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Marcelli V, Giannoni B, Volpe G, Faralli M, Fetoni AR, Pettorossi VE. Downbeat nystagmus: a clinical and pathophysiological review. Front Neurol 2024; 15:1394859. [PMID: 38854962 PMCID: PMC11157062 DOI: 10.3389/fneur.2024.1394859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Accepted: 04/29/2024] [Indexed: 06/11/2024] Open
Abstract
Downbeat nystagmus (DBN) is a neuro-otological finding frequently encountered by clinicians dealing with patients with vertigo. Since DBN is a finding that should be understood because of central vestibular dysfunction, it is necessary to know how to frame it promptly to suggest the correct diagnostic-therapeutic pathway to the patient. As knowledge of its pathophysiology has progressed, the importance of this clinical sign has been increasingly understood. At the same time, clinical diagnostic knowledge has increased, and it has been recognized that this sign may occur sporadically or in association with others within defined clinical syndromes. Thus, in many cases, different therapeutic solutions have become possible. In our work, we have attempted to systematize current knowledge about the origin of this finding, the clinical presentation and current treatment options, to provide an overview that can be used at different levels, from the general practitioner to the specialist neurologist or neurotologist.
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Affiliation(s)
- Vincenzo Marcelli
- Audiology and Vestibology Unit, Department of ENT, Ospedale del Mare, ASL Napoli 1 Centro, Napoli, Italy
- Department of Neuroscience, Reproductive Science and Dentistry, Section of Audiology, University of Naples ‘’Federico II’’, Napoli, Italy
| | - Beatrice Giannoni
- Department of Neuroscience, Psychology, Drug’s Area and Child’s Health, University of Florence, Florence, Italy
| | - Giampiero Volpe
- Department of Neurology, Ospedale San Luca di Vallo della Lucania, ASL Salerno, Salerno, Italy
| | - Mario Faralli
- Department of ENT, University of Perugia, Perugia, Italy
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Anna Rita Fetoni
- Department of Neuroscience, Reproductive Science and Dentistry, Section of Audiology, University of Naples ‘’Federico II’’, Napoli, Italy
| | - Vito E. Pettorossi
- Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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Xia S, Lai Y, Dong L, Yu D, Li Z, Xing Y. Assessments of Subjective Visual Gravity and Spontaneous Nystagmus in Patients With Vestibular Neuritis. Otolaryngol Head Neck Surg 2024. [PMID: 38699944 DOI: 10.1002/ohn.798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 02/05/2024] [Accepted: 04/13/2024] [Indexed: 05/05/2024]
Abstract
OBJECTIVE This study aimed to assess the correlation between the spontaneous nystagmus (SN) and the subjective visual vertical/horizontal (SVV/SVH) among patients with vestibular neuritis (VN) at the different head positions. STUDY DESIGN Case-control study. SETTING Affiliated Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine. METHODS This study evaluated the SVV/SVH in both healthy subjects and patients with VN. These evaluations were performed in 5 different head positions: upright, 45° tilt to the left, 90° tilt to the left, 45° tilt to the right, and 90° tilt to the right. Additionally, the intensity of SN, as measured by slow-phase velocity, was recorded. RESULTS In patients with VN, a significant correlation was observed between SN and SVV/SVH in an upright position. The intensity of SN was higher when the head was tilted 90° toward the affected side compared to other positions. The SVV/SVH displayed an ipsiversive shift, when the head was tilted toward both the lesion and unaffected sides, exhibiting a contraversive direction. Furthermore, the changes in position-induced SN were consistent with the displacements of SVV and SVH caused by head tilt. CONCLUSION The presence of SN in patients with VN was observed to vary across different head position. These variations could potentially be attributed to the diverse activation patterns of the mechanical properties of otolith organs that are induced by head tilts.
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Affiliation(s)
- Shan Xia
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Otolaryngology, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, China
| | - Yajing Lai
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- School of Medical Technology and Information Engineering, Zhejiang Chinese Medical University, Hangzhou, China
| | - Lingkang Dong
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dongzhen Yu
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhuangzhuang Li
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yazhi Xing
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Macher S, Dunkler D, Fiehl AT, Rommer PS, Platho-Elwischger K, Schwarz FK, Wiest G. Gravity-Dependent Modulation of Downbeat Nystagmus and Subjective Visual Vertical in the Roll Plane. CEREBELLUM (LONDON, ENGLAND) 2024:10.1007/s12311-024-01685-y. [PMID: 38499815 DOI: 10.1007/s12311-024-01685-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/09/2024] [Indexed: 03/20/2024]
Abstract
Downbeat nystagmus (DBN) is the most common form of acquired central vestibular nystagmus. Gravity perception in patients with DBN has previously been investigated by means of subjective visual straight ahead (SVA) and subjective visual vertical (SVV) in the pitch and roll planes only during whole-body tilts. To our knowledge, the effect of head tilt in the roll plane on the SVV and on DBN has not yet been systematically studied in patients. In this study, we investigated static and dynamic graviceptive function in the roll-plane in patients with DBN (patients) and healthy-controls (controls) by assessment of the Subjective Visual Vertical (SVV) and the modulation of slow-phase-velocity (SPV) of DBN. SPV of DBN and SVV were tested at different head-on trunk-tilt positions in the roll-plane (0°,30° clockwise (cw) and 30° counterclockwise (ccw)) in 26 patients suffering from DBN and 13 controls. In patients, SPV of DBN did not show significant modulations at different head-tilt angles in the roll-plane. SVV ratings did not differ significantly between DBN patients vs. controls, however patients with DBN exhibited a higher variability in mean SVV estimates than controls. Our results show that the DBN does not exhibit any modulation in the roll-plane, in contrast to the pitch-plane. Furthermore, patients with DBN show a higher uncertainty in the perception of verticality in the roll-plane in form of a higher variability of responses.
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Affiliation(s)
- Stefan Macher
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Daniela Dunkler
- Center for Medical Data Science, Institute of Clinical Biometrics, Medical University of Vienna, Vienna, Austria.
| | | | | | | | | | - Gerald Wiest
- Department of Neurology, Medical University of Vienna, Vienna, Austria
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Yun SY, Lee JH, Kim HJ, Choi JY, Kim JS. Effects of Baclofen on Central Paroxysmal Positional Downbeat Nystagmus. CEREBELLUM (LONDON, ENGLAND) 2024:10.1007/s12311-024-01684-z. [PMID: 38498146 DOI: 10.1007/s12311-024-01684-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/09/2024] [Indexed: 03/20/2024]
Abstract
Paroxysmal positional nystagmus frequently occurs in lesions involving the cerebellum, and has been ascribed to disinhibition and enhanced canal signals during positioning due to cerebellar dysfunction. This study aims to elucidate the mechanism of central positional nystagmus (CPN) by determining the effects of baclofen on the intensity of paroxysmal positional downbeat nystagmus due to central lesions. Fifteen patients with paroxysmal downbeat CPN were subjected to manual straight head-hanging before administration of baclofen, while taking baclofen 30 mg per day for at least one week, and two weeks after discontinuation of baclofen. The maximum slow phase velocity (SPV) and time constant (TC) of the induced paroxysmal downbeat CPN were analyzed. The positional vertigo was evaluated using an 11-point numerical rating scale (0 to 10) in 9 patients. After treatment with baclofen, the median of the maximum SPV of paroxysmal downbeat CPN decreased from 30.1°/s [interquartile range (IQR) = 19.6-39.0°/s] to 15.2°/s (IQR = 11.2-22.0°/s, Wilcoxon signed rank test, p < 0.001) with the median decrement ratio at 40.2% (IQR = 28.2-50.6%). After discontinuation of baclofen, the maximum SPV re-increased to 24.6°/s (IQR = 13.1-34.4°/s, Wilcoxon signed rank test, p = 0.001) with the median increment ratio at 23.5% (IQR = 5.2-87.9%). In contrast, the TCs of paroxysmal downbeat CPN remained unchanged at approximately 3.0 s throughout the evaluation. The positional vertigo also decreased with the medication (Wilcoxon signed rank test, p = 0.020), and remained unchanged even after discontinuation of medication (Wilcoxon signed rank test, p = 0.737). The results of this study support the prior presumption that paroxysmal CPN is caused by enhanced responses of the semicircular canals during positioning due to cerebellar disinhibition. Baclofen may be tried in symptomatic patients with paroxysmal CPN.
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Affiliation(s)
- So-Yeon Yun
- Department of Neurology, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jong-Hee Lee
- Dizziness Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyo-Jung Kim
- Biomedical Research Institute, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jeong-Yoon Choi
- Dizziness Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Neurology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji-Soo Kim
- Dizziness Center, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
- Department of Neurology, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Zhu W, Steenerson KK, Kattah JC. Generalized vestibular hyporeflexia and chronic upbeat nystagmus due to thiamine deficiency. J Neurol 2023; 270:1713-1720. [PMID: 36520241 DOI: 10.1007/s00415-022-11514-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 12/01/2022] [Accepted: 12/01/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Ocular motor and vestibular manifestations of Wernicke's thiamine deficiency (WTD) are frequent and heterogeneous. Previous neuropathological and neuroimaging findings identified brainstem and cerebellar lesions responsible for these findings, however, peripheral vestibular lesions are probably uncommon in human WTD, though noted on an avian thiamine deficient study. MATERIAL Single case study of a WTD patient post-gastric bypass who developed ataxia, oscillopsia and nystagmus, with low serum thiamine, and increased MRI T2 signal in the thalami, but normal brainstem and cerebellum. Vestibular evaluation showed significant vestibular hyporreflexia affecting all six canals, and a chronic upbeat nystagmus, now for 14 months after WTD onset. METHODS Serial clinical, video head impulse, nystagmus analysis, cervical and ocular vestibular evoked responses. She is undergoing treatment with Memantine, Clonazepam and vestibular rehabilitation, and feels improvement. CONCLUSION This report shows a novel combination of central and peripheral vestibular findings, of relevance for diagnosis and treatment, in addition to the development of a coherent hypothesis on the ocular motor and vestibular findings in WTD.
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Affiliation(s)
- William Zhu
- Department of Neurology and Neurological Sciences, Neurotology, Stanford School of Medicine, Stanford, CA, USA
| | - Kristen K Steenerson
- Department of Otolaryngology-Head and Neck Surgery and Department of Neurology and Neurological Sciences, Stanford School of Medicine, Stanford, CA, USA
| | - Jorge C Kattah
- Department of Neurology, University of Illinois College of Medicine, Peoria, IL, USA.
