Clinical characteristics and natural course of recurrent vestibulopathy: a long-term follow-up study

Clinical and VEMPS Characteristics of Benign Recurrent Vertigo With Cochlear Symptoms and Migraine

Objectives: To explore the clinical manifestations and vestibular-evoked myogenic potential (VEMP) characteristics in patients diagnosed with benign recurrent vertigo (BRV) accompanied by cochlear symptoms or migraine history. Methods: A total of 34 patients were diagnosed with BRV (57 ears) and 30 healthy volunteers (60 ears) were recruited. They were divided into 4 groups: Group A consisted of 17 patients diagnosed as BRV with cochlear symptoms (21 ears), Group B consisted of 11 patients diagnosed as BRV with migraine history (22 ears), and Group C consisted of 7 patients with BRV without cochlear symptoms and migraine history (14 ears). Group D, as a Normal control (NC) group, consisted of 30 healthy volunteers without a history of migraine and cochlear symptoms. Detailed consultations and VEMP testing were performed separately. The VEMPs elicitation rate, amplitude ratio at different frequencies and amplitude statistics were compared and analyzed among the 4 groups. Results: The amplitudes of cervical vestibular evoked myogenic potential (cVEMP) have significant differences between Groups D and A, and Group C, under 500 Hz (PAD = .017, PBD = .052, PCD = .044), but the amplitudes of cVEMP have significant differences between Groups D and A, and Group B under 1000 Hz, respectively (PAD = .008, PBD = .020, PCD = .119). The amplitudes of ocular vestibular evoked myogenic potential (oVEMP) have significant differences between Groups D and A, and Group B, under 500 Hz, respectively (PAD = .029, PBD = .005, PCD = .198). oVEMP amplitudes significantly differ between Groups D and A under 1000 Hz (PAD = .049, PBD = .079, PCD = .103). The statistical difference was absent in elicit rates of cVEMP and oVEMP between the NC and experimental groups (cVEMP: PAD = .525, PBD = .917, PCD = .374; oVEMP: PAD = .678, PBD = .523, PCD = .427). Moreover, there is no significant difference between the NC group and experimental groups among VEMPs and VEMP frequency amplitude ratio (P > .05). Conclusion: VEMPs could be a diagnostic indicator for BRV patients with cochlear symptoms. The pathogenesis of BRV may be related to damage to the otolithic apparatus.

Positive Relationship Between Paroxysmal Vertigo and Right-to-Left Shunt: A Large Observational Study

Background

The association between paroxysmal vertigo and right-to-left shunt (RLS) is rarely reported. This study investigates the prevalence and correlation of RLS in patients with different paroxysmal vertigo diseases.

Methods

Patients with paroxysmal vertigo from seven hospitals in China were included in this observational study between 2017 and 2021. Migraine patients within the same period were included for comparison. Demographic data and medical history were collected; contrast transthoracic echocardiography was performed; and the clinical features, Dizziness Handicap Inventory, and incidence of RLS in each group were recorded.

Results

A total of 2,751 patients were enrolled. This study's results demonstrated that the proportion of RLS in patients with benign recurrent vertigo (BRV) and vestibular migraine (VM) was significantly higher than that in patients with benign paroxysmal positional vertigo, Meniere's disease, and vestibular paroxysmia (P < 0.05). No statistical difference was shown between the frequency of RLS in patients with BRV and those with migraine and VM. A positive correlation was shown between the RLS grade and Dizziness Handicap Inventory scores of patients with VM and BRV (P < 0.01) after effectively controlleding the effect of confounding variables.

Conclusions

RLS was significantly associated with BRV and VM. RLS may be involved in the pathogeneses of BRV and VM and may serve as a differential reference index for the paroxysmal vertigo.

Trial Registration

CHRS, NCT04939922, registered 14 June 2021- retrospectively registered, https://register.clinicaltrials.gov.

Is There an “Acquired Idiopathic Head-Shaking Nystagmus”?—A Discussion of Mechanisms and Clinical Implications Based on a Case Report

Background

Head-shaking nystagmus (HSN) occurs in both peripheral and central vestibular disorders. In most cases, HSN can be attributed to an asymmetric peripheral vestibular input or a structural lesion mostly in the cerebellum affecting the central velocity storage mechanism. An isolated HSN is very rare.

