Prevalence of stroke in acute vertigo presentations: A UK tertiary stroke centre perspective

The reported prevalence of stroke amongst patients presenting to hospital with acute vertigo and/or imbalance is c. 5%, leading to the pervasive notion amongst emergency and stroke physicians, that stroke is uncommon in this cohort. To interrogate the veracity of this notion, we systematically and retrospectively screened the electronic care records in our institution of patients referred as suspected stroke, to a hyperacute stroke service at a large tertiary referral centre. We screened 24,310 consecutive patients' electronic case records presenting to our hospital as an emergency over a 4-month period, 332 of whom were referred as suspected stroke whose case records were assessed via structured review. Of these 332 cases, 61 presented with a vestibular syndrome, i.e. having at least one of imbalance, dizziness or vertigo. Of the 61 vestibular cases, 38 (62%) were diagnosed as stroke confirmed by imaging in 25/38 or upon clinical grounds only (13/38). None of the 38 vestibular stroke cases received thrombolysis or thrombectomy treatment. In a UK urban population (2.5mn), acute vestibular syndrome cases referred to stroke services have a 50% stroke prevalence. None of the vestibular stroke cases received hyperacute stroke treatment e.g., thrombolysis, due to delay in diagnosis. The high stroke prevalence in our cohort may indicate an excessively high threshold for referring acute vestibular cases for stroke, implying a high number of missed stroke cases. We suggest that early access to vestibular neurologists in acute vestibular cases should improve the proportion of vestibular stroke cases receiving definitive stroke treatment.

A Review of Posterior Fossa Lesions

Posterior fossa lesions can occur in patients of all ages. Patients present with subtle findings of hearing loss, tinnitus, headache, cranial neuropathies, imbalance, vertigo, nausea, and vomiting depending on the location and type of lesion. The presentation can be particularly insidious as the most common symptom is slowly progressive hearing loss. Posterior fossa lesions should be included in the differential diagnosis for patients with this presentation and appropriate audiologic testing and imaging should be performed. Management involves collaboration between multiple subspecialties and has evolved significantly over the years leading to increased patient involvement and improved outcomes.

[Correlation between video head impulse test parameters and DHI score in patients with vestibular neuritis]

Objective:To explore the correlation between the parameters of video head impulse test （vHIT）and dizziness handicap inventory （DHI） score in patients with vestibular neuritis. Methods:Clinical data of 46 patients with vestibular neuritis were retrospectively analyzed. All the patients underwent DHI evaluation and vHIT examination. They were divided into mild handicap group, moderate handicap group and severe handicap group according to DHI score. The correlations between the parameters of vHIT and DHI score were compared among the three groups. The important parameters of vHIT were compared including vestibulo-ocular reflex （VOR） gain, gain asymmetry ratio （GA）, abnormal saccade dispersion （PR%）. Results:Of the 46 patients, 10 were in the mild handicap group, 21 in the moderate handicap group, and 15 in the severe handicap group. ①In the comparison of the mean value of lateral semicircular canal VOR gain, the vHIT gain of patients with mild, moderate and severe handicap were 0.64±0.06, 0.53±0.11 and 0.37±0.10, respectively, the mean value of VOR gain was negatively correlated with DHI score among the three groups（r=-0.545, P<0.001）, and the pairwise comparisons among the three groups was statistically significant（P<0.05）. In comparison of the mean values of lateral semicircular canal GA, the GA values of mild, moderate and severe handicap groups were 46.40±21.81, 47.59±15.17 and 56.57±17.39, respectively, there was no significant linear correlation between GA values and DHI scores among the three groups（r=0.246, P>0.05）, there was no significant difference between the three groups（P>0.05）. In comparison of the mean PR% of the lateral semicircular canal, the mean PR% of patients with mild, moderate and severe handicap group were 32.00±10.62, 53.82±17.09 and 76.00±10.01, respectively, PR% was positively correlated with DHI score（r=0.726, P<0.001）, and the comparison among the three groups was statistically significant（P<0.05）. ②The vertical semicircular canal vHIT gain of patients with mild, moderate and severe handicap was 0.63±0.06, 0.52±0.15 and 0.38±0.16, respectively, the mean of VOR gain was negatively correlated with DHI score among the three groups（r=-0.487, P<0.01）, the comparison of mild-severe and moderate-severe group was statistically significant（P<0.05）, while there was no significant difference between the mild and moderate group（P>0.05）. In the comparison of the mean values of vertical semicircular canal GA, the GA values of mild, moderate and severe handicap groups were 40.40±15.31, 46.10±19.59 and 47.87±18.05, respectively, there was no significant linear correlation between GA values and DHI scores among the three groups（r=0.047, P>0.05）, there was no significant difference in GA among the three groups（P>0.05）. The PR% of patients with mild, moderate and severe handicap were 42.40±15.39, 54.14±17.60 and 64.93±10.95, respectively, there was a positive significant correlation between PR% and DHI score（r=0.454, P<0.05）, there was statistically significant in the comparison of mild-severe group（P<0.05）, while there was no statistical significance between the other groups（P>0.05）. Conclusion:The VOR gain and PR% value of vHIT in patients with vestibular neuritis are closely related to the DHI score, which can evaluate the vestibular function and the degree of vertigo.

Emergency Department Use of the HINTS Exam

The Research to Practice column is designed to improve translational research critique skills of advanced practice nurses (APNs). In this issue, the article "Diagnostic Accuracy of the HINTS Exam in an Emergency Department: A Retrospective Chart Review" is discussed in the context of a patient presenting to the emergency department (ED) with acute dizziness. The study was designed to assess the efficacy and appropriate use of the HINTS exam in the ED. Assessing and evaluating dizziness is complex, and with the growing cost associated with the ED assessment of dizziness, appropriate use of the HINTS exam could reduce cost. APNs need to be aware of the appropriateness of use when administering the HINTS exam and how to interpret the findings from the assessment. Improved awareness and education regarding the HINTS exam could streamline the workup of vertigo and dizziness in the ED.

Migrainous Vertigo, Tinnitus, and Ear Symptoms and Alternatives

Migraine headaches frequently coexist with vestibular symptoms such as vertigo, motion sickness, and gait instability. Migraine-related vasospasm can also damage the inner ear, which results in symptoms such as sudden sensorineural hearing loss and resultant tinnitus. The pathophysiology of these symptoms is not yet fully understood, and despite their prevalence, there is no universally approved management. This review summarizes the data on complementary and integrative medicine in treating patients with migrainous ear disorders.

Vestibular Migraine

PURPOSE OF REVIEW

To explore recent developments in vestibular migraine (VM).

RECENT FINDINGS

This review discusses the current diagnostic criteria for VM in the adult and pediatric populations, as proposed by the International Headache Society and Bárány Society. Recent VM studies confirm the prior findings and reveal new insights, including the wide range of vestibular symptoms, symptoms in the attack-free period, and triggers. Many patients experience persistent vestibular symptoms, even in the absence of acute attacks, which often significantly impact patients' quality of life. The syndrome of benign recurrent vertigo and its relationship to migraine, VM, and Meniere's disease is also discussed. There is a dearth of randomized controlled trials in VM treatment. Prospective and retrospective studies support the benefit of many migraine treatments are effective in VM, including neuromodulation, and calcitonin gene-related peptide monoclonal antibodies. VM affects almost 3% of the population, but remains under-diagnosed. Recent diagnostic criteria can help clinicians diagnose VM in adults and children.