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Dietrich H, Pradhan C, Heidger F, Schniepp R, Wuehr M. Downbeat nystagmus becomes attenuated during walking compared to standing. J Neurol 2022; 269:6222-6227. [PMID: 35412151 DOI: 10.1007/s00415-022-11106-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 03/24/2022] [Accepted: 03/24/2022] [Indexed: 11/28/2022]
Abstract
Downbeat nystagmus (DBN) is a common form of acquired fixation nystagmus related to vestibulo-cerebellar impairments and associated with impaired vision and postural imbalance. DBN intensity becomes modulated by various factors such as gaze direction, head position, daytime, and resting conditions. Further evidence suggests that locomotion attenuates postural symptoms in DBN. Here, we examined whether walking might analogously influence ocular-motor deficits in DBN. Gaze stabilization mechanisms and nystagmus frequency were examined in 10 patients with DBN and 10 age-matched healthy controls with visual fixation during standing vs. walking on a motorized treadmill. Despite their central ocular-motor deficits, linear and angular gaze stabilization in the vertical plane were functional during walking in DBN patients and comparable to controls. Notably, nystagmus frequency in patients was considerably reduced during walking compared to standing (p < 0.001). The frequency of remaining nystagmus during walking was further modulated in a manner that depended on the specific phase of the gait cycle (p = 0.015). These attenuating effects on nystagmus intensity during walking suggest that ocular-motor control disturbances are selectively suppressed during locomotion in DBN. This suppression is potentially mediated by locomotor efference copies that have been shown to selectively govern gaze stabilization during stereotyped locomotion in animal models.
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Affiliation(s)
- Haike Dietrich
- German Center for Vertigo and Balance Disorders, University Hospital, LMU, Munich, Germany
| | - Cauchy Pradhan
- German Center for Vertigo and Balance Disorders, University Hospital, LMU, Munich, Germany
| | - Felix Heidger
- German Center for Vertigo and Balance Disorders, University Hospital, LMU, Munich, Germany
| | - Roman Schniepp
- German Center for Vertigo and Balance Disorders, University Hospital, LMU, Munich, Germany
| | - Max Wuehr
- German Center for Vertigo and Balance Disorders, University Hospital, LMU, Munich, Germany.
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Tran TM, Lee MS, McClelland CM. Downbeat nystagmus: a clinical review of diagnosis and management. Curr Opin Ophthalmol 2021; 32:504-514. [PMID: 34456290 DOI: 10.1097/icu.0000000000000802] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW This review will extensively cover the clinical manifestations, causes, diagnostic evaluation, and management strategies of downbeat nystagmus (DBN). RECENT FINDINGS Historically, MRI to assess for structural lesions at the cervicomedullary junction has been the primary diagnostic test in the evaluation of DBN since the 1980s. In recent years, there is increasing awareness of nonstructural causes of DBN including gluten ataxia, nutritional deficiencies, and paraneoplastic syndromes, among others. Medical management with aminopyridines has become first-line therapy in addition to disease-specific therapies. SUMMARY DBN is a common form of acquired nystagmus and the differential diagnosis remains broad, including both benign and potentially fatal causes. For practical purposes, the causes can be categorized as structural vs. nonstructural with MRI as the ideal, initial diagnostic study to differentiate the two. General therapeutic options include pharmacotherapy to enhance Purkinje cell function, strabismus surgery or prisms to shift null points, and behavioural changes. Disease-specific treatment is necessarily broad, though a significant proportion of patients will be idiopathic.
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Affiliation(s)
- Tu M Tran
- Department of Ophthalmology and Visual Neurosciences
| | - Michael S Lee
- Department of Ophthalmology and Visual Neurosciences
- Department of Neurology
- Department of Neurosurgery, University of Minnesota, Minneapolis, USA
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Bery AK, Wang CF, Gold DR, Chang TP. The fixation suppression test can uncover vertical nystagmus of central origin in some patients with dizziness. Neurol Sci 2021; 42:5343-5352. [PMID: 34698943 DOI: 10.1007/s10072-021-05676-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 10/15/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Identifying dangerous causes of dizziness is a challenging task for neurologists, as it requires interpretation of subtle bedside exam findings, which become even more subtle with time. Nystagmus can be instrumental in differentiating peripheral from central vestibular disorders. Conventional teaching is that peripheral vestibular nystagmus is accentuated by removal of visual fixation. We sought to systematically test the hypothesis that, in some cases, vertical nystagmus due to central vestibular disorders may also be easier to identify when fixation is removed. METHODS To identify patients with vertical nystagmus, we retrospectively reviewed clinical, MRI, and VNG data of consecutive patients undergoing VNG in our vestibular clinic over a 9-month period. We analyzed clinical features, bedside neuro-otological examination, MRI results, and VNG findings in fixation as well as those with fixation removed. RESULTS Two hundred and fourteen charts were reviewed. Twenty-six patients had vertical nystagmus with fixation removed on VNG. Only three (11.5%) of these patients had vertical nystagmus apparent with fixation (and only two had nystagmus observed clearly at the bedside with the unaided eye). Thirteen (50%) of the patients had posterior fossa lesions on MRI and eight of the rest (30.8%) were diagnosed with central vestibular disorders. Of the 13 patients with MRI-confirmed lesions, 3 patients (23.1%) had no neurological signs or conventional bedside oculomotor signs; in these cases, vertical nystagmus without fixation was the only sign of a central lesion. CONCLUSIONS Our findings go against conventional teaching and show that removing fixation can uncover subtle vertical nystagmus due to central vestibular disease, particularly from focal or chronic lesions.
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Affiliation(s)
- Anand K Bery
- Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Ching-Fu Wang
- Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Hsinchu, Taiwan.,Neurobit Technologies Co., Ltd., Taipei, Taiwan
| | - Daniel R Gold
- Department of Neurology, Ophthalmology, Neurosurgery, Otolaryngology - Head & Neck Surgery, Emergency Medicine, and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tzu-Pu Chang
- Department of Neurology/Neuro-medical Scientific Center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No.88, Sec. 1, Fengxing Rd., Tanzi Dist., Taichung, 427, Taiwan. .,Department of Neurology, School of Medicine, Tzu Chi University, Hualien, Taiwan.
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Péus D, Straumann D, Huber A, Bockisch CJ, Wettstein V. Therapy-Resistant Atypical Downbeat Nystagmus with Vertigo Confined to Specific Head-Hanging Positions: Mapping to the Gravity Vector on a Multi-Axis Turntable. Case Rep Neurol 2021; 13:464-469. [PMID: 34413748 PMCID: PMC8339484 DOI: 10.1159/000517840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 06/03/2021] [Indexed: 12/21/2022] Open
Abstract
Downbeat nystagmus (DBN) observed in head-hanging positions, may be of central or peripheral origin. Central DBN in head-hanging positions is mostly due to a disorder of the vestibulo-cerebellum, whereas peripheral DBN is usually attributed to canalolithiasis of an anterior semicircular canal. Here, we describe an atypical case of a patient who, after head trauma, experienced severe and stereotypic vertigo attacks after being placed in various head-hanging positions. Vertigo lasted 10–15 s and was always associated with a robust DBN. The provocation of transient vertigo and DBN, which both showed no decrease upon repetition of maneuvers, depended on the yaw orientation relative to the trunk and the angle of backward pitch. On a motorized, multi-axis turntable, we identified the two-dimensional Helmholtz coordinates of head positions at which vertigo and DBN occurred (y-axis: horizontal, space-fixed; z-axis: vertical, and head-fixed; x-axis: torsional, head-fixed, and unchanged). This two-dimensional area of DBN-associated head positions did not change when whole-body rotations took different paths (e.g., by forwarding pitch) or were executed with different velocities. Moreover, the intensity of DBN was also independent of whole-body rotation paths and velocities. So far, therapeutic approaches with repeated liberation maneuvers and cranial vibrations were not successful. We speculate that vertigo and DBN in this patient are due to macular damage, possibly an unstable otolithic membrane that, in specific orientations relative to gravity, slips into a position causing paroxysmal stimulation or inhibition of macular hair cells.
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Affiliation(s)
- Dominik Péus
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Zurich and University Hospital Zurich, Zurich, Switzerland.,Department of Neurology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Dominik Straumann
- Department of Ophthalmology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Alexander Huber
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Christopher J Bockisch
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Zurich and University Hospital Zurich, Zurich, Switzerland.,Department of Ophthalmology, University of Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Vincent Wettstein
- Department of Otorhinolaryngology, Head and Neck Surgery, University of Zurich and University Hospital Zurich, Zurich, Switzerland.,Rautipraxis AG, Zurich, Switzerland
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Horizontal nystagmus is gravity-dependent in patients with vestibular neuritis. Am J Otolaryngol 2021; 42:102967. [PMID: 33713888 DOI: 10.1016/j.amjoto.2021.102967] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 02/04/2021] [Accepted: 02/14/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Horizontal nystagmus can be observed in the acute stage of vestibular neuritis, Although the direction of the nystagmus is gravity independent, its intensity can be influenced by gravity. In this study, we compared the slow phase velocity (SPV) of horizontal nystagmus in different head positions in patients with vestibular neuritis to analyze the static effects of gravity on horizontal nystagmus. METHODS The study enrolled 22 vestibular neuritis patients with spontaneous horizontal nystagmus (9 men, 13 women; median age 40 years). The deficits were right-sided in 9 patients and left-sided in 13. The nystagmus was recorded in the sitting, supine, right and left ear down positions. The intensity of spontaneous nystagmus in the sitting versus while supine position, and SPV in affected ear down (AED), healthy ear down (HED), and supine positions were compared. The position-induced nystagmus was calculated to quantify the effect of head positions on nystagmus. RESULTS The nystagmus intensity in the supine position had no statistic difference than when sitting, with a median value of 6.3°/s and 5.6°/s, respectively(P = 0.355). SPV in AED had a median value of 7.8°/s, which was greater than when supine (P = 0.008) and HED (4.8°/s) (P < 0.001). Position-induced nystagmus in left and right ear-down positions were 1.4°/s and -1.4°/s respectively, which were significantly correlated (Spearman's ρ = -0.848, P < 0.001). CONCLUSIONS The nystagmus intensity in vestibular neuritis is gravity dependent; it's greater in AED than in supine and HED, and the effect of head position on nystagmus was nearly symmetrical in left and right ear-down positions.
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Inner ear conductive hearing loss and downbeat nystagmus: A clinical case report. OTOLARYNGOLOGY CASE REPORTS 2020. [DOI: 10.1016/j.xocr.2020.100189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Lee SU, Kim HJ, Choi JY, Kim JS. Ictal downbeat nystagmus in Ménière disease: A cross-sectional study. Neurology 2020; 95:e2409-e2417. [PMID: 32817190 DOI: 10.1212/wnl.0000000000010653] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/21/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the mechanism of ictal downbeat nystagmus in Ménière disease (MD), we compared the head impulse gain of the vestibulo-ocular reflex (VOR) for each semicircular canal between patients with (n = 7) and without (n = 70) downbeat nystagmus during attacks of MD. METHODS We retrospectively analyzed the results of video-oculography, video head-impulse tests, and cervical vestibular-evoked myogenic potentials (VEMPs) in 77 patients with definite MD who were evaluated during an attack. RESULTS Pure or predominant downbeat nystagmus was observed in 7 patients (9%) with unilateral MD during the attacks. All 7 patients showed spontaneous downbeat nystagmus without visual fixation with a slow phase velocity ranging from 1.5 to 11.2°/s (median 5.4, interquartile range 3.7-8.5). All showed a transient decrease of the head impulse VOR gains for the posterior canals (PCs) in both ears (n = 4) or in the affected ear (n = 3). Cervical VEMPs were decreased in the affected (n = 2) or both ears (n = 2) when evaluated during the attacks. Downbeat nystagmus disappeared along with normalization of the VOR gains for PCs after the attacks in all patients. During the attacks, the head impulse VOR gains for the PC on the affected side were lower in the patients with ictal downbeat nystagmus than in those without (Mann-Whitney U test, p < 0.001), while the gains for other semicircular canals did not differ between the groups. CONCLUSION Downbeat nystagmus may be observed during attacks of MD due to an asymmetry in the vertical VOR or saccular dysfunction. MD should be considered in recurrent audiovestibulopathy and ictal downbeat nystagmus.
