Efficacy of steroid therapy based on symptomatic and functional improvement in patients with vestibular neuritis: a prospective randomized controlled trial

Early vestibular rehabilitation training of peripheral acute vestibular syndrome-a systematic review and meta-analysis

Objective

This study aimed to investigate the impact of early vestibular rehabilitation training combined with corticosteroids initiated within 2 weeks, compared with corticosteroid treatment, after the peripheral acute vestibular syndrome (pAVS) onset.

Data sources

PubMed, CINAHL, EMBASE, and SCOPUS. From inception to January 24, 2024. The International Prospective Register of Systematic Reviews approved this study (CRD42023422308).

Results

Five studies involving 235 patients were included in this systematic review and meta-analysis. The subjective outcome measure Dizziness Handicap Inventory (DHI) was pooled for a meta-analysis and was statistically significantly in favor of early vestibular rehabilitation training (early VRT) plus corticosteroids compared with corticosteroids alone: at one-month follow-up (p = 0.00) and 12 months follow-up (p = 0.01). DHI was a critical outcome for measuring the differences in effect of early VRT. The objective outcome measures of caloric lateralization, cervical vestibular-evoked myogenic potentials, and posturography were gathered for a narrative synthesis.

Conclusion

This meta-analysis showed that early VRT in combination with corticosteroids was more effective for treating pAVS than corticosteroid treatment alone. No adverse effects were reported for early VRT.

Dyslipidemia Treatment and Cerebrovascular Disease: Evidence Regarding the Mechanism of Stroke

Dyslipidemia stands as a significant risk factor for stroke, on par with the impact of hypertension, diabetes, and smoking. While the role of dyslipidemia is firmly established in the context of coronary artery disease, its influence on strokes remains somewhat enigmatic. This complexity likely arises from the diverse mechanisms underpinning strokes, which encompass a heterogeneous spectrum (hemorrhagic and ischemic; large artery atherosclerosis, small vessel occlusion, cardioembolism, and etc.). The extent to which lipid-lowering treatments affect stroke outcomes may vary depending on the specific stroke subtype. For instance, in cases of large artery atherosclerosis (LAA), the optimal target level of low-density lipoprotein cholesterol (LDL-C) is relatively clear. However, when dealing with other stroke subtypes like small vessel occlusion or cardioembolism, the appropriate LDL-C target remains uncertain. Furthermore, reperfusion therapy has emerged as the foremost treatment for acute ischemic stroke. Nevertheless, the precise relationship between LDL-C levels and outcomes in patients undergoing reperfusion therapy remains shrouded in uncertainty. Consequently, we have undertaken an in-depth exploration of the existing evidence supporting the utilization of lipid-lowering medications such as statins, ezetimibe, and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. Our objective is to elucidate their role in secondary stroke prevention and the management of dyslipidemia across the various stroke subtypes.

[Vestibular rehabilitation for peripheral vestibular hypofunction: an interdisciplinary consensus]

The literature review presents approaches to the management of patients with vestibular disorders. The principles of organization of vestibular rehabilitation in peripheral vestibular hypofunction, indications for appointment, factors influencing its implementation, technique, methods of evaluating effectiveness are considered in detail. Attention is drawn to the fact that the selection of exercises and the duration of vestibular rehabilitation is carried out individually and depends on many factors, including the nature of vestibular deficiency and the specific characteristics of the patient. The possibilities of using additional pharmacological therapy with histamine preparations, which can accelerate the onset of vestibular compensation, are shown. It is noted that vestibular rehabilitation is a safe and effective method of treating peripheral vestibular hypofunction and should be recommended to patients of all ages with vestibular disorders leading to limited social and physical activity.

Efficacy of Vestibular Rehabilitation in Vestibular Neuritis: A Systematic Review and Meta-analysis

OBJECTIVE

This study aimed to evaluate the efficacy of vestibular rehabilitation in vestibular neuritis.

DESIGN

A randomized controlled trial was collected from MEDLINE, Embase, Cochrane Library, PEDro, LILACS, and Google Scholar before May 2023.

RESULTS

This study included 12 randomized controlled trials involving 536 patients with vestibular neuritis. Vestibular rehabilitation was comparable with steroids in dizziness handicap inventory score at the first, sixth, and 12th months (pooled mean differences: -4.00, -0.21, and -0.31, respectively); caloric lateralization at the third, sixth, and 12th months (pooled mean difference: 1.10, 4.76, and -0.31, respectively); and abnormal numbers of vestibular-evoked myogenic potentials at the first, sixth, and 12th months. Patients receiving a combination of rehabilitation and steroid exhibited significant improvement in dizziness handicap inventory score at the first, third, and 12th months (mean difference: -14.86, pooled mean difference: -4.63, mean difference: -9.50, respectively); caloric lateralization at the first and third months (pooled mean difference: -10.28, pooled mean difference: -8.12, respectively); and numbers of vestibular-evoked myogenic potentials at the first and third months (risk ratios: 0.66 and 0.60, respectively) than did those receiving steroids alone.

CONCLUSIONS

Vestibular rehabilitation is recommended for patients with vestibular neuritis. A combination of vestibular rehabilitation and steroids is more effective than steroids alone in the treatment of patients with vestibular neuritis.

Effects of vestibular rehabilitation training combined with anti-vertigo drugs on vertigo and balance function in patients with vestibular neuronitis: a systematic review and meta-analysis

Objective

To investigate the effects of vestibular rehabilitation training (VRT) combined with anti-vertigo drugs on vertigo and balance function in patients with vestibular neuronitis (VN).

