[Brain perfusion disturbances in patients with vertigo -- a study with SPECT]

BACKGROUND AND PURPOSE

The aim of our study was to evaluate brain perfusion in patients with vertigo using the SPECT technique.

METHODS

The study involved a group of 32 patients and was performed in the Neurological Department of the Medical University in Bialystok. Patients with vertigo of peripheral origin like middle ear pathology were excluded from the study. Tomographic pictures were taken with Nucline X-Ring camera after administration of Tc99m-ECD. Perfusion maps were estimated by qualitative and semi-quantitative methods.

RESULTS

In 8 patients (25%) perfusion maps were normal in the hemispheres, cerebellum and subcortical structures. In 10 patients (31.2%) there was a substantial decrease in perfusion in the left temporal region, in 8 patients (25%) -- hypoperfusion was seen in the right temporal region. In 4 patients (12.5%) there was a substantial decrease in perfusion in the cerebellum, in two persons -- in the frontal lobes.

CONCLUSIONS

The results obtained so far confirm the major role of ischemia in etiology of the central origin vertigo and balance disturbances. It involves not only the brainstem and cerebellar structures, but the temporal lobes as well. The test has also proved that the qualitative and semi-quantitative methods of assessing brain perfusion with a SPECT are satisfactory in diagnostics of vertigo.

Canalolithiasis of the superior semicircular canal: an anomaly in benign paroxysmal vertigo

According to the canalolithiasis theory, benign paroxysmal vertigo (BPPV) is caused by gravity-dependent movements of otoconial debris that collects in the endolymph of the posterior semicircular canal. Other parts of the vestibular organ are rarely affected, and it is mainly the horizontal canal that is affected by this atypical form of BPPV. Canalolithiasis of the superior semicircular canal must be considered an anomaly because the superior semicircular canal is the highest point of the vestibular organ and debris normally cannot collect in this special location. Until now, BPPV of the superior canal has mainly been dealt with theoretically in the literature. The authors present three patients with canalolithiasis of the superior semicircular canal and offer direct proof of the condition using high-resolution 3D MRI.

[Study on the causes and risk factors on vertigo and balance disorders in 118 elderly patients]

OBJECTIVE

To understand the various factors causing vertigo and balance disorders in the elderly.

METHODS

118 elderly patients (aged equal or older than 60 years of age) with vertigo or balance disorders were retrospectively analyzed through clinical symptoms, audio-vestibular function tests, X-ray, CT scan or MRI in cervical vertebras, brain and inner ears, ultrasonography, transcranial doppler (TCD) or magnetic resonance angiography (MRA) in blood vessels on head and neck.

RESULTS

Of 118 patients, 70 (23%) of them suffered perip heral vestibular disorders while 29 (58%) having cerebral vertigo or dizzness, leaving 19 cases (16%) as unclassified.

CONCLUSION

For elderly patients, vertigo and balance disorders were commonly caused by many kinds of peripheral and cerebral vestibular pathological disfunctions while the functional weakness of vestibular organs and systems affected by the physiological process of ageing and different concommitant diseases as well as environmental, psychogenic factors should also be considered.

Cupular deposits and aminoglycoside administration in human temporal bones

In this study, the deposits of basophilic material on the cupula of the semicircular canals in temporal bones from patients who had aminoglycoside administration within six months prior to death were compared with normal temporal bones. Subjects were divided into two groups. Group I included 24 normal control temporal bones age-matched to group II patients. Group II consisted of 23 temporal bones that had received aminoglycosides within six months prior to death. All temporal bones were examined under light microscopy. One (4.2 per cent) of 24 temporal bones in group I (normal) showed basophilic deposits. In group II, deposits were observed in 8 (34.8 per cent) of 23 temporal bones. The prevalence of basophilic deposits in group II was significantly higher than group I. This study demonstrates that within six months after aminoglycoside administration there is an increased prevalence of basophilic deposits on the surface of the cupula. Such changes may be related to the benign paroxysmal positional vertigo (BPPV) seen in some patients who have had aminoglycoside administration.

Experimental selective posterior semicircular canal laser deafferentation

In this experimental study, we attempted to perform selective deafferentation of the posterior semicircular canal ampulla of guinea pigs using carbon dioxide laser beam. The results of this study document the efficacy of this procedure in achieving deafferentation of the posterior semicircular canal safely with regards to the other semicircular canals, the otolithic organ and the organ of hearing. Moreover, the procedure is performed with relative ease compared with other procedures previously described for selective deafferentation of the posterior semicircular canal. The clinical application of such a procedure for the treatment of intractable benign paroxysmal positional vertigo in humans is suggested.

Image fusion of CT and MRI for the visualization of the auditory and vestibular system

The aim of this study was to perform a realistic visualization of the auditory and vestibular system using volume data sets from high-resolution computed tomography (HR-CT) and high-resolution magnetic resonance imaging (HR-MRI). - In 10 patients with conductive and/or sensorineural hearing loss, vertigo and tinnitus, HR-CT and HR-MRI of the petrous bone were performed consecutively. CT was performed with a 16-slice computed tomography scanner using a high spatial resolution. MRI was performed with a 3.0 Tesla scanner using a three-dimensional-constructive interference in steady state (3D-CISS) gradient-echo, and T2-weighted, unenhanced and gadolinium (GD)-enhanced T1-weighted turbo spin-echo sequences. The middle ear structures were interactively segmented and visualized with a color-coded shaded-surface rendering method using the HR-CT volume data sets. The inner ear structures were interactively segmented and visualized with a color-coded shaded-surface rendering method using the high-resolution 3D-CISS MRI volume data sets. Finally, both shaded-surface rendered models were superimposed semi-automatically using a commercial available software program to visualize the auditory and vestibular system. - The representation of the middle and inner ear structures with image fusion of HR-CT and HR-MRI takes advantage of both the high bony contrast of HR-CT and the high soft tissue contrast discrimination and sensitivity to fluids of HR-MRI, as well as the high spatial resolution of both modalities. In comparison to the fused axial CT/MRI, the images of 3D CT/MRI fusion facilitates a clear representation and better spatial orientation. - The middle and inner ear consists of bony structures, soft tissue structures and fluid-filled spaces. For this reason, the image fusion of volume data sets from HR-CT and HR-MRI allowed an optimized and realistic visualization of the auditory and vestibular system.

