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Jaganathan N, Mohamed MH, Md Pauzi AL, Mahayidin H, Hanapai AF, Wan Sulaiman WA, Basri H, Inche Mat L. Video head impulse test in stroke: a review of published studies. Front Neurol 2024; 15:1339039. [PMID: 38497038 PMCID: PMC10940455 DOI: 10.3389/fneur.2024.1339039] [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: 11/15/2023] [Accepted: 02/19/2024] [Indexed: 03/19/2024] Open
Abstract
Accurate and timely diagnosis of posterior circulation stroke in patients with acute dizziness is a challenge that can lead to misdiagnosis and significant harm. The present review sought to identify and describe published research on the clinical application of vHIT in posterior circulation stroke. vHIT, a portable device, has gained prominence in evaluating peripheral vestibular disorders and offers potential applications in diagnosing neurological disorders, particularly posterior circulation stroke. Several studies have shown that vHIT can differentiate between stroke and vestibular neuritis based on VOR gain values, with high sensitivity and specificity. The manuscript also discusses vHIT's performance in differentiating between types of posterior circulation stroke, such as PICA, AICA, and SCA strokes. While vHIT has demonstrated promise, the review emphasizes the need for further research to validate its use as a tool to rule out stroke in acute dizziness patients in the emergency department. In conclusion, the manuscript underscores the potential of vHIT as a valuable addition to the diagnostic arsenal for acute dizziness, particularly in the context of posterior circulation stroke. It calls for further research and wider adoption of vHIT in clinical settings to improve patient care and reduce unnecessary costs associated with misdiagnoses.
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Affiliation(s)
- Niranjana Jaganathan
- Department of Neurology, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Selangor, Malaysia
| | - Mohd Hazmi Mohamed
- Department of Otorhinolaryngology, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Selangor, Malaysia
| | - Ahmad Luqman Md Pauzi
- Department of Emergency, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Selangor, Malaysia
| | - Hasni Mahayidin
- Department of Pathology, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Selangor, Malaysia
| | - Ahmad Firdaus Hanapai
- Department of Neurology, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Selangor, Malaysia
| | - Wan Aliaa Wan Sulaiman
- Department of Neurology, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Selangor, Malaysia
| | - Hamidon Basri
- Department of Neurology, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Selangor, Malaysia
| | - Liyana Inche Mat
- Department of Neurology, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Selangor, Malaysia
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Lee SH, Kim JM, Kim JT, Tarnutzer AA. Video head impulse testing in patients with isolated (hemi)nodular infarction. Front Neurol 2023; 14:1124217. [PMID: 36814996 PMCID: PMC9939438 DOI: 10.3389/fneur.2023.1124217] [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: 12/14/2022] [Accepted: 01/18/2023] [Indexed: 02/08/2023] Open
Abstract
Background Isolated (hemi)nodular strokes as underlying cause of acute dizziness are rare, thus there are still gaps of knowledge in the clinical presentation of affected patients. Clinical and experimental evidence has suggested that lesions involving the nodulus lead to various vestibulo-ocular deficits including prolonged velocity-storage, periodic-alternating nystagmus, positional nystagmus, abolished suppression of post-rotatory nystagmus by head-tilt and impaired verticality perception. At the bedside, the angular vestibulo-ocular reflex (aVOR), as assessed by the horizontal head-impulse test (HIT), has been reported to be normal, however quantitative assessments of all six semicircular canals are lacking. Objective The primary aim of this case series was to characterize the spectrum of clinical presentations in isolated (hemi)nodular strokes. Furthermore, based on preliminary observations, we hypothesized that the aVOR is within normal limits in isolated nodular strokes. Methods We retrospectively included patients with isolated (hemi)nodular stroke on diffusion-weighted MR-imaging from a prospective stroke-registry. All patients received a standardized bedside neuro-otological assessment and quantitative, video-based HIT (vHIT) of all six semicircular canals. Overall ratings of vHIT (normal vs. abnormal function) were performed independently by two reviewers and disagreements were resolved. Results Between January 2015 and December 2021 six patients with isolated nodular (n = 1) or heminodular (n = 5) ischemic stroke were included. Clinical presentation met diagnostic criteria for acute vestibular syndrome (AVS) in 5/6 patients and for episodic vestibular syndrome (EVS) in 1/6 patients. Ocular motor abnormalities observed included the presence of spontaneous horizontal nystagmus (n = 2), positional nystagmus (5/6), head-shaking nystagmus (3/6), skew deviation (n = 1), and moderate or severe truncal ataxia (5/6). Bedside HIT was normal in all patients and no gaze-evoked or periodic alternating nystagmus was observed. aVOR-gains were within normal range in all patients and overall aVOR-function as assessed by vHIT was rated as normal in all six patients. Conclusions Using quantitative, video-based testing of the horizontal and vertical aVOR, preserved integrity of the aVOR in (hemi)nodular strokes was confirmed, extending preliminary findings at the bedside. Furthermore, widespread deficits of both ocular stability, postural control and volitional eye movements were observed in our study cohort, being consistent with findings reported in previous studies.