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Affiliation(s)
- Sun-Uk Lee
- From the Department of Neurology (S.-U.L.), Korea University Medical Center; Department of Neurology (S.-U.L., J.-Y.C., J.-S.K.), Seoul National University College of Medicine; and Research Administration Team (H.-J.K.) and Dizziness Center (J.-Y.C., J.-S.K.), Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hyo-Jung Kim
- From the Department of Neurology (S.-U.L.), Korea University Medical Center; Department of Neurology (S.-U.L., J.-Y.C., J.-S.K.), Seoul National University College of Medicine; and Research Administration Team (H.-J.K.) and Dizziness Center (J.-Y.C., J.-S.K.), Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jeong-Yoon Choi
- From the Department of Neurology (S.-U.L.), Korea University Medical Center; Department of Neurology (S.-U.L., J.-Y.C., J.-S.K.), Seoul National University College of Medicine; and Research Administration Team (H.-J.K.) and Dizziness Center (J.-Y.C., J.-S.K.), Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Ji-Soo Kim
- From the Department of Neurology (S.-U.L.), Korea University Medical Center; Department of Neurology (S.-U.L., J.-Y.C., J.-S.K.), Seoul National University College of Medicine; and Research Administration Team (H.-J.K.) and Dizziness Center (J.-Y.C., J.-S.K.), Seoul National University Bundang Hospital, Seongnam, South Korea.
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Jorge A, Martins AI, Gouveia A, Lemos J. The Use of Video-Head Impulse Test in Different Head Positions in Vertical Nystagmus and Ataxia Associated with Probable Thiamine Deficiency. CEREBELLUM (LONDON, ENGLAND) 2020; 19:611-615. [PMID: 32410095 DOI: 10.1007/s12311-020-01140-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Upward and downward bias of eye movement signals in the semicircular canals (SCC)- and/or otolith-related central pathways have been proposed to explain the occurrence of vertical nystagmus (downbeat nystagmus [DBN] and upbeat nystagmus [UBN]) and its frequent modulation with head position. Video-head impulse test (VHIT), usually performed in upright position, is a recent development for measuring SCC function. We performed longitudinal nystagmus and VHIT assessments in different head positions in a patient with probable thiamine deficiency, in order to explore a possible relationship between the positional behavior of vertical nystagmus and SCC function. Initially, UBN in upright position changed to DBN in prone position and remained relatively unchanged in supine position. This was associated with both anterior and posterior SCC hyperactive responses in upright position, and a relative enhancement of the anterior SCC responses in prone position and the posterior SCC responses in supine position. Over 1 year, in prone position, change from UBN to DBN and the enhancement of anterior SCC responses remained, while in supine position, UBN either decreased or changed to DBN, when compared to upright position. This was associated with a relative enhancement of the anterior SCC responses in supine position, albeit inconsistently, and the presence of posterior SCC hypoactive responses in all positions, including prone. While not contradicting a primary otolithic dysfunction in the genesis of UBN change to DBN with head position, we provide evidence for positional modulation of SCC function in thiamine deficiency and a possible relationship with nystagmus positional behavior.
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Affiliation(s)
- André Jorge
- Neurology Department, Coimbra University Hospital Centre, Praceta Mota Pinto, 3000-135, Coimbra, Portugal
| | - Ana Inês Martins
- Neurology Department, Coimbra University Hospital Centre, Praceta Mota Pinto, 3000-135, Coimbra, Portugal
| | - Ana Gouveia
- Neurology Department, Tondela-Viseu Hospital Centre, Viseu, Portugal
| | - João Lemos
- Neurology Department, Coimbra University Hospital Centre, Praceta Mota Pinto, 3000-135, Coimbra, Portugal.
- Faculty of Medicine, Coimbra University, Coimbra, Portugal.
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Abstract
The cerebellum works as a network hub for optimizing eye movements through its mutual connections with the brainstem and beyond. Here, we review three key areas in the cerebellum that are related to the control of eye movements: (1) the flocculus/paraflocculus (tonsil) complex, primarily for high-frequency, transient vestibular responses, and also for smooth pursuit maintenance and steady gaze holding; (2) the nodulus/ventral uvula, primarily for low-frequency, sustained vestibular responses; and (3) the dorsal vermis/posterior fastigial nucleus, primarily for the accuracy of saccades. Although there is no absolute compartmentalization of function within the three major ocular motor areas in the cerebellum, the structural-functional approach provides a framework for assessing ocular motor performance in patients with disease that involves the cerebellum or the brainstem.
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Lee JY, Kwon E, Kim HJ, Choi JY, Oh HJ, Kim JS. Opsoclonus Following Downbeat Nystagmus in Absence of Visual Fixation in Multiple System Atrophy: Modulation and Mechanisms. THE CEREBELLUM 2019; 20:724-733. [PMID: 31838647 DOI: 10.1007/s12311-019-01090-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report atypical opsoclonus in a patient with multiple system atrophy and propose a mechanism based on the patterns of modulation by visual, vestibular, and saccadic and vergence stimulation. Firstly, the 6-Hz opsoclonus mostly in the vertical plane occurred only after the development of downbeat nystagmus in darkness without visual fixation. Even after a substantial build-up, visual suppression of the opsoclonus was immediate and complete. Furthermore, the latency for re-emergence of opsoclonus in darkness was greater when the duration of preceding visual fixation was longer. Secondly, the effect of preceding downbeat nystagmus on the development of opsoclonus was evaluated by changing the head position. The opsoclonus did not occur in the supine position when the downbeat nystagmus was absent. After horizontal head shaking, the opsoclonus in the vertical plane gradually evolved into horizontal plane and resumed its vertical direction again after vertical head shaking. Thirdly, any opsoclonus was not triggered by imaginary saccades in the supine position. Lastly, combined vergence and saccadic eye movements during the Müller paradigm did not induce opsoclonus. From these findings of modulation, we suggest that the opsoclonus observed in our patient was invoked by vestibular signals. When the function of the omnipause neurons and saccadic system was impaired, the centrally mediated vestibular eye velocity signals may activate the saccadic system to generate opsoclonus. These atypical patterns of opsoclonus, distinct from the classic opsoclonus frequently observed in para-neoplastic or para-infectious disorders, may be an unrevealing sign of degenerative brainstem or cerebellar disorders.
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Affiliation(s)
- Ju-Young Lee
- Dizziness Center and Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam, 13620, South Korea
| | - Eunjin Kwon
- Dizziness Center and Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam, 13620, South Korea
| | - Hyo-Jung Kim
- Research Administration Team, Seoul National Univertisy Bundang Hospital, Seongnam, South Korea
| | - Jeong-Yoon Choi
- Dizziness Center and Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea. .,Department of Neurology, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam, 13620, South Korea. .,Department of Neurology, College of Medicine, Seoul National University, Seoul, South Korea.
| | - Hui Jong Oh
- The MTV (Migraine, Tinnitus, and Vertigo) Clinic, Oh Neurology Center, Daegu, South Korea
| | - Ji-Soo Kim
- Dizziness Center and Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea. .,Department of Neurology, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam, 13620, South Korea. .,Department of Neurology, College of Medicine, Seoul National University, Seoul, South Korea.
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16
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Kattah JC, Tehrani AS, du Lac S, Newman-Toker DE, Zee DS. Conversion of upbeat to downbeat nystagmus in Wernicke encephalopathy. Neurology 2019; 91:790-796. [PMID: 30348852 DOI: 10.1212/wnl.0000000000006385] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 06/27/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To explain (1) why an initial upbeat nystagmus (UBN) converts to a permanent downbeat nystagmus (DBN) in Wernicke encephalopathy (WE) and (2) why convergence and certain vestibular provocative maneuvers may transiently switch UBN to DBN. METHODS Following a literature review and study of our 2 patients, we develop hypotheses for the unusual patterns of vertical nystagmus in WE. RESULTS Our overarching hypothesis is that there is a selective vulnerability and a selective recovery from thiamine deficiency of neurons within brainstem gaze-holding networks. Furthermore, since the circuits affected in WE are commonly paraventricular, especially medially, just under the floor of the fourth ventricle where lie structures important for control of vertical gaze, we suggest the patterns of involvement in WE also reflect a breakdown in vulnerable areas of the blood-brain barrier. Many of the initial deficits of our patients improved over time, but their DBN did not. Irreversible changes in paramedian tract neurons, which project to the cerebellar flocculus, may be the cause. Here we suggest that conversion of UBN to permanent DBN points to thiamine deficiency and may argue for a chronic, nonprogressive DBN/truncal ataxia syndrome. Finally, we posit that the transient switch of UBN to DBN reflects abnormal processing of otolith information about linear acceleration, and often points to a diagnosis of WE. CONCLUSION Recognizing the unusual patterns of transient switching and then permanent conversion of UBN to DBN in WE is vital since long-term disability from WE may be prevented by timely, parenteral high-dose thiamine.