Episodic vertigo

PURPOSE OF REVIEW

This review focuses on three neuro-otological syndromes, which are all marked by rapid scientific progress on the one hand but under-recognition or undertreatment on the other: benign paroxysmal positional vertigo and its variants, superior semicircular canal dehiscence syndrome, and migrainous vertigo.

RECENT FINDINGS

The efficacy of Epley's maneuver for treatment of benign paroxysmal positional vertigo has been convincingly demonstrated by a meta-analysis of nine randomized controlled trials. Head vibration during Epley's procedure and keeping upright for 48 h after effective treatment do not improve the outcome. Superior canal dehiscence syndrome presents not only with sound and pressure-induced vertigo but also with conductive hearing loss at low frequencies. Migrainous vertigo may present not only with spontaneous attacks but also with positional vertigo or with chronic dizziness and imbalance. Vestibular rehabilitation has been proven to relieve chronic dizziness and visual vertigo.

SUMMARY

Recent studies have eliminated several white spots on the neuro-otological map. However, many areas are still unexplored, particularly with regard to treatment of specific vestibular syndromes where randomized controlled trials are just at their beginning.

Vertigo and medico-legal problems

Forensic medicine deals with the interactions of medical science with the law. All branches of medicine can play a role in dealing with medico-legal problems. Clinical and forensic evaluators need to be able to recognize variations of symptoms or syndromes that "don't read the textbooks". Atypical presentations of dizziness or vertigo have the potential to cause much confusion in diagnosis, treatment planning, and legal adjudication, if not correctly recognized. This article describes the forensic medicine in the legal system and forensic aspects of other medical specialities, gives an overview about medico-legal viewpoint of vertigo, and underlines the importance of objective clinical and forensic evaluation of the patient with vertigo.

[Benign paroxysmal positional vertigo of the anterior semicircular canal: clinical aspects and treatment]

OBJECTIVE

To describe the videonystagmographic characteristics and the treatment of the patients reached with a canalolithiasis or a cupulolithiasis of the anterior semicircular canal.

MATERIAL AND METHOD

Retrospective study concerning patients treated for a Benign Paroxysmal Positional Vertigo (BPPV) of the anterior semicircular canal. Each patient after analysis under videonystagmoscopy (VNS) and under videonystagmography (VNG) was treated by maneuvers.

RESULTS

On 462 observations of typical BPPV 6 cases of VPPB of the anterior semicircular canal were treated concerning 5 patients (1.3%).

CONCLUSION

The BPPV of the anterior semicircular canal are rare. We modified our method of diagnosis, and our therapeutic techniques could be validated with the help of the two-dimensional videonystagmography.

[Vertigo and pathology of the cerebello-pontine angle]

Many pathologies of the cerebello-pontine angle can induce vertigo or dizziness. Usually they are due to benign or malignant tumors. Pathophysiology of this vertigo involve lesion of the labyrinth with erosion, of the endolymphatic sac by invasion or compression, or directly by lesion of the vestibular nerve like in vestibular schwannomas. The vestibular nerve can also be injured by extrinsic compression like in meningiomas. Finally very big tumors can be compressive on the cerebellum or on the brainstem inducing also dizziness. Vertigo is often an important symptom of cerebello-pontine angle tumors. In association with others it will guide the diagnosis. Nevertheless, auditory evoked potentials, video-nystagmography, and otolithic evoked potentials are very important to determine exactly if the vestibular nerve is injured and if there are signs of central compression before surgery.

Temporal bone histopathology in dominantly inherited audiovestibular syndrome

OBJECTIVE

To describe the clinical and pathologic features of a new dominantly inherited audiovestibular syndrome.

METHODS

History, examination, and audiometric testing in the proband, brother, and son; quantitative rotational testing in the proband and son; histopathology of the cochlea and vestibular labyrinth in the proband; sequencing candidate genes COCH and MYO7A in the brother and son.

RESULTS

Affected family members developed slowly progressive hearing loss beginning in their late 30s and progressive imbalance in their early 70s. Three of four affected had brief (minutes) episodes of vertigo typically occurring a few times per year. Auditory and vestibular function testing documented a slowly progressive loss of auditory and vestibular function. Postmortem examination showed a loss of hair cells in the cochlea and vestibular receptor organs. There were no cellular infiltrates or acidophilic deposits. No mutations were found in the COCH or MYO7A genes.

CONCLUSIONS

This dominantly inherited audiovestibular syndrome results in a selective loss of hair cells in the auditory and vestibular end organs. Finding the causative gene could have important implications for understanding the pathophysiology of presbycusis and dysequilibrium of aging.

[Alarming symptoms in vertebrobasilar circulatory disorders. Part I]

Dizziness and vertigo--like headache--are the most common complaints which leads patients to visit the doctor. In spite of the headache--which may be primary (e.g. migraine) or symptomatic--dizziness and vertigo do not appear to be a separate nosologic entity but rather the symptoms of several neurological disorders. For differential diagnosis, interdisciplinary thinking and activity is needed because the vestibular, neurological and psychiatric disorders might have a common role in the development of symptoms and further overlapping can also occur. The vascular disorders of the vertebrobasilar system are discussed in detail in this review. The importance, occurrence and causes of vertigo as a warning symptom is in the focus. The author draws attention to life-threatening conditions with acute onset in cases of the posterior scale ischemia and emphasizes the importance of the correct and early diagnosis. The author tries to clear up the nihilistic aspect in treating of stroke and stresses the necessity of thrombolysis and interventional radiological procedures which may be the only chance for the recovery of the patients. The pharmacological prevention of recurrent vascular events is also important and obligatory for the clinicians.