Data sources

PubMed, EMBASE, The Cochrane Library, Web of Science, CNKI, Wan Fang Data, VIP, and CBM were searched until July 13, 2023.

Participants

Patients with vestibular neuronitis participated in the study.

Results

Twenty one studies including 1,415 patients were included in this review for meta-analysis. According to the Physiotherapy Evidence Database (PEDro) quality assessment, four studies received high quality (≥seven scores) and 17 studies received moderate quality (six scores). The meta-analysis showed that VRT combined with anti-vertigo drugs significantly reduced the Dizziness Handicap Inventory (DHI) score, the Vestibular Disorders Activities of Daily Living Scale (VADL) score and the Canal Paresis (CP) score, and improved the overall efficiency and the Berg Balance Scale (BBS) score, promoting vestibular evoked myogenic potentials (VEMPs) returned to normal in VN compared to simple anti-vertigo drugs or VRT alone.

Conclusion

The results of this meta-analysis demonstrate the efficacy and safety of VRT combined with anti-vertigo drugs in patients with VN. Combined therapy can alleviate vestibular dysfunction such as vertigo and vomiting in patients, improve daily activity ability and balance ability, in addition to VRT has fewer adverse reactions, so it is extremely safe. However, there are shortcomings such as lack of long-term follow-up and different frequency and duration of treatment. Therefore, future randomized controlled trials (RCTs) with larger sample sizes and longer-term observations are needed to verify the effectiveness of VRT in combination with anti-vertigo drugs for VN.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/.

Prospective analysis of video head impulse tests in patients with acute posterior circulation stroke

Background

Video head impulse tests (vHITs), assessing the vestibulo-ocular reflex (VOR), may be helpful in the differential diagnosis of acute dizziness. We aimed to investigate vHITs in patients with acute posterior circulation stroke (PCS) to examine whether these findings could exhibit significant abnormalities based on lesion locations, and to evaluate diagnostic value of vHIT in differentiating dizziness between PCS and vestibular neuritis (VN).

Methods

We prospectively recruited consecutive 80 patients with acute PCS and analyzed vHIT findings according to the presence of dorsal brainstem stroke (DBS). We also compared vHIT findings between PCS patients with dizziness and a previously studied VN group (n = 29). Receiver operating characteristic (ROC) analysis was performed to assess the performance of VOR gain and its asymmetry in distinguishing dizziness between PCS and VN.

Results

Patients with PCS underwent vHIT within a median of 2 days from stroke onset. Mean horizontal VOR gain was 0.97, and there was no significant difference between PCS patients with DBS (n = 15) and without (n = 65). None exhibited pathologic overt corrective saccades. When comparing the PCS group with dizziness (n = 40) to the VN group (n = 29), patients with VN demonstrated significantly lower mean VOR gains in the ipsilesional horizontal canals (1.00 vs. 0.57, p < 0.001). VOR gain and their asymmetry effectively differentiated dizziness in the PCS from VN groups, with an area under the ROC curve of 0.86 (95% CI 0.74-0.98) and 0.91 (95% CI 0.83-0.99, p < 0.001), respectively.

Conclusion

Significantly abnormal vHIT results were rare in patients with acute PCS, even in the presence of DBS. Moreover, vHIT effectively differentiated dizziness between PCS and VN, highlighting its potential for aiding differential diagnosis of acute dizziness.

Acute vestibular neuritis may provoke atrial fibrillation

BACKGROUND

Exclusion of stroke is the focus of guidelines in the emergency department assessment of acute vertigo, especially with new-onset atrial fibrillation (AF). Early diagnosis of vestibular neuritis (VN) is also important but may be deferred awaiting brain magnetic resonance imaging (MRI) for exclusion of stroke. This may delay potentially beneficial corticosteroid therapy.

AIMS

To highlight that VN can provoke acute AF.

METHODS

In the course of a prospective study of acute vertigo in patients assessable within 24 h of admission, we encountered three patients with acute onset transient AF associated with VN. We performed a detailed neurological examination and quantitated the vestibulo-ocular reflex (VOR) gain with video-oculography. Brain MRI was performed in all patients.

RESULTS

There were two men and one woman, aged 58-66 (mean 61) years. All patients had typical non-direction-changing rotatory nystagmus and positive head impulse tests. The horizontal VOR gains ranged 0.38-0.62 (mean 0.47). Diffusion-weighted MRI within 36 h was normal in all. AF reverted in all three within 24 h.

CONCLUSIONS

Acute AF can be precipitated by vertigo such as in VN. In VN, the concurrence of acute AF may distract from the correct neurological diagnosis, delaying potentially beneficial corticosteroid therapy, especially if exclusion of stroke is dependent on MRI, which may be delayed.

Systemic Steroids for Otolaryngology-Head and Neck Surgery Disorders: An Evidence-Based Primer for Clinicians

OBJECTIVE

To offer pragmatic, evidence-informed guidance on the use of systemic corticosteroids (SCS) for common otolaryngologic disorders.

DATA SOURCES

PubMed, Cochrane Library, and American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guidelines.

REVIEW METHODS

A comprehensive search of published literature through November 2021 was conducted on the efficacy of SCS, alone or in combination with other treatments, for managing disorders in otolaryngology and the subdisciplines. Clinical practice guidelines, systematic reviews, and randomized controlled trials, when available, were preferentially retrieved. Interventions and outcomes of SCS use were compiled to generate summary tables and narrative synthesis of findings.