Case Presentation

We report on a young female patient with the clinical picture of recurrent episodes of vertigo, which were induced by fast head movements and were accompanied by a severe right-beating HSN with a long time constant of 60 s. There was no other clinical and instrument-based evidence of peripheral vestibular dysfunction (including video head impulse test, caloric test, vestibular-evoked myogenic potentials) or indication of a structural lesion in the nodulus, uvula or pontomedullary brainstem on fine-slice magnetic resonance imaging. She had no previous history of migraine, hearing deficits, or other focal neurological symptoms. Diagnostic criteria for vestibular paroxysmia, vestibular migraine, benign peripheral paroxysmal vertigo, or any other known vestibular disorders were not fulfilled. Chart review in the database of the German Center for Vertigo and Balance Disorders indicated eight additional patients with a similar clinical phenotype between 2018 and 2022.

Conclusion

We propose a clinical entity called acquired idiopathic head shaking nystagmus (aiHSN) as a rare cause of episodic vertigo induced by fast head movements. Nystagmus characteristics suggest a subtle functional pathology of the central velocity storage mechanism in the nodulus and uvula, which is exacerbated during symptomatic episodes.

Benign Recurrent Vertigo: The Course of Vertigo Attacks Compared to Patients With Menière's Disease and Vestibular Migraine

Objective

To explore the course of vertigo attacks in patients with benign recurrent vertigo (BRV) as compared to patients with Menière's disease (MD) and vestibular migraine (VM).

Study design

Prospective cohort study.

Setting

Tertiary referral center.

Patients

Adult patients who visited the Apeldoorn Dizziness Center between January 2015 and November 2016 and who were diagnosed with BRV, VM or MD. During 3 years participants were contacted every 6 months by telephone to complete a study-specific questionnaire.

Main Outcome Measures

Vertigo attack frequency, use of medication, and Hospital Anxiety and Depression Scale (HADS).

Results

The study population (n = 121) consisted of 44 patients with BRV, 34 with VM, and 43 with MD. For the total follow-up period no statistically significant differences between the three diagnosis groups were observed for being attack-free in the past 6 months: OR = 0.86 (95% CI 0.34–2.17; p = 0.745) for VM and OR = 1.06 (95% CI 0.44–2.51; p = 0.902) for MD, compared to BRV. Overall, 19 patients (43.2%) with BRV, 13 (38.2%) with VM, and 35 (81.0%) with MD used medication to prevent vertigo attacks at any point during their 3-year follow-up. Throughout the observation period patients with MD showed an average of 3.37 points (95% CI 0.68–6.07; p = 0.014) higher HADS scores relative to patients with BRV.

Conclusion

The course of vertigo attacks was rather favorable in the three groups, as 67–70% of the patients were free of vertigo attacks after 3 years of follow-up. The course of disease in patients with BRV was not distinctive from patients with MD and VM. We assume that BRV is a mild or incomplete variant of VM and MD, rather than a separate disease entity with distinct pathognomonic features.

Recurrent Vestibular Symptoms Not Otherwise Specified: Clinical Characteristics Compared With Vestibular Migraine and Menière's Disease