Benign paroxysmal positional vertigo predominantly affects the right labyrinth

Benign paroxysmal positional vertigo (BPPV) occurs when there are freely moving particles in a semicircular canal and the head is turned in the plane of the affected canal. The aim of the present study was to clarify whether BPPV manifests equally in both labyrinths or whether there is a preponderance for one side. We conducted a PubMed literature search of BPPV case series which specified the affected side and a retrospective chart review of 80 consecutive patients with BPPV of the posterior canal who had presented at our dizziness clinic. Eighteen studies with a total of 3426 patients were identified. In our own series the right side was affected in 54 of 80 patients (right/left ratio 2.08). Altogether, in 3506 patients the right labyrinth was involved 1.41 times more often than the left (95% CI 1.37 to 1.45). We think that the reason for the predominant involvement of the right ear in BPPV is the habit-of most patients-of sleeping on the right side.

Repeated vs single physical maneuver in benign paroxysmal positional vertigo

OBJECTIVES

To evaluate the effectiveness and possible side effects of a single session of repeated particle repositioning maneuver (PRM) to treat posterior canal benign paroxysmal positional vertigo (BPPV) and the usefulness of post-treatment restrictions.

MATERIALS AND METHODS

A total of 125 consecutive patients with idiopathic BPPV participated in the study. Fifty patients received a single session of repeated PRM only (group I). Results were compared with those of 50 patients with BPPV who received a single PRM (group IIb), and 25 patients who received a single PRM followed by the use of a neck collar and keeping the head upright for 48 h (group IIa).

RESULTS

Forty-six patients (92%) of group I, 40 patients (80%) of group IIb, and 21 patients (84%) of group IIa were completely free of signs and symptoms when re-examined 1 week after treatment. Transient nausea and disequilibrium following treatment were reported equally in all subgroups and well tolerated. Nearly all patients of group IIa considered the post-treatment restrictions very inconvenient.

CONCLUSIONS

A single session of repeated physical procedure seems to be clinically superior to one single maneuver and well tolerated. Additional post-treatment measurements are inconvenient and should be abandoned.

Sudden deafness with vertigo as a sole manifestation of anterior inferior cerebellar artery infarction

Sudden deafness without associated neurological symptoms and signs is typically attributed to a viral inflammation of the labyrinth. Although sudden deafness occurs with anterior inferior cerebellar artery (AICA) infarction, the deafness is usually associated with other brainstem or cerebellum signs such as crossed sensory loss, lateral gaze palsy, facial palsy, Horner syndrome or cerebellar dysmetria. An 84-year-old woman suddenly developed right-sided tinnitus, hearing loss, vertigo and vomiting. Audiometry and electronystagmography documented absent auditory and vestibular function on the right side. T2-weighted and diffusion-weighted MRI showed a tiny infarct in the right lateral inferior pontine tegmentum. AICA occlusion can cause sudden deafness and vertigo without brainstem or cerebellar signs.

Neuroradiological features of vertigo

The diagnostic pathway in a patient with vertigo starts with the accurate evaluation of medical history followed by a general physical and neurological examination. This step can often lead to the identification of the correct cause of the disease or, at least, to a distinction between peripheral and central vertigo. Neuroradiological investigations have to be considered as elective diagnostic procedures and include: computed tomography (CT), magnetic resonance (MR), MR angiography (MRA), angiography. For the diagnosis of peripheral vertigo, benign paroxysmal positional vertigo, labyrinthitis, Meniere disease, perilymphatic fistula, local trauma, toxic labyrinthitis, acute otitis media and chronic middle ear effusion,the role of imaging techniques is controversial. CT and MR are performed to rule out other pathologies and to confirm the diagnosis. Increased resolution and application of special MR sequences enhancing the intralabyrinthine fluids have enabled more detailed analysis of labyrinthine structures and pathology. Both T2 and T1 contrast sequences are necessary. A high resolution CT study is required when otitis media is suspected and in the follow-up of post-traumatic vertigo. The causes of central vertigo are numerous and include: vertebro-basilar circulation vascular events, multiple sclerosis (MS), migraine-associated vertigo, cerebellar and brainstem tumors, CNS infections. Among them cerebrovascular ischemia and multiple sclerosis are the most frequent. In these situations imaging studies become mandatory. CT can diagnose most cerebellar hemorrhages and some cerebellar and brainstem acute ischemia, enhanced MR has proved to be the most sensitive tool to detect posterior fossa lesion. Diffusion-weighted MR can reveal acute ischemic changes before routine MR. There has been evidence that MR angiography, providing angiogram-like images of the intracranial vessels may sometimes avoid invasive angiography. MRA resolution is not as good as traditional angiography and may also be compromised by movements and other artifacts. Selective angiography of the posterior circulation is often indicated for therapeutic decisions.

Horizontal canal benign paroxysmal positioning vertigo with ipsilateral hearing loss

The etiology of benign paroxysmal positioning vertigo (h-BPPV) of the horizontal semicircular is unknown. Insight was obtained from two patients with h-BPPV and associated hearing impairment. Based on the different inner ear lesion patterns in neurolabyrinthitis contrary to ischemic labyrinthine infarction we assessed multiple vestibulo-cochlear functions for the first time in two patients who suffered from h-BPPV with sudden unilateral hearing loss. While in patient no. 1 the lesion pattern (posterior canal paresis in addition to the sudden hearing loss) could possibly be caused by ischemia of the common cochlear artery, the lesion pattern of patient no. 2 (hearing loss and ipsilateral paresis of the posterior and horizontal semicircular canal) exceeds the typical vascular labyrinthine territories and may indicate viral neurolabyrinthitis.

