Benign paroxysmal positional vertigo: Diagnostic criteria Consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society

Clinical Findings in Patients With Persistent Positional Nystagmus: The Designation of "Heavy and Light Cupula"

Objective: Direction-changing positional nystagmus (DCPN) had been observed as persistent horizontal apogeotropic and was considered as “cupulolithiasis or heavy cupula. ” Recently, the concept of “light cupula” exhibiting persistent geotropic DCPN has been introduced. However, the light cupula is not systematically described, while the identification and diagnosis of “light cupula” should be improved. Here we investigated the underlying characteristics and therapeutic options designed to the “light” and “heavy” cupula, respectively; and summarized the clinical characteristics and therapeutic effect in the two groups.

Methods: A total of 359 cases with vertigo and bilateral DCPN were found in the supine roll test. Only 25 patients with persistent DCPN were enrolled and followed up. According to the direction of nystagmus, we further divided the patients into “heavy cupula” (apogeotropic) and “light cupula” (geotropic) groups. We compared the incidence, characteristics of nystagmus and the efficacy of repositioning maneuver in the two groups.

Results: Nine patients with persistent horizontal geotropic DCPN were confirmed as “light cupula,” other 16 patients with persistent horizontal ageotropic DCPN were confirmed as heavy cupula. All 25 patients had null plane; the mean value and standard deviation of the null plane in light cupula and heavy cupula was 25.67 ± 9.31° and 27.06 ± 6.29°, respectively. The mean value and standard deviation of the termination plane in light cupula was 28.78 ± 10.00°, and 30.25 ± 6.53° in heavy cupula. There was no statistical significance between the two groups. We found that the direction of evoked nystagmus in the supine position was toward the intact side in light cupula, while in heavy cupula, it was toward the lesion side. The null plane appeared on the lesion side. For light cupula patients, the effect was not obvious at Day-7 after the treatment, however, treatment for most heavy cupula patients were effective. All patients recovered after 30 days of treatment.

Conclusion: The null plane is crucial in determining the lesion side for light or heavy cupula. Although the short-term therapeutic effect of the light cupula is not as promising as the effect seen in heavy cupula, the long-term prognosis in both groups is comparable; with all patients recovered after 30 days of treatment.

Study design: This is a retrospective cohort study.

Influence of Visual and Vestibular Hypersensitivity on Derealization and Depersonalization in Chronic Dizziness

Objective: The aim of this study was to investigate the relation between visual and vestibular hypersensitivity, and Depersonalization/Derealization symptoms in patients with chronic dizziness. Materials and Methods: 319 adult patients with chronic dizziness for more than 3 months (214 females and 105 males, mean age: 58 years, range: 13-90) were included in this prospective cross-sectional study. Patients underwent a complete audio-vestibular workup and 3 auto questionnaires: Hospital Anxiety and Depression (HAD), Depersonalization/Derealization Inventory (DDI), and an in-house questionnaire (Dizziness in Daily Activity, DDA) assessing 9 activities with a score ranging from 0 (no difficulty) to 10 (maximal discomfort) and 11 (avoidance) to detect patients with visual and vestibular hypersensitivity (VVH, a score > 41 corresponding to mean + 1 standard deviation). Results: DDI scores were higher in case of VVH (6.9 ± 6.79, n = 55 vs. 4.2 ± 4.81, n = 256 without VVH, p < 0.001, unpaired t-test), migraine (6.1 ± 6.40, n = 110 vs. 4.0 ± 4.42, n = 208no migraine, p < 0.001, unpaired t-test), and motion sickness (6.8 ± 5.93, n = 41 vs. 4.4 ± 5.11, n = 277 no motion sickness, p < 0.01, unpaired t-test). Women scored DDI higher than men (5.1 ± 5.42, n = 213 vs. 3.9 ± 4.91, n = 105, respectively, p < 0.05, unpaired t-test). DDI scores were also related to depression and anxiety. DDI score was also higher during spells than during the basal state. Conclusion: During chronic dizziness, Depersonalization/Derealization symptoms seem to be related to anxiety and depression. Moreover, they were prominent in women, in those with visual and vestibular hypersensitivity, migraine, and motion sickness.

Diagnosis of Vertigo and Dizziness Syndromes in a Neurological Outpatient Clinic

BACKGROUND

Dizziness and vertigo are frequent complaints of outpatients in the neurological department. Our objective was to explore the epidemiological category and clinical features of patients with dizziness or vertigo in the neurological outpatient department of a tertiary hospital.

METHODS

We consecutively recruited all patients with dizziness and/or vertigo visiting the neurological outpatient clinic of the First Affiliated Hospital of Chongqing Medical University from January 2016 to June 2017. All patients were interviewed by 4 neurologists and they completed self-administered questionnaires. General physical and standardized neuro-otology bedside examinations were performed in all participants. Instrumental examinations and other related examinations were prescribed as needed.

RESULTS

A total of 392 patients, 272 female and 120 male, were enrolled and the ratio of males to females was 1: 2.27. The mean age was 52.39 ± 13.87 years (range 11-90). Elderly patients (≥60 years) accounted for about one-third of the patients. Peripheral vestibular disorders accounted for 54.6% of patients, central vestibular disorders (including vestibular migraine [VM]) accounted for 22.4% of patients, psychogenic vertigo in 64 (16.3%), other reasons in 9 (2.3%) and unknown in 17 (4.3%). Benign paroxysmal positional vertigo (BPPV; 30.8%), psychiatric dizziness (20.5%), and VM (14.4%) were the 3 major vestibular diseases in patients under 60 years of age; however, BPPV (27.9%), central vertigo (21.7%), and Meniere's disease (11.7%) were more common in patients over 60 years of age.

CONCLUSIONS

This study provided a classification and clinical features of vestibular disorders in a neurological outpatient department of a tertiary hospital in China. The spectrum of vertigo or dizziness is different between different age groups and clinicians should pay attention to this difference in clinical reasoning.

Pseudo-spontaneous nystagmus in patients with geotropic direction-changing positional nystagmus

Background

Pseudo-spontaneous nystagmus has been reported in patients with direction-changing positional nystagmus (DCPN). Recently, the concept of a “light cupula” has been introduced as a pathophysiology that can exhibit persistent geotropic DCPN. Patients with persistent DCPN could have different characteristics of nystagmus. Therefore, we investigated the pseudo-spontaneous nystagmus in patients with transient (canalolithiasis) and persistent (belong to light cupula theory) geotropic DCPN.

Methods

In this study, prospectively, 49 patients with persistent geotropic DCPN and 67 patients with transient geotropic DCPN were enrolled. We compared the incidence of pseudo-spontaneous nystagmus between persistent and transient DCPN patients and characteristics of pseudo-spontaneous nystagmus and positional nystagmus by the head roll test in these patients. A prospective study was conducted at a dizziness clinic.

Results

Patients with persistent geotropic DCPN exhibited significantly higher incidence of pseudo-spontaneous nystagmus than patients with transient geotropic DCPN. Patients with transient DCPN showed a significantly higher mean SPV value during the head roll test than patients with persistent DCPN. All patients exhibiting pseudo-spontaneous nystagmus in patients with persistent DCPN had a null plane, and all patients had nystagmus beats to the opposite side of the null plane or the lesion side.

Conclusion

Our results support the possibility that the mechanism between persistent and transient geotropic DCPN may be different. However, more studies are needed on the pathogenesis and mechanism of the two diseases, including the occurrence of pseudo-spontaneous nystagmus in the disease entity.