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Affiliation(s)
- Jorge C Kattah
- From the Department of Neurology (J.C.K., A.S.T.), University of Illinois College of Medicine; Illinois Neurologic Institute (J.C.K., A.S.T.), Peoria; Departments of Otolaryngology-Head and Neck Surgery (S.d.L., D.E.N.-T., D.S.Z.), Neuroscience (S.d.L., D.E.N.-T., D.S.Z.), and Neurology (S.d.L., D.E.N.-T., D.S.Z.), and Division of Neuro-Visual & Vestibular Disorders (D.E.N.-T.), Johns Hopkins University, Baltimore, MD.
| | - Ali Saber Tehrani
- From the Department of Neurology (J.C.K., A.S.T.), University of Illinois College of Medicine; Illinois Neurologic Institute (J.C.K., A.S.T.), Peoria; Departments of Otolaryngology-Head and Neck Surgery (S.d.L., D.E.N.-T., D.S.Z.), Neuroscience (S.d.L., D.E.N.-T., D.S.Z.), and Neurology (S.d.L., D.E.N.-T., D.S.Z.), and Division of Neuro-Visual & Vestibular Disorders (D.E.N.-T.), Johns Hopkins University, Baltimore, MD
| | - Sascha du Lac
- From the Department of Neurology (J.C.K., A.S.T.), University of Illinois College of Medicine; Illinois Neurologic Institute (J.C.K., A.S.T.), Peoria; Departments of Otolaryngology-Head and Neck Surgery (S.d.L., D.E.N.-T., D.S.Z.), Neuroscience (S.d.L., D.E.N.-T., D.S.Z.), and Neurology (S.d.L., D.E.N.-T., D.S.Z.), and Division of Neuro-Visual & Vestibular Disorders (D.E.N.-T.), Johns Hopkins University, Baltimore, MD
| | - David E Newman-Toker
- From the Department of Neurology (J.C.K., A.S.T.), University of Illinois College of Medicine; Illinois Neurologic Institute (J.C.K., A.S.T.), Peoria; Departments of Otolaryngology-Head and Neck Surgery (S.d.L., D.E.N.-T., D.S.Z.), Neuroscience (S.d.L., D.E.N.-T., D.S.Z.), and Neurology (S.d.L., D.E.N.-T., D.S.Z.), and Division of Neuro-Visual & Vestibular Disorders (D.E.N.-T.), Johns Hopkins University, Baltimore, MD
| | - David S Zee
- From the Department of Neurology (J.C.K., A.S.T.), University of Illinois College of Medicine; Illinois Neurologic Institute (J.C.K., A.S.T.), Peoria; Departments of Otolaryngology-Head and Neck Surgery (S.d.L., D.E.N.-T., D.S.Z.), Neuroscience (S.d.L., D.E.N.-T., D.S.Z.), and Neurology (S.d.L., D.E.N.-T., D.S.Z.), and Division of Neuro-Visual & Vestibular Disorders (D.E.N.-T.), Johns Hopkins University, Baltimore, MD
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17
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Choi JY, Glasauer S, Kim JH, Zee DS, Kim JS. Characteristics and mechanism of apogeotropic central positional nystagmus. Brain 2019; 141:762-775. [PMID: 29373699 DOI: 10.1093/brain/awx381] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 11/23/2017] [Indexed: 11/12/2022] Open
Abstract
Here we characterize persistent apogeotropic type of central positional nystagmus, and compare it with the apogeotropic nystagmus of benign paroxysmal positional vertigo involving the lateral canal. Nystagmus was recorded in 27 patients with apogeotropic type of central positional nystagmus (22 with unilateral and five with diffuse cerebellar lesions) and 20 patients with apogeotropic nystagmus of benign paroxysmal positional vertigo. They were tested while sitting, while supine with the head straight back, and in the right and left ear-down positions. The intensity of spontaneous nystagmus was similar while sitting and supine in apogeotropic type of central positional nystagmus, but greater when supine in apogeotropic nystagmus of benign paroxysmal positional vertigo. In central positional nystagmus, when due to a focal pathology, the lesions mostly overlapped in the vestibulocerebellum (nodulus, uvula, and tonsil). We suggest a mechanism for apogeotropic type of central positional nystagmus based on the location of lesions and a model that uses the velocity-storage mechanism. During both tilt and translation, the otolith organs can relay the same gravito-inertial acceleration signal. This inherent ambiguity can be resolved by a 'tilt-estimator circuit' in which information from the semicircular canals about head rotation is combined with otolith information about linear acceleration through the velocity-storage mechanism. An example of how this mechanism works in normal subjects is the sustained horizontal nystagmus that is produced when a normal subject is rotated at a constant speed around an axis that is tilted away from the true vertical (off-vertical axis rotation). We propose that when the tilt-estimator circuit malfunctions, for example, with lesions in the vestibulocerebellum, the estimate of the direction of gravity is erroneously biased away from true vertical. If the bias is toward the nose, when the head is turned to the side while supine, there will be sustained, unwanted, horizontal positional nystagmus (apogeotropic type of central positional nystagmus) because of an inappropriate feedback signal indicating that the head is rotating when it is not.
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Affiliation(s)
- Jeong-Yoon Choi
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Stefan Glasauer
- Center for Sensorimotor Research, Department of Neurology, Ludwig-Maximilian University Munich, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig-Maximilian University Munich, Munich, Germany
| | - Ji Hyun Kim
- Department of Neurology, Korea University College of Medicine, Korea University Guro Hospital, Seoul, Korea
| | - David S Zee
- Departments of Neurology, Ophthalmology, Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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18
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Choi JY, Kim JS. Central positional nystagmus: Characteristics and model-based explanations. PROGRESS IN BRAIN RESEARCH 2019; 249:211-225. [PMID: 31325981 DOI: 10.1016/bs.pbr.2019.04.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The central vestibular system operates to precisely estimate the rotational velocity and gravity orientation using the inherently ambiguous information from peripheral vestibular system. Therefore, any lesions disrupting this function can generate positional nystagmus. Central positional nystagmus (CPN) can be classified into the paroxysmal (transient) and persistent forms. The paroxysmal CPN has the features suggesting a semicircular canal origin regarding the latency, duration, and direction of nystagmus. Patients with paroxysmal CPN commonly show several different types of nystagmus classified according to the provoking positioning. The persistent form of CPN mostly appears as downbeat nystagmus while prone or supine, or apogeotropic or geotropic horizontal nystagmus when the head is turned to either side while supine. CPN may be ascribed to erroneous neural processing within the velocity-storage circuit that functions in estimating angular head velocity, gravity direction, and inertia. Paroxysmal CPN appears to be post-rotatory rebound nystagmus due to lesions involving the cerebellar nodulus and uvula. In contrast, persistent CPN may arise from erroneous gravity estimation. The overlap of lesion location responsible for both paroxysmal and persistent CPN may account for the frequent coexistence of both forms of nystagmus in a single patient.
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Affiliation(s)
- Jeong-Yoon Choi
- Department of Neurology, Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Ji-Soo Kim
- Department of Neurology, Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea.
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19
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20
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Sanchez K, Rowe FJ. Role of neural integrators in oculomotor systems: a systematic narrative literature review. Acta Ophthalmol 2018; 96:e111-e118. [PMID: 27874249 DOI: 10.1111/aos.13307] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 09/25/2016] [Indexed: 11/28/2022]
Abstract
PURPOSE To evaluate the role of neural integrators (NI) in the oculomotor system. METHODS A literature search was carried out using several electronic databases during the months of June 2014 to March 2015. The following keywords were used to generate focused results: 'neural integrators', 'gaze-holding', 'oculomotor integration', 'impaired gaze-holding', 'gaze evoked nystagmus' and 'gaze dysfunction'. Further materials were found through searching relevant articles within reference lists. Seventy-one articles were sourced for this review which analysed animal and human subjects and network models; 45 were studies of humans, 16 studies of primates, three studies of felines and one study from rats and network models. The remaining articles were literature reviews. RESULTS The horizontal and vertical, including torsional, NI are located logically in the brainstem, nearby their appropriate target extraocular motoneuron nuclei for stable eye position in eccentric position. The nucleus prepositus hypoglossi (NPH) and medial vestibular nuclei (MVN) are closely linked at the caudal pons and dorsal rostral medulla, integrating horizontal conjugate eye movement. The interstitial nucleus of Cajal (INC) integrates vertical and torsional eye movement at the upper midbrain. The integrator time constant is averaged to 25 seconds in human horizontal and animal vertical NI to perform its function. Case reports revealed that dysfunction of horizontal NI also resulted in vertical ocular deviations, indicating some overlap of horizontal and vertical gaze control. Furthermore, pharmacological inactivation of NI exposed a population of inhibitory neurotransmitters that permits its mechanism of action; allowing for smooth conjugate movement. CONCLUSIONS Neural integrators operate to integrate eye velocity and eye position information to provide signals to extraocular motoneurons to attain and maintain a new position. Therefore, NI allow image stabilization during horizontal and vertical eye movements at eccentric positions for comfortable single vision.
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Affiliation(s)
| | - Fiona J. Rowe
- Department of Health Services Research; University of Liverpool; Liverpool UK
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21
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Tarnutzer AA, Straumann D, Salman MS. Neuro-ophthalmologic assessment and investigations in children and adults with cerebellar diseases. THE CEREBELLUM: FROM EMBRYOLOGY TO DIAGNOSTIC INVESTIGATIONS 2018; 154:305-327. [DOI: 10.1016/b978-0-444-63956-1.00019-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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22
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Spiegel R, Claassen J, Teufel J, Bardins S, Schneider E, Lehrer Rettinger N, Jahn K, da Silva FA, Hahn A, Farahmand P, Brandt T, Strupp M, Kalla R. Resting in darkness improves downbeat nystagmus: evidence from an observational study. Ann N Y Acad Sci 2017; 1375:66-73. [PMID: 27447539 DOI: 10.1111/nyas.13172] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 06/01/2016] [Accepted: 06/15/2016] [Indexed: 11/27/2022]
Abstract
Resting in an upright position during daytime decreases downbeat nystagmus (DBN). When measured in brightness only, that is, without intermitting exposure to darkness, it does not make a significant difference whether patients have previously rested in brightness or in darkness. In real-world scenarios, people are often exposed to brightness and darkness intermittently. The aim of this study was to analyze whether resting in brightness or resting in darkness was associated with a lower post-resting DBN after intermitting exposures to brightness and darkness. Eight patients were recorded with three-dimensional video-oculography in brightness and darkness conditions, each following two 2-h resting intervals under either brightness or darkness resting conditions. The dependent variable was DBN intensity, measured in mean slow phase velocity. A repeated measures ANOVA with the factors measurement condition (brightness vs. darkness), resting condition (brightness vs. darkness), and time (after first vs. second resting interval) showed a significant effect for the factor resting condition, where previous resting in darkness was associated with a significantly lower DBN relative to previous resting in brightness (P < 0.01). The clinical relevance is to advise patients with DBN to rest in darkness.