Contrast enhancement of the cochlear aqueduct in MR imaging: its frequency and clinical significance

There have been no previous reports on contrast enhancement of the cochlear aqueduct in magnetic resonance imaging. The purpose of the present study was to evaluate the frequency and significance of this finding. Thirty-one patients (15 men and 16 women; age range 18-81 years) with otologic symptoms (sudden sensorineural hearing loss, vertigo, or tinnitus) were examined using contrast-enhanced imaging on a 1.5-T MR scanner. The normal ear served as the control. Two radiologists evaluated contrast enhancement in the area of the cochlear aqueduct. Forty-eight of 62 ears (77.4%) showed contrast enhancement of the cochlear aqueduct, but no significant differences in the frequency of contrast enhancement were observed between patients with and patients without vertigo, tinnitus, sensorineural hearing loss, cerebellopontine angle tumors, or a high-riding jugular bulb. In addition, no gender- or age-related differences were noted. Contrast enhancement of the cochlear aqueduct was frequently observed, but the frequency of enhancement in symptomatic ears was not significantly higher than in control ears. The results of this study may prove helpful in avoiding unnecessary examinations and potential diagnostic confusion.

Pathology of benign paroxysmal positional vertigo revisited

The pathophysiology of benign paroxysmal positional vertigo (BPPV) is not completely understood. Although the concept of degenerated otoconia transforming the posterior canal (PC) crista into a gravity-sensitive sense organ has gained popular support, several temporal bone (TB) series have revealed similar deposits in normal TBs, suggesting they are a normal change in the aging labyrinth. Furthermore, some TBs from patients with BPPV do not contain particles in the posterior canal. Five TBs from patients with BPPV were studied quantitatively and qualitatively. A small PC cupular deposit was found in 1 TB, while none was seen in the other 4 TBs. The major pathological changes were 1) a 50% loss of ganglion cells in the superior vestibular division of all 5 TBs and 2) a 50% loss of neurons in the inferior division of 3 TBs, and a 30% loss in 2 TBs that contained abnormal saccular ganglion cells. These observations support a concept in the pathophysiology of BPPV that includes loss of the inhibitory effect of otolith organs on canal sense organs.

Positional vertigo and macroscopic downbeat positioning nystagmus in spinocerebellar ataxia type 6 (SCA6)

To investigate the frequency of positioning nystagmus in degenerative ataxic disorders, we examined downbeat positioning nystagmus (DPN) in 25 patients with spinocerebellar ataxia type 6 (SCA6) and 58 patients with other types of degenerative ataxia. DPN was observed in 21 of the 25 patients with SCA6 (84 %) versus only 3 of the 58 patients (5.2 %) with other types of degenerative ataxia, including multiple system atrophy, SCA1, SCA2, SCA3/Machado-Joseph disease, and non-SCA6 late-onset pure cerebellar ataxia. Our findings indicated that DPN is a distinct part of the clinical presentation of SCA6, showing that vestibular cerebellum is more affected in SCA6 than other types of degenerative ataxia.

Sudden bilateral simultaneous deafness with vertigo as a sole manifestation of vertebrobasilar insufficiency

A 68 year old woman presented with bilateral sudden simultaneous hearing loss and transient spontaneous vertigo as a sole manifestation of vertebrobasilar insufficiency. Extensive investigation to exclude other causes was unremarkable. Magnetic resonance imaging of the brain, including diffusion images, showed no abnormalities. A magnetic resonance angiogram showed severe stenosis of the middle third of the basilar artery. A pure tone audiogram showed moderate sensorineural-type hearing loss bilaterally. The localisation and mechanism of an isolated cochleovestibular dysfunction are discussed.

Vertigo and cranial nerve palsy caused by different forms of spontaneous dissections of internal and vertebral arteries

In this report we compare a subintimal hemorrhage of a dissected vertebral artery to a subadventitial hemorrhage of a dissected extracranial internal carotid artery. A subintimal hemorrhage compresses the lumen of the artery. Therefore, magnetic resonance imaging (MRI), angiography and ultrasound are screening methods. For the subadventitial hemorrhage, which does not really compress the lumen but forms an aneurysmal dilatation, MRI is the only method of choice. We describe a case in which vertigo, nausea and vomiting are the only symptoms of a subintimal vertebral artery dissection. In this case an infarction of the cerebellar region supplied by the superior cerebellar artery could be demonstrated. Our second case demonstrates a palsy of the 10th, 11th and 12th cranial nerves, which is a less frequent symptom of internal artery dissections. The palsy of these cranial nerves seems to be caused by compression of the nerves or their nutritional arteries close to the aneurysmal dilatation of the subadventitial dissected internal carotid artery. In both cases clinical symptoms were resolved after anticoagulation.

Revision surgery after saccotomy for Meniere's disease: does it make sense?

Saccotomy is an established surgical treatment for Meniere's disease that involves exposing and opening the endolymphatic sac and draining the endolymph. However, in patients experiencing recurrent vertigo after saccotomy, it is questionable whether revision saccotomy should be recommended as opposed to more invasive procedures, such as neurectomy of the vestibular nerve. To determine the utility of revision saccotomy, we conducted a retrospective study of 29 patients undergoing this procedure for recurrent vertigo. Patient charts were reviewed for the re-occurrence of any vertiginous symptoms and outcomes with regard to hearing results and post-operative complications. An attempt was made to correlate vertigo status post-revision with surgical findings at the time of revision. After an average follow-up of 20 months, 18 patients (62%) were free of vertigo, and four patients (14%) had a significant decrease in the frequency and intensity of vertiginous attacks. Two patients (7%) relapsed after a vertigo-free period of 18 months, and five patients (17%) experienced no clinical improvement after revision surgery. In patients with a successful sac revision, a common finding at the time of revision was new bone formation in the endolymphatic sac area (n=11), which may have caused blocking of the endolymphatic drainage. Our results demonstrate that revision saccotomy should be considered for recurrent Meniere disease before other, more invasive, surgical options.