Despite the huge progress in the definition and classification of vestibular disorders within the last decade, there are still patients whose recurrent vestibular symptoms cannot be attributed to any of the recognized episodic vestibular syndromes, such as Menière's disease (MD), vestibular migraine (VM), benign paroxysmal positional vertigo (BPPV), vestibular paroxysmia, orthostatic vertigo or transient ischemic attack (TIA). The aim of the present international, multi-center, cross-sectional study was to systematically characterize the clinical picture of recurrent vestibular symptoms not otherwise specified (RVS-NOS) and to compare it to MD and VM. Thirty-five patients with RVS-NOS, 150 patients with VM or probable VM and 119 patients with MD were included in the study. The symptoms of RVS-NOS had been present for 5.4 years on average before inclusion, similar to VM and MD in this study, suggesting that RVS-NOS is not a transitory state before converting into another diagnosis. Overall, the profile of RVS-NOS vestibular symptoms was more similar to VM than MD. In particular, the spectrum of vestibular symptom types was larger in VM and RVS-NOS than in MD, both at group comparison and the individual level. However, in contrast to VM, no female preponderance was observed for RVS-NOS. Positional, head-motion and orthostatic vertigo were reported more frequently by patients with RVS-NOS than MD, while external vertigo was more prevalent in the MD group. At group level, the spectrum of attack durations from minutes to 3 days was evenly distributed for VM, while a small peak for short and long attacks in RVS-NOS and a big single peak of hours in MD were discernible. In general, vertigo attacks and associated vegetative symptoms (nausea and vomiting) were milder in RVS-NOS than in the other two disorders. Some patients with RVS-NOS described accompanying auditory symptoms (tinnitus: 2.9%, aural fullness and hearing loss: 5.7% each), migrainous symptoms (photophobia, phonophobia or visual aura in 5.7% each) or non-migrainous headaches (14%), but did not fulfill the diagnostic criteria for MD or VM. Absence of a life time diagnosis of migraine headache and attack duration of <5 min were further reasons not to qualify for VM. In some RVS-NOS patients with accompanying ear symptoms, attack durations of <20 min excluded them from being diagnosed with MD. These findings suggest that RVS-NOS is a stable diagnosis over time whose overall clinical presentation is more similar to VM than to MD. It is more likely to be composed of several disorders including a spectrum of mild or incomplete variants of known vestibular disorders, such as VM and MD, rather than a single disease entity with distinct pathognomonic features.

Endolymphatic Hydrops in Fluctuating Hearing Loss and Recurrent Vertigo

Background: Endolymphatic hydrops (EH) is the histopathological hallmark of Ménière's disease (MD) and has been found by in vivo magnetic resonance imaging (MRI) in patients with several inner ear syndromes without definite MD criteria. The incidence and relevance of this finding is under debate.

Purpose: The purpose of the study is to evaluate the prevalence and characteristics of EH and audiovestibular test results in groups of patients with fluctuating audiovestibular symptoms not fulfilling the actual criteria for definite MD and compare them with a similar group of patients with definite MD and a group of patients with recent idiopathic sudden neurosensory hearing loss (ISSNHL).

Material and Methods: 170 patients were included, 83 with definite MD, 38 with fluctuating sensorineural hearing loss, 34 with recurrent vertigo, and 15 with ISSNHL. The clinical variables, audiovestibular tests, and EH were evaluated and compared. Logistic proportional hazard models were used to obtain the odds ratio for hydrops development, including a multivariable adjusted model for potential confounders.

Results: No statistical differences between groups were found regarding disease duration, episodes, Tumarkin spells, migraine, vascular risk factors, or vestibular tests; only hearing loss showed differences. Regarding EH, we found significant differences between groups, with odds ratio (OR) for EH presence in definite MD group vs. all other patients of 11.43 (4.5–29.02; p < 0.001). If the ISSNHL group was used as reference, OR was 55.2 (11.9–253.9; p < 0.001) for the definite MD group, 9.9 (2.1–38.9; p = 0.003) for the recurrent vertigo group, and 5.1 (1.2–21.7; p = 0.03) for the group with fluctuating sensorineural hearing loss.

Conclusion: The percentage of patients with EH varies between groups. It is minimal in the ISSNHL group and increases in groups with increasing fluctuating audiovestibular symptoms, with a rate of severe EH similar to the known rate of progression to definite MD in those groups, suggesting that presence of EH by MRI could be related to the risk of progression to definite MD. Thus, EH imaging in these patients is recommended.

Clinical features and outcomes of benign recurrent vertigo: A longitudinal study

OBJECTIVE

To study the demographics, vertigo profiles, and outcomes of adult patients with benign recurrent vertigo (BRV).

PATIENTS AND METHODS

This prospective study included patients with BRV who were admitted to a tertiary neurology clinic between June 2013 and June 2017. All patients underwent detailed clinical interviews and related examinations. A follow-up was then conducted through an outpatient or telephone interview.