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Affiliation(s)
- Rainer Spiegel
- Division of Internal Medicine, Basel University Hospital, Basel, Switzerland
| | - Jens Claassen
- Department of Neurology, Essen University Hospital, Essen, Germany
| | - Julian Teufel
- Department of Neurology and German Center for Vertigo and Balance Disorders, University Hospital, Munich, Germany
| | - Stanislav Bardins
- Department of Neurology and German Center for Vertigo and Balance Disorders, University Hospital, Munich, Germany
| | - Erich Schneider
- Department of Neurology and German Center for Vertigo and Balance Disorders, University Hospital, Munich, Germany.,Institute of Medical Technology, Brandenburg University of Technology, Cottbus-Senftenberg, Senftenberg, Germany
| | - Nicole Lehrer Rettinger
- Department of Neurology and German Center for Vertigo and Balance Disorders, University Hospital, Munich, Germany
| | - Klaus Jahn
- Department of Neurology and German Center for Vertigo and Balance Disorders, University Hospital, Munich, Germany
| | - Fábio Anciães da Silva
- Serviço de Neurologia, Hospital Universitário Antonio Pedro, Universidade Federal Fluminense, Niteroi, Rio de Janeiro, Brazil
| | - Ales Hahn
- Ear, Nose and Throat Department of the 3rd Medical Faculty, Charles University, Prague, Czech Republic
| | - Parvis Farahmand
- Department of Medicine, Giessen University Hospital, Giessen, Germany
| | - Thomas Brandt
- Department of Neurology and German Center for Vertigo and Balance Disorders, University Hospital, Munich, Germany
| | - Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, University Hospital, Munich, Germany
| | - Roger Kalla
- Department of Neurology, Bern University Hospital, Bern, Switzerland
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23
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Delva A, Thakore N, Pioro EP, Poesen K, Saunders-Pullman R, Meijer IA, Rucker JC, Kissel JT, Van Damme P. Finger extension weakness and downbeat nystagmus motor neuron disease syndrome: A novel motor neuron disorder? Muscle Nerve 2017; 56:1164-1168. [PMID: 28440863 PMCID: PMC5656559 DOI: 10.1002/mus.25669] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 03/26/2017] [Accepted: 04/17/2017] [Indexed: 12/11/2022]
Abstract
Introduction: Disturbances of eye movements are infrequently encountered in motor neuron diseases (MNDs) or motor neuropathies, and there is no known syndrome that combines progressive muscle weakness with downbeat nystagmus. Methods: To describe the core clinical features of a syndrome of MND associated with downbeat nystagmus, clinical features were collected from 6 patients. Results: All patients had slowly progressive muscle weakness and wasting in combination with downbeat nystagmus, which was clinically most obvious in downward and lateral gaze. Onset was in the second to fourth decade with finger extension weakness, progressing to other distal and sometimes more proximal muscles. Visual complaints were not always present. Electrodiagnostic testing showed signs of regional motor axonal loss in all patients. Discussion: The etiology of this syndrome remains elusive. Because finger extension weakness and downbeat nystagmus are the discriminating clinical features of this MND, we propose the name FEWDON‐MND syndrome. Muscle Nerve56: 1164–1168, 2017
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Affiliation(s)
- Aline Delva
- Department of Neurology, University Hospitals Leuven, Campus Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium
| | - Nimish Thakore
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Erik P Pioro
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Koen Poesen
- Laboratory for Molecular Neurobiomarker Research, University of Leuven (KU Leuven), Leuven, Belgium.,Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Rachel Saunders-Pullman
- Department of Neurology, Mount Sinai Beth Israel and Icahn School of Medicine at Mount Sinai, New York, USA
| | - Inge A Meijer
- Department of Neurology, Mount Sinai Beth Israel and Icahn School of Medicine at Mount Sinai, New York, USA
| | - Janet C Rucker
- Department of Neurology, Mount Sinai Beth Israel and Icahn School of Medicine at Mount Sinai, New York, USA
| | - John T Kissel
- Department of Neurology, Wexner Medical Center, Ohio State University, Columbus, Ohio, USA
| | - Philip Van Damme
- Department of Neurology, University Hospitals Leuven, Campus Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium.,Department of Neurosciences, University of Leuven (KU Leuven), Leuven, Belgium.,Laboratory of Neurobiology, VIB Center for Brain & Disease Research, VIB, Leuven, Belgium
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24
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Schniepp R, Möhwald K, Wuehr M. Gait ataxia in humans: vestibular and cerebellar control of dynamic stability. J Neurol 2017; 264:87-92. [PMID: 28397001 DOI: 10.1007/s00415-017-8482-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/31/2017] [Accepted: 04/01/2017] [Indexed: 01/15/2023]
Abstract
During human locomotion, vestibular feedback control is fundamental for maintaining dynamic stability and adapting the gait pattern to external circumstances. Within the supraspinal locomotor network, the cerebellum represents the key site for the integration of vestibular feedback information. The cerebellum is further important for the fine-tuning and coordination of limb movements during walking. The aim of this review article is to highlight the shared structural and functional sensorimotor principles in vestibular and cerebellar locomotion control. Vestibular feedback for the maintenance of dynamic stability is integrated into the locomotor pattern via midline, caudal cerebellar structures (vermis, flocculonodular lobe). Hemispheric regions of the cerebellum facilitate feed-forward control of multi-joint coordination and higher locomotor functions. Characteristic features of the gait disorder in patients with vestibular deficits or cerebellar ataxia are increased levels of spatiotemporal gait variability in the fore-aft and the medio-lateral gait dimension. In the fore-aft dimension, pathologic increases of gait fluctuations critically depend on the locomotion speed and predominantly manifest during slow walking velocities. This feature is associated with an increased risk of falls in both patients with vestibular hypofunction as well as patients with cerebellar ataxia. Pharmacological approaches for the treatment of vestibular or cerebellar gait ataxia are currently not available. However, new promising options are currently tested in randomized, controlled trials (fampridine/FACEG; acetyl-DL-leucine/ALCAT).
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Affiliation(s)
- Roman Schniepp
- Department of Neurology, University of Munich, Bavaria, Germany. .,German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Bavaria, Germany.
| | - Ken Möhwald
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Bavaria, Germany
| | - Max Wuehr
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Bavaria, Germany
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25
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Abstract
INTRODUCTION The significance of cervical proprioception for human balance has thus far not been sufficiently elucidated. The aim of this study was to provoke selective cervico-vestibular stimulation using the trunk excursion test (TET) we ourselves constructed. This chair is designed to enable evaluation of cervico-ocular reactions during isolated trunk excursion and possible effects of aging. METHODS The previously used head excursion test (HET) was statistically compared to the TET. In both methods, 100 healthy subjects of two age groups (group(26): median age = 26 years, n = 50; group(50): median age = 50 years, n = 50) were randomized for comparison of similar neck-to-trunk-positions. RESULTS HET enabled detection of significant nystagmus modulation in horizontal and vertical dimensions; whereas in pure cervical stimulation using the new TET, this was only evident in the horizontal dimension and only during trunk torsion. Comparison of the two methods confirmed significantly stronger nystagmus modulation through head excursion. In terms of the HET, group(50) showed significantly more vertical nystagmus activity than group(26). However, no significant difference was found between the groups in terms of their reactions to trunk excursion in the TET. In a group-specific comparison of the methods, group(26) showed a significant increase in horizontal nystagmus in head compared to trunk excursion, whereas group(50) generally displayed a significantly greater response to provocation by head excursion in HET. Analysis of the significant vertical nystagmus modulation produced with the TET method showed predominance of upbeat- (UBN) over downbeat-nystagmus (DBN). Through head excursion with the HET, DBN was more frequently evoked in group(50) than in group(26). No significant age-dependent difference could be derived in UBN. CONCLUSION The results of the pilot study indicate that head-to-trunk provocation is a suitable means of evaluating cervicotonic provocation nystagmus. Only by evaluation of adequate excursion limits and consistent analysis of patients with cervical deficiency can the effects of the method be further assessed.
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Helmchen C, Kirchhoff JB, Göttlich M, Sprenger A. Postural Ataxia in Cerebellar Downbeat Nystagmus: Its Relation to Visual, Proprioceptive and Vestibular Signals and Cerebellar Atrophy. PLoS One 2017; 12:e0168808. [PMID: 28056109 PMCID: PMC5215796 DOI: 10.1371/journal.pone.0168808] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 12/06/2016] [Indexed: 12/01/2022] Open
Abstract
Background The cerebellum integrates proprioceptive, vestibular and visual signals for postural control. Cerebellar patients with downbeat nystagmus (DBN) complain of unsteadiness of stance and gait as well as blurred vision and oscillopsia. Objectives The aim of this study was to elucidate the differential role of visual input, gaze eccentricity, vestibular and proprioceptive input on the postural stability in a large cohort of cerebellar patients with DBN, in comparison to healthy age-matched control subjects. Methods Oculomotor (nystagmus, smooth pursuit eye movements) and postural (postural sway speed) parameters were recorded and related to each other and volumetric changes of the cerebellum (voxel-based morphometry, SPM). Results Twenty-seven patients showed larger postural instability in all experimental conditions. Postural sway increased with nystagmus in the eyes closed condition but not with the eyes open. Romberg’s ratio remained stable and was not different from healthy controls. Postural sway did not change with gaze position or graviceptive input. It increased with attenuated proprioceptive input and on tandem stance in both groups but Romberg’s ratio also did not differ. Cerebellar atrophy (vermal lobule VI, VIII) correlated with the severity of impaired smooth pursuit eye movements of DBN patients. Conclusions Postural ataxia of cerebellar patients with DBN cannot be explained by impaired visual feedback. Despite oscillopsia visual feedback control on cerebellar postural control seems to be preserved as postural sway was strongest on visual deprivation. The increase in postural ataxia is neither related to modulations of single components characterizing nystagmus nor to deprivation of single sensory (visual, proprioceptive) inputs usually stabilizing stance. Re-weighting of multisensory signals and/or inappropriate cerebellar motor commands might account for this postural ataxia.
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Affiliation(s)
| | | | - Martin Göttlich
- Department of Neurology, University of Lübeck, Lubeck, Germany
| | - Andreas Sprenger
- Department of Neurology, University of Lübeck, Lubeck, Germany
- Institute of Psychology II, University of Lübeck, Lubeck, Germany
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Martens C, Goplen FK, Nordfalk KF, Aasen T, Nordahl SHG. Prevalence and Characteristics of Positional Nystagmus in Normal Subjects. Otolaryngol Head Neck Surg 2016; 154:861-7. [PMID: 26908561 DOI: 10.1177/0194599816629640] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 01/08/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE In clinical practice, patients are often referred due to a finding of positional nystagmus that does not always appear to correlate with clinical symptoms of benign paroxysmal positional vertigo. To know when to consider nystagmus to be of clinical relevance, it is necessary to know the prevalence and characteristics of positional nystagmus in a healthy population. STUDY DESIGN Case series of 75 healthy subjects. SETTING Two tertiary referral centers in Norway. SUBJECTS AND METHODS Seventy-five adult subjects aged 40 ± 13 years (mean ± SD; range, 21-87) without a history of vertigo or balance disorder were included from 2013 to 2015. The subjects underwent 6 different standardized positional tests in a repositioning chair. Videonystagmography was used to record eye movements. Of 1350 recordings, 1329 were included and analyzed. RESULTS Positional nystagmus was detected in 88% of the subjects. The most common finding was nystagmus in the Dix-Hallpike position, which occurred in 55% of the subjects. The 95th percentile of the maximum slow-phase velocity for each subject was found to be 5.06° per second (n = 54) in the horizontal plane and 6.48° per second (n = 48) in the vertical plane. CONCLUSION Positional nystagmus is a common finding in normal subjects and occurred in 88% of the healthy subjects in the present study. Horizontal direction-changing apogeotropic or geotropic nystagmus may occur in asymptomatic subjects. However, nystagmus that is of the paroxysmal type or has a slow-phase velocity greater than approximately 5° per second in the horizontal plane or 6.5° per second in the vertical plane should be considered outside the 95th percentile.