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Affiliation(s)
- Seung-Han Lee
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Jae-Myung Kim
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Alexander Andrea Tarnutzer
- Department of Neurology, Cantonal Hospital, Baden, Switzerland,Faculty of Medicine, University of Zurich, Zurich, Switzerland,*Correspondence: Alexander Andrea Tarnutzer ✉
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Fracica E, Hale D, Gold DR. Diagnosing and localizing the acute vestibular syndrome - Beyond the HINTS exam. J Neurol Sci 2022; 442:120451. [PMID: 36270149 DOI: 10.1016/j.jns.2022.120451] [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: 06/20/2022] [Revised: 09/11/2022] [Accepted: 10/02/2022] [Indexed: 10/31/2022]
Abstract
When assessing the acutely dizzy patient, the HINTS 'Plus' (Head Impulse, Nystagmus, Test of Skew, 'Plus' a bedside assessment of auditory function) exam is a crucial component of the bedside exam. However, there are additional ocular motor findings that can help the clinician distinguish peripheral from central etiologies and enable accurate localization, especially when the patient has acute dizziness, vertigo and/or imbalance but without spontaneous nystagmus. We will review the literature on these findings which are 'beyond HINTS' and include saccades/ocular lateropulsion, smooth pursuit, and provocative maneuvers including head-shaking and positional testing (not part of the HINTS exam). Additionally, we will expound on the localizing value of nystagmus, ocular alignment and the ocular tilt reaction (parts of the HINTS exam). The paper has been organized neuroanatomically, based on brainstem and cerebellar structures that have been reported to cause the acute vestibular syndrome.
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Affiliation(s)
- Elizabeth Fracica
- The Johns Hopkins Hospital, Department of Neurology, United States of America.
| | - David Hale
- The Johns Hopkins Hospital, Department of Neurology, United States of America
| | - Daniel R Gold
- The Johns Hopkins Hospital, Department of Neurology, United States of America; The Johns Hopkins Hospital, Department of Neurology, Division of Neuro-Visual & Vestibular Disorders, United States of America
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Bery AK, Chang TP. Positive horizontal-canal head impulse test is not a benign sign for acute vestibular syndrome with hearing loss. Front Neurol 2022; 13:941909. [PMID: 36226090 PMCID: PMC9549073 DOI: 10.3389/fneur.2022.941909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 09/06/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundDiagnosis of acute vestibular syndrome (AVS) with hearing loss is challenging because the leading vascular cause—AICA territory stroke—can appear benign on head impulse testing. We evaluated the diagnostic utility of various bedside oculomotor tests to discriminate imaging-positive and imaging-negative cases of AVS plus hearing loss.MethodWe reviewed 13 consecutive inpatients with AVS and acute unilateral hearing loss. We compared neurologic findings, bedside and video head impulse testing (bHIT, vHIT), and other vestibular signs (including nystagmus, skew deviation, and positional testing) between MRI+ and MRI– cases.ResultsFive of thirteen patients had a lateral pontine lesion (i.e., MRI+); eight did not (i.e., MRI–). Horizontal-canal head impulse test showed ipsilateral vestibular loss in all five MRI+ patients but only in three MRI– patients. The ipsilesional VOR gains of horizontal-canal vHIT were significantly lower in the MRI+ than the MRI– group (0.56 ± 0.11 vs. 0.87 ± 0.24, p = 0.03). All 5 MRI+ patients had horizontal spontaneous nystagmus beating away from the lesion (5/5). One patient (1/5) had direction-changing nystagmus with gaze. Two had skew deviation (2/5). Among the 8 MRI– patients, one (1/8) presented as unilateral vestibulopathy, four (4/8) had positional nystagmus and three (3/8) had isolated posterior canal hypofunction.ConclusionThe horizontal-canal head impulse test poorly discriminates central and peripheral lesions when hearing loss accompanies AVS. Paradoxically, a lateral pontine lesion usually mimics unilateral peripheral vestibulopathy. By contrast, patients with peripheral lesions usually present with positional nystagmus or isolated posterior canal impairment, risking misdiagnosis as central vestibulopathy.
