Recurrent spontaneous vertigo with interictal headshaking nystagmus

Objective

To define a disorder characterized by recurrent spontaneous vertigo (RSV) of unknown etiology and interictal headshaking nystagmus (HSN).

Methods

We characterized HSN in 35 patients with RSV-HSN compared to that recorded in randomly selected patients with compensated vestibular neuritis (VN), vestibular migraine (VM), and Ménière disease (MD).

Results

The estimated time constant (TC) of the primary phase of HSN was 12 seconds (95% confidence interval [CI] 12–13) in patients with RSV-HSN, which was larger than those in patients with VN (5 seconds, 95% CI 4–5), VM (5 seconds, 95% CI 5–6), or MD (6 seconds, 95% CI 5–6). TCs of the horizontal vestibulo-ocular reflex were also larger during the rotatory chair test in patients with RSV-HSN. Among the 35 patients with RSV-HSN, 7 showed vigorous long-lasting HSN with a peak slow-phase velocity >50.0°/s. In 5 patients (5 of 7, 71%) with vigorous HSN, HSN could have been induced even with headshaking for only 2 to 5 seconds. Long-term prognosis was favorable, with a resolution or improvement of the symptoms in more than half of the patients during the median follow-up of 12 (range 2–58) years from symptom onset. None developed VM, MD, or cerebellar dysfunction during the follow-up.

Conclusion

The clinical features and characteristics of HSN in our patients indicate a hyperactive and asymmetric velocity-storage mechanism that gives rise to intermittent attacks of spontaneous vertigo probably when marginal compensation of underlying pathology is disrupted by endogenous or exogenous factors.

Acute Unilateral Audiovestibulopathy due to Embolic Labyrinthine Infarction

Introduction

Labyrinthine infarction is a cause of acute audiovestibulopathy, but can be diagnosed only in association with other infarctions involving the brainstem or cerebellar areas supplied by the anterior inferior cerebellar artery (AICA) since current imaging techniques cannot visualize an infarction confined to the labyrinth. This case series aimed to establish embolic labyrinthine infarction as a mechanism of isolated acute audiovestibulopathy.

Methods

We analyzed clinical features, imaging findings, and mechanisms of embolism in 10 patients (8 men, age range: 38–76) who had developed acute audiovestibulopathy in association with an obvious source of embolism and concurrent acute embolic infarctions in the non-anterior inferior cerebellar artery territories. The presence of audiovestibulopathy was defined when bedside or laboratory evaluation documented unilateral vestibular (head-impulse tests or caloric tests) or auditory loss (audiometry).

Results

Six patients showed combined audiovestibulopathy while three had isolated vestibulopathy. One patient presented isolated hearing loss. Audiovestibular findings were the only abnormalities observed in nine patients. In all patients, MRIs documented single or multiple infarctions in the cerebellum (n = 5) or cerebral hemispheres (n = 5). Especially three patients showed single or scattered foci of tiny acute infarctions only in the cerebral hemispheres. Cardiac sources of embolism were found in eight, and artery-to-artery embolism was presumed in two patients.

Conclusion

Selective embolism to the labyrinth may be considered in patients with acute unilateral audiovestibulopathy and concurrent acute infarctions in the non-AICA territories.

Long-Term Outcomes of Patients with Stent Tips Embedded into Internal Carotid Artery Branches during Aneurysm Coiling

BACKGROUND AND PURPOSE

During stent-assisted coiling of ICA aneurysms, stent tips are sometimes unintentionally embedded into ICA branches. Stent tips can be visualized because they have radiopaque markers. Concerns regarding stent tip misplacement include risks of artery perforation and occlusion. The aim of this study was to evaluate the long-term outcomes of ICA branches with embedded stent tips.

MATERIALS AND METHODS

ICA branches with embedded stent tips were identified among 35 patients with unruptured ICA aneurysms treated with stent-assisted coiling between November 2003 and November 2014. Patient clinical and angiographic outcomes associated with the embedded stent tip were analyzed.

RESULTS

Most of the 35 studied aneurysms were paraclinoid ICA aneurysms (n = 30). The most commonly involved ICA branch was the posterior communicating artery (26 patients, 74.3%), followed by the anterior choroidal artery (8 patients, 22.9%) and ophthalmic artery (1 patient, 2.9%). During the follow-up period (38.6 ± 17.9 months), no new neurologic deficits developed. Neither hemorrhagic nor thromboembolic events occurred. Angiography was performed during the final follow-up evaluation at a mean of 32.7 ± 18.0 months, and all ICA branches with embedded stent tips showed patent blood flow without severe luminal narrowing.