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Affiliation(s)
- Camilla Martens
- National Competence Service for Vestibular Disorders, Department of Otorhinolaryngology, Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
| | - Frederik Kragerud Goplen
- National Competence Service for Vestibular Disorders, Department of Otorhinolaryngology, Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
| | - Karl Fredrik Nordfalk
- Department of Otorhinolaryngology, Head and Neck Surgery, Oslo University Hospital, Oslo, Norway
| | - Torbjørn Aasen
- National Competence Service for Vestibular Disorders, Department of Otorhinolaryngology, Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
| | - Stein Helge Glad Nordahl
- National Competence Service for Vestibular Disorders, Department of Otorhinolaryngology, Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Downbeat nystagmus: evidence for enhancement of utriculo-ocular pathways by ocular vestibular evoked myogenic potentials? Eur Arch Otorhinolaryngol 2015; 272:3575-83. [DOI: 10.1007/s00405-015-3653-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 05/10/2015] [Indexed: 11/26/2022]
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Choi JY, Kim JH, Kim HJ, Glasauer S, Kim JS. Central paroxysmal positional nystagmus: Characteristics and possible mechanisms. Neurology 2015; 84:2238-46. [PMID: 25957336 DOI: 10.1212/wnl.0000000000001640] [Citation(s) in RCA: 89] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2014] [Accepted: 02/23/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The diagnosis of central paroxysmal positional nystagmus (CPPN) is challenging, and the mechanisms require further elucidation. This study aimed to determine the characteristics and mechanisms of CPPN. METHODS Seventeen patients with CPPN were subjected to analyses of their clinical findings, MRI lesions, and oculographic data on spontaneous and positional nystagmus. RESULTS The direction of CPPN was mostly aligned with that of the head motion during the positioning, and 3 types of CPPN were identified: downbeat nystagmus on straight-head hanging, upbeat nystagmus on uprighting, and apogeotropic nystagmus during supine head roll test. The direction of CPPN was aligned with the vector sum of the rotational axes of the semicircular canals that were normally inhibited during the positioning. The intensity of evoked nystagmus was at its peak initially and then decreased exponentially over time. The time constants (TC) of the vertical CPPN ranged from 3 to 8 seconds, which corresponds to the TC of the vertical rotational vestibulo-ocular reflex. Sixteen patients (94.1%) showed more than one type of CPPN. Furthermore, persistent downbeat or apogeotropic positional nystagmus was associated in 11 patients (64.7%). Most patients with CPPN from a circumscribed brain lesion showed an involvement of the cerebellar nodulus or uvula. CONCLUSION CPPN may be ascribed to enhanced responses of the vestibular afferents due to lesions involving the nodulus and uvula. CPPN could be differentiated from benign paroxysmal positional nystagmus by positional nystagmus induced in multiple planes, temporal patterns of nystagmus intensity, and associated neurologic findings suggestive of central pathologies.
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Affiliation(s)
- Jeong-Yoon Choi
- From the Department of Neurology (J.-Y.C.), Korea University College of Medicine, Korea University Ansan Hospital; the Department of Neurology (J.H.K.), Korea University College of Medicine, Korea University Guro Hospital, Seoul; the Department of Biomedical Laboratory Science (H.J.K.), Kyungdong University, Goseong-gun, Gangwon-do; the Center for Sensorimotor Research (S.G.), Institute for Clinical Neuroscience, Ludwig-Maximilian University Munich, Germany; and the Department of Neurology (J.-S.K.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Hyun Kim
- From the Department of Neurology (J.-Y.C.), Korea University College of Medicine, Korea University Ansan Hospital; the Department of Neurology (J.H.K.), Korea University College of Medicine, Korea University Guro Hospital, Seoul; the Department of Biomedical Laboratory Science (H.J.K.), Kyungdong University, Goseong-gun, Gangwon-do; the Center for Sensorimotor Research (S.G.), Institute for Clinical Neuroscience, Ludwig-Maximilian University Munich, Germany; and the Department of Neurology (J.-S.K.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyo Jung Kim
- From the Department of Neurology (J.-Y.C.), Korea University College of Medicine, Korea University Ansan Hospital; the Department of Neurology (J.H.K.), Korea University College of Medicine, Korea University Guro Hospital, Seoul; the Department of Biomedical Laboratory Science (H.J.K.), Kyungdong University, Goseong-gun, Gangwon-do; the Center for Sensorimotor Research (S.G.), Institute for Clinical Neuroscience, Ludwig-Maximilian University Munich, Germany; and the Department of Neurology (J.-S.K.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Stefan Glasauer
- From the Department of Neurology (J.-Y.C.), Korea University College of Medicine, Korea University Ansan Hospital; the Department of Neurology (J.H.K.), Korea University College of Medicine, Korea University Guro Hospital, Seoul; the Department of Biomedical Laboratory Science (H.J.K.), Kyungdong University, Goseong-gun, Gangwon-do; the Center for Sensorimotor Research (S.G.), Institute for Clinical Neuroscience, Ludwig-Maximilian University Munich, Germany; and the Department of Neurology (J.-S.K.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji-Soo Kim
- From the Department of Neurology (J.-Y.C.), Korea University College of Medicine, Korea University Ansan Hospital; the Department of Neurology (J.H.K.), Korea University College of Medicine, Korea University Guro Hospital, Seoul; the Department of Biomedical Laboratory Science (H.J.K.), Kyungdong University, Goseong-gun, Gangwon-do; the Center for Sensorimotor Research (S.G.), Institute for Clinical Neuroscience, Ludwig-Maximilian University Munich, Germany; and the Department of Neurology (J.-S.K.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
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Benign intermittent upbeat nystagmus in infancy: a new clinical entity. Eur J Paediatr Neurol 2015; 19:262-5. [PMID: 25601640 DOI: 10.1016/j.ejpn.2014.12.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 12/08/2014] [Accepted: 12/09/2014] [Indexed: 11/21/2022]
Abstract
BACKGROUND Upbeat nystagmus in childhood is a rare phenomenon, which is classically associated with neurological or anterior visual pathway dysfunction. METHODS We report a series of five infants with an intermittent upbeat nystagmus, without any other ocular or neurological abnormality, having spontaneously resolved before the age of 14 months. RESULTS Nystagmus beating frequency was between 1.5 and 2.5 Hz for all patients, amplitude was remarkably large due to a baseline position in downgaze. The nystagmus mostly occurred in supine position and could be triggered by head rotations in the supine position. Age of onset was from the first weeks of life to two months; age of resolution was 5-14 months. All infants underwent complete clinical examination with ophthalmological, oto-neurological and neurological assessments and MRI-scan. CONCLUSIONS Clinical characteristics of the nystagmus suggest an involvement of the otolithic system, with a secondary recalibration of the vestibulo-ocular pathways; however, no obvious vestibular abnormality was found. The pathophysiology of this nystagmus therefore remains unclear.
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Beh SC, Frohman TC, Frohman EM. Neuro-ophthalmic Manifestations of Cerebellar Disease. Neurol Clin 2014; 32:1009-80. [DOI: 10.1016/j.ncl.2014.07.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Shin C Beh
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Teresa C Frohman
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Elliot M Frohman
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA; Department of Ophthalmology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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Schniepp R, Wuehr M, Huth S, Pradhan C, Schlick C, Brandt T, Jahn K. The gait disorder in downbeat nystagmus syndrome. PLoS One 2014; 9:e105463. [PMID: 25140517 PMCID: PMC4139349 DOI: 10.1371/journal.pone.0105463] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2014] [Accepted: 07/24/2014] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Downbeat nystagmus (DBN) is a common form of acquired fixation nystagmus with key symptoms of oscillopsia and gait disturbance. Gait disturbance could be a result of impaired visual feedback due to the involuntary ocular oscillations. Alternatively, a malfunction of cerebellar locomotor control might be involved, since DBN is considered a vestibulocerebellar disorder. METHODS Investigation of walking in 50 DBN patients (age 72 ± 11 years, 23 females) and 50 healthy controls (HS) (age 70 ± 11 years, 23 females) using a pressure sensitive carpet (GAITRite). The patient cohort comprised subjects with only ocular motor signs (DBN) and subjects with an additional limb ataxia (DBNCA). Gait investigation comprised different walking speeds and walking with eyes closed. RESULTS In DBN, gait velocity was reduced (p<0.001) with a reduced stride length (p<0.001), increased base of support (p<0.050), and increased double support (p<0.001). Walking with eyes closed led to significant gait changes in both HS and DBN. These changes were more pronounced in DBN patients (p<0.001). Speed-dependency of gait variability revealed significant differences between the subgroups of DBN and DBNCA (p<0.050). CONCLUSIONS (I) Impaired visual control caused by involuntary ocular oscillations cannot sufficiently explain the gait disorder. (II) The gait of patients with DBN is impaired in a speed dependent manner. (III) Analysis of gait variability allows distinguishing DBN from DBNCA: Patients with pure DBN show a speed dependency of gait variability similar to that of patients with afferent vestibular deficits. In DBNCA, gait variability resembles the pattern found in cerebellar ataxia.
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Affiliation(s)
- Roman Schniepp
- Department of Neurology, University of Munich, Munich, Germany
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Munich, Germany
- * E-mail:
| | - Max Wuehr
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Munich, Germany
| | - Sabrina Huth
- Department of Neurology, University of Munich, Munich, Germany
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Munich, Germany
| | - Cauchy Pradhan
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Munich, Germany
| | - Cornelia Schlick
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Munich, Germany
| | - Thomas Brandt
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Munich, Germany
- Institute for Clinical Neurosciences, University of Munich, Munich, Germany
| | - Klaus Jahn
- Department of Neurology, University of Munich, Munich, Germany
- German Center for Vertigo and Balance Disorders (DSGZ), University of Munich, Munich, Germany
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Barona-Lleo L, Zulueta-Santos C, Murie-Fernandez M, Pérez-Fernández N. Recent onset disequilibrium mimicking acute vestibulopathy in early multiple sclerosis. Am J Otolaryngol 2014; 35:529-34. [PMID: 24746632 DOI: 10.1016/j.amjoto.2014.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 03/16/2014] [Indexed: 11/16/2022]
Abstract
The differential diagnosis of patients with acute unilateral vestibulopathy rests in the proper clinical assessment and use of selected tests of vestibular function. In case of a central nervous system lesion as in Multiple Sclerosis, the case shown here, it is of particular importance to observe congruency between severity of symptoms and signs and, of topographic diagnosis. We report a case of a 37-year-old woman with recent onset disequilibrium that after careful analysis of the different test results several incongruences were found; this prompted a radiological study that provided the clue to diagnosis. After treatment the patient recovered completely not only clinically but also in vestibular deficit.