CONCLUSIONS

Evidence on the effectiveness of SCS varies widely across otolaryngology disorders. High-level evidence supports SCS use for Bell's palsy, sinonasal polyposis, and lower airway disease. Conversely, evidence is weak or absent for upper respiratory tract infection, eustachian tube dysfunction, benign paroxysmal positional vertigo, adenotonsillar hypertrophy, or nonallergic rhinitis. Evidence is indeterminate for acute laryngitis, acute pharyngitis, acute sinusitis, angioedema, chronic rhinosinusitis without polyps, Ménière's disease, postviral olfactory loss, postoperative nerve paresis/paralysis, facial pain, and sudden sensorineural hearing loss.

IMPLICATIONS FOR PRACTICE

Clinicians should bring an evidence-informed lens to SCS prescribing to best counsel patients regarding the risks, anticipated benefits, and limited data on long-term effects. Alternate routes of corticosteroid administration-such as sprays, drops, inhalers, and intralesional injections-may be preferable for many disorders, particularly those that are self-limited or require a prolonged duration of therapy. Prudent use of SCS reduces the risk of medication-related adverse effects. Clinicians who are conversant with high-level evidence can achieve optimal outcomes and stewardship when prescribing SCS.

Dynamic change of vestibular function and the long-term prognosis of vestibular neuritis

AIM

To comprehensively evaluate the dynamic change of vestibular function during long-term follow-up of vestibular neuritis, as well as the co-relationship with the outcomes of vestibular neuritis (VN), which provides the recommendations for vestibular function tests during the course of VN.

METHODS

A prospective cohort study was conducted on 16 patients with acute VN. Caloric test, vHIT, rotatory chair tests, VEMP, dizziness handicap inventory (DHI) score, and dynamic dizzy scales (VAS-DD) was first performed within 7 days of neuritis onset, which were further re-evaluated during the 6-12 months of follow-up. The dynamic changes on multiple objective vestibular examinations were analyzed during the acute and recovery stage of VN. We further evaluated the co-relationship between the vestibular dysfunction scales and the prognosis of VN.

RESULTS

In more than 6 months of follow-up, 44% of the ultralow frequency, 94% of the low-to-mid frequency, and 44% of the high-frequency function of the horizontal semicircular canal returned to normal (p < 0.05). The change degree in symmetry of the rotatory chair test was correlated with the gain of the horizontal semicircular canal on the vHIT and the unilateral weakness (UW) value on the caloric test (p < 0.05). The change in DHI score was correlated with the phase; change in VAS-DD level correlated with the symmetry and TC of the rotatory chair test at VN recovery stage (p < 0.05). There was no significant correlation between the change in DHI score or change in VAS-DD and the degree of vestibular function recovery (p > 0.05).

CONCLUSION

In general, vestibular function improved during the course of VN. The rotatory chair test can be used to evaluate the overall function of the vestibular system and the compensatory state in patients with VN.

Vestibular Rehabilitation Therapy and Corticosteroids for Vestibular Neuritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background and Objectives: Besides corticosteroids, clinicians found that vestibular rehabilitation therapy (VRT) has a potential effect on vestibular neuritis (VN) improvement. This study aimed to investigate the efficacy of both corticosteroid therapy (CT) compared to VRT, and each group compared to their combination (CT vs. (CT+VRT) and VRT vs. (CT + VRT). Materials and Methods: Systematic searches were performed in PubMed, CINAHL, and Scopus for randomized controlled trials (RCTs) reporting the administration of at least CT and VRT for VN. The outcome of interest was VN's subjective and objective improvement parameters. Results: Four RCTs involving a total of 182 patients with VN were eligible for systematic review and meta-analysis. The weighted mean difference (WMD) of canal paresis (objective parameter) in the CT group is significantly lower than in the VRT group after a 1 month follow-up (8.31; 95% CI: 0.29, -16.32; p = 0.04; fixed effect). Meanwhile, the WMD of Dizziness Handicap Inventory (DHI) (subjective parameter) in the VRT group is significantly lower than in the CT group after a 1 month follow-up (-3.95; 95% CI: -7.69, -0.21; p = 0.04; fixed effect). Similarly, the WMD of DHI in the combination group (CT+VRT) is significantly lower than in the CT group after a 3 month follow-up (3.15; 95% CI: 1.50, 4.80; p = 0.0002; fixed effect). However, there is no significant difference in all outcomes after 12 months of follow-ups in all groups (CT vs. VRT, CT vs. combination, and VRT vs. combination). Conclusions: This study indicates that CT enhances the earlier canal paresis improvement, as the objective parameter, while VRT gives the earlier DHI score improvement, as the subjective parameter. However, their long-term efficacy does not appear to be different. VRT has to be offered as the primary option for patients with VN, and corticosteroids can be added to provide better recovery in the absence of its contraindication. However, whether to choose VRT, CT, or its combination should be tailored to the patient's condition. Future studies are still needed to revisit this issue, due to the small number of trials in this field. (PROSPERO ID: CRD42021220615).

