinical informations (significant ataxia, neurological signs, gaze nystagmus, pursuit anomaly,...). Almost all acute lesions of central vestibular pathways, as for the peripheral ones, lead to a harmonious vestibular syndrome. The vascular lesion of the vertebro-basilar territory and multiple sclerosis are two main causes to it. The pseudo-labyrinthine forms are essentially described in occlusion infarcts of the AICA and PICA, but a hematoma can lead to the same picture; the diagnostic of multi- or monosymptomatic forms with a peripheral lesion is often very difficult, the classical classification of the central and peripheral vestibular syndromes has become obsolete and should be abandoned.