Meta-Analysis of the Use of Head Impulse Test and Head Impulse Test with Direction Changing Nystagmus and Test of Skew Deviation in the Diagnosis of Peripheral Vertigo and Stroke

<b><i>Introduction:</i></b> The head impulse test (HIT) and HIT combined with direction-changing Nystagmus-Test of Skew deviation (HINTS) have been proposed as bedside tests to differentiate between peripheral and central causes of vertigo in the emergency department (ED). We conducted a meta-analysis of the HIT and HINTS tests to diagnose peripheral vertigo (PV) and central vertigo. <b><i>Methods:</i></b> Pubmed, Google Scholar, EmBase, and articles references published in English up to July 2021 were searched for keywords “vertigo” or “acute vestibular syndrome” or “dizziness” and “head impulse” and “stroke.” The bivariate method for meta-analysis was used to calculate positive (PLR) and negative likelihood ratios (NLR) and summary receiver operating characteristics area under the curve (AUC). <b><i>Results:</i></b> A total of 11 studies were included analysing both HIT (8 studies, <i>N</i> = 417) and HINTS (6 studies, <i>N</i> = 405). HIT and HINTS were performed within 24 h in 4 of 11 studies. PLR and NLR for HIT in PV was 4.85 (95% CI: 2.83–8.08) and 0.19 (95% CI: 0.12–0.29, <i>I</i>² 63.25%), respectively. The AUC for HIT the diagnosis of PV and stroke was 0.90 and 0.92, respectively. PLR and NLR for a negative HIT in stroke was 5.85 (95% CI: 3.07–10.6) and 0.17 (95% CI: 0.08–0.30), respectively. PLR and NLR for peripheral HINTS pattern for PV was 17.3 (95% CI: 8.38–32.1) and 0.15 (95% CI: 0.07–0.26), respectively. PLR and NLR for central HINTS pattern for stroke: 5.61 (95% CI: 4.19–7.7) and 0.06 (95% CI: 0.03–0.12). In all included studies, HIT and HINTS exams were administered by neurology residents or neurology specialists with additional neuro-otology or neuro-ophthalmology subspeciality experience, and two studies included ED physicians. Raters reported high degree of bias and high concern regarding applicability in most domains of the quality assessment of diagnostic accuracy studies (QUADAS-2) tool. Meta-regression did not demonstrate a statistically significant effect of publication year, time to test, and type of assessor on sensitivity or false positive rate. <b><i>Conclusion:</i></b> The HIT and HINTS exams appear to be moderately good discriminators of central and PV. However, in most papers, the tests were administered by neurologists and were evaluated beyond 24 h, which may limit utility in the ED setting.

[The application value of video head impulse test, caloric test and dizziness handicap inventory in the diagnosis of acoustic neuroma]

Objective:To explore the application value of video head impulse test（vHIT）, caloric test（CT） and the dizziness handicap inventory（DHI） in the diagnosis of acoustic neuroma（AN）, to analyze the correlation between vHIT and CT, and to determine the correlationsof tumor size, vHIT, CT and DHI score. Methods:The clinical data of 24 patients with AN who underwent surgery in our department from January 2019 to January 2022 were analyzed retrospectively, including craniocerebral MRI, vHIT, caloric test and DHI score. All the data were statistically analyzed by GraphPadPrism9.0. Results:There was a significant negative correlation between the UW value of CT and the vestibular eye reflex gain of vHIT（P<0.01, r=-0.62）. The tumor size was significantly correlated with the increase of UW value of CT（P<0.01, r=0.69）, and with the decrease of vestibulo-ocular reflex gain of vHIT（P<0.01, r=-0.53）. The average Dizziness Handicap Inventory score was 8.9±16.2, which was not correlated with tumor size（P>0.05）. Conclusion:Both vHIT and CT can effectively evaluate the vestibular function of patients with AN（and they are complementary）, and they are related to the size of the tumor and have certain value in the diagnosis of acoustic neuroma.

[Vertigo and ocular inflammation: Cogan syndrome]

BACKGROUND

Cogan syndrome is a rare inflammatory condition that mainly affects adults and is characterised by inflammation of various ocular structures and by audiovestibular symptoms such as hearing loss and vertigo.

CASE DESCRIPTION

A 63-year old woman recently diagnosed with an anterior uveitis presented at A&E with vertigo, nausea, vomiting, tinnitus and headache, and she developed bilateral sudden deafness within days. Blood testing revealed elevated inflammatory parameters, without signs of infection. Additional laboratory and imaging tests showed no abnormalities. We finally diagnosed her with Cogan syndrome. Our patient started oral prednisolon and methotrexate and she gradually improved.

CONCLUSION

Cogan syndrome is a rare inflammatory condition that warrants a multidisciplinary approach by an ophthalmologist, neurologist, ENT-physician, and rheumatologist / immunologist for swift diagnosis and treatment with immunosuppressive medication. A timely recognition of the syndrome at first presentation and with new flares improves the chances of full or partial recovery.

Treatment of Meniere's disease by Multi-session Dexamethasone Injections

BACKGROUND

Meniere's Disease (MD) is a complex and multifactorial inner ear problem characterized by episodic vertigo, unilateral sensori-neural hearing loss and tinnitus or fullness in the ear due to Endolymphatic hydrops. There are multiple treatment options available for this disease; from which cortisone therapy can be given in different routes and in different doses.

OBJECTIVES

is to identify the successfulness of treatment of MD by multi-session intra-tympanic dexamethasone injection compared to the single-session method.

METHOD

Interventional prospective study of study 70 cases of definite MD treated by 4 sessions of intra-tympanic injection weekly and compared to a control group of 66 cases of age matched patients with definite MD treated by the traditional single intra-tympanic injection. Patients In the study and the control group were observed for 6 months after the treatment for the development of any vertiginous attacks.

RESULTS

only 3 patients in the study group and 30 patients in the control group failed to respond to treatment and developed vertigo in the period of 6 months after treatment. The difference between the success rate in the two groups was statistically highly significant.

CONCLUSION

multi-session Intra-tympanic dexamethasone injection is superior to the single injection in control of vertigo in patients with definite MD.

Recognizing vestibular migraine

ABSTRACT

Vestibular migraine is a recently defined disorder that is underrecognized by clinicians across specialties. Acute attacks cause symptoms of migraine headaches as well as vestibular symptoms such as dizziness or vertigo. Further research is needed to determine the pathophysiology of vestibular migraine. No consensus treatment guidelines exist for this condition, and treatment is based on other migraine guidelines. Clinicians who are aware of vestibular migraine can speed diagnosis and treatment for patients and improve their quality of life.

Depression scores and quality of life of vertiginous patients, suffering from different vestibular disorders

Purpose

To contrast the quality of life (QoL) impairment and depression scores of patients suffering from different vestibular disorders.

Methods

301 patients were examined due to vertiginous complaints at the Neurotology Centre of the Department of Otolaryngology and Head and Neck Surgery of Semmelweis University. These patients completed the Hungarian version of the Dizziness Handicap Inventory (DHI), the Beck Depression Inventory, and the Symptom Checklist-90-Revised questionnaires.

Results

According to neurotological examination, the distribution of the different diagnoses was as follows: Menière’s disease (n = 101), central vestibular disorders (n = 67), BPPV (n = 47), vestibular neuritis (n = 39), other unilateral peripheral vestibulopathy (n = 18), PPPD (Persistent Postural-Perceptual Dizziness) (n = 16), vestibular migraine (n = 8), and vestibular Schwannoma (n = 5). The results of the DHI questionnaire have indicated worsened QoL in 86.4%, out of which 33.6% was defined as severe. The Beck scale has shown depressive symptoms in 42.3% of the cases, with severe symptoms in 6.3%. Significantly higher total DHI and Beck scale results were observed in patients with central vestibular disorders, vestibular migraine, PPPD and peripheral vestibulopathy, contrasted to the results of the other four diagnosis groups. The onset of the symptoms did not significantly affect the severity of QoL worsening and depression symptoms.

Conclusion

In this study, the QoL of vertiginous patients was worse in general, with the occurrence of depression symptoms. A difference was observed in the case of the values of patients with different vestibular disorders, indicating the importance of different factors, e.g., central vestibular compensation, behavioural strategies and psychological factors.

The INVEST trial: a randomised feasibility trial of psychologically informed vestibular rehabilitation versus current gold standard physiotherapy for people with Persistent Postural Perceptual Dizziness

Background

Persistent postural perceptual dizziness (PPPD) is a common and disabling functional neuro-vestibular disorder. We aimed to determine the feasibility and acceptability of conducting a randomised controlled trial of cognitive-behavioural therapy informed vestibular rehabilitation (INVEST intervention) designed for persistent dizziness.

Methods

A two-armed parallel groups randomised feasibility study of INVEST vs. a time-matched gold standard vestibular rehabilitation (VRT) control. Participants with PPPD were recruited from a specialist vestibular clinic in London, UK. Participants were individually randomised using a minimisation procedure with allocation concealment. Measures of feasibility and clinical outcome were collected and assessed at 4 months.