CONCLUSIONS

In our experience, placement of a stent tip into ICA branches during stent-assisted coiling was not associated with any major adverse events.

Abnormal Cervical Vestibular-Evoked Myogenic Potentials Predict Evolution of Isolated Recurrent Vertigo into Meniere's Disease

Introduction

Vestibular-evoked myogenic potentials (VEMPs) can be abnormal in patients with idiopathic recurrent spontaneous vertigo. We aimed to determine whether abnormal cervical vestibular-evoked myogenic potentials (cVEMPs) can predict evolution of isolated recurrent vertigo into Meniere’s disease (MD).

Methods

We had followed up 146 patients with isolated recurrent vertigo and an evaluation of cVEMPs for 0–142 months [median = 6, interquartile range (IQR) = 0–29] at the Dizziness Clinic of Seoul National University Bundang Hospital from June 2003 to May 2014. We defined the variables associated with a progression into MD and calculated cumulative progression rates.

Results

Among the 94 patients with recurrent vertigo and abnormal cVEMPs, 18 (18/94, 19%) showed an evolution into MD while only 2 of the 50 (4%) patients with normal cVEMPs evolved into MD during the follow-up (p = 0.01). The interval between onset of vertigo and development of cochlear symptoms ranged from 1 month to 13.6 years (median = 3 years, IQR = 0.5–4.5 years). Overall, pure tone audiometry (PTA) threshold at 0.25 kHz [hazard ratio (HR) = 1.1, 95% confidence interval (CI) = 1.0–1.2] and abnormalities of cVEMPs (HR = 5.6, 95% CI = 1.3–25.5) were found to be significantly associated with a later conversion into MD. The cumulative progression rate was 12% (95% CI = 5–18) at 1 year, 18% (8–26) at 2 years, and 22% (11–32) at 3 years.

Conclusion

Abnormal cVEMPs may be an indicator for evolution of isolated recurrent vertigo into MD. Patients with isolated recurrent vertigo may be better managed conforming to MD when cVEMPs are abnormal.

Comparison of caloric and head-impulse tests during the attacks of Meniere's disease

OBJECTIVES/HYPOTHESIS

To aid in diagnosis of Meniere's disease (MD) during the attacks using caloric and head-impulse tests (HITs).

STUDY DESIGN

Retrospective case series review.

METHODS

We analyzed the results of bithermal caloric and HITs during the attacks in 16 patients with MD. Quantitative analyses of HITs were conducted using a magnetic search coil technique.

RESULTS

In unilateral MD (14 patients, 42 semicircular canals), the head impulse gain of the vestibulo-ocular reflex (VOR) was either normal (28 of 42, 67%), decreased (8 of 42, 19%), or increased (6 of 42, 14%) for each semicircular canal in the affected ear. Likewise, the head impulse VOR gain was either normal (29 of 42, 69%), increased (11 of 42, 26%), or decreased (2 of 42, 5%) in the intact ear. The VOR gain for the horizontal canal was significantly lower on the affected side (P = 0.013). However, the VOR gains for the anterior and posterior canals did not differ between the sides (P = 0.270, P = 0.282). In bilateral MD (two patients, 12 semicircular canals), the VOR gain was either decreased (6 of 12, 50%) or normal (6 of 12, 50%) in either ear. In contrast, the caloric responses were usually decreased in the affected ear (7 of 11, 64%, including one with bilateral MD).

CONCLUSION

During the attacks of MD, HITs showed varied results between the ears and among the canals, although the caloric responses were usually decreased in the involved ear. These dissociations suggest a frequency-dependent impairment of canal function or mechanical property of the endolymphatic hydrops during the attacks of MD.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:702-708, 2017.

Differentiating Carotid Terminus Occlusions into Two Distinct Populations Based on Willisian Collateral Status

Background and Purpose

The outcomes of acute internal carotid artery (ICA) terminus occlusions are poor. We classified ICA terminus occlusions into 2 groups according to the occlusion pattern of the circle of Willis and hypothesized that clinical outcomes would significantly differ between them.