Microglial Dynamics Modulate Vestibular Compensation in a Rodent Model of Vestibulopathy and Condition the Expression of Plasticity Mechanisms in the Deafferented Vestibular Nuclei

Unilateral vestibular loss (UVL) induces a vestibular syndrome composed of posturo-locomotor, oculomotor, vegetative, and perceptivo-cognitive symptoms. With time, these functional deficits progressively disappear due to a phenomenon called vestibular compensation, known to be supported by the expression in the deafferented vestibular nuclei (VNs) of various adaptative plasticity mechanisms. UVL is known to induce a neuroinflammatory response within the VNs, thought to be caused by the structural alteration of primary vestibular afferents. The acute inflammatory response, expressed in the deafferented VNs was recently proven to be crucial for the expression of the endogenous plasticity supporting functional recovery. Neuroinflammation is supported by reactive microglial cells, known to have various phenotypes with adverse effects on brain tissue. Here, we used markers of pro-inflammatory and anti-inflammatory phenotypes of reactive microglia to study microglial dynamics following a unilateral vestibular neurectomy (UVN) in the adult rat. In addition, to highlight the role of acute inflammation in vestibular compensation and its underlying mechanisms, we enhanced the inflammatory state of the deafferented VNs using systemic injections of lipopolysaccharide (LPS) during the acute phase after a UVN. We observed that the UVN induced the expression of both M1 proinflammatory and M2 anti-inflammatory microglial phenotypes in the deafferented VNs. The acute LPS treatment exacerbated the inflammatory reaction and increased the M1 phenotype while decreasing M2 expression. These effects were associated with impaired postlesional plasticity in the deafferented VNs and exacerbated functional deficits. These results highlight the importance of a homeostatic inflammatory level in the expression of the adaptative plasticity mechanisms underlying vestibular compensation. Understanding the rules that govern neuroinflammation would provide therapeutic leads in neuropathologies associated with these processes.

Corticosteroids in patients with vestibular neuritis: An updated meta-analysis

Vestibular neuritis is a common neuro-otological entity. Therapeutically, corticosteroids are advised, although the evidence is limited. The objective of this review is to update meta-analyses of clinical trials that address the question of whether patients with vestibular neuritis treated with corticosteroids show better recovery than control patients. The electronic databases Medline, Scopus and Cochrane were searched for clinical trials for the years 1970-2020 without language restriction. Data were extracted, and outcome parameters were subjected to conventional and cumulative meta-analysis using a commercially available software program (www.meta-analysis.com). Finally, 15 trials with 363 participants in the treatment and 489 in the control groups were identified and could be included. Eight studies were judged to be at high risk of bias. The odds ratio (OR) for good outcome in the acute phase was 3.1 (95% CI 1.2-7.8; p = .015) in favour of steroid treatment leading to the number needed to treat (NNT) = 6 (95% CI 4-23). The odds ratio (OR) for restoration of vestibular function in the follow-up was 2.4 (95% CI 1.3-4.4; p = .004) for the benefit of steroid treatment resulting in a NNT = 7 (95% CI 5-18). The results of the cumulative statistics did not differ. The risk of adverse effects was higher in patients treated with steroids with an OR of 10.9 (95% CI 1.3-93.8; p = .015) and an estimated number needed to harm (NNH) = 4 (95% CI 3-19). The advantage for corticosteroids remained when differentiating between patients who participated in randomized or non-randomized clinical trials. Steroid treatment in vestibular neuritis resulted in a statistically significant benefit compared to control therapies. However, broad heterogeneity of the studies, mostly low-grade quality of studies, high risk of bias and broad confidence intervals put the findings into perspective allowing only a careful judgement of some benefit of corticosteroids. The findings, however, support the call for an adequately powered and well-designed randomized controlled trial to re-evaluate the effectiveness of corticosteroids.

Corticosteroids for patients with vestibular neuritis: an evidence synthesis for guidelines for reasonable and appropriate care in the emergency department

BACKGROUND

A short course of corticosteroids is among the management strategies considered by specialists for the treatment of vestibular neuritis (VN). We conducted an umbrella review (systematic review of systematic reviews) to summarize the evidence of corticosteroids use for the treatment of VN.

METHODS

We included systematic reviews of randomized controlled trials (RCTs) and observational studies that evaluated the effects of corticosteroids as compared to placebo or usual care in adult patients with acute VN. Titles, abstracts, and full texts were screened in duplicate. The quality of reviews was assessed with the A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2) tool. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment was used to rate certainty of evidence. No meta-analysis was performed.

RESULTS

From 149 titles, 5 systematic reviews were selected for quality assessment, and 2 reviews were of higher methodological quality and were included. These 2 reviews included 12 individual studies and 660 patients with VN. In a meta-analysis of 2 RCTs including a total of 50 patients, the use of corticosteroids (as compared to placebo) was associated with higher complete caloric recovery (risk ratio 2.81, 95% CI 1.32 to 6.00, low certainty). It is very uncertain whether this translates into clinical improvement as shown by the imprecise effect estimates for outcomes such as patient-reported vertigo or patient-reported dizziness disability. There was a wide confidence interval for the outcome of dizziness handicap score (1 study, 30 patients, 20.9 points in corticosteroids group vs 15.8 points in placebo, mean difference +5.1, 95% CI -8.09 to +18.29, very low certainty). Higher rates of minor adverse effects for those receiving corticosteroids were reported, but the certainty in this evidence was very low.

CONCLUSIONS

There is limited evidence to support the use of corticosteroids for the treatment of vestibular neuritis in the emergency department.

Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Updated Clinical Practice Guideline From the Academy of Neurologic Physical Therapy of the American Physical Therapy Association

Background:

Uncompensated vestibular hypofunction can result in symptoms of dizziness, imbalance, and/or oscillopsia, gaze and gait instability, and impaired navigation and spatial orientation; thus, may negatively impact an individual's quality of life, ability to perform activities of daily living, drive, and work. It is estimated that one-third of adults in the United States have vestibular dysfunction and the incidence increases with age. There is strong evidence supporting vestibular physical therapy for reducing symptoms, improving gaze and postural stability, and improving function in individuals with vestibular hypofunction. The purpose of this revised clinical practice guideline is to improve quality of care and outcomes for individuals with acute, subacute, and chronic unilateral and bilateral vestibular hypofunction by providing evidence-based recommendations regarding appropriate exercises.

Methods:

These guidelines are a revision of the 2016 guidelines and involved a systematic review of the literature published since 2015 through June 2020 across 6 databases. Article types included meta-analyses, systematic reviews, randomized controlled trials, cohort studies, case-control series, and case series for human subjects, published in English. Sixty-seven articles were identified as relevant to this clinical practice guideline and critically appraised for level of evidence.

Results:

Based on strong evidence, clinicians should offer vestibular rehabilitation to adults with unilateral and bilateral vestibular hypofunction who present with impairments, activity limitations, and participation restrictions related to the vestibular deficit. Based on strong evidence and a preponderance of harm over benefit, clinicians should not include voluntary saccadic or smooth-pursuit eye movements in isolation (ie, without head movement) to promote gaze stability. Based on moderate to strong evidence, clinicians may offer specific exercise techniques to target identified activity limitations and participation restrictions, including virtual reality or augmented sensory feedback. Based on strong evidence and in consideration of patient preference, clinicians should offer supervised vestibular rehabilitation. Based on moderate to weak evidence, clinicians may prescribe weekly clinic visits plus a home exercise program of gaze stabilization exercises consisting of a minimum of: (1) 3 times per day for a total of at least 12 minutes daily for individuals with acute/subacute unilateral vestibular hypofunction; (2) 3 to 5 times per day for a total of at least 20 minutes daily for 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction; (3) 3 to 5 times per day for a total of 20 to 40 minutes daily for approximately 5 to 7 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may prescribe static and dynamic balance exercises for a minimum of 20 minutes daily for at least 4 to 6 weeks for individuals with chronic unilateral vestibular hypofunction and, based on expert opinion, for a minimum of 6 to 9 weeks for individuals with bilateral vestibular hypofunction. Based on moderate evidence, clinicians may use achievement of primary goals, resolution of symptoms, normalized balance and vestibular function, or plateau in progress as reasons for stopping therapy. Based on moderate to strong evidence, clinicians may evaluate factors, including time from onset of symptoms, comorbidities, cognitive function, and use of medication that could modify rehabilitation outcomes.

Discussion:

Recent evidence supports the original recommendations from the 2016 guidelines. There is strong evidence that vestibular physical therapy provides a clear and substantial benefit to individuals with unilateral and bilateral vestibular hypofunction.

Limitations:

The focus of the guideline was on peripheral vestibular hypofunction; thus, the recommendations of the guideline may not apply to individuals with central vestibular disorders. One criterion for study inclusion was that vestibular hypofunction was determined based on objective vestibular function tests. This guideline may not apply to individuals who report symptoms of dizziness, imbalance, and/or oscillopsia without a diagnosis of vestibular hypofunction.

Disclaimer:

These recommendations are intended as a guide to optimize rehabilitation outcomes for individuals undergoing vestibular physical therapy. The contents of this guideline were developed with support from the American Physical Therapy Association and the Academy of Neurologic Physical Therapy using a rigorous review process. The authors declared no conflict of interest and maintained editorial independence.

Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A369).

Therapeutic effect of steroids on vestibular neuritis: Systematic review and meta-analysis

OBJECTIVES

The present meta-analysis sought to assess further evidence for the efficacy of steroids in vestibular neuritis (VN).

METHODS

The PubMed, EMBASE and Cochrane Library databases were searched through 30 August 2019. The main outcome measure was dizziness handicap inventory (DHI) and secondary outcomes included complete caloric recovery and improvement of canal paresis (CP). The follow-up times were divided into short, mid and long-term.

RESULTS

Among 276 records identified, 5 studies (n = 253) were included in the analysis. The therapeutic effect of steroid on VN was confirmed (Hedges' g = 0.172, 95% CI 0.05-0.30, p = .006). Although there was no significant difference between steroids and control in the DHI score (Hedges' g = -0.323, 95% CI -0.533 to -0.113, p < .01), significant effect was seen on complete caloric recovery and improvement in CP (Hedges' g = 0.364, 95% CI 0.18-0.55, p < .0001; Hedges' g = 0.592, 95% CI 0.32-0.59, p < .0001).

CONCLUSIONS

The results suggest that corticosteroids have an effect on the results of caloric tests for VN recovery, especially in long-term follow-up. However, in terms of dizziness handicap, we did not find any evidence of positive effect on corticosteroid. More data are required before recommendations can be made regarding management in patients on corticosteroids.

Breaking a dogma: acute anti-inflammatory treatment alters both post-lesional functional recovery and endogenous adaptive plasticity mechanisms in a rodent model of acute peripheral vestibulopathy

BACKGROUND

Due to their anti-inflammatory action, corticosteroids are the reference treatment for brain injuries and many inflammatory diseases. However, the benefits of acute corticotherapy are now being questioned, particularly in the case of acute peripheral vestibulopathies (APV), characterized by a vestibular syndrome composed of sustained spinning vertigo, spontaneous ocular nystagmus and oscillopsia, perceptual-cognitive, posturo-locomotor, and vegetative disorders. We assessed the effectiveness of acute corticotherapy, and the functional role of acute inflammation observed after sudden unilateral vestibular loss.