Results

Forty adults with PPPD were randomised to six sessions of INVEST (n = 20) or gold standard VRT (n = 20). Overall, 59% of patients screened met the inclusion criteria, of which 80% enrolled. Acceptability of INVEST, as assessed against the theoretical framework of acceptability (TFA), was excellent and 80% adhered to all 6 sessions. There were small to moderate treatment effects in favour of INVEST across all measures, including dizziness handicap, negative illness perceptions, symptom focussing, fear avoidance, and distress (standardised mean difference [SMD]_g = 0.45; SMD_g = 0.77; SMD_g = 0.56; SMD_g = 0.50, respectively). No intervention-related serious adverse events were reported.

Conclusions

The study results give strong support for the feasibility of a full-scale trial. Both arms had high rates of recruitment, retention, and acceptability. There was promising support of the benefits of integrated cognitive-behavioural therapy-based vestibular rehabilitation compared to gold standard vestibular rehabilitation. The study fulfilled all the a-priori criteria to advance to a full-scale efficacy trial.

Trial registration number

ISRCTN10420559.

Clinician's perspectives in using head impulse-nystagmus-test of skew (HINTS) for acute vestibular syndrome: UK experience

BACKGROUND

Acute vestibular syndrome (AVS) features continuous dizziness and may result from a benign inner ear disorder or stroke. The head impulse-nystagmus-test of skew (HINTS) bedside assessment is more sensitive than brain MRI in identifying stroke as the cause of AVS within the first 24 hours. Clinicians' perspectives of the test in UK secondary care remains unknown. Here, we explore front-line clinicians' perspectives of use of the HINTS for the diagnosis of AVS.

METHODS

Clinicians from two large UK hospitals who assess AVS patients completed a short online survey, newly designed with closed and open questions.

RESULTS

Almost half of 73 total responders reported limited (n=33), or no experience (n=19), reflected in low rates of use of HINTS (n=31). While recognising the potential utility of HINTS, many reported concerns about subjectivity, need for specialist skills and poor patient compliance. No clinicians reported high levels of confidence in performing HINTS, with 98% identifying training needs. A lack of formalised training was associated with onward specialist referrals and neuroimaging (p=0.044).

CONCLUSIONS

Although the low sample size in this study limits the generalisability of findings to wider sites, our preliminary data identified barriers to the application of the HINTS in AVS patients and training needs to improve rapid, cost-effective and accurate clinical diagnosis of stroke presenting with vertigo.

[The comorbid mechanism of vestibular migraine and persistent postural-perceptual dizziness]

Vestibular migraine and persistent postural-perceptual dizziness both involve the vestibular system and are similar in clinical manifestations. After acute attack of vestibular migraine, it can gradually evolve into persistent posture-perceptual dizziness; persistent posture-perceptual dizziness caused by various factors can be combined with symptoms similar to vestibular migraine. Studies have shown that abnormal multi-sensory signal integration, abnormal neurotransmitters and genetic factors may be the co-disease mechanism of the two.

A Portrait of Menière's Disease Using Contemporary Hearing and Balance Tests

OBJECTIVE

Menière's disease (MD) is characterized by recurrent vertigo and fluctuating aural symptoms. Diagnosis is straightforward in typical presentations, but a proportion of patients present with atypical symptoms. Our aim is to profile the array of symptoms patients may initially present with and to analyze the vestibular and audiological test results of patients with a diagnosis of MD.

DESIGN

A retrospective study of patient files.

SETTING

A tertiary, neuro-otology clinic Royal Prince Alfred Hospital, Sydney, Australia.

METHOD

We identified 375 patients. Their history, examination, vestibular-evoked myogenic potentials (VEMP), video head-impulse test, canal-paresis on caloric testing, subjective visual horizontal (SVH), electrocochleography, ictal nystagmus, and audiometry were assessed.

RESULTS

Atypical presenting symptoms were disequilibrium (n = 49), imbalance (n = 13), drop-attacks (n = 12), rocking vertigo (n = 2), and unexplained vomiting (n = 3), nonspontaneous vestibular symptoms in 21.6%, fluctuation of aural symptoms only (46%), and headaches (31.2%). Low velocity, interictal spontaneous-nystagmus in 13.3% and persistent positional-nystagmus in 12.5%. Nystagmus recorded ictally in 90 patients was mostly horizontal (93%) and of high velocity (48 ± 34°/s). Testing yielded abnormal caloric responses in 69.6% and abnormal video head impulse test 12.7%. Air-conducted cervical VEMPs were abnormal in 32.2% (mean asymmetry ratio [AR] 30.2 ± 46.5%) and bone-conducted ocular VEMPs abnormal in 8.8% (AR 11.2 ± 26.8%). Abnormal interictal SVH was in 30.6%, (ipsiversive n = 46 and contraversive n = 19). Mean pure-tone averages 50 dB ± 23.5 and 20 dB ± 13 for affected and unaffected ears.

CONCLUSION

Menière's disease has a distinctive history, but atypical presentations with normal vestibular function and hearing are a diagnostic challenge delaying treatment initiation.

[Dynamic changes of vestibular autorotation test in patients with unilateral vestibular dysfunction during rehabilitation]

Objective: To explore the dynamic changes of vestibular autorotation test (VAT) before and after vestibular rehabilitation treatment in patients with unilateral vestibular hypofunction (UVH). Methods: A retrospective study was carried out,48 patients who were diagnosed with UVH and under vestibular rehabilitation in department of otorhinolaryngology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, from January 2019 to January 2021 were enrolled. Among them, there were 21 males and 27 females, with an average age of 46.9 years old, including 25 cases of Meniere's disease, 13 cases of sudden deafness with vertigo and 10 cases of vestibular neuritis. The course of disease ranged from 5 days to 10 years. Demographic characteristics, detailed case data and routine examination were collected for the patients. The horizontal gain/phase, vertical gain/phase, and asymmetry of VAT at different frequencies before and after vestibular rehabilitation were collected. The absolute value of the difference between the measured value of 2.0-5.9 Hz before and after rehabilitation and the standard value were statistically analyzed. Results: Before vestibular rehabilitation, the incidence of abnormal gain was 62.5% (30/48), the incidence of abnormal phase was 56.3% (27/48), and the incidence of asymmetry was 16.7% (8/48). After 4-6 weeks of vestibular rehabilitation, the incidence of gain abnormality was 22.9% (11/48), the incidence of phase abnormality was 31.3% (15/48), and the incidence of asymmetry was 12.5% (6/48).The horizontal gain at frequency of 2.0-3.9 Hz showed statistically significant difference compared with before vestibular rehabilitation (P<0.05), and the horizontal gain at frequency of 4.3-5.9 Hz showed that there was no significant difference (P>0.05); the horizontal phase at 5.9 Hz showed that the difference was statistically significant (P=0.043), and there was no significant difference before and after rehabilitation treatment at 2.0-5.5 Hz (P>0.05); the vertical gain at 4.3 Hz showed the difference was statistically significant (P=0.020), and the remaining frequency showed no significant difference (P>0.05); No frequency of asymmetry and vertical phase showed the difference before and after rehabilitation was statistically significant (P>0.05). Conclusion: VAT can be used to monitor the change trend of multiple frequency bands before and after vestibular rehabilitation in UVH, in order to provide reference for the formulation of personalized rehabilitation strategies.

Clinical Evaluation of Neck in Patients with Proprioceptive Cervicogenic Dizziness

OBJECTIVE

To establish a functional connection between neck physical evaluations, dizziness discomfort and image findings among subjects diagnosed with proprioceptive cervical dizziness.

METHODS

After exclusion of peripheral vestibular disorders, 20 subjects with proprioceptive cervical dizziness hypothesis were selected. A Visual Analogue Scale (VAS) was used to quantify pain and vertigo. The active neck Range of Motion (ROM) and the Muscle Strength (MS) of the neck region were examined. The manipulation of vertebral bodies by the Maitland method and imaging scan were performed.

RESULTS

A positive correlation between pain and vertigo VAS scores was found. The ROM of the cervical spine was limited and vertebral joint movement was restricted, especially at C3 and C5. No loss of MS was noticed.

CONCLUSIONS

Proprioceptive cervical dizziness is usually an exclusion diagnosis among episodic chronic vertigos. Characteristically, it is reported by patients as instability or vertigo in crises. It is directly related to the neck ache severity and worsens with neck movements. The common pattern on clinical examination includes restriction and pain during neck flexion without loss of MS. Reduction of joint mobility and pain are also observed, especially at C3 and C54 kHz.