Methods

Consecutive patients with acute ICA terminus occlusions evaluated by baseline computed tomographic angiography were enrolled. We investigated the occlusion patterns in the circle of Willis, retrospectively classified patients into simple ICA terminus occlusion (STO; with good Willisian collaterals from neighboring cerebral circulation) and complex ICA terminus occlusion (CTO; with one or more of A2 anterior cerebral artery, fetal posterior cerebral artery occlusion, or hypoplastic/absent contralateral A1; or with poor collaterals from anterior communicating artery) groups, and compared their baseline characteristics and outcomes.

Results

The STO group (n=58) showed smaller infarct volumes at 72 hours than the CTO group (n=34) (median, 81 mL [interquartile range, 38-192] vs. 414 mL [193-540], P<0.001) and more favorable outcomes (3-month modified Rankin Scale 0-3, 44.8% vs. 8.8%, P<0.001; 3-month mortality, 24.1% vs. 67.6%, P<0.001). In multivariable analyses, STO remained an independent predictor for favorable outcomes (odds ratio 6.1, P=0.010).

Conclusions

Favorable outcomes in STO group suggested that the outcomes of acute ICA terminus occlusions depend on Willisian collateral status. Documenting the subtypes on computed tomographic angiography would help predict patient outcome.

Abstract T P21: Complex Internal Carotid Artery T Occlusion By Computed Tomographic Angiography Is A Very Malignant Subtype With Massive Infarcts And Poor Outcomes Despite Revascularization Treatment

Background: ICA T/L occlusions appear to have a particular poor prognosis due to low recanalization with intravenous tissue plasminogen activator alone. What is not known however is whether all ICA T/L occlusions remain as good candidates for endovascular treatment. We divided ICA T/L occlusions into distinct types according to Willisian collaterals and compared infarct core volumes and clinical outcomes in the two groups as well as other anterior circulation occlusion sites.

Methods: We enrolled patients with acute ischemic stroke in anterior circulation whose CT angiography showed major intracranial artery occlusion. Patients were included if their MRI was taken just after CT scan and within 6 hours from onset. We classified patients into Complex ICA T, Simple ICA T/L, MCA M1, MCA M2, and extracranial to intracranial tandem groups. Among patients with ICA T/L occlusion, patients were classified into simple ICA T/L occlusion group if ACA A2 and PCA P2 segments are patent whereas those into complex ICA T group if A2, P2 or their distal branches were occluded, or contralateral occlusion was seen in ICA or contralesional A1 absent or hypoplastic. Other occlusion types were excluded in this study.

Results: Table shows comparisons among groups. Age, sex and vascular risk factors did not differ among groups. Initial NIHSS score was different among groups. Pretreatment infarct core volume with ADC value threshold of 600 x 10-5 mm2/s was significantly different according to cerebral artery occlusion types. Clinical outcome significantly differed among groups regarding NIHSS score at discharge, frequency of good outcome (mRS 0-2 at 3 months), and frequency of 3-month mortality.

Conclusion: We describe a subtype of carotid occlusions we have named as complex ICA T occlusions in which Willisian collateral flow is limited. This group is associated with very large infarct core volumes and poor 3-month outcomes despite acute revascularization treatment.

Ipsilesional limb ataxia and truncal ipsipulsion in isolated infarction of the superior cerebellar peduncle

The clinical features of a lesion confined to the superior cerebellar peduncle (SCP) have not been defined well in human. A 92-year-old woman suddenly developed mild dysarthria and severe imbalance from an isolated unilateral SCP infarction, and examination showed ipsiversive ocular torsion, severe ipsilesional limb ataxia, and truncal ipsipulsion. These findings are well consistent with those observed in monkeys when the SCP was severed. In addition to the dentate-rubro-thalamic projections, the SCP appears to contain the fibers involved in the control of eye motion in the roll plane.

Epileptic nystagmus: A case report and systematic review

PURPOSE

We aimed to define the characteristics of epileptic nystagmus and correlate those with other clinical findings in a large number of patients.

METHODS

We report a patient with epileptic nystagmus and additionally reviewed the reported clinical features of 36 more patients through a systematic literature search. We analyzed the characteristics of epileptic nystagmus and attempted correlations of those with alertness of the patients and epileptic foci on EEG.