METHODS

We used the rodent model of unilateral vestibular neurectomy, mimicking the syndrome observed in patients with APV. We treated the animals during the acute phase of the vestibular syndrome, either with placebo or methylprednisolone, an anti-inflammatory corticosteroid. At the cellular level, impacts of methylprednisolone on endogenous plasticity mechanisms were assessed through analysis of cell proliferation and survival, glial reactions, neuron's membrane excitability, and stress marker. At the behavioral level, vestibular and posturo-locomotor functions' recovery were assessed with appropriate qualitative and quantitative evaluations.

RESULTS

We observed that acute treatment with methylprednisolone significantly decreases glial reactions, cell proliferation and survival. In addition, stress and excitability markers were significantly impacted by the treatment. Besides, vestibular syndrome's intensity was enhanced, and vestibular compensation delayed under acute methylprednisolone treatment.

CONCLUSIONS

We show here, for the first time, that acute anti-inflammatory treatment alters the expression of the adaptive plasticity mechanisms in the deafferented vestibular nuclei and generates enhanced and prolonged vestibular and postural deficits. These results strongly suggest a beneficial role for acute endogenous neuroinflammation in vestibular compensation. They open the way to a change in dogma for the treatment and therapeutic management of vestibular patients.

Acute Vestibular Syndrome and ER Presentations of Dizziness

Acute vestibular syndrome (AVS) describes sudden onset, severe, continuous dizziness that persists for more than 24 hours. Its wide differential presents a diagnostic challenge. Vestibular neuritis is the most common cause, but stroke, trauma, medication effects, infectious, and inflammatory causes all present similarly. The TiTrATE model (Timing, Triggers, And Targeted Exam) is systematic way to evaluate these patients, and the HINTS Plus exam (Head Impulse, Nystagmus, Test of Skew, plus hearing loss) is critical in differentiating central and peripheral causes. The importance of recognizing risk factors for stroke and the role of imaging is also discussed.

Efficacy and Pharmacological Appropriateness of Cinnarizine and Dimenhydrinate in the Treatment of Vertigo and Related Symptoms

Vertigo is not itself a disease, but rather a symptom of various syndromes and disorders that jeopardize balance function, which is essential for daily activities. It is an abnormal sensation of motion that usually occurs in the absence of motion, or when a motion is sensed inaccurately. Due to the complexity of the etiopathogenesis of vertigo, many pharmacological treatments have been tested for efficacy on vertigo. Among these drugs, cinnarizine, usually given together with dimenhydrinate, appears to be the first-line pharmacotherapy for the management of vertigo and inner ear disorders. Based on these considerations, the present non-interventional study aimed to investigate the clinical efficacy and tolerability of a fixed combination of cinnarizine (20 mg) and dimenhydrinate (40 mg) in patients suffering from vertigo-related symptoms. To this end, we enrolled 120 adults-70 males, and 50 females-with an average age of 64 years. Before beginning pharmacological treatment, all patients were screened for the intensity of vertigo, dizziness, and concomitant symptoms through the Visual Scale of Dizziness Disorders and Dizziness Handicap Inventory scales. At the end of the anamnestic evaluation, patients received the fixed-dose combination of cinnarizine (20 mg) plus dimenhydrinate (40 mg) 3 times daily, for 60 days. The results of this study provide further insight regarding the efficacy of the fixed combination when used to reduce symptoms of vestibular vertigo of central and/or peripheral origin, after both the 15- and 60-day therapies. Independent of the type of vertigo, the fixed combination was able to reduce dizziness- and vertigo-associated symptoms in more than 75% of all patients treated, starting from 15 days of therapy, and improving 60 days after starting the therapy. Interestingly, we also found differences between male and female patients in the framework of the pharmacological effects of therapy. This study provides further details concerning the therapeutic efficacy of the fixed combination of cinnarizine and dimenhydrinate, and also focuses attention on the possibility that these drugs could act in a gender-specific manner, paving the way for further research.

Systematic Review and Meta-analysis: Effectiveness of Corticosteroids in Treating Adults With Acute Vestibular Neuritis

OBJECTIVES

To determine whether steroids are effective in treating adults with acute vestibular neuritis.

DATA SOURCES

PubMed, Embase, CINAHL, Cochrane CENTRAL, Web of Science, CAB Abstract, ICTRP, LILACS, PEDRO, ClinicalTrials.Gov, Google Scholar, NARIC, and OT Seeker.

REVIEW METHODS

A systematic review was undertaken for articles reporting subjective and/or objective outcomes of corticosteroids in adults with acute vestibular neuritis between December 2010 and October 2019. Reports of patient recovery from clinical vestibular outcomes at various time points and adverse effects from corticosteroids were of interest. Statistical analysis included qualitative and quantitative assessments. A limited meta-analysis of the data was performed through a random effects model.

RESULTS

Eight studies met the criteria, and 6 were included in the meta-analysis. No significant differences between the groups (corticosteroid vs placebo, corticosteroid vs vestibular exercise, or corticosteroid vs combination of vestibular exercise and corticosteroid) were reported in the proportion of patients with complete recovery at 1, 6, and 12 months. The corticosteroid group had significantly better caloric recover at 1 month (95% CI, -16.33 to -0.32); however, there was no significant difference to the overall effect between the groups across 12 months. Subjective recovery did not differ between the groups. Five of the 8 studies reported on adverse effects from corticosteroids.