RESULTS

A total of 66 patients (48 females) were enrolled, and the mean age at the onset of vertigo was 35.2 years. Spontaneous vertigo was the most common type (77.8%), followed by positional vertigo (16.7%). The duration of vertigo attacks varied from minutes to 72 hours. A family history of migraine and/or recurrent vertigo was reported in 51.5% of patients. The overall response rate was 80.3%（53/66）after a median follow-up time of 32.5 months (range: 18-60 months). Forty (75.5%, of 53) patients still reported having vertigo attacks at the follow-up. The frequency of vertigo attacks was reduced in 32 (60.4%) patients and was unchanged in 8 (15.1%). Four (7.5%) cases developed into vestibular migraine, but none developed into Meniere's disease.

CONCLUSION

The outcomes of patients with BRV were benign, and the frequency of vertigo is significantly reduced. Few cases developed into vestibular migraine.

Clinical Characteristics of Benign Recurrent Vestibulopathy: Clearly Distinctive From Vestibular Migraine and Menière's Disease?

OBJECTIVE

We aimed to systematically investigate the clinical characteristics of benign recurrent vestibulopathy (BRV), vestibular migraine (VM), and Menière's disease (MD) and to assess whether clinical symptoms exist that are unique to BRV.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary referral center.

METHODS

Between January 2015 and November 2016, patients were prospectively recruited at a specialized dizziness clinic. Patients were included if they met the diagnostic criteria for BRV, VM, or MD which was evaluated by simultaneous consultation of an otorhinolaryngologist and neurologist. All patients received a comprehensive clinical examination that included vestibular tests and pure-tone audiometry. A questionnaire was designed to systematically document symptoms of the three vestibular disorders.

RESULTS

A total of 122 patients were included in our study, 65 (53%) were females in whom 29 (24%) were postmenopausal. The mean age was 55.5 ± 13.7 years and the mean age of onset of vertigo attacks was 49.2 ± 14.8 years (n = 119). Forty-five (37%) patients had a clinical diagnosis of BRV, 34 (28%) of VM, and 43 (35%) of MD. No symptom could be identified which was specifically linked to BRV. In patients with BRV, similar to those with VM, we found a female preponderance (p = 0.05 in BRV, p = 0.001 in VM). Patients with VM reported significantly more often a positive history of motion sickness (p = 0.01). In addition, canal paresis was most profound in patients with MD (p = 0.001).

CONCLUSION

We found no clinical characteristics that were distinctive for BRV. However, we did find several distinctive clinical features for VM and MD which may assist the physician in their history taking.

Recurrent peripheral vestibulopathy: Is MRI useful for the diagnosis of endolymphatic hydrops in clinical practice?

OBJECTIVES

Recurrent peripheral vestibulopathy (RPV) is a public health problem, yet the aetiology remains unclear. Recent developments in MRI of endolymphatic hydrops (EH) allow for a better understanding of inner ear disorders. We intended to study the prevalence of EH in patients with RPV, in comparison to those with Meniere's disease (MD).

METHODS

MRI examinations were performed 4 hours after intravenous injection of gadoteric acid in 132 patients with RPV (n = 64) and MD (n = 68). Two radiologists retrospectively studied the prevalence and localization of EH in RPV and MD groups. Patients were graded based on the number and localization of hydrops, between 1 (EH in either cochlea or vestibule on one side) and 4 (EH in cochlea and vestibule on both ears).

RESULTS

We identified EH in 31 out of 64 patients and in 61 out of 68 patients in the RPV and MD groups, respectively. There was a significant difference regarding the number of subjects with EH between the two groups (p ≤ 0.01), with a higher average number of hydrops localization in MD group (p ≤ 0.01).

CONCLUSION

MRI may reveal EH in some cases among patients with RPV, suggesting a similar pathophysiological mechanism in comparison with MD.

KEY POINTS

• MRI may reveal endolymphatic hydrops in some patients with recurrent peripheral vestibulopathy. • We suggest a similar pathophysiological mechanism in recurrent vestibulopathy and Meniere's Disease. • MRI with delayed acquisition helps clinicians to assess patients with recurrent vestibulopathy. • The outcome would be to aid the development of adapted therapeutic strategies. • MRI of endolymphatic hydrops should probably be included in future diagnostic protocols.