The incidence and distribution of cupular deposits in the pediatric vestibular labyrinth

OBJECTIVES

Deposits of basophilic material on the cupulae of the semicircular ducts have been described in adult human temporal bones, and such deposits have been implicated in the clinical phenomenon of benign paroxysmal positional vertigo (BPPV). Although relatively rare, BPPV has been reported to occur in children. The goal of this study was to evaluate the occurrence of cupular deposits in pediatric material.

STUDY DESIGN

Basic science, two-center histopathologic temporal bone study.

METHODS

We examined 186 temporal bones from 121 individuals between the ages of newborn and 10 years. The average age was 14.7 months. All temporal bones were acquired at autopsy, embedded in celloidin, and sectioned for light microscopic study. The cupulae of the semicircular ducts were identified and any deposits found were graded according to their size and position on the cupula.

RESULTS

A total of 276 cupulae were identified, and in 35 (12.7%) of these a basophilic deposit was found. In many cases the deposits contained recognizable otoconial crystals. Most deposits were small and they were almost equally distributed between the three semicircular ducts. However, the lateral and posterior cupulae were somewhat more involved than the superior cupula. Our data showed that cupular deposits are less frequently found in the pediatric labyrinth, compared with adults as reported in previous studies.

CONCLUSIONS

The lower occurrence in children versus adults suggests that the deposits may be a phenomenon of the aging vestibular labyrinth.

July 2001: 58-year-old man with a temporal bone mass

The July 2001 Case of the Month (COM). A 58-year-old man with right ear hearing loss since childhood presented with a two year history of dizziness and vertigo. Neuroradiological studies showed a large mass arising from the petrous portion of the temporal bone. The lesion was resected and microscopic examination revealed a cholesterol granuloma with a small component of cholesteatoma. It is important to distinguish between cholesterol granuloma and cholesteatoma because of treatment differences. However, these two entities can occasionally be seen together and rare giant variants have been described.

Spectrum of medial medullary infarction: clinical and magnetic resonance imaging findings

Among 4200 consecutive patients admitted to three hospitals with acute ischemic stroke, we found only 11 patients in whom magnetic resonance imaging (MRI) had proved that they had medial medullary infarction (MMI). In our centers, patients with MMI were less than 1% of those with vertebrobasilar stroke. The infarcts documented by MRI were unilateral in 10 patients and bilateral in one. On clinico-topographical analysis there were four clinical patterns: (1) Classical Dejerine's syndrome was the most frequent, consisting of contralateral hemiparesis, lemniscal sensory loss and ipsilateral lingual palsy in 7 of the eleven patients. (2) Pure hemiparesis was present in 2 patients; (3) Sensorimotor stroke was present in 1 patient with contralateral hemiparesis, hypesthesia and mild decrease in pain sensation without lingual palsy; (4) Bilateral MMI syndrome in 1 patient, accompanied by tetraparesis, bilateral loss of deep sensation, dysphagia, dysphonia and anarthria. Presumed causes of MMI were intrinsic branch penetrator artery disease with concomitant vertebral artery stenosis in 6 of the 11 patients, vertebral artery occlusion in 2, dolichoectatic vertebrobasilar arteries in 2, a source of cardiac embolism in 1. Prognosis at 3 months was favorable in 8 patients, but the patient with bilateral MMI syndrome had persisting motor deficit causing limitation of daily activities, and 2 died from systemic causes. The classical triad of acute MMI facilitates the diagnosis, although the recognition of this syndrome in patients with incomplete manifestations can be difficult and occurs more frequently than commonly thought. Moreover, vertebral artery atherosclerosis and branch atheromatous disease of the penetrating arteries are the main causes of medullary infarction.

The usefulness of MR imaging of the temporal bone in the evaluation of patients with facial and audiovestibular dysfunction

OBJECTIVE

To evaluate the clinical utility of MR imaging of the temporal bone in patients with facial and audiovestibular dysfunction with particular emphasis on the importance of contrast enhancement.

MATERIALS AND METHODS

We retrospectively reviewed the MR images of 179 patients [72 men, 107 women; average age, 44 (range, 1-77) years] who presented with peripheral facial palsy (n=15), audiometrically proven sensorineural hearing loss (n=104), vertigo (n=109), or tinnitus (n=92). Positive MR imaging findings possibly responsible for the patients' clinical manifestations were categorized according to the anatomic sites and presumed etiologies of the lesions. We also assessed the utility of contrast-enhanced MR imaging by analyzing its contribution to the demonstration of lesions which would otherwise not have been apparent. All MR images were interpreted by two neuroradiologists, who reached their conclusions by consensus.

RESULTS

MR images demonstrated positive findings, thought to account for the presenting symptoms, in 78 (44%) of 179 patients, including 15 (100%) of 15 with peripheral facial palsy, 43 (41%) of 104 with sensorineural hearing loss, 40 (37%) of 109 with vertigo, and 39 (42%) of 92 with tinnitus. Thirty (38%) of those 78 patients had lesions that could be confidently recognized only at contrast-enhanced MR imaging.

CONCLUSION

Even though its use led to positive findings in less than half of these patients, MR imaging of the temporal bone is a useful diagnostic procedure in the evaluation of those with facial and audiovestibular dysfunction. Because it was only at contrast-enhanced MR imaging that a significant number of patients showed positive imaging findings which explained their clinical manifestations, the use of contrast material is highly recommended.