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Affiliation(s)
- Anand K. Bery
- Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Tzu-Pu Chang
- Department of Neurology/Neuro-Medical Scientific Center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- Department of Neurology, School of Medicine, Tzu Chi University, Hualien, Taiwan
- *Correspondence: Tzu-Pu Chang
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Lee S, Koo YJ, Kim HJ, Kim JS. Pseudo-reversed catch-up saccades during head impulses: a new cerebellar sign. J Neurol 2022; 269:5651-5654. [PMID: 35474391 DOI: 10.1007/s00415-022-11150-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/17/2022] [Accepted: 04/18/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Seonkyung Lee
- Dizziness Center, Clinical Neuroscience Center, Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, South Korea
| | - Yu Jin Koo
- Dizziness Center, Clinical Neuroscience Center, Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, South Korea
| | - Hyo-Jung Kim
- Research Administration Team, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Ji-Soo Kim
- Dizziness Center, Clinical Neuroscience Center, Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeonggi-do, 463-707, South Korea.
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea.
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Cabaraux P, Agrawal SK, Cai H, Calabro RS, Casali C, Damm L, Doss S, Habas C, Horn AKE, Ilg W, Louis ED, Mitoma H, Monaco V, Petracca M, Ranavolo A, Rao AK, Ruggieri S, Schirinzi T, Serrao M, Summa S, Strupp M, Surgent O, Synofzik M, Tao S, Terasi H, Torres-Russotto D, Travers B, Roper JA, Manto M. Consensus Paper: Ataxic Gait. CEREBELLUM (LONDON, ENGLAND) 2022; 22:394-430. [PMID: 35414041 DOI: 10.1007/s12311-022-01373-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/20/2022] [Indexed: 12/19/2022]
Abstract
The aim of this consensus paper is to discuss the roles of the cerebellum in human gait, as well as its assessment and therapy. Cerebellar vermis is critical for postural control. The cerebellum ensures the mapping of sensory information into temporally relevant motor commands. Mental imagery of gait involves intrinsically connected fronto-parietal networks comprising the cerebellum. Muscular activities in cerebellar patients show impaired timing of discharges, affecting the patterning of the synergies subserving locomotion. Ataxia of stance/gait is amongst the first cerebellar deficits in cerebellar disorders such as degenerative ataxias and is a disabling symptom with a high risk of falls. Prolonged discharges and increased muscle coactivation may be related to compensatory mechanisms and enhanced body sway, respectively. Essential tremor is frequently associated with mild gait ataxia. There is growing evidence for an important role of the cerebellar cortex in the pathogenesis of essential tremor. In multiple sclerosis, balance and gait are affected due to cerebellar and spinal cord involvement, as a result of disseminated demyelination and neurodegeneration impairing proprioception. In orthostatic tremor, patients often show mild-to-moderate limb and gait ataxia. The tremor generator is likely located in the posterior fossa. Tandem gait is impaired in the early stages of cerebellar disorders and may be particularly useful in the evaluation of pre-ataxic stages of progressive ataxias. Impaired inter-joint coordination and enhanced variability of gait temporal and kinetic parameters can be grasped by wearable devices such as accelerometers. Kinect is a promising low cost technology to obtain reliable measurements and remote assessments of gait. Deep learning methods are being developed in order to help clinicians in the diagnosis and decision-making process. Locomotor adaptation is impaired in cerebellar patients. Coordinative training aims to improve the coordinative strategy and foot placements across strides, cerebellar patients benefiting from intense rehabilitation therapies. Robotic training is a promising approach to complement conventional rehabilitation and neuromodulation of the cerebellum. Wearable dynamic orthoses represent a potential aid to assist gait. The panel of experts agree that the understanding of the cerebellar contribution to gait control will lead to a better management of cerebellar ataxias in general and will likely contribute to use gait parameters as robust biomarkers of future clinical trials.