Migraine and dizziness

PURPOSE OF REVIEW

Awareness of the importance of migraine in patients with symptoms of vestibular dysfunction is increasing. This article gives an overview of the multiple facets of the link between migraine and vestibular dysfunction.

RECENT FINDINGS

The vestibular and the headache community have published a consensual definition of vestibular migraine, which is an important step to promote research on the topic and the awareness of clinicians. Vestibular migraine is considered the most common cause of spontaneous recurrent vertigo. So far, the evidence for vestibular migraine has been mainly epidemiological, but the recent follow-up of a cohort over 9 years could show the robustness of the diagnosis over time.Additionally, migraine and vestibular dysfunction have multiple potential interactions and links through a range of comorbidities such as Menière's disease, benign paroxysmal positional vertigo, anxiety and motion sickness, which go beyond the diagnostic entity of vestibular migraine.

SUMMARY

The further refinement and wider acceptance of the diagnostic entity of vestibular migraine is an important development as it is one the most common vestibular disorders. But the relationship between migraine and vestibular dysfunction is complex and has many aspects beyond vestibular migraine.

Asymmetry in semicircular canal diameters may account for circling behavior in EphB-deficient mice

OBJECTIVES/HYPOTHESIS

Determine if differences in right and left semicircular size account for phenotypic behavior, indicating vestibulopathy in EphB deficient mice.

STUDY DESIGN

The diameters of the superior semicircular canals (SCC) were measured. The differences in the right and left superior SCC diameters were analyzed in homozygous EphB2 and EphB3 double knockout mice known to have head bobbing and circling behavior. Results were compared to similar analysis in wild type controls that displayed no signs of vestibulopathy.

METHODS

Axial frozen sections through the superior (SCC) were analyzed by light microscopy; and the diameters of the left and right canals were measured in μm for both EphB2 and EphB3 double knockout mice, as well as in wild type control mice. The differences in diameter between the left and right superior SCC was determined for each animal.

RESULTS

Overall, the EphB2 and EphB3 double knockout mice had smaller superior SCC diameters compared to wild type (109.0±21.4 μm vs. 185.0±5.2 μm (P<0.0001). The mean difference in left and right diameter of the superior SCC of EphB2/EphB3 double knockout mice was 29.0±8.7 μm; in wild-type controls this difference was 6.0±5.1 μm (P=0.002). In addition, the direction of circling appeared to be independent of the laterality of the smaller (or larger) superior SCC.

CONCLUSION

Mice deficient in EphB2/EphB3 signaling have smaller superior SCC and asymmetry in lumen sizes between the left and right sides. The laterality of the larger versus smaller is not correlated with the direction of circling behavior.

LEVEL OF EVIDENCE

N/A.

Vibration-induced nystagmus in patients with unilateral peripheral vestibular disorders

This study was done to clarify the clinical significance of vibration-induced nystagmus (VIN) and to calculate the sensitivity and the specificity of the vibration test. One hundred and twelve patients with unilateral peripheral vestibular disorders and thirty normal subjects were enrolled into this study. However, patients with spontaneous nystagmus were excluded. Vibration stimuli (approximately 100 Hz) were presented to the mastoids and the forehead. Patients and normal subjects also underwent head shaking nystagmus (HSN) test and caloric testing. Among the 112 patients, 91(81 %) showed VIN which were mainly horizontal. VIN was more frequently elicited on the mastoids than on the forehead. In the majority of patients (76 cases), the direction of VIN was toward the healthy side, whereas patients with Meniere's disease (15 cases), showed nystagmus toward the affected side. None of 30 normal subjects showed VIN. Whereas HSN was found in 70 (63 %) patients and 9 (30 %) in normal subjects. Among 112 patients, 10 showed a canal paresis (CP) value of caloric testing less than 25 %, while 32 with a CP value between 25 and 40 %, 48 with a CP value between 40 and 70 %, and 22 with a CP value no less than 70 %. It is notable that with increasing CP value on caloric testing, VIN was more likely to be elicited. So VIN test is a simple, non-invasive and well-tolerated clinical test that indicates unilateral peripheral vestibular dysfunction. VIN test had greater sensitivity and specificity than HSN test in the diagnosis of unilateral peripheral vestibular disorders.