CONCLUSION

There is insufficient evidence to support the use of corticosteroids in managing acute vestibular neuritis in adults. At present, corticosteroids appear to have short-term benefits in canal paresis but no long-term benefits in canal paresis and symptomatic recovery. Future studies should consider including a wider variety of clinical vestibular tests and frequent acute follow-ups to monitor the effects of corticosteroids.

Spontaneous Recovery of the Vestibulo-Ocular Reflex After Vestibular Neuritis; Long-Term Monitoring With the Video Head Impulse Test in a Single Patient

Vestibular rehabilitation of patients in whom the level of vestibular function is continuously changing requires different strategies than in those where vestibular function rapidly becomes stable: where it recovers or where it does not and compensation is by catch-up saccades. In order to determine which of these situations apply to a particular patient, it is necessary to monitor the vestibulo-ocular reflex (VOR) gains, rather than just make a single measurement at a given time. The video Head Impulse Test (vHIT) is a simple and practical way to monitor precisely the time course and final level of VOR recovery and is useful when a patient has ongoing vestibular symptoms, such as after acute vestibular neuritis. In this study, we try to show the value of ongoing monitoring of vestibular function in a patient recovering from vestibular neuritis. Acute vestibular neuritis can impair function of any single semicircular canal (SCC). The level of impairment of each SCC, initially anywhere between 0 and 100%, can be accurately measured by the vHIT. In superior vestibular neuritis the anterior and lateral SCCs are the most affected. Unlike after surgical unilateral vestibular deafferentation, SCC function as measured by the VOR can recover spontaneously after acute vestibular neuritis. Here we report monitoring the VOR from all 6 SCCs for 500 days after the second attack in a patient with bilateral sequential vestibular neuritis. Spontaneous recovery of the VOR in response to anterior and lateral SCC impulses showed an exponential recovery with a time to reach stable levels being longer than previously considered or reported. VOR gain in response to low-velocity lateral SCC impulses recovered with a time constant of around 100 days and reached a stable level at about 200 days. However, in response to high-velocity lateral SCC and anterior SCC impulses, VOR gain recovered with a time constant of about 150 days and only reached a stable level toward the end of the 500 days monitoring period.

Vestibular Nerve Atrophy After Vestibular Neuritis - Results from a Prospective High-Resolution MRI Study

PURPOSE

 Sudden unilateral peripheral vestibular deficit is mostly termed vestibular neuritis (VN), even if its cause or the exact location of the lesion remains unclear. Thus, therapy is mostly symptomatic. We aimed to prove if there is peripheral atrophy after VN with persistent canal paresis.

METHODS

 After approval by the ethics committee and according to the declaration of Helsinki and with informed consent, ten patients with persistent canal paresis after VN and ten age-matched healthy controls were included. High-resolution measurement (in-plane resolution 0.2 mm) of the internal auditory canal (IAC) using a 3 D CISS sequence at 3 Tesla was performed. The course of the pertaining nerves was reconstructed in the 3 D dataset and the measurement was performed at 60 % of the length of the IAC. The cross-sectional areas of the superior (SVN) and inferior vestibular nerve (IVN) were taken independently by two blinded readers.

RESULTS

 The interrater difference regarding the area was 22 %. We found significant atrophy of the SVN with a 24 % smaller area (p = 0.026) and found a smaller ratio of SVN/IVN on the symptomatic side (p = 0.017). Concerning single subject data, only 5 patients showed extensive atrophy of the NVS, while 5 patients did not. The time since symptom onset did not significantly influence the atrophy.

CONCLUSION

 MRI measuring of the area of the NVS after VN could detect atrophy after VN. However, only 5 patients exhibited marked atrophy, while the other 5 patients did not. With the background of stringent inclusion criteria (more than 6 months of symptom duration and proven persistent canal paresis), one has to wonder if there might be different etiologies behind the apparently identical symptoms.

KEY POINTS

  · MRI measuring of the area of the NVS after VN could detect atrophy after VN. · Only half of the 10 researched patients showed atrophy, while the other patients did not. · There are different etiologies to be suspected for VN.

CITATION FORMAT

· Freund W, Weber F, Schneider D et al. Vestibular Nerve Atrophy After Vestibular Neuritis - Results from a Prospective High-Resolution MRI Study. Fortschr Röntgenstr 2020; 192: 854 - 861.

[Recovery of vestibulo-ocular reflex in vestibular neuronitis depending on severity of vestibulo-ocular reflex damage]

AIM

The aim of this study is to evaluate clinical symptoms and recovery of vestibule-ocular reflex (VOR) in patients with vestibular neuronitis (VN) in dependence on severity of VOR damage according to video head impulse test (vHIT).

PATIENTS AND METHODS

45 patients with VN and superior or both superior and inferior vestibular nerves involvement were recruited and horizontal gain was measured with vHIT. According to gain asymmetry the patients were divided in three groups: 11 patients with 8-19% gain asymmetry, 10 patients with 20-39% gain asymmetry and 24 patients with more than 40% gain asymmetry.