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Affiliation(s)
- Luz Barona-Lleo
- Department of Otorhinolaryngology, Clinica Universidad de Navarra, University of Navarra, Pamplona, Spain
| | - Cristina Zulueta-Santos
- Department of Otorhinolaryngology, Clinica Universidad de Navarra, University of Navarra, Pamplona, Spain
| | - Manuel Murie-Fernandez
- Department of Neurology, Clinica Universidad de Navarra, University of Navarra, Pamplona, Spain
| | - Nicolas Pérez-Fernández
- Department of Otorhinolaryngology, Clinica Universidad de Navarra, University of Navarra, Pamplona, Spain.
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Choi JY, Park YM, Woo YS, Kim SU, Jung JM, Kwon DY. Perverted head-shaking and positional downbeat nystagmus in pregabalin intoxication. J Neurol Sci 2014; 337:243-4. [DOI: 10.1016/j.jns.2013.12.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 11/18/2013] [Accepted: 12/03/2013] [Indexed: 10/25/2022]
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Shaikh AG. Motion perception without Nystagmus--a novel manifestation of cerebellar stroke. J Stroke Cerebrovasc Dis 2013; 23:1148-56. [PMID: 24268101 DOI: 10.1016/j.jstrokecerebrovasdis.2013.10.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Revised: 09/24/2013] [Accepted: 10/07/2013] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE The motion perception and the vestibulo-ocular reflex (VOR) each serve distinct functions. The VOR keeps the gaze steady on the target of interest, whereas vestibular perception serves a number of tasks, including awareness of self-motion and orientation in space. VOR and motion perception might abide the same neurophysiological principles, but their distinct anatomical correlates were proposed. In patients with cerebellar stroke in distribution of medial division of posterior inferior cerebellar artery, we asked whether specific location of the focal lesion in vestibulocerebellum could cause impaired perception of motion but normal eye movements. METHODS/RESULTS Thirteen patients were studied, 5 consistently perceived spinning of surrounding environment (vertigo), but the eye movements were normal. This group was called "disease model." Remaining 8 patients were also symptomatic for vertigo, but they had spontaneous nystagmus. The latter group was called "disease control." Magnetic resonance imaging in both groups consistently revealed focal cerebellar infarct affecting posterior cerebellar vermis (lobule IX). In the "disease model" group, only part of lobule IX was affected. In the disease control group, however, complete lobule IX was involved. CONCLUSIONS This study discovered a novel presentation of cerebellar stroke where only motion perception was affected, but there was an absence of objective neurologic signs.
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Affiliation(s)
- Aasef G Shaikh
- Department of Neurology, Case Western Reserve University, Cleveland, Ohio.
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Gravity-dependent nystagmus and inner-ear dysfunction suggest anterior and posterior inferior cerebellar artery infarct. J Stroke Cerebrovasc Dis 2013; 23:788-90. [PMID: 23800506 DOI: 10.1016/j.jstrokecerebrovasdis.2013.05.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Revised: 05/10/2013] [Accepted: 05/13/2013] [Indexed: 11/20/2022] Open
Abstract
Cerebellar lesions may present with gravity-dependent nystagmus, where the direction and velocity of the drifts change with alterations in head position. Two patients had acute onset of hearing loss, vertigo, oscillopsia, nausea, and vomiting. Examination revealed gravity-dependent nystagmus, unilateral hypoactive vestibulo-ocular reflex (VOR), and hearing loss ipsilateral to the VOR hypofunction. Traditionally, the hypoactive VOR and hearing loss suggest inner-ear dysfunction. Vertigo, nausea, vomiting, and nystagmus may suggest peripheral or central vestibulopathy. The gravity-dependent modulation of nystagmus, however, localizes to the posterior cerebellar vermis. Magnetic resonance imaging in our patients revealed acute cerebellar infarct affecting posterior cerebellar vermis, in the vascular distribution of the posterior inferior cerebellar artery (PICA). This lesion explains the gravity-dependent nystagmus, nausea, and vomiting. Acute onset of unilateral hearing loss and VOR hypofunction could be the manifestation of inner-ear ischemic injury secondary to the anterior inferior cerebellar artery (AICA) compromise. In cases of combined AICA and PICA infarction, the symptoms of peripheral vestibulopathy might masquerade the central vestibular syndrome and harbor a cerebellar stroke. However, the gravity-dependent nystagmus allows prompt identification of acute cerebellar infarct.
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4-aminopyridine does not enhance flocculus function in tottering, a mouse model of vestibulocerebellar dysfunction and ataxia. PLoS One 2013; 8:e57895. [PMID: 23451282 PMCID: PMC3581497 DOI: 10.1371/journal.pone.0057895] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Accepted: 01/27/2013] [Indexed: 01/06/2023] Open
Abstract
The potassium channel antagonist 4-aminopyridine (4-AP) improves a variety of motor abnormalities associated with disorders of the cerebellum. The most rigorous quantitative data relate to 4-AP's ability to improve eye movement deficits in humans referable to dysfunction of the cerebellar flocculus. Largely based on work in the ataxic mouse mutant tottering (which carries a mutation of the Cacna1a gene of the P/Q voltage-activated calcium channel), 4-AP is hypothesized to function by enhancing excitability or rhythmicity of floccular Purkinje cells. We tested this hypothesis by determining whether systemic or intrafloccular administration of 4-AP would ameliorate the eye movement deficits in tottering that are attributable to flocculus dysfunction, including the reductions in amplitude of the yaw-axis vestibulo-ocular reflex (VOR) and vision-enhanced vestibulo-ocular reflex (VVOR), and the optokinetic reflex (OKR) about yaw and roll axes. Because tottering's deficits increase with age, both young and elderly mutants were tested to detect any age-dependent 4-AP effects. 4-AP failed to improve VOR, VVOR, and OKR gains during sinusoidal stimuli, although it may have reduced the tendency of the mutants' responses to VOR and VVOR to decline over the course of a one-hour recording session. For constant-velocity optokinetic stimuli, 4-AP generated some enhancement of yaw OKR and upward-directed roll OKR, but the effects were also seen in normal C57BL/6 controls, and thus do not represent a specific reversal of the electrophysiological consequences of the tottering mutation. Data support a possible extra-floccular locus for the effects of 4-AP on habituation and roll OKR. Unilateral intrafloccular 4-AP injections did not affect ocular motility, except to generate mild eye elevations, consistent with reduced floccular output. Because 4-AP did not produce the effects expected if it normalized outputs of floccular Purkinje cells, there is a need for further studies to elucidate the drug's mechanism of action on cerebellar motor dysfunction.
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Shaikh AG, Termsarasab P, Riley DE, Katirji B. The floccular syndrome in herpes simplex type 1 encephalitis. J Neurol Sci 2013; 325:154-5. [DOI: 10.1016/j.jns.2012.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2012] [Revised: 10/31/2012] [Accepted: 11/01/2012] [Indexed: 11/30/2022]
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Stahl JS, Thumser ZC, Oommen BS. The ataxic mouse as a model for studying downbeat nystagmus. J Vestib Res 2013; 22:221-41. [PMID: 23302704 DOI: 10.3233/ves-120463] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Downbeat nystagmus (DBN) is a common eye movement complication of cerebellar disease. Use of mice to study pathophysiology of vestibulocerebellar disease is increasing, but it is unclear if mice can be used to study DBN; it has not been reported in this species. We determined whether DBN occurs in the ataxic mutant tottering, which carries a mutation in the Cacna1a gene for P/Q calcium channels. Spontaneous DBN occurred only rarely, and its magnitude did not exhibit the relationship to head tilt seen in human patients. DBN during yaw rotation was more common and shares some properties with the tilt-independent, gaze-independent component of human DBN, but differs in its dependence on vision. Hyperactivity of otolith circuits responding to pitch tilts is hypothesized to contribute to the gaze-independent component of human DBN. Mutants exhibited hyperactivity of the tilt maculo-ocular reflex (tiltMOR) in pitch. The hyperactivity may serve as a surrogate for DBN in mouse studies. TiltMOR hyperactivity correlates with hyperdeviation of the eyes and upward deviation of the head during ambulation; these may be alternative surrogates. Muscimol inactivation of the cerebellar flocculus suggests a floccular role in the tiltMOR hyperactivity and provides insight into the rarity of frank DBN in ataxic mice.
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Affiliation(s)
- John S Stahl
- Neurology Division, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA.
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Kremmyda O, Zwergal A, la Fougère C, Brandt T, Jahn K, Strupp M. 4-Aminopyridine suppresses positional nystagmus caused by cerebellar vermis lesion. J Neurol 2012. [PMID: 23180177 DOI: 10.1007/s00415-012-6737-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
Paraneoplastic syndromes affecting the brainstem and cerebellum are reported to cause a variety of abnormalities of eye movements. Recent studies have begun to account for the mechanisms underlying several syndromes, characterized by opsoclonus, slow, or dysmetric saccades, as well as downbeat nystagmus. We provide evidence that upbeat nystagmus in a female patient with pancreatic cancer reflected a cerebellar-induced imbalance of otolithic pathways: she showed marked retropulsion, and her nystagmus was dependent on head position, being absent when supine, and suppressed with convergence. In addition to anti-Hu antibodies, we demonstrated antibodies to a novel neuronal cell surface antigen. Taken with other recent studies, our findings suggest that paraneoplastic syndromes arise due to antibodies against surface neuronal antigens, including receptors and channels. Abnormal eye movements in paraneoplastic syndromes offer insights into the pathogenesis of these disorders and the opportunity to test potential therapies, such as new drugs with effects on neuronal channels.
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Affiliation(s)
- Shirley H Wray
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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43
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Abstract
The ocular motor system consists of several subsystems, including the vestibular ocular nystagmus saccade system, the pursuit system, the fixation and gaze-holding system and the vergence system. All these subsystems aid the stabilization of the images on the retina during eye and head movements and any kind of disturbance of one of the systems can cause instability of the eyes (e.g. nystagmus) or an inadequate eye movement causing a mismatch between head and eye movement (e.g. bilateral vestibular failure). In both situations, the subjects experience a movement of the world (oscillopsia) which is quite disturbing. New insights into the patho-physiology of some of the ocular motor disorders have helped to establish new treatment options, in particular in downbeat nystagmus, upbeat nystagmus, periodic alternating nystagmus, acquired pendular nystagmus and paroxysmal vestibular episodes/attacks. The discussed patho-physiology of these disorders and the current literature on treatment options are discussed and practical treatment recommendations are given in the paper.
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Affiliation(s)
- A Straube
- University of Munich, Munich, Germany.