VERTIGo: A Visual Platform for Querying and Exploring Large Multilayer Networks

Many real world data can be modeled by a graph with a set of nodes interconnected to each other by multiple relationships. Such a rich graph is called multilayer graph or network. Providing useful visualization tools to support the query process for such graphs is challenging. Although many approaches have addressed the visual query construction, few efforts have been done to provide a contextualized exploration of query results and suggestion strategies to refine the original query. This is due to several issues such as i) the size of the graphs ii) the large number of retrieved results and iii) the way they can be organized to facilitate their exploration. In this article, we present VERTIGo, a novel visual platform to query, explore and support the analysis of large multilayer graphs. VERTIGo provides coordinated views to navigate and explore the large set of retrieved results at different granularity levels. In addition, the proposed system supports the refinement of the query by visual suggestions to guide the user through the exploration process. Two examples and a user study demonstrate how VERTIGo can be used to perform visual analysis (query, exploration, and suggestion) on real world multilayer networks.

Validity of the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS) in Patients With Dizziness

HYPOTHESIS

The Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS) will be a valid and reliable combined measure of depression and anxiety in people with vertigo and dizziness.

BACKGROUND

Co-occurrence of depressive, anxiety, and somatic symptoms are common. The Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder Scale-7 (GAD-7) measure symptoms of depression and anxiety respectively, although measuring them separately may be suboptimal in people who have illness-related distress. There is some evidence that these scales can be combined in long-term conditions resulting in the PHQ-ADS, but validity is yet to be determined in people with vertigo and dizziness.

METHODS

Two separate datasets from a tertiary vestibular clinic were analyzed where the PHQ-ADS was completed at initial clinical assessment (n = 624) and while on a waiting list (n = 185). A cross-sectional design was used to examine the factor structure (confirmatory factor analysis), internal consistency (omega index), and construct validity (Pearson correlation coefficient) of the PHQ-ADS. Construct validity was determined against the dizziness handicap inventory (DHI).

RESULTS

A bi-factor PHQ-ADS model had good fit to the data (χ2 = 397.163, 249.763; comparative fit index [CFI] = 0.954, 0.919; Tucker-Lewis index [TLI] = 0.938, 0.892; root mean squared error of approximation [RMSEA] = 0.076, 0.098). The general distress factor explained 81 to 85% of the common variance between items. There were moderate to large significant positive correlations between the PHQ-ADS and DHI.

CONCLUSION

The PHQ-ADS appears to have good structural validity in patients with vertigo and dizziness. Clinicians and researchers can use this scale where a composite psychological measure is desired.

Hearing Loss, Tinnitus, and Dizziness in COVID-19: A Systematic Review and Meta-Analysis

OBJECTIVES

Extensive studies indicate that severe acute respiratory syndrome coronavirus (SARS-CoV-2) involves human sensory systems. A lack of discussion, however, exists given the auditory-vestibular system involvement in CoV disease 2019 (COVID-19). The present systematic review and meta-analysis were performed to determine the event rate (ER) of hearing loss, tinnitus, and dizziness caused by SARS-CoV-2.

METHODS

Databases (PubMed, ScienceDirect, Wiley) and World Health Organization updates were searched using combined keywords: 'COVID-19,' 'SARS-CoV-2,' 'pandemic,' 'auditory dysfunction,' 'hearing loss,' 'tinnitus,' 'vestibular dysfunction,' 'dizziness,' 'vertigo,' and 'otologic symptoms.'

RESULTS

Twelve papers met the eligibility criteria and were included in the study. These papers were single group prospective, cross-sectional, or retrospective studies on otolaryngologic, neurologic, or general clinical symptoms of COVID-19 and had used subjective assessments for data collection (case histories/medical records). The results of the meta-analysis demonstrate that the ER of hearing loss (3.1%, CIs: 0.01-0.09), tinnitus (4.5%, CIs: 0.012-0.153), and dizziness (12.2%, CIs: 0.070-0.204) is statistically significant in patients with COVID-19 (Z ≤ -4.469, p ≤ 0.001).

CONCLUSIONS

COVID-19 can cause hearing loss, tinnitus, and dizziness. These findings, however, should be interpreted with caution given insufficient evidence and heterogeneity among studies. Well-designed studies and follow-up assessments on otologic symptoms of SARS-CoV-2 using standard objective tests are recommended.

[Research progress on the mechanism of comorbidities of vestibular migraine and sleep disorders]

Vestibular migraine （VM） is one of the common vestibular diseases characterized by recurrent vertigo and migraine. Studies have shown that the sleep structure of VM patients is similar to that of migraine patients, and they have a common pathophysiological pathogenesis. There is a strong correlation between VM and the clinical symptoms of sleep disorders. Sleep disorders can trigger VM. On the contrary, VM can affect sleep regulatory centers and lead to structural sleep disorders. In addition, there is a common relationship between VM and sleep disorders in neuroanatomy, neurotransmitters and neural pathways. A correct understanding of the relationship between vestibular migraine and sleep disorders can provide some help for clinical diagnosis and treatment. This article reviews the relationship between vestibular migraine and the pathogenesis of sleep disorders.

How Age Matters in the Assessment of Vertigo in the Pediatric Emergency Department: A 10-Year Age-Stratified Etiology Survey

ABSTRACT

Vertigo is a relatively frequent cause for referral to the pediatric emergency department, and it is usually caused by benign or self-limiting etiology. However, it could be difficult to evaluate especially in the younger child and could also conceal serious illness as encephalitis or cerebellitis. Our survey collected in a 10-year period 757 children assessed in pediatric emergency department for vertigo and stratified this population for etiology and for group of age: younger than 6 years (113, 14.9%), between 7 and 12 years (251, 33.2%), and older than 12 years (393, 51.9%). In addition, associated signs and symptoms, evaluation by a neurologist or an otorhinolaryngologist, and instrumental investigations were recorded.We found that age is the most important variable to assess the possibility of a central nervous system disease as etiology cause of vertigo with a significant difference of incidence between the younger group (younger than 6 years, 23%) and older groups (3% and 1%; P < 0.001).This finding should reinforce the index of suspicion for a central nervous system illness as cause of vertigo in the preschool children with an accurate workup including evaluation by a neurologist or an otorhinolaryngologist and instrumental investigations as needed.

Are the Persistent Postural-Perceptual Dizziness (PPPD) Patients More Anxious than the Patients with Other Dizziness?

BACKGROUND

The Behavioral Subcommittee of the Bárány Society Committee for Classification of Vestibular Disorders recently established the diagnostic criteria for a persistent postural-perceptive dizziness (PPPD).

OBJECTIVES

This study aims to determine how significant the degree of anxiety and depression of PPPD patients is, compared to the patients with other dizziness.

SUBJECTS AND METHODS

The study was conducted on 78 patients, 39 (50%) of whom suffer from PPPD, and of a control group consisting of the same number of patients with other types of dizziness. All the patients filled out the DHI and HADS questionnaire and were subjected to a VNG and VEMP examination.

RESULTS

The DHI showed significant disability in the majority of patients, slightly more in the control group. The HADS showed an equal degree of anxiety in both groups of patients, but significantly higher pathological anxiety in the PPPD group (49%:31%).

CONCLUSIONS

Majority of the patients in both groups experienced mild anxiety, while those with the pathological degree were more represented in the PPPD group. Depression was more expressed in the group of other dizziness. We can consider only the patients with a pathological degree of anxiety as predisposed to the emergence of PPPD.

Visual stress responses to static images are associated with symptoms of Persistent Postural Perceptual Dizziness (PPPD)

BACKGROUND

Images that deviate from natural scene statistics in terms of spatial frequency and orientation content can produce visual stress (also known as visual discomfort), especially for migraine sufferers. These images appear to over-activate the visual cortex.

OBJECTIVE

To connect the literature on visual discomfort with a common chronic condition presenting in neuro-otology clinics known as persistent postural perceptual dizziness (PPPD). Patients experience dizziness when walking through highly cluttered environments or when watching moving stimuli. This is thought to arise from maladaptive interaction between vestibular and visual signals for balance.