Fluctuant, progressive hearing loss associated with Menière like vertigo in three patients with the Pendred syndrome

OBJECTIVE

To evaluate vestibular and long-term audiometric findings in patients with Pendred syndrome.

STUDY DESIGN

Retrospective analysis of long-term clinical data.

SETTING

University hospital department.

PATIENTS

Three patients with Pendred syndrome caused by a mutation in the SLC26A4 gene.

METHODS

Perchlorate discharge test, mutation analysis of the SLC26A4 gene, MR imaging of temporal bones, vestibular function test (in two cases) and serial audiometry. A saturation hyperbola with onset age was fitted to the audiometric threshold-on-age data using a nonlinear regression method. The residues remaining after regression were analyzed in a correlation analysis to detect significant ipsilateral or contralateral cofluctuation.

RESULTS

All three patients had a mutation in the SLC26A4 gene and bilateral enlarged vestibular aqueduct; two of them had a positive perchlorate discharge test but in one of two siblings this test was negative. Hearing loss was significantly progressive with significant ipsilateral and contralateral cofluctuation in all evaluable cases, combined with episodes of Menière like vertigo in two cases. The episodes of vertigo are as seen in Menière disease. One case had unilateral caloric areflexia and one had bilateral vestibular hyporeflexia, proven to be progressive in a repeat examination.

CONCLUSIONS

Patients with Pendred syndrome may exhibit progressive and fluctuant hearing loss with episodes of vertigo.

Deafness associated with vertebrobasilar insufficiency

The incidence of auditory disturbances in vertebrobasilar insufficiency (VBI) is considered much rarer than vestibular disturbances, but no routine audiometric test results for VBI patients have been published. To determine the incidence of deafness associated with VBI and the sites predominantly involved in deafness, we studied 70 vertiginous patients with VBI using a routine audiological examination and magnetic resonance imaging (MRI). MRI detected a lacunar infarct involving the cochlear nuclei in one patient, but lacunae did not involve central auditory structures in the other patients. Twenty-five patients experienced tinnitus, deafness, or both, during vertigo episodes. Audiological examinations confirmed the development of unilateral deafness in 15 (21%) patients, involving the cochlea in 14 and cochlear nuclei in one. These findings indicate that hearing loss occurs in approximately one-fifth of VBI patients, much less frequently than vestibular disturbances, and that deafness associated with VBI mainly involves the cochlea.

Perceived vertical and lateropulsion: clinical syndromes, localization, and prognosis

We present a clinical classification of central vestibular syndromes according to the three major planes of action of the vestibulo-ocular reflex: yaw, roll, and pitch. The plane-specific syndromes are determined by ocular motor, postural, and perceptual signs. Yaw plane signs are horizontal nystagmus, past pointing, rotational and lateral body falls, deviation of perceived straight-ahead to the left or right. Roll plane signs are torsional nystagmus, skew deviation, ocular torsion, tilts of head, body, and perceived vertical in a clockwise or counterclockwise direction. Pitch plane signs are upbeat/downbeat nystagmus, forward/backward tilts and falls, deviations of the perceived horizon. The thus defined vestibular syndromes allow a precise topographic analysis of brainstem lesions according to their level and side. Special emphasis is placed on the vestibular roll plane syndromes of ocular tilt reaction, lateropulsion in Wallenberg's syndrome, thalamic and cortical astasia and their association with roll plane tilt of perceived vertical. Recovery is based on a functionally significant central compensation of a vestibular tone imbalance, the mechanism of which is largely unknown. Physical therapy may facilitate this central compensation, but this has not yet been proven in prospective studies.

[The vertigo syndrome, magnetic resonance and magnetic angiography of the head in patients on a chronic hemodialysis program]

BACKGROUND

Vertiginous syndrome appears in more then 100 diseases, therefore subject of intensive investigation. Insufficient research has been done on vertiginous syndrome in patients on chronic program of haemodialisis. The aim of this study is to search anatomical and structural changes on blood vessels of the brain by neuroimaging techniques, as well as increased circulatory resistance on TCD, in patients on chronic program of haemodialysis.

METHODS

The research has been done on 30 patients with vertiginous syndrome, 22 males and 8 females, average age 45.9 years, average duration of haemodialysis 5.83 +/- 4.5. In all patients relevant diagnostic procedures had been done (EEG, TCD, audio vestibulogram, X-ray of cervical spine), and in 14 patients with increased circulatory resistance TCD we have done MRI and MRA of the brain. Pathological EEG has been found in 10%, 40% of the patients have had normal EEG finding, while 50% had slowing (non-specific disfunction) in EEG record.

RESULTS

MRI and MRA had been done in 14 patients of average age 51.21 +/- 10.82. In 13 patients we had a pathological finding of MRI and MRA, while in one patient only we had normal finding of MRA, and another one patient with normal MRI scan. In 64.2% of the sample we have had cortical cerebral atrophy, in 57.1% cortical atrophy of cerebellum, while in 35.8% apart from the mentioned changes atrophy of cerebellar vermis had been found. In 71.4% of all patients cerebrovascular disease (stroke) could be identified. Atherosclerosis changes in blood vessels of anterior or posterior circulatory segment were found in 78.5% of the patients, while spasm of arteries had been registered in 21.4% of the sample.

CONCLUSION

MRI and MRA of the brain brought light on aethiological aspect of vertigo in these patients. Results of our research indicate vascular aethiology of vertiginous syndrome in patients on chronic program of haemodialysis.