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44
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Wray SH, Martinez-Hernandez E, Dalmau J, Maheshwari A, Chen A, King S, Bishop Pitman M, Leigh RJ. Paraneoplastic upbeat nystagmus. Neurology 2011; 77:691-3. [PMID: 21813784 DOI: 10.1212/wnl.0b013e318229e6a5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- S H Wray
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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45
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Strupp M, Brandt T. Current treatment of vestibular, ocular motor disorders and nystagmus. Ther Adv Neurol Disord 2011; 2:223-39. [PMID: 21179531 DOI: 10.1177/1756285609103120] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Vertigo and dizziness are among the most common complaints with a lifetime prevalence of about 30%. The various forms of vestibular disorders can be treated with pharmacological therapy, physical therapy, psychotherapeutic measures or, rarely, surgery. In this review, the current pharmacological treatment options for peripheral and central vestibular, cerebellar and ocular motor disorders will be described. They are as follows for peripheral vestibular disorders. In vestibular neuritis recovery of the peripheral vestibular function can be improved by treatment with oral corticosteroids. In Menière's disease a recent study showed long-term high-dose treatment with betahistine has a significant effect on the frequency of the attacks. The use of aminopyridines introduced a new therapeutic principle in the treatment of downbeat and upbeat nystagmus and episodic ataxia type 2 (EA 2). These potassium channel blockers presumably increase the activity and excitability of cerebellar Purkinje cells, thereby augmenting the inhibitory influence of these cells on vestibular and cerebellar nuclei. A few studies showed that baclofen improves periodic alternating nystagmus, and gabapentin and memantine, pendular nystagmus. However, many other eye movement disorders such as ocular flutter opsoclonus, central positioning, or see-saw nystagmus are still difficult to treat. Although progress has been made in the treatment of vestibular neuritis, downbeat and upbeat nystagmus, as well as EA 2, state-of-the-art trials must still be performed on many vestibular and ocular motor disorders, namely Menière's disease, bilateral vestibular failure, vestibular paroxysmia, vestibular migraine, and many forms of central eye movement disorders.
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Affiliation(s)
- Michael Strupp
- Professor of Neurology and Clinical Neurophysiology, University of Munich, Klinikum Grosshadern, Munich, Germany
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46
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Strupp M, Thurtell MJ, Shaikh AG, Brandt T, Zee DS, Leigh RJ. Pharmacotherapy of vestibular and ocular motor disorders, including nystagmus. J Neurol 2011; 258:1207-22. [PMID: 21461686 PMCID: PMC3132281 DOI: 10.1007/s00415-011-5999-8] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Revised: 03/01/2011] [Accepted: 03/04/2011] [Indexed: 01/28/2023]
Abstract
We review current pharmacological treatments for peripheral and central vestibular disorders, and ocular motor disorders that impair vision, especially pathological nystagmus. The prerequisites for successful pharmacotherapy of vertigo, dizziness, and abnormal eye movements are the "4 D's": correct diagnosis, correct drug, appropriate dosage, and sufficient duration. There are seven groups of drugs (the "7 A's") that can be used: antiemetics; anti-inflammatory, anti-Ménière's, and anti-migrainous medications; anti-depressants, anti-convulsants, and aminopyridines. A recovery from acute vestibular neuritis can be promoted by treatment with oral corticosteroids. Betahistine may reduce the frequency of attacks of Ménière's disease. The aminopyridines constitute a novel treatment approach for downbeat and upbeat nystagmus, as well as episodic ataxia type 2 (EA 2); these drugs may restore normal "pacemaker" activity to the Purkinje cells that govern vestibular and cerebellar nuclei. A limited number of trials indicate that baclofen improves periodic alternating nystagmus, and that gabapentin and memantine improve acquired pendular and infantile (congenital) nystagmus. Preliminary reports suggest suppression of square-wave saccadic intrusions by memantine, and ocular flutter by beta-blockers. Thus, although progress has been made in the treatment of vestibular neuritis, some forms of pathological nystagmus, and EA 2, controlled, masked trials are still needed to evaluate treatments for many vestibular and ocular motor disorders, including betahistine for Ménière's disease, oxcarbazepine for vestibular paroxysmia, or metoprolol for vestibular migraine.
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Affiliation(s)
- Michael Strupp
- Department of Neurology, University of Munich, Munich, Germany
| | - Matthew J. Thurtell
- Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, IA USA
| | - Aasef G. Shaikh
- Neurology Service, Veterans Affairs Medical Center and Case Medical Center, Cleveland, OH USA
| | - Thomas Brandt
- Department of Neurology, University of Munich, Munich, Germany
| | - David S. Zee
- Department of Neurology, John Hopkins Medical Center, Baltimore, MD USA
| | - R. John Leigh
- Neurology Service, Veterans Affairs Medical Center and Case Medical Center, Cleveland, OH USA
- Department of Neurology, University Hospitals, 11100 Euclid Avenue, Cleveland, OH 44106-5040 USA
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Shaikh AG, Marti S, Tarnutzer AA, Palla A, Crawford TO, Straumann D, Carey JP, Nguyen KD, Zee DS. Ataxia telangiectasia: a “disease model” to understand the cerebellar control of vestibular reflexes. J Neurophysiol 2011; 105:3034-41. [DOI: 10.1152/jn.00721.2010] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Experimental animal models have suggested that the modulation of the amplitude and direction of vestibular reflexes are important functions of the vestibulocerebellum and contribute to the control of gaze and balance. These critical vestibular functions have been infrequently quantified in human cerebellar disease. In 13 subjects with ataxia telangiectasia (A-T), a disease associated with profound cerebellar cortical degeneration, we found abnormalities of several key vestibular reflexes. The vestibuloocular reflex (VOR) was measured by eye movement responses to changes in head rotation. The vestibulocollic reflex (VCR) was assessed with cervical vestibular-evoked myogenic potentials (cVEMPs), in which auditory clicks led to electromyographic activity of the sternocleidomastoid muscle. The VOR gain (eye velocity/head velocity) was increased in all subjects with A-T. An increase of the VCR, paralleling that of the VOR, was indirectly suggested by an increase in cVEMP amplitude. In A-T subjects, alignment of the axis of eye rotation was not with that of head rotation. Subjects with A-T thus manifested VOR cross-coupling, abnormal eye movements directed along axes orthogonal to that of head rotation. Degeneration of the Purkinje neurons in the vestibulocerebellum probably underlie these deficits. This study offers insights into how the vestibulocerebellum functions in healthy humans. It may also be of value to the design of treatment trials as a surrogate biomarker of cerebellar function that does not require controlling for motivation or occult changes in motor strategy on the part of experimental subjects.
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Affiliation(s)
- Aasef G. Shaikh
- Department of Neurology, Case Western Reserve University, Cleveland, Ohio
| | - Sarah Marti
- Department of Neurology, Zürich University Hospital, Zürich, Switzerland; and
| | | | - Antonella Palla
- Department of Neurology, Zürich University Hospital, Zürich, Switzerland; and
| | | | - Dominik Straumann
- Department of Neurology, Zürich University Hospital, Zürich, Switzerland; and
| | - John P. Carey
- Otolaryngology, The Johns Hopkins University, Baltimore, Maryland
| | - Kimanh D. Nguyen
- Otolaryngology, The Johns Hopkins University, Baltimore, Maryland
| | - David S. Zee
- Departments of 3Neurology and
- Otolaryngology, The Johns Hopkins University, Baltimore, Maryland
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Abstract
PURPOSE OF REVIEW The aim is to re-interpret disorders of vergence in the light of recent studies that view disjunctive eye movements as but one component of three-dimensional gaze control. RECENT FINDINGS Most natural eye movements combine vergence with saccades, pursuit and vestibular eye movements. Electrophysiological studies in epileptic patients, as well as evidence from monkeys, indicate that frontal and parietal cortex govern vergence as a component of three-dimensional gaze. Clinicians apply Hering's law of equal innervation to interpret disjunctive movements as the superposition of conjugate and vergence commands. However, electrophysiological studies indicate that disjunctive saccades are achieved by programming each eye's movement independently. Patients with internuclear ophthalmoplegia (INO) may have preserved vergence, which can be recruited to compensate for loss of conjugacy. Vergence may also enable gaze shifts in saccadic palsy. Some forms of nystagmus suppress or change with convergence; co-contraction of the horizontal rectus muscles does not appear to be the explanation. Rather, effects of near viewing on central vestibular mechanisms or differential activation of specific types of extra-ocular muscle fiber may be responsible. SUMMARY Interpretation of disorders of vergence is aided by applying a scheme in which their contributions to three-dimensional gaze control is considered.
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Tarnutzer AA, Shaikh AG, Palla A, Straumann D, Marti S. Vestibulo-cerebellar disease impairs the central representation of self-orientation. Front Neurol 2011; 2:11. [PMID: 21431098 PMCID: PMC3049414 DOI: 10.3389/fneur.2011.00011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2010] [Accepted: 02/13/2011] [Indexed: 11/18/2022] Open
Abstract
Transformation of head-fixed otolith signals into a space-fixed frame of reference is essential for perception of self-orientation and ocular motor control. In monkeys the nodulus and ventral uvula of the vestibulo-cerebellum facilitate this transformation by computing an internal estimate of direction of gravity. These experimental findings motivated the hypothesis that degeneration of the vestibulo-cerebellum in humans alter perceptual and ocular motor functions that rely on accurate estimates of gravity, such as subjective visual vertical (SVV), static ocular counterroll (OCR), and gravity-dependent modulation of vertical ocular drifts. We assessed the SVV, OCR, and spontaneous vertical ocular drifts in 12 patients with chronic vestibulo-cerebellar disease and in 10 controls. Substantially increased variability in estimated SVV was noted in the patients. Furthermore, gravity-dependent modulation of spontaneous vertical ocular drifts along the pitch plane was significantly (p < 0.05) larger in the patients. However, the gain and variability of static OCR and errors in SVV were not significantly different. In conclusion, in chronic vestibulo-cerebellar disease SVV and OCR remain intact except for an abnormal variability in the perception of verticality and impaired stabilization of gaze mediated by the otoliths. These findings suggest that OCR and perceived vertical are relatively independent from the cerebellum unless there is a cerebellar imbalance like an acute unilateral cerebellar stroke. The increased trial-to-trial SVV variability may be a general feature of cerebellar disease since a function of the cerebellum may be to compensate for such. SVV variability might be useful to monitor disease progression and treatment response in patients.
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50
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Abstract
We review current concepts of nystagmus and saccadic oscillations, applying a pathophysiological approach. We begin by discussing how nystagmus may arise when the mechanisms that normally hold gaze steady are impaired. We then describe the clinical and laboratory evaluation of patients with ocular oscillations. Next, we systematically review the features of nystagmus arising from peripheral and central vestibular disorders, nystagmus due to an abnormal gaze-holding mechanism (neural integrator), and nystagmus occurring when vision is compromised. We then discuss forms of nystagmus for which the pathogenesis is not well understood, including acquired pendular nystagmus and congenital forms of nystagmus. We then summarize the spectrum of saccadic disorders that disrupt steady gaze, from intrusions to flutter and opsoclonus. Finally, we review current treatment options for nystagmus and saccadic oscillations, including drugs, surgery, and optical methods. Examples of each type of nystagmus are provided in the form of figures.
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Affiliation(s)
- Matthew J Thurtell
- Departments of Neurology and Daroff-Dell'Osso Laboratory, Veterans Affairs Medical Center and University Hospitals, Case Western Reserve University, Cleveland, OH 44106, USA
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