METHODS

We measured visual discomfort to stationary images in patients with PPPD (N = 30) and symptoms of PPPD in a large general population cohort (N = 1858) using the Visual Vertigo Analogue Scale (VVAS) and the Situational Characteristics Questionnaire (SCQ).

RESULTS

We found that patients with PPPD, and individuals in the general population with more PPPD symptoms, report heightened visual discomfort to stationary images that deviate from natural spectra (patient comparison, F (1, 1865) = 29, p < 0.001; general population correlations, VVAS, rs (1387) = 0.46, p < 0.001; SCQ, rs (1387) = 0.39, p < 0.001). These findings were not explained by co-morbid migraine. Indeed, PPPD symptoms showed a significantly stronger relationship with visual discomfort than did migraine (VVAS, zH = 8.81, p < 0.001; SCQ, zH = 6.29, p < 0.001).

CONCLUSIONS

We speculate that atypical visual processing -perhaps due to a visual cortex more prone to over-activation -may predispose individuals to PPPD, possibly helping to explain why some patients with vestibular conditions develop PPPD and some do not.

Vestibular migraine: Diagnostic criteria1

This paper presents diagnostic criteria for vestibular migraine, jointly formulated by the Committee for Classification of Vestibular Disorders of the Bárány Society and the Migraine Classification Subcommittee of the International Headache Society (IHS). It contains a literature update while the original criteria from 2012 were left unchanged. The classification defines vestibular migraine and probable vestibular migraine. Vestibular migraine was included in the appendix of the third edition of the International Classification of Headache Disorders (ICHD-3, 2013 and 2018) as a first step for new entities, in accordance with the usual IHS procedures. Probable vestibular migraine may be included in a later version of the ICHD, when further evidence has accumulated. The diagnosis of vestibular migraine is based on recurrent vestibular symptoms, a history of migraine, a temporal association between vestibular symptoms and migraine symptoms and exclusion of other causes of vestibular symptoms. Symptoms that qualify for a diagnosis of vestibular migraine include various types of vertigo as well as head motion-induced dizziness with nausea. Symptoms must be of moderate or severe intensity. Duration of acute episodes is limited to a window of between 5 minutes and 72 hours.

[Dizziness - What Next?]

Dizziness - What Next? Abstract. Dizziness is a very common symptom with an extensive differential diagnosis that includes both benign and serious conditions. Acute care physicians must be able to distinguish the majority of patients with self-limiting benign complaints from those with serious conditions. Our structured approach is intended to serve as a guide for acute medicine.

Guidelines of the French Society of Otorhinolaryngology (SFORL) for teleconsultation in patients with vertigo during the COVID-19 pandemic

OBJECTIVES

In the context of the SARS-CoV-2 pandemic, patients may have been dissuaded from seeking consultation, thus exposing themselves to a risk of loss of chance. This guide aims to define how teleconsultation can assist in assessing vertiginous adults or children, and to gather the information needed to provide quick medical care.

METHODS

These recommendations rely on the authors' experience as well as on literature. A survey on otoneurologic approach via telemedicine has been conducted based on a literature search until March 2020.

RESULTS

The first clinical assessment of the vertiginous patient via teleconsultation can only be successful if the following conditions are met: initial contact to verify the feasibility of the assessment at a distance, the presence of a caregiver in order to assist the patient, the possibility of making video recordings. Medical history via telemedicine, as in a face-to-face assessment, allows to assess the characteristics, duration, frequency, and potential triggering factors of the vertigo, in both children and adults. During teleconsultation, the following tests can be carried out: oculomotricity evaluation, assessment of balance, simple neurological tests, checking for positional vertigo/nystagmus and, eventually to perform canalith-repositioning procedures. In children, the following should be searched for: history of hearing or visual impairment, a context of fever or trauma, otorrhea, signs of meningeal irritation.

CONCLUSION

The neurotologic telemedicine relies on the accuracy of the clinical assessment, which is based on history taking and a few simple tests, encouraging the development of a decision-making algorithm adapted for teleconsultation. However, the latter has its limitations during an emergency examination of a new patient presenting vertigo, and, at least in some cases, cannot replace a face-to-face consultation. Teleconsultation is often adapted for follow-up consultations of previously selected vertiginous patients during face-to-face assessment.

Posturographic Findings in Patients With Psychological Dizziness

BACKGROUND

The diagnosis and treatment of patients with psychogenic vertigo (PSY) is difficult because of the lack of reliable objective findings for this condition. We examined the characteristics of foam posturography in patients with peripheral vestibular disorders (PVD) and those with PSY. In particular, we focused on the objective findings of foam posturography in PSY.

METHODS

Between January 2010 and December 2011, 2-legged stance tasks were conducted in patients with vertigo/dizziness under 4 conditions: eyes opened with/without foam rubber and eyes closed with/without foam rubber. In terms of the velocity of movement of the center of pressure, we examined Romberg ratios, that is, the ratios of changes in visual conditions under the fixed foam rubber conditions, and foam rubber ratios, that is, the ratios of changes in foam rubber conditions under fixed visual conditions. These ratios were compared among 3 groups: healthy controls (CONT) (n=195), PVD (n=178), and PSY (n=32).

RESULTS

Romberg ratios using foam rubber in the PVD group were significantly higher than those in the CONT group. Those in the PSY group were significantly lower. Likewise, the foam rubber ratios in the PVD group were significantly higher than those in the CONT group when the eyes were closed. Those in the PSY group were significantly lower.

CONCLUSION

Judging from scores in Romberg ratios using foam rubber and foam rubber ratios when eyes were closed, foam posturography might have the potential to differentiate PSY from PVD.

Machine learning method intervention: Determine proper screening tests for vestibular disorders

OBJECTIVE

To evaluate the performance of different vestibular indicators in disease classification based on machine learning method.

METHODS

This study use retrospective analysis of the vertigo outpatient database from a tertiary care general hospital. 1491 patients with definite clinical diagnoses were enrolled in this study. Spontaneous nystagmus, head-shaking nystagmus, positional nystagmus, unilateral weakness in caloric test, and gain and saccade in video head impulse test (vHIT) were recorded as variables. Diagnoses were mainly reorganized as acute vestibular syndrome, episodic vestibular syndrome, and chronic vestibular syndrome. The trained random forest model was applied based on exploratory data analysis results.

RESULTS

Random forest accuracies on acute, episodic, and chronic vestibular syndrome are 90%, 81.74%, and 91.3%, respectively. The most important features in acute vestibular syndrome are spontaneous nystagmus, and vHIT variables. In episodic vestibular syndrome, unilateral weakness in caloric test, gain and saccades on lateral semicircular canal are the top three parameters. Lateral vHIT gain, head-shaking nystagmus, and unilateral weakness in caloric test are the main parameters on chronic vestibular syndrome. In acute vestibular syndrome, spontaneous nystagmus and vHIT make major contributions in vestibular disorders distinction. When the disease course prolongation, unilateral weakness and head-shaking nystagmus become increasingly important.

CONCLUSION

Fast clinical test sets including spontaneous nystagmus, head shaking nystagmus, and vHIT should be the first consideration in screening vestibular disorders.

An observation of the peer-assisted learning (PAL) method in the clinical teaching of vertigo/dizziness-related diseases for standardized residency training (SRT) students in China: a randomized, controlled, multicenter study

BACKGROUND

Vertigo and dizziness (VD) are among the most frequently seen symptoms in clinics and are important for medical students, especially for those in Chinese standardized residency training (SRT). The aim of our study was to examine the PAL method's feasibility in the clinical teaching of VD-related diseases for SRT students in China.

METHODS

This is a randomized, controlled, multicenter study. A total of 228 residents were invited to participate in this study, of which 198 completed the program. The students were randomized into two groups, and VD-related diseases were taught using lecture-based learning (control group) or peer-assisted learning (PAL). An examination paper and a rating scale were used to evaluate students' performance in the mastery of VD-related theoretical knowledge and clinical skills, meanwhile students' perceptions, satisfaction, and risk of burnout were also analyzed using a questionnaire. Independent-samples t-test and chi-square analysis were performed to evaluate statistical significance for continuous variables and categorical variables, respectively, using SPSS 18.0 software.

RESULTS

The PAL group performed better in mastering theoretical knowledge and clinical skills than the control group. And more students believed that PAL could help improve their personal qualities such as teamwork skills. However, more students reported that PAL increased the risk of burnout.

CONCLUSIONS

PAL was a suitable and effective method in the clinical teaching of some specialized diseases, especially it was recommended for students who had gained initial knowledge and skills, such as Chinese SRT students. However, we should draw attention to the increased risk of burnout if PAL is intended to be widely used in clinical teaching.

TRIAL REGISTRATION

ISRCTN registry, ISRCTN53773239 , 05/07/2021, retrospectively registered.

Vertigo: Streamlining the Evaluation through Symptom Localization

Vertigo is defined as the illusion of internal or external motion. The evaluation of a patient with vertigo in the primary care setting should not necessarily focus on providing a specific diagnosis. Rather, the physician should aim to localize the lesion. This practice streamlines the workup of patients. This article provides detailed information regarding appropriate organ system-based clinical history and the clinical workup of vertigo. Additional signs and symptoms that can facilitate appropriate referral and treatment are highlighted. Although disorder-specific treatments exist the mainstay of therapy for vertigo-induced pathology is physical therapy.

The Value of Subjective Visual Vertical in Diagnosis of Vestibular Migraine

OBJECTIVE

To study the value of the subjective visual vertical (SVV) in the diagnosis of vestibular migraine (VM).

METHODS

This study recruited 128 VM patients and 64 age-matched normal subjects. We detected the SVV during the interval between attacks in both groups, in sitting upright, and the head tilted at 45° to the left or right. We then examined the correlation between the SVV results with the vestibular evoked myogenic potential (VEMP) and canal paresis (CP).

RESULTS

It was found there was a significant difference in SVV at the upright position between VM patients and normal controls (P=0.006) and no significant difference was found at the tilts of 45° to the left or right between the two groups. The SVV results at the upright position were significantly correlated with cervical VEMP (P=0.042) whereas not significantly correlated with CP and VEMP. There existed no significant difference in the conformity to the Müller effect (M effect) between the two groups. ROC analysis exhibited that the sensitivity, specificity of SVVs at the upright were 67.200% and 62.500% respectively. The diagnostic value of SVV at the upright position was significantly higher than that at tilts of 45° to the left and right (P=0.006). Nonetheless the diagnostic accuracy was relatively low.

CONCLUSION

Abnormality in SVV possibly stems from the lasting functional disorder of cerebellar or high-level cortical centers in VM patients or is linked to the vestibular compensation. The SVV is of low diagnostic value for VM and the value of SVV in VM warrants further study.

Stroke hospitalization after misdiagnosis of "benign dizziness" is lower in specialty care than general practice: a population-based cohort analysis of missed stroke using SPADE methods

OBJECTIVES

Isolated dizziness is a challenging stroke presentation in the emergency department, but little is known about this problem in other clinical settings. We sought to compare stroke hospitalizations after treat-and-release clinic visits for purportedly "benign dizziness" between general and specialty care settings.

METHODS

This was a population-based retrospective cohort study from a national database. We included clinic patients with a first incident treat-and-release visit diagnosis of non-specific dizziness/vertigo or a peripheral vestibular disorder (ICD-9-CM 780.4 or 386.x [not 386.2]). We compared general care (internal medicine, family medicine) vs. specialty care (neurology, otolaryngology) providers. We used propensity scores to control for baseline stroke risk differences unrelated to dizziness diagnosis. We measured excess (observed>expected) stroke hospitalizations in the first 30 d (i.e., missed strokes associated with an adverse event).

RESULTS

We analyzed 144,355 patients discharged with "benign dizziness" (n=117,117 diagnosed in general care; n=27,238 in specialty care). After propensity score matching, patients in both groups were at higher risk of stroke in the first 30 d (rate difference per 10,000 treat-and-release visits for "benign dizziness" 24.9 [95% CI 18.6-31.2] in general care and 10.6 [95% CI 6.3-14.9] in specialty care). Short-term stroke risk was higher in general care than specialty care (relative risk, RR 2.2, 95% CI 1.5-3.2) while the long-term risk was not significantly different (RR 1.3, 95% CI 0.9-1.9), indicating higher misdiagnosis-related harms among dizzy patients who initially presented to generalists after adequate propensity matching.

CONCLUSIONS

Missed stroke-related harms in general care were roughly twice that in specialty care. Solutions are needed to address this care gap.

[Vestibular Disorders in the Pediatric Age: Retrospective Analysis and Review of the Literature]

INTRODUCTION

Vestibular disorders in pediatric patients is still a controversial subject but has gained relevance over the years. In recent studies, its prevalence varied between 0.7% and 15%. Nevertheless, the true prevalence can be underestimated given that its clinical presentation is expressed compared to adults; it can present as rotatory vertigo, but It can also cause vision complaints, headaches, motor delay, and learning disability. Although middle ear effusion is considered the main cause of vestibular dysfunction in this age group, other diagnoses should be considered. The aim of this study was to describe clinical features of the pediatric population referred to a subspecialist Otorhinolaryngology vertigo clinic in a tertiary hospital between 2013 and 2017. We also aimed to compare the results and carry out a literature about the most common causes, diagnostic features and treatment approach.

MATERIAL AND METHODS

Clinical records of patients referred to a subspecialist Otorhinolaryngology vertigo clinic with suspicion of vestibular dysfunction aged between 0 and 18 years old were reviewed. Patients with middle ear effusion were excluded.

RESULTS

Thirty-seven patients met the inclusion criteria. From these, 59% were female, with a mean age of 10.9 years old during the first consultation. The most common reason for referral was rotatory vertigo. Nausea and headache were also frequent complaints in our population. All patients performed audiometry; videonistagmography was performed in 41% of the cases; imaging studies were done in 59% of patients. The most common causes of vestibular dysfunction were vestibular migraine and benign paroxysmal vertigo of childhood (both in 27% of the cases), followed by vestibular neuritis (in 22% of the cases).

DISCUSSION

Although our findings partially concur with the literature, compared with other specialist centers, the range of reasons for referral and of conditions is not as diverse, which may suggest that there is underdiagnosis of vestibular dysfunction in this age group.

CONCLUSION

Vestibular dysfunction in the pediatric age can have several causes; pediatricians, neurologists, physiatrists, family doctors and otorhinolaryngologists must be aware of the different forms of presentation. Referral and evaluation protocols addressing pediatric patients should be created.

Driving ability in patients with dizziness: a systematic review

PURPOSE

The aim of this systematic review was to identify and evaluate studies dealing with driving performance of dizzy patients or patients with a vestibular disorder.

METHODS

A systematic review was performed according to the preferred reporting items for systematic reviews and meta-analysis guidelines. (1) PubMed, Embase, and Cochrane library. (2) Study selection: articles about driving ability and reported driving difficulties in patients with dizziness, or a diagnosed vestibular disorder, were included. (3) Data extraction was performed by two independent authors using predefined data fields: patient's characteristics, diagnostic criteria, sample size, and type of evaluation of driving ability and outcome of the study.

RESULTS

Eight out of 705 articles matched the inclusion criteria but varied widely regarding the study population, study design, and outcome measures. The majority of studies reported a negative impact of dizziness and/or vestibular disorders on self-reported driving ability and car accidents. Yet several studies could not identify any impairment of driving ability.

CONCLUSIONS

Driving ability was negatively affected by dizziness or a vestibular disorder in the majority of included studies with low risk of bias. This systematic review revealed a significant heterogeneity in studies reporting driving performance and contradictory results. We were, therefore, unable to identify a causal relationship between dizziness and driving ability. There is a need for prospective studies in populations with different vestibular disorders using subjective and objective outcome measures that have been validated to evaluate driving performance.

VERTIcal Grid lOgistic regression with Confidence Intervals (VERTIGO-CI)

Federated learning of data from multiple participating parties is getting more attention and has many healthcare applications. We have previously developed VERTIGO, a distributed logistic regression model for vertically partitioned data. The model takes advantage of the linear separation property of kernel matrices of a dual space model to harmonize information in a privacy-preserving manner. However, this method does not handle the variance estimation and only provides point estimates: it cannot report test statistics and associated P-values. In this work, we extend VERTIGO by introducing a novel ring-structure protocol to pass on intermediary statistics among clients and successfully reconstructed the covariance matrix in the dual space. This extension, VERTIGO-CI, is a complete protocol to construct a logistic regression model from vertically partitioned datasets as if it is trained on combined data in a centralized setting. We evaluated our results on synthetic and real data, showing the equivalent accuracy and tolerable performance overhead compared to the centralized version. This novel extension can be applied to other types of generalized linear models that have dual objectives.

Clinical Diagnosis of Central Vertigo in Patients With Dizziness in Emergency Practice

BACKGROUND

Life-threatening diseases should be promptly identified to provide appropriate medical care for emergency outpatients experiencing dizziness. However, dizziness is associated with various medical conditions; thus, a definitive diagnosis is challenging. To accurately diagnose vertigo in an emergency outpatient, we conducted a survey on the need to identify vertigo patients in the current outpatient departments.

MATERIALS AND METHODS

The participants included 509 patients who visited the outpatient department at our hospital from February 2014 to May 2017. Overall, 12 characteristics were retrospectively extracted from the patients' medical records: age, sex, visit method, medical history (diabetes, hypertension, cardiac, or cerebrovascular disease), dizziness history, vertigo characteristics, concomitant symptoms, systolic blood pressure, nystagmus, imaging history, diagnosis, and hospitalization department. Univariate and multivariate analyses were performed to identify factors related to central vertigo.

RESULTS

The diagnosis of central vertigo was confirmed when intracranial lesions were detected through imaging. In multivariate analysis, the presence/absence of a history of headache and cardiovascular disease were significantly correlated with central vertigo (P=0.002 and 0.006, respectively), with odds ratios of 5.18 and 4.38, respectively.

CONCLUSIONS

To avoid missing central dizziness in a patient, diagnostic abilities should be improved by including careful interviews and confirmation of the presence/absence of accompanying symptoms. Furthermore, collaboration with neurology and neurosurgery departments is important for improving the diagnosis in suspected cases.

Video-nystagmographic evidence in more than 700 consecutive cases of road traffic whiplash injury

PURPOSE

Whiplash injury is a frequent traumatic lesion occurring mainly in road accidents, which may also cause dizziness severe enough to impact everyday life. Vestibular examination is routinely performed on these patients, although the role of the neuro-otologist is still not clearly defined. The main endpoint of this study was to describe the videonystagmography (VNG) evidence in a large cohort of patients who underwent road traffic whiplash injury.

METHODS

717 consecutive patients who reported whiplash-associated disorders due to a road traffic accident underwent clinical examination and VNG.

RESULTS

Patients with saccadic test latency anomalies more frequently complained of vertigo, nausea and cochlear symptoms after trauma (p = 0.031, 0.028 and 0.006), while patients with bilateral vestibular weakness at caloric stimulation more often displayed neck pain after trauma (p = 0.005). Patients complaining of positional or cochlear symptoms or with accuracy anomalies at the saccadic test were significantly older than those with no positional, no cochlear symptoms and without accuracy anomalies (p = 0.022, p = 0.034 and p = 0.001). Patients with bilateral vestibular hypofunction were significantly younger (p < 0.001).

CONCLUSIONS

VNG evidence, particularly vestibular function and saccadic tests, may be related to damage in the cervical region due to whiplash trauma. These findings suggest that neuro-otologic examination may play a role in properly identifying those who suffer damage caused by whiplash trauma, and in characterizing the severity and prognosis of whiplash-associated disorders.

Reliability and validity of the Turkish version of the vestibular rehabilitation benefit questionnaire

Background/aims

Vestibular rehabilitation has an important role in the reduction of symptoms and in the recovery of patients in peripheral vestibular pathologies. Objective and subjective vestibular assessment tools are needed to assess vestibular rehabilitation effectiveness. The aims of the study were to develop the Turkish version of the internationally used Vestibular Rehabilitation Benefit Questionnaire (VRBQ) measure and to demonstrate the reliability and validity properties of the Turkish version in patients with peripheral vestibular hypofunction (PVH).

Materials and methods

110 patients with unilateral PVH were included. For the analysis of test-retest reliability, Turkish version of VRBQ developed by translation-back translation method was applied to patients on the day of admission and the day after admission. To assess validity, patients were also evaluated with the VRBQ, Dizziness Handicap Inventory (DHI), Vertigo Symptom Scale-Short Form (VSS-SF), Vertigo Dizziness Imbalance (VDI) Questionnaire.

Results

The VRBQ showed moderate to excellent internal consistency in total score and subscales scores (VRBQ-total Cronbach’s α = 0.91; dizziness α = 0.81; anxiety α = 0.68; motion-provoked dizziness α = 0.89; aypmtoms α = 0.88; health-related quality of life α = 0.87). In the test-retest reliability of VRBQ-total score was excellent (ICC = 0.94). The dizziness, the anxiety, the motion-provoked dizziness, symptoms and the health-related quality of life domains’ ICC were found respectively 0.90, 0.89, 0.84, 0.90, and 0.92. The construct validity of the VRBQ was determined. The VRBQ total was correlated with all parameters (r: 0.308 to –0.699, P < 0.05). The highest positive correlation was found between VRBQ total and DHI-functional (r: 0.680). The highest negative correlation was found between VRBQ total and VDI-total (r: –0.699).

Conclusion

The results suggest that the Turkish version of the VRBQ is reliable and valid for evaluating the vestibular rehabilitation results.

Improving mobility and participation of older people with vertigo, dizziness and balance disorders in primary care using a care pathway: feasibility study and process evaluation

BACKGROUND

Community-dwelling older people are frequently affected by vertigo, dizziness and balance disorders (VDB). We previously developed a care pathway (CPW) to improve their mobility and participation by offering standardized approaches for general practitioners (GPs) and physical therapists (PTs). We aimed to assess the feasibility of the intervention, its implementation strategy and the study procedures in preparation for the subsequent main trial.

METHODS

This 12-week prospective cohort feasibility study was accompanied by a process evaluation designed according to the UK Medical Research Council's Guidance for developing and evaluating complex interventions. Patients with VDB (≥65 years), GPs and PTs in primary care were included. The intervention consisted of a diagnostic screening checklist for GPs and a guide for PTs. The implementation strategy included specific educational trainings and a telephone helpline. Data for mixed-method process evaluation were collected via standardized questionnaires, field notes and qualitative interviews. Quantitative data were analysed using descriptive statistics, qualitative data using content analysis.

RESULTS

A total of five GP practices (seven single GPs), 10 PT practices and 22 patients were included in the study. The recruitment of GPs and patients was challenging (response rates: GP practices: 28%, PT practices: 39%). Ninety-one percent of the patients and all health professionals completed the study. The health professionals responded well to the educational trainings; the utilization of the telephone helpline was low (one call each from GPs and PTs). Familiarisation with the routine of application of the intervention and positive attitudes were emphasized as facilitators of the implementation of the intervention, whereas a lack of time was mentioned as a barrier. Despite difficulties in the GPs' adherence to the intervention protocol, the GPs, PTs and patients saw benefit in the intervention. The patients' treatment adherence to physical therapy was good. There were minor issues in data collection, but no unintended consequences.

CONCLUSION

Although the process evaluation provided good support for the feasibility of study procedures, the intervention and its implementation strategy, we identified a need for improvement in recruitment of participants, the GP intervention part and the data collection procedures. The findings will inform the main trial to test the interventions effectiveness in a cluster RCT.

TRIAL REGISTRATION

Projektdatenbank Versorgungsforschung Deutschland (German registry Health Services Research) VfD_MobilE-PHY_17_003910, date of registration: 30.11.2017; Deutsches Register Klinischer Studien (German Clinical Trials Register) DRKS00022918, date of registration: 03.09.2020 (retrospectively registered).

Vertigo Related to Central Nervous System Disorders

PURPOSE OF REVIEW

This article provides an overview of the numerous causes of vertigo and dizziness that are due to central nervous system (CNS) pathology and guides clinicians in formulating a differential diagnosis and treating patients with CNS causes of vertigo.

RECENT FINDINGS

Specific autoimmune vestibulocerebellar syndromes may now be tested for, and this article discusses the antibodies known to cause such syndromes. Superficial siderosis can be more accurately diagnosed with imaging studies, and treatment using iron chelation has recently been studied but has not yet been established as an effective treatment. Central autonomic network damage in the brain can cause central orthostatic hypotension in some neurodegenerative diseases, and medication has been approved for treatment.

SUMMARY

CNS causes of vertigo are numerous and important for clinicians to recognize. Examination findings are still an extremely valuable way to diagnose central vertigo; therefore, learning how to differentiate central from peripheral vertigo based on examination is an important skill. CNS causes of vertigo often have available treatments.

Approach to the History and Evaluation of Vertigo and Dizziness

PURPOSE OF REVIEW

This article reviews a method of obtaining the medical history of patients presenting with dizziness, vertigo, and imbalance. By combining elements of the history with examination, the goal is to identify patterns and an effective differential diagnosis for this group of patients to help lead to an accurate diagnosis.

RECENT FINDINGS

Studies over the past dozen years have changed the historical approach to patients with dizziness from one based primarily on how the patient describes the sensation of dizziness. This older approach can lead to misdiagnosis, so a preferred method puts greater emphasis on whether the dizziness is acute or chronic, episodic or continuous, or evoked by or brought on by an event or circumstance so that a pattern may be derived that better narrows the differential diagnosis and focused examination can further narrow to a cause or causes.

SUMMARY

Dizziness is a common symptom of many possible causes. This article will help clinicians navigate gathering the history and examination to formulate a working diagnosis in patients affected by dizziness.

Vestibular Testing

PURPOSE OF REVIEW

Vestibular testing, both at the bedside and in the laboratory, is often critical in diagnosing patients with symptoms of vertigo, dizziness, unsteadiness, and oscillopsia. This article introduces readers to core concepts, as well as recent advances, in bedside and instrumented vestibular assessments.

RECENT FINDINGS

Vestibular testing has improved immensely in the past 2 decades. While history and bedside testing is still the primary method of differential diagnosis in patients with dizziness, advances in technology such as the ocular vestibular-evoked myogenic potential test for superior canal dehiscence and the video head impulse test for vestibular neuritis have capabilities that go far beyond the bedside examination. Current vestibular testing now allows clinicians to test all five vestibular sensors in the inner ear.

SUMMARY

Contemporary vestibular testing technology can now assess the entire vestibular periphery. Relatively subtle conditions, such as superior canal dehiscence or a subtle vestibular neuritis, can now be diagnosed with far greater certainty.

Episodic Spontaneous Dizziness

PURPOSE OF REVIEW

Conditions causing recurrent spontaneous episodes of dizziness or vertigo span several medical specialties, making it challenging for clinicians to gain confidence in evaluating and managing the spectrum of episodic vestibular disorders. Patients are often asymptomatic and have normal examinations at the time of evaluation. Thus, diagnosis depends heavily on eliciting key features from the history. Overreliance on symptom quality descriptions commonly leads to misdiagnosis. The goal of this article is to provide the reader with a straightforward approach to the diagnosis and management of conditions that cause episodic spontaneous dizziness.

RECENT FINDINGS

Consensus diagnostic criteria have been established for vestibular migraine, Ménière disease, vestibular paroxysmia, and hemodynamic orthostatic dizziness/vertigo. Vertigo has been recognized as a common symptom in vertebrobasilar ischemia, cardiogenic dizziness, and orthostatic hypotension. Treatment recommendations for vestibular migraine still lack high-quality evidence, but controlled trials are occurring.

SUMMARY

The evaluation should start with a detailed description of the episodes from the patient and any observers. Rather than focusing first on whether the symptom quality is most consistent with vertigo, dizziness, lightheadedness, or unsteadiness, the clinician should clarify the timing (episode frequency and duration), possible triggers or circumstances (eg, position changes, upright posture), and accompanying symptoms. History should identify any auditory symptoms, migraine features, posterior circulation ischemic symptoms, vascular risk factors, clues for anxiety, and potentially relevant medications. Carefully selected testing can help secure the diagnosis, but excessive and indiscriminate testing can lead to more confusion. Treatments for these conditions are vastly different, so an accurate diagnosis is critical.

Selected Otologic Disorders Causing Dizziness

PURPOSE OF REVIEW

This article details updated clinical presentations and current treatment paradigms of the common otologic disorders that may present to the neurologist for vertigo, including Ménière disease, superior semicircular canal dehiscence syndrome, perilymphatic fistula, barotrauma, cholesteatoma, Ramsay Hunt syndrome, enlarged vestibular aqueduct syndrome, and autoimmune inner ear disease including Cogan syndrome.

RECENT FINDINGS

The recent data on modern imaging techniques with three-dimensional delayed IV contrast in Ménière disease, findings on the clinical and testing parameters to diagnose semicircular canal dehiscence and barotrauma, and clinical findings in Ramsay Hunt syndrome, cholesteatoma, and enlarged vestibular aqueduct syndrome are discussed in the article. The most recent findings on the treatment and evaluation of autoimmune inner ear disease and Cogan syndrome are also covered.

SUMMARY

This article discusses the common clinical otologic entities in patients who may present to the neurologist for vertigo, and it can be used as a guide in the diagnosis of these conditions with the use of auditory, vestibular, and imaging results.

Rare Disorders of the Vestibular Labyrinth: of Zebras, Chameleons and Wolves in Sheep's Clothing

The differential diagnosis of vertigo syndromes is a challenging issue, as many - and in particular - rare disorders of the vestibular labyrinth can hide behind the very common symptoms of "vertigo" and "dizziness". The following article presents an overview of those rare disorders of the balance organ that are of special interest for the otorhinolaryngologist dealing with vertigo disorders. For a better orientation, these disorders are categorized as acute (AVS), episodic (EVS) and chronic vestibular syndromes (CVS) according to their clinical presentation. The main focus lies on EVS sorted by their duration and the presence/absence of triggering factors (seconds, no triggers: vestibular paroxysmia, Tumarkin attacks; seconds, sound and pressure induced: "third window" syndromes; seconds to minutes, positional: rare variants and differential diagnoses of benign paroxysmal positional vertigo; hours to days, spontaneous: intralabyrinthine schwannomas, endolymphatic sac tumors, autoimmune disorders of the inner ear). Furthermore, rare causes of AVS (inferior vestibular neuritis, otolith organ specific dysfunction, vascular labyrinthine disorders, acute bilateral vestibulopathy) and CVS (chronic bilateral vestibulopathy) are covered. In each case, special emphasis is laid on the decisive diagnostic test for the identification of the rare disease and "red flags" for potentially dangerous disorders (e. g. labyrinthine infarction/hemorrhage). Thus, this chapter may serve as a clinical companion for the otorhinolaryngologist aiding in the efficient diagnosis and treatment of rare disorders of the vestibular labyrinth.

[The chronically dizzy patient]

Many medical, neurologic and psychiatric conditions as well as drugs can give chronic dizziness, and a systematic diagnostic workup is essential. Chronic vestibular syndrome is a clinical syndrome of chronic vertigo, dizziness or unsteadiness lasting months to years. There is generally a persistent unilateral or bilateral vestibular loss. Treatment depends on the aetiology, but in general, treatment with vestibular rehabilitation is effective, which is summarised in this review. Betahistin or other anti-vertigo-drugs are not indicated in the treatment of chronic vertigo.

Increased Risk of Injury Following a Diagnosis of Vertigo: A Population-based Study

BACKGROUND

This study aimed to evaluate whether peripheral vestibular disorders (PVD) are associated with subsequent injury.

METHODS

Data for this follow-up study were retrieved from the Taiwan's National Health Insurance (NHI) Dataset. A total of 251,355 patients with newly diagnosed PVD during January 2015 to December 2016 was identified as the study cohort, the diagnosis date being their index date. Comparison patients were identified by propensity score-matching (one per case, n = 251,355 controls) from the remaining NHI beneficiaries in 2015 with their index date being the date of their first health service claim in 2015. We tracked each subject's claims history for 1 year from the index date to identify those who suffered an injury. Cox proportional hazards regressions were performed to calculate the injury hazard ratio of cases versus controls.

RESULTS

The incidence of injury during 1-year follow-up was 128.6 (95% CI = 127.6-129.5) per 1,000 person-years, 158.2 (95% CI = 156.8-159.6) and 97.5 (95% CI = 96.3-98.7) among the study and comparison cohorts, respectively. After adjusting for demographic variables, the hazard ratio (HR) for injury during 1-year was 1.663 (95% CI: 1.636-1.690) for cases relative to controls.

CONCLUSIONS

Patients with PVD were at a higher risk for a wide range of injuries, most of all, joint dislocation and sprain.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1633-1638, 2021.