Epileptic vertigo: evidence for vestibular representation in human frontal cortex

The authors report a 5-year-old boy with episodes of epileptic rotational clockwise vertigo without nystagmus. Video-EEG monitoring showed a left frontocentral onset of epileptic discharges accompanied by complaints of vertigo. MRI showed a small low-grade astrocytoma in the left frontal middle gyrus. After lesionectomy, vertiginous seizures ceased. The patient's vertigo seems to be induced by epileptic discharges in a vestibular representation area within the frontal cortex.

Modified particle repositioning procedure

OBJECTIVES

To evaluate the efficacy of modifications to traditional particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo.

STUDY DESIGN

Prospective trial of 118 patients with cupolocanalithiasis of the posterior canal treated with three different canal-repositioning techniques.

METHODS

Results were compared with the maneuvers employed and the statistical importance of rotating patients by 360 degrees along their longitudinal axis and head shaking on reaching each single position were evaluated.

RESULTS

Treatment of patients with our maneuver, which, in comparison with traditional repositioning maneuvers, was modified by breaking the procedure up into seven positions and rotating patients by 360 degrees along their longitudinal axis, gives a higher, but not statistically significant, number of treatment successes (84.5%) than the traditional Parnes maneuver (60%) (P = .154); treatment of a third group of patients with our modified particle repositioning maneuver with the addition of head-shaking on reaching each single position gives a higher (95.6%), statistically significant number of treatment successes than traditional Parnes maneuver (P = .00011).

CONCLUSIONS

The success rates achieved from modified particle repositioning maneuvers are statistically significant. Onset or persistence of dizziness, which patients frequently complain of after liberatory maneuvers, affects only 5.6% of the patients treated. This low incidence is statistically correlated to head-shaking.

Cervical vertigo after hair shampoo treatment at a hairdressing salon: a case report

STUDY DESIGN

A case report of cervical vertigo that occurred after shampoo treatment in a hairdressing salon. Abnormalities were detected on magnetic resonance images and magnetic resonance angiography scans.

OBJECTIVES

To describe the diagnosis of cervical vertigo caused by neck hyperextension.

SUMMARY OF BACKGROUND DATA

Neck hyperextension may induce vertigo and dizziness; the pathophysiology remains unclear, however, because subjective findings are usually difficult to document.

METHODS

The diagnosis, treatment, and outcome of a patient with cervical vertigo that occurred after hair shampoo treatment in a hair dressing salon were assessed.

RESULTS

Magnetic resonance angiography demonstrated narrowing of the left vertebral artery, whereas magnetic resonance imaging showed cerebellar infarction. Treatment included rest and drugs that activate cerebral circulation and prevent platelet aggregation. Improvement was noted within few days.

CONCLUSIONS

The authors suggest that the hyperextended neck position during hair shampoo treatment in a beauty parlor may be a risk factor for back lifting or cerebellum vascular insufficiency. Public education should lead to avoidance of this position during hair shampoo treatment at hair dressing salons.

A method for quantitative assessment of vestibular otopathology

BACKGROUND

Quantitative studies of the vestibular system using serial sections from human temporal bones have been limited because it has been generally difficult to reliably differentiate hair cells from supporting cells and type I from type II hair cells.

OBJECTIVES

1. To develop a new method to overcome the above limitations and permit quantitative assessments of types I and II vestibular hair cells in archival temporal bone sections. 2. To demonstrate that this method is reliable, valid, and repeatable. 3. To describe the advantages of this method compared with other traditional techniques. 4. To discuss the potential of this method to provide new insight into the etiology, pathology, and pathophysiology of vestibular disorders.

STUDY DESIGN

Examination of archival human temporal sections prepared for conventional light microscopy.

METHODS

The method used Nomarski (differential interference contrast) microscopy to permit visualization of the cuticular plate and stereociliary bundle, to allow unambiguous identification of hair cells. Types I and II hair cells were distinguished by their morphological characteristics. The method was used to measure the density of types I and II hair cells in each vestibular sense organ. Raw-density counts were corrected for potential double counting using Abercrombie's formula.

RESULTS

Intrarater and interrater reliability was strong as judged by high Pearson and Spearman correlation values (P < .01). Abercrombie's formula was shown to be valid by comparison with counts made by an unbiased calibration technique using the optical disector principle (correlation coefficients > 0.9, P < .01).

CONCLUSIONS

The method described in this report has several advantages when compared with alternative techniques such as surface preparations. The method is applicable to archival bones, permits simultaneous evaluation of the rest of the labyrinth, is relatively inexpensive, and does not preclude other techniques of study (e.g., polymerase chain reaction and immunostaining). Case studies of temporal bones with aminoglycoside ototoxicity and Meniere's disease are used to show how this method has the potential to provide new insight into the pathology and pathophysiology of vestibular disorders.

An unusual complication of cochlear implant: benign paroxysmal positional vertigo

Three days after the initial fitting of the cochlear device a 40-year-old woman complained of severe rotational vertigo following head movements associated with neurovegetative symptoms. Otoneurological evaluation revealed a horizontal paroxysmal positional nystagmus beating towards the lowermost ear, induced by rolling the patient's head from supine both to the right or to the left lateral position suggesting the diagnosis of benign paroxysmal positional vertigo of the left horizontal semicircular canal. The nystagmus characteristics were the same whether the cochlear device was switched on or off. The hypothesis of an otolith dislodging due to the electrical stimulation during the initial fitting is discussed.

Anatomical and theoretical observations on otolith repositioning for benign paroxysmal positional vertigo

OBJECTIVE

To determine if there is an anatomic basis for the assumption that loose, "rogue" otoliths presumed to arise from the utricular macula and theorized to cause benign paroxysmal positional vertigo (BPPV) by impinging on semicircular canal ampullae could be returned to their original site by a series of changes in the position of the head called particle repositioning maneuvers (PRMs). Further, if such otolith movement were possible, once they were replaced into the utricle, would they adhere to the utricular macula?