RESULTS

Coexisting chronic heart and endocrinological diseases could contribute to greater damage of VOR in VN. In patients with less gain asymmetry the full recovery of gain on the affected side was more often. When gain asymmetry was more than 40%, only 10% of patients demonstrated full recovery of gain in 8-12 months. Dynamic visual acuity (DVA) could normalize in patients with clinically significant gain asymmetry. DVA stays decreased more often in patients with in the most gain asymmetry even after vestibular rehabilitation. Benign paroxysmal positional vertigo appeared in 8.9% of patients with VN and had no correlation with VOR asymmetry. Steroid treatment didn't show significant impact on VOR recovery in patients with VN.

Effect of the novel histamine H4 receptor antagonist SENS-111 on spontaneous nystagmus in a rat model of acute unilateral vestibular loss

BACKGROUND AND PURPOSE

Histamine H₄ receptors are expressed in the peripheral vestibular system, and their selective inhibition improves vertigo symptoms in rats with unilateral vestibular lesions. The effects of SENS-111, a selective oral H₄ receptor antagonist with high affinity to both animal and human receptors, on vertigo symptoms was evaluated in a translational in vivo model of unilateral vestibular loss.

EXPERIMENTAL APPROACH

Pharmacokinetics of SENS-111 in rats was determined to aid dose selection for efficacy testing. Vestibular lesions were induced in rats by unilateral transtympanic injection of kainic acid. The effect of SENS-111 (10 or 20 mg·kg^-1 ) on spontaneous nystagmus was evaluated compared with placebo vehicle using video-nystagmography, and the effective dose was compared with those of similar drugs used clinically, as single agents or combined with SENS-111.

KEY RESULTS

Doses were selected for plasma exposure were consistent with published phase 1 results from healthy volunteers. SENS-111 of 10 mg·kg^-1 gave a 21-22% reduction in nystagmus at 1 hr post-administration, whereas a loss of efficacy was seen with 20 mg·kg^-1 . Compared with SENS-111, meclizine and methylprednisolone had minimal effects on nystagmus as single agents, and meclizine abolished the effect of SENS-111 when combined with SENS-111. All evaluated drugs were well tolerated.

CONCLUSIONS AND IMPLICATIONS

The exposure-efficacy relationship for improved spontaneous nystagmus seen with SENS-111 in this in vivo model is consistent with phase 1 clinical results and provides preclinical support for pharmacokinetic/pharmacodynamic modelling and selection of effective clinical drug concentrations.

LINKED ARTICLES

This article is part of a themed section on New Uses for 21st Century. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v177.3/issuetoc.

Dizziness handicap and clinical characteristics of posterior and lateral canal BPPV

PURPOSE

Benign paroxysmal positional vertigo (BPPV) is diagnosed and divided into subtypes based on positioning vertigo and nystagmus. Whether these subtypes entail any significant differences in patient-reported symptoms; is yet not known. Such differences may have clinical and therapeutic consequences. Our aim was to assess dizziness handicap and clinical characteristics of posterior and lateral canal BPPV.

METHODS

This prospective observational multicentre study analysed consecutive patients with BPPV, confirmed by standardized procedures including videonystagmography under diagnostic manoeuvres in a biaxial rotational chair. Patients were screened for other neurological and otological disorders.

OUTCOMES

Dizziness handicap inventory (DHI), posterior vs. lateral canal involvement.

FACTORS

age, gender, positional nystagmus intensity (maximum slow-phase velocity), symptom duration, 25-hydroxyvitamin D-level and traumatic aetiology.

RESULTS

132 patients aged 27-90 (mean 57, SD 13) years were included. Higher DHI scores were associated with lateral canal BPPV [95% CI (1.59-13.95), p = 0.01] and female gender [95% CI (0.74-15.52), p = 0.03]. Lateral canal BPPV was associated with longer symptom duration [OR 1.10, CI (1.03-1.17), p = 0.01] and lower 25-hydroxyvitamin D-levels [OR 0.80, CI (0.67-0.95), p = 0.03]. There was no correlation between DHI scores and nystagmus intensity.

CONCLUSIONS

This study suggests that patients with lateral canal BPPV have increased patient-perceived disability, lower vitamin D-levels and longer duration of symptoms. This subtype might therefore require closer follow-up. Patient-perceived disability is not related to positional nystagmus intensity.

Corticosteroids versus vestibular rehabilitation in long-term outcomes in vestibular neuritis

BACKGROUND:

The management strategy for functional recovery after vestibular neuritis (VN) has not yet been established. Therapeutic choices involve corticosteroids, vestibular rehabilitation therapy (VRT) and the combination of corticosteroids with VRT.

OBJECTIVE:

The present study aimed to compare the efficacy of corticosteroids, vestibular rehabilitation, and combination of them in terms of subjective and objective improvement in patients with VN.

METHODS:

A prospective randomized study was conducted on 60 patients with acute vestibular neuritis within 3 days after symptom onset. The patients were divided into three groups; steroid group treated with corticosteroids (n = 20), VRT group (n = 20) managed with vestibular rehabilitation exercises and combination group (n = 20) received combined (corticosteroids and vestibular exercises). Groups were compared by caloric lateralization, vestibular myogenic potential amplitude asymmetry and Dizziness Handicap Inventory scores, both at presentation and up to 12 months.

RESULTS:

The study found no statistically significant difference between the three groups of the study at the end of the follow up period.

CONCLUSION:

Corticosteroids and VRT seem to be equivalently effective in patients with VN. The study proposes that corticosteroids may accelerate the recovery of VN, with no more beneficial role in the long-term prognosis of the disease.