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Affiliation(s)
- Pierre Cabaraux
- Unité Des Ataxies Cérébelleuses, Department of Neurology, CHU de Charleroi, Charleroi, Belgium.
| | | | - Huaying Cai
- Department of Neurology, Neuroscience Center, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310016, China
| | | | - Carlo Casali
- Department of Medico-Surgical Sciences and Biotechnologies, University of Rome Sapienza, Latina, Italy
| | - Loic Damm
- EuroMov Digital Health in Motion, Univ Montpellier, IMT Mines Ales, Montpellier, France
| | - Sarah Doss
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, USA
| | - Christophe Habas
- Université Versailles Saint-Quentin, Versailles, France.,Service de NeuroImagerie, Centre Hospitalier National des 15-20, Paris, France
| | - Anja K E Horn
- Institute of Anatomy and Cell Biology I, Ludwig Maximilians-University Munich, Munich, Germany
| | - Winfried Ilg
- Section Computational Sensomotorics, Hertie Institute for Clinical Brain Research, University Tübingen, Tübingen, Germany
| | - Elan D Louis
- Department of Neurology, University of Texas Southwestern, Dallas, TX, USA
| | - Hiroshi Mitoma
- Department of Medical Education, Tokyo Medical University, Tokyo, Japan
| | - Vito Monaco
- The BioRobotics Institute, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Maria Petracca
- Department of Human Neurosciences, University of Rome Sapienza, Rome, Italy
| | - Alberto Ranavolo
- Department of Occupational and Environmental Medicine, Epidemiology and Hygiene, INAIL, Monte Porzio Catone, Rome, Italy
| | - Ashwini K Rao
- Department of Rehabilitation & Regenerative Medicine (Programs in Physical Therapy), Gertrude H. Sergievsky Center, College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Serena Ruggieri
- Department of Human Neurosciences, University of Rome Sapienza, Rome, Italy.,Neuroimmunology Unit, IRCSS Fondazione Santa Lucia, Rome, Italy
| | - Tommaso Schirinzi
- Department of Systems Medicine, University of Roma Tor Vergata, Rome, Italy
| | - Mariano Serrao
- Department of Medico-Surgical Sciences and Biotechnologies, University of Rome Sapienza, Latina, Italy.,Movement Analysis LAB, Policlinico Italia, Rome, Italy
| | - Susanna Summa
- MARlab, Neuroscience and Neurorehabilitation Department, Bambino Gesù Children's Hospital - IRCCS, Rome, Italy
| | - Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, Hospital of the Ludwig Maximilians-University Munich, Munich, Germany
| | - Olivia Surgent
- Neuroscience Training Program and Waisman Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Matthis Synofzik
- Department of Neurodegeneration, Hertie Institute for Clinical Brain Research and Centre of Neurology, Tübingen, Germany
| | - Shuai Tao
- Dalian Key Laboratory of Smart Medical and Health, Dalian University, Dalian, 116622, China
| | - Hiroo Terasi
- Department of Neurology, Tokyo Medical University, Tokyo, Japan
| | - Diego Torres-Russotto
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, USA
| | - Brittany Travers
- Department of Kinesiology and Waisman Center, University of Wisconsin-Madison, Madison, WI, USA
| | - Jaimie A Roper
- School of Kinesiology, Auburn University, Auburn, AL, USA
| | - Mario Manto
- Unité Des Ataxies Cérébelleuses, Department of Neurology, CHU de Charleroi, Charleroi, Belgium.,Service Des Neurosciences, University of Mons, UMons, Mons, Belgium
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Kim JS, Newman-Toker DE, Kerber KA, Jahn K, Bertholon P, Waterston J, Lee H, Bisdorff A, Strupp M. Vascular vertigo and dizziness: Diagnostic criteria. J Vestib Res 2022; 32:205-222. [PMID: 35367974 PMCID: PMC9249306 DOI: 10.3233/ves-210169] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This paper presents diagnostic criteria for vascular vertigo and dizziness as formulated by the Committee for the Classification of Vestibular Disorders of the Bárány Society. The classification includes vertigo/dizziness due to stroke or transient ischemic attack as well as isolated labyrinthine infarction/hemorrhage, and vertebral artery compression syndrome. Vertigo and dizziness are among the most common symptoms of posterior circulation strokes. Vascular vertigo/dizziness may be acute and prolonged (≥24 hours) or transient (minutes to < 24 hours). Vascular vertigo/dizziness should be considered in patients who present with acute vestibular symptoms and additional central neurological symptoms and signs, including central HINTS signs (normal head-impulse test, direction-changing gaze-evoked nystagmus, or pronounced skew deviation), particularly in the presence of vascular risk factors. Isolated labyrinthine infarction does not have a confirmatory test, but should be considered in individuals at increased risk of stroke and can be presumed in cases of acute unilateral vestibular loss if accompanied or followed within 30 days by an ischemic stroke in the anterior inferior cerebellar artery territory. For diagnosis of vertebral artery compression syndrome, typical symptoms and signs in combination with imaging or sonographic documentation of vascular compromise are required.