STUDY DESIGN

Kodachrome photographs of 2-mm-thick macrosections of human temporal bones were available for evaluation. The bones were sectioned in horizontal, coronal, and sagittal planes. Rice grains were placed on the photographs of the cross-sections to demonstrate the possible paths taken by loose otoliths under the influence of gravity in different positions of the head.

RESULTS

A study of cross-sections of the temporal bone shows that loose macular otoliths after PRMs would tend to fall into the lumen of the utricle. Once the patient assumes the erect position, however, repositioned otoliths would tend to fall into the near or utriculopetal side of the cupula of the posterior semicircular canal, which opens directly into the inferior portion of the utricle, and could cause labyrinth stimulation and BPPV by the same mechanism of misplaced otoliths on the opposite or far side of the cupula. Loose otoliths in the utricle could also stimulate the horizontal ampullae.

CONCLUSIONS

PRMs do not remove or fix otoliths in any specific site in the labyrinth. Repositioning of loose otoliths onto the original site in the macula of the utricle, which lies superiorly in the vestibule, could not be accomplished by any of the repositioning maneuvers. If otoliths were to be repositioned on the utricular macula, there is no evidence that the otoliths would adhere to the macula when the patient assumes the erect position. The good results obtained by physiotherapeutic procedures suggest that some other mechanism than repositioning of otoliths is responsible for the relief of BPPV.

Solitary plasmacytoma of the skull base presenting with unilateral sensorineural hearing loss

Solitary plasmacytoma of the skull base is a rare entity with only a few reported cases in the literature. We review the literature and present our experience with this lesion that produced ipsilateral sensorineural hearing loss, vertigo and ipsilateral sixth nerve palsy.

Clinical value of MRA analysis of the vertebrobasilar system in vertiginous patients

Vertebrobasilar haemodynamics correlate closely with syndromal vertigo. The aim of this study is to examine the clinical value of MRA for evaluation of vertebrobasilar haemodynamics in vertiginous patients. We examined 40 individuals (20 with vertebrobasilar insufficiency and 20 diagnosed with other vestibular disorders). MRA results were quantified on the basis of the severity of vascular stenosis in the major arteries of the vertebrobasilar system and we analysed the relationship of these results with otoneurological diagnoses, eye-tracking tests (ETT) and optokinetic nystagmus (OKN). MRA results correlated well with otoneurological diagnoses and ETT results. Consequently, MRA can be used as a screening examination to evaluate vertebrobasilar haemodynamics and ETT may be a sensitive functional parameter of vertebrobasilar insufficiency.

Internal auditory artery infarction: clinicopathologic correlation

OBJECTIVE

To study the pathophysiology of labyrinthine infarction.

BACKGROUND

The syndrome of sudden onset vertigo or hearing loss is commonly attributed to inner ear vascular disease, yet histologic studies of isolated labyrinthine infarction in humans have been rare and have not included a complete examination of the vertebrobasilar vascular system.

METHODS

Temporal bones, brainstem, cerebellum, and the supplying blood vessels were subjected to gross and microscopic postmortem examinations in a 92-year-old woman who had a sudden onset of vertigo and hearing loss in the right ear 7 years before death.

RESULTS

There were prominent atherosclerotic changes at the vertebrobasilar junction, but the internal auditory artery and its branches were patent on both sides. Histologic studies showed degenerative changes in the cochlea and vestibular labyrinth on the right. The posterior canal ampulla and saccular macule were relatively preserved showing partial areas of intact sensory epithelium with underlying nerve fibers. The right vestibulocochlear nerve showed a fibrotic scar and multiple patchy areas of degeneration. These findings are most consistent with a transient period of reduced perfusion of the internal auditory artery.

CONCLUSION

The partial sparing of the inferior vestibular labyrinth may indicate a decreased vulnerability to ischemia because of its better collateral blood supply.

3D MRI of the membranous labyrinth. An age related comparison of MR findings in patients with labyrinthine fibrosis and in persons without inner ear symptoms

PURPOSE

We compared MRI of the membranous labyrinth in patients with chronic non-neoplastic inner ear disease and MR signs of labyrinthine fibrosis and controls depending on their age, in order to establish whether there were any MR differences regarding patient age groups, control age groups and between the patients and controls themselves.

MATERIALS AND METHODS

Clinical ENT examinations as well as a T2* weighted 3D CISS (Constructive Interference in Steady State) sequence with a slice thickness of 0.7 mm were performed. Our collective was subdivided as follows: 0-19 years (10 controls, 3 patients with chronic non-neoplastic inner ear disease), 20-49 years (55 controls, 8 patients), 50 years and older (40 controls, 22 patients). Detectability of labyrinthine structures (e.g. cochlea, vestibule, semicircular canals) and filling defects were evaluated.

RESULTS

In the 3 age-groups of the control collective no significant differences were observed in the membranous labyrinth. However differences concerning labyrinthine detectability emerged between controls and patients in both the 20-49 years and 50 years and older age groups. In the patient collective the 3 age groups showed no significant discrepancy in the mean number of lesions.

CONCLUSION

Filling defects of the membranous labyrinth on 3D CISS MR images are pathological even in older persons. We would therefore recommend high resolution T2* weighted MRI in the case of suspected labyrinthine fibrosis.

[Study of the vestibule in patients with dizziness and vertigo after 60 years of age]

Aging of the vestibular apparatus is shown to consist of processes similar to those occurring in other parts of the nervous system. The recognition of these findings is a first step in the clinical differentiation of presbyastasis from symptoms related to specific disease processes. Authors had reviewed results of otoneurological investigations in the material of 8328 patients and realised that 1034 of them (12.4%) were over-60-year-old. These patients suffered from pathology of peripheral as well as central part of vestibular system.