RESULTS

All 33 patients with unilateral horizontal nystagmus showed nystagmus beating away from the side of ictal discharges. Epileptic nystagmus was preceded by gaze deviation in 21 patients, with contraversive in 19 and ipsiversive in 2. Seizures associated with epileptic nystagmus were mostly focal (25/29, 86.2%) with or without loss of awareness. Ictal discharges originated from the occipital (n = 16), parietal (n = 9), temporo-occipital (n = 6), frontal (n = 4), and temporal (n = 3) areas, and two patients had multiple epileptic foci. Seizures were usually symptomatic (24/37, 64.9%). The presence of preceding gaze deviation and midline crossing of the nystagmus did not correlate with the ictal onset zone or alertness of the patients. Recording of epileptic nystagmus was available only in 6 patients, and the epileptic nystagmus could be localized to the saccadic areas in two and to the smooth pursuit areas in another two. Two patients showed the features of epileptic nystagmus from both areas.

CONCLUSION

Even though the localizing value of epileptic nystagmus seems limited in previous reports, the fast phase of epileptic nystagmus was almost always directed away from the epileptic focus that mostly arose from the posterior part of the cerebral hemisphere.

Apparent treatment-resistant hypertension among elderly Korean hypertensives: an insight from the HIT registry

The aim of this study was to determine the clinical characteristics of patients with resistant hypertension (RH) and predictors among elderly Korean hypertensives. This prospective, multi-center, observational study evaluated 2439 elderly hypertensive patients between December 2008 and November 2011, who visited secondary hypertension clinics for high blood pressure (BP). Patients were categorized as resistant if their BP was ≥140/90 mm Hg and if they reported using antihypertensive medications from three different drug classes, including a diuretic or drugs from ≥4 antihypertensive drug classes, regardless of BP. Characteristics of patients with RH were compared with those of patients who were controlled with one or two antihypertensive medications after 6-month antihypertensive treatment. In comparison with 837 patients with non-RH, 404 patients with RH were more likely to be aware of their status of high BP before enrollment and have a high baseline systolic BP ≥160 mm Hg, microalbuminuria, high body mass index (BMI) ≥24 kg m(-2) and diabetes mellitus (DM). In drug-naive patients, awareness of hypertension at baseline was the only independent predictor for RH. In elderly Korean hypertensives, BMI (≥24 kg m(-2)), baseline systolic BP (≥160 mm Hg), microalbuminuria, DM and awareness of hypertension showed an association with RH.

Clinical outcomes of multicenter domino kidney paired donation

Domino kidney paired donation (KPD) is a method by which an altruistic living nondirected donor (LND) is allocated to a pool of incompatible donor-recipient pairs (DRP) and a series of KPDs is initiated. To evaluate the feasibility and clinical outcomes of multicenter domino KPD, we retrospectively analyzed a cohort of DRPs who underwent domino KPD between February 2001 and July 2007 at one of 16 transplant centers. One hundred seventy-nine kidney transplants were performed, with 70 domino chains initiated by altruistic LND. There were 45 two-pair chains, 15 three-pair chains, 7 four-pair chains, 2 five-pair chains and 1 six-pair chain. A majority of donors were spouses (47.5%) or altruistic LNDs (39.1%). DRPs with a blood type O recipient or an AB donor comprised 45.9% of transplanted DRPs. HLA mismatch improved in transplanted donors compared to intended donors in pairs enrolled to improve HLA mismatch (3.4 +/- 0.7 vs. 4.8 +/- 1.0, p < 0.001). One-year and 5-year graft survival rates were 98.3% and 87.7%, respectively, with a median follow-up of 46 months. One-year and 5-year patient survival rates were 97.2% and 90.8%, respectively. In conclusion, multicenter domino KPD could multiply the benefits of donation from LNDs, with patients and graft survival rates comparable to those seen with conventional KPD.

Cerebral lipiodol embolism during transcatheter arterial chemoembolization

Cerebral lipiodol embolism (CLE) is a rare complication that may occur during chemoembolization. The authors present three cases of CLE during transcatheter arterial chemoembolization for hepatocellular carcinoma. Multiple small nonconfluent hyperintense intracerebral lesions were found on the diffusion-weighted and fluid-attenuated inversion recovery MRI. Clinical signs completely resolved and MRI lesions markedly improved on follow-up evaluation within a 3-week period.

Identity of activation molecule 3 on superantigen-stimulated bovine cells is CD26

Most CD8(+) T cells in cultures of bovine mononuclear cells stimulated with staphylococcal enterotoxin C1 develop an unusual phenotype characterized by expression of activation molecule 3 (ACT3). This superantigen-dependent phenotype may be relevant to immunopathogenesis mediated by certain microbial toxins. The size and N-terminal sequence of immunoprecipitated ACT3 indicate that ACT3 is the bovine orthologue of CD26.