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Affiliation(s)
- Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Kevin A Kerber
- Department of Neurology, University of Michigan Health System, Ann Arbor, USA
| | - Klaus Jahn
- Department of Neurology Schoen Clinic Bad Aibling and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
| | | | - John Waterston
- Monash Department of Neuroscience, Alfred Hospital, Melbourne, Australia
| | - Hyung Lee
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
| | - Alexandre Bisdorff
- Department of Neurology, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg
| | - Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
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Kim JG, Kim SH, Lee SU, Lee CN, Kim BJ, Kim JS, Park KW. Head-impulse tests aid in differentiation of multiple system atrophy from Parkinson's disease. J Neurol 2021; 269:2972-2979. [PMID: 34767067 DOI: 10.1007/s00415-021-10885-z] [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: 07/21/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 10/19/2022]
Abstract
The integrity of the vestibulo-ocular reflex (VOR) remains to be delineated in patients with parkinsonism. We aimed to define the findings of the VOR using head-impulse tests (HITs) and their differential diagnostic value in patients with Parkinson's disease (PD) and multiple system atrophy (MSA). From December 2019 to January 2021, 30 patients with PD and 23 patients with MSA (17 with cerebellar-type MSA and 6 with parkinsonian-type MSA) had a video-oculographic recording of HITs at two university hospitals in South Korea. Reversed (p = 0.034) and perverted (p = 0.015) catch-up saccades were more frequently observed in MSA than in PD during HITs. The gain difference between the ACs and the PCs were larger in MSA than in PD (p = 0.031), and positively correlated with the disease duration in patients with MSA (Spearman's coefficient = 0.512, p = 0.012). Multivariate logistic regression analysis showed that reversed (p = 0.044) and perverted (p = 0.039) catch-up saccades were more frequently associated with MSA than with PD during HITs. In conclusion, HITs aid in differentiation of MSA from PD, and may serve as a surrogate marker for the clinical decline.
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Affiliation(s)
- Jae-Gyum Kim
- Department of Neurology, Korea University Medical Center, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, South Korea
| | - Sung-Hwan Kim
- Department of Neurology, Korea University Medical Center, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, South Korea
| | - Sun-Uk Lee
- Department of Neurology, Korea University Medical Center, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, South Korea. .,Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea.
| | - Chan-Nyoung Lee
- Department of Neurology, Korea University Medical Center, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, South Korea
| | - Byung-Jo Kim
- Department of Neurology, Korea University Medical Center, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, South Korea.,BK21 FOUR Program in Learning Health Systems, Korea University, Seoul, South Korea
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea.,Dizziness Center, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Kun-Woo Park
- Department of Neurology, Korea University Medical Center, 73 Goryeodae-ro, Seongbuk-gu, Seoul, 02841, South Korea
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Choi JH, Oh EH, Choi SY, Kim HJ, Lee SK, Choi JY, Kim JS, Choi KD. Vestibular impairments in episodic ataxia type 2. J Neurol 2021; 269:2687-2695. [PMID: 34709445 DOI: 10.1007/s00415-021-10856-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 10/14/2021] [Accepted: 10/15/2021] [Indexed: 10/20/2022]
Abstract
Episodic ataxia type 2 (EA2) can present diverse ocular motor abnormalities, but few studies have systematically evaluated vestibular function during the interictal periods. This study aimed to determine vestibular impairments in patients with EA2 during the interictal periods. We recruited 17 patients with genetically confirmed EA2 (10 men, age range = 16-85 years, median = 32 years). We systematically evaluated the vestibular function by measuring the semicircular canals (SCCs) function with bithermal caloric tests, rotatory chair test, and video head impulse test (vHIT), and the otolith function with subjective visual vertical (SVV) tilt and variability, and cervical and ocular vestibular-evoked myogenic potentials (VEMPs). Patients with EA2 commonly showed abnormal VOR responses at least for one SCC with high-acceleration, high-frequency head impulses (14/16, 88%), and impaired visual-vestibular interaction (7/12, 58%). In response to low acceleration and frequency stimuli, the VOR gains were generally normal. The majority of EA2 patients had impairments in at least one of the otolith function tests (13/16, 81%): SVV tilt or variability (7/14, 50%), oVEMP (8/15, 53%), and cVEMP (4/16, 25%). Vestibular impairments are common in EA2 even during the interictal periods. Selective decrease in the VOR responses during higher acceleration stimuli along with impaired visual-vestibular interaction and otolith function suggests degeneration of the vestibulocerebellum or vestibular nuclei.
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Affiliation(s)
- Jae-Hwan Choi
- Department of Neurology, Pusan National University School of Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Eun Hye Oh
- Department of Neurology, Pusan National University School of Medicine, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Seo Young Choi
- Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, South Korea
| | - Hyo Jung Kim
- Research Administration Team, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Seon Kyung Lee
- Dizziness Center, Clinical Neuroscience Center, Department of Neurology, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea
| | - Jeong Yoon Choi
- Dizziness Center, Clinical Neuroscience Center, Department of Neurology, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea
| | - Ji-Soo Kim
- Dizziness Center, Clinical Neuroscience Center, Department of Neurology, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam, Gyeonggi-do, 13620, South Korea.
| | - Kwang-Dong Choi
- Department of Neurology, Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute, Busan, South Korea. .,Department of Neurology, College of Medicine, Pusan National University Hospital, 1-10 Ami-dong, Seo-gu, Busan, 49241, South Korea.
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Lee JWY, Hassannia F, Rutka JA. Contralesional High-Acceleration Vestibulo-Ocular Reflex Function in Vestibular Schwannoma. Otol Neurotol 2021; 42:e1106-e1110. [PMID: 34191780 DOI: 10.1097/mao.0000000000003207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Impairment of ipsilesional vestibulo-ocular reflex (VOR) function is well described in vestibular schwannoma (VS) and a correlation between gain of the VOR and tumor size has been suggested. Bilateral VOR impairment may also occur in VS patients, but its mechanisms are poorly understood. We sought to explore the effect of unilateral VS on ipsilesional and contralesional high-acceleration VOR function using video head impulse testing, and evaluate potential factors responsible for contralesional VOR impairment. MATERIALS AND METHODS Chart review in tertiary referral center of patients with unilateral VS, who completed neurotological examination and vestibular function testing. RESULTS One hundred one patients (mean age 57.4 yrs) were included. Maximal tumor diameter ranged from 0.3 to 5.0 cm. Forty one patients had evidence of brainstem compression from VS on magnetic resonance imaging (MRI). Ipsilesional and contralesional VOR impairment was present in 81 (80%) and 44 (43%) patients, respectively. Bilateral VOR impairment was seen in 42 (42%) patients. Bilateral VOR impairment correlated with tumor size. Presence of brainstem compression was associated with reduced ipsilesional VOR gain, but not contralesional VOR gain.
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Affiliation(s)
- Jennifer Wing Yee Lee
- Department of Otolaryngology-Head and Neck Surgery, University Health Network, Toronto, ON, Canada
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Yacovino DA, Zanotti E, Cherchi M. The spectrum of acute vestibular neuropathy through modern vestibular testing: A descriptive analysis. Clin Neurophysiol Pract 2021; 6:137-145. [PMID: 34013097 PMCID: PMC8113650 DOI: 10.1016/j.cnp.2021.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/02/2021] [Accepted: 02/24/2021] [Indexed: 02/07/2023] Open
Abstract
Video head impulse testing and vestibular evoked myogenic potentials show that acute vestibular neuropathy is heterogeneous. Peripheral vestibular pathway vulnerability is approximately inversely correlated with its proportion of afferent fibers. Caloric testing, while useful, should no longer be considered the gold standard for diagnosing acute vestibular neuropathy.
Objective Acute vestibular neuropathy (AVN), often referred to as vestibular neuritis, is a cranial neuropathy responsible for a significant proportion of cases of acute vertigo. This study describes the spectrum of lesion patterns in AVN as identified by video head impulse testing (vHIT) which assesses the high frequency vestibulo-ocular reflex function of the semicircular canals, and cervical and ocular vestibular evoked myogenic potentials (VEMPs) which assess otolith function. Methods We used vHIT and VEMPs to assess 35 patients with vestibular neuropathy in the acute stage. Results Unilateral superior division vestibular nerve involvement was the most common variant (57.1%), followed by unilateral superior and inferior division (28.5%), bilateral superior division (8.5%) and unilateral inferior division (5.7%). We observed a partial inverse correlation between the proportion of afferent fibers from an organelle, and the likelihood that the test of that organelle’s function will be abnormal. Conclusion vHIT and VEMPs provide more detailed characterization of lesion pattern in AVN than caloric testing. Significance Comparison of lesion patterns from neuro-physiological testing with what is known about the proportional distribution of afferent fibers from the vestibular end-organelles suggests a new, neuro-anatomically based insight regarding susceptibility of these pathways to AVN.
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Affiliation(s)
- Dario Andrés Yacovino
- Department of Neurology, Dr. Cesar Milstein Hospital, Buenos Aires, Argentina.,Memory and Balance Clinic, Buenos Aires, Argentina
| | - Estefanía Zanotti
- Department of Neurology, Dr. Cesar Milstein Hospital, Buenos Aires, Argentina
| | - Marcello Cherchi
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Chicago Dizziness and Hearing, Chicago, IL, USA
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Abstract
PURPOSE OF REVIEW To provide an update on diagnostic algorithms for differential diagnosis of acute vertigo and dizziness and swift identification of potentially harmful causes. RECENT FINDINGS About 25% of patients with acute vertigo and dizziness have a potentially life-threatening diagnosis, including stroke in 4-15%. Diagnostic work-up relies on the combination of symptom features (triggers, duration, history of vertigo/dizziness, accompanying symptoms) and a comprehensive vestibular, ocular motor, and balance exam. The latter includes head impulse, head-shaking nystagmus, positional nystagmus, gaze-holding, smooth pursuit, skew deviation, and Romberg's test. Recent standardized diagnostic algorithms (e.g., HINTS, TriAGe+) suggest the combination of several elements to achieve a good diagnostic accuracy in differentiation of central and peripheral vestibular causes. Neuroimaging with MRI must be applied and interpreted with caution, as small strokes are frequently overlooked, especially in the acute setting (false-negative rate of up to 50%). SUMMARY Diagnostic differentiation of acute vertigo and dizziness remains a complex task, which can be tackled by a structured clinical assessment focusing on symptom characteristics and constellations of ocular motor and vestibular findings. Specific challenges arise in cases of transient or atypical vestibular syndromes.
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Abstract
BACKGROUND AND PURPOSE The team that manages acute vertigo in patients requires multispecialty skills. This special interest article offers a simplified list of common pitfalls to be avoided when applying the HINTS (Head-Impulse, Nystagmus, Test-of-Skew) Plus examination protocol in patients with acute vertigo. Benign paroxysmal positional vertigo is the most frequent cause of positional vertigo. The lack of systematic evaluation of symptom duration and triggers, and/or incomplete target examination, leads to improper diagnosis and management. Pitfalls to avoid and pearls to apply are offered to avoid misclassification of acute vertigo. SUMMARY OF KEY POINTS Appropriate, expeditious treatment implemented upon diagnostic certainty by the first health professional evaluating the patient is key to a good outcome. The absence of a typical positional nystagmus is particularly concerning for an alternative diagnosis. Misclassification of the type of vertigo leads to potential diagnostic error. The HINTS Plus examination is useful when applied to the correct clinical scenario. The most common misclassification of vertigo relates to an inability to detect spontaneous nystagmus suppressed by visual fixation and subsequent classification and treatment for positional vertigo. The second most common classification relates to inadequate evaluation of the HINTS Plus examination. RECOMMENDATIONS FOR CLINICAL PRACTICE Through an organized evaluation of the acutely vertiginous patient, common pitfalls in the classification of vertigo can be avoided. Such an evaluation leads to identification of those patients who require canal repositioning maneuvers and those who need referral for evaluation of other causes.
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Lee SU, Kim JS, Kim HJ, Choi JY, Park JY, Kim JM, Yang X. Evolution of the vestibular function during head impulses in spinocerebellar ataxia type 6. J Neurol 2020; 267:1672-1678. [DOI: 10.1007/s00415-020-09756-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/06/2020] [Accepted: 02/08/2020] [Indexed: 12/19/2022]
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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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Abstract
PURPOSE OF REVIEW The current review covers recent advances in vascular vertigo in terms of diagnostic strategies, clinical/laboratory features, pathophysiology, and differential diagnosis. RECENT FINDINGS Acute strokes presenting with isolated dizziness/vertigo without other obvious symptoms or signs of central nervous system involvements may be easily mistaken as peripheral vestibulopathy. For correct diagnosis of vascular vertigo, the importance of clinical history (timing and triggers) and targeted bedside examination cannot be overemphasized. In addition to Head Impulse-Nystagmus-Test of Skew, several differential strategies have been advanced by adopting a combination of clinical history, bedside or laboratory examination, and imaging for diagnosis of vascular vertigo. Circumscribed cerebellar and brainstem lesions may cause isolated central vestibular syndromes with characteristic vestibular and ocular motor manifestations. Recognition of these findings would aid in localizing the lesions and understanding the function of each central vestibular structure. Central positional nystagmus (CPN) may mimic benign paroxysmal positional vertigo (BPPV), but additional oculomotor or neurological findings mostly permit differentiation of CPN from BPPV. SUMMARY In acute vestibular syndrome, discriminating vascular causes is still challenging especially when other central symptoms and signs are not evident. An integrated approach based on understanding of clinical features, laboratory findings, speculated mechanisms, and limitations of current diagnostic tests will lead to better clinical practice.
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Oh EH, Choi SY, Choi KD, Choi JH. Isolated tonsilar infarction presenting with positional vertigo and nystagmus. J Neurol 2019; 266:2578-2580. [DOI: 10.1007/s00415-019-09468-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/10/2019] [Accepted: 07/11/2019] [Indexed: 10/26/2022]
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Kattah JC. Use of HINTS in the acute vestibular syndrome. An Overview. Stroke Vasc Neurol 2018; 3:190-196. [PMID: 30637123 PMCID: PMC6312070 DOI: 10.1136/svn-2018-000160] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 05/18/2018] [Accepted: 05/24/2018] [Indexed: 01/10/2023] Open
Abstract
Following the initial description of HINTS to diagnose acute vestibular syndrome (AVS) in 2009, there has been significant interest in the systematic evaluation of HINTs to diagnose stroke and other less common central causes of AVS. This trend increased with availability of the video head impulse test (video-HIT). This article reviews the original papers and discusses the main publications from 2009 to 2017. Many authors use video-HIT in the diagnosis of patients with AVS; this paper focuses on the major publications on the topic featuring nystagmus, manual and video-HIT, and skew deviation. Twenty-five papers provide a summary of the last 8 years' application of HINTS, the video-HIT added quantitative information to the early clinical observations. Further research will undoubtedly provide specific combination of abnormalities with high degree of lesion localisation and aetiology. In a short time following the original description, neurotologist and neurologists in the evaluation of AVS use the HINTS triad. The introduction of the video-HIT added greater understanding of the complex interaction between the primary vestibular afferents, brainstem and cerebellum. In addition, it permits evaluation of the angular vestibulo-ocular reflex in the plane of all six semicircular canals, with accurate peripheral versus central lesion localisation often corroborated by brain imaging.
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Affiliation(s)
- Jorge C Kattah
- Department of Neurology, University of Illinois College of Medicine, Peoria, Illinois, USA
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Vascular vertigo: updates. J Neurol 2018; 266:1835-1843. [PMID: 30187161 DOI: 10.1007/s00415-018-9040-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/29/2018] [Accepted: 08/29/2018] [Indexed: 02/05/2023]
Abstract
Discriminating strokes in patients with acute dizziness/vertigo is challenging especially when other symptoms and signs of central nervous involvements are not evident. Despite the developments in imaging technology over the decades, a significant proportion of acute strokes may escape detection on imaging especially during the acute phase or when the lesions are small. Thus, small strokes causing isolated dizziness/vertigo would have a higher chance of misdiagnosis in the emergency department. Even though several diagnostic algorithms have been advanced for acute vascular vertigo, we still await more comprehensive and sophisticated ones that can also be applied to transient vestibular symptoms due to vascular compromise. In this respect, vascular and perfusion imaging would be informative. Application of artificial intelligence and tele-consultation may be future perspectives for real-time decision in acute dizziness and vertigo. Several new constellations of ocular motor and vestibular findings have been added to the strokes involving the brainstem and cerebellum. Defining these characteristics would help understanding the function of central vestibular structures and allow more accurate localization of the strokes involving these structures.
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Choi JY, Kim HJ, Kim JS. Recent advances in head impulse test findings in central vestibular disorders. Neurology 2018; 90:602-612. [PMID: 29490911 DOI: 10.1212/wnl.0000000000005206] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 01/02/2018] [Indexed: 11/15/2022] Open
Abstract
The head impulse test (HIT) is used to evaluate the vestibulo-ocular reflex (VOR) during a high-velocity head rotation. Corrective catch-up saccades that occur during or after the HITs usually indicate peripheral vestibular hypofunction, whereas in acute vestibular syndrome, normal clinical (bedside) HITs should prompt a search for a central lesion. However, recent quantitative studies that evaluated HITs using magnetic search coils or video-based techniques have demonstrated that specific patterns of HIT abnormalities are associated with central vestibular disorders. While normal clinical HITs are typical of central lesions, discrepancies have been observed between clinical and quantitative HITs. The horizontal head impulse VOR gains can be significantly reduced unilaterally or bilaterally (positive HITs) in lesions involving the vestibular nucleus, nucleus prepositus hypoglossi, or flocculus. In diffuse cerebellar lesions, the VOR gain during horizontal head impulses may increase (hyperactive) with corrective saccades directed the opposite way. The presence of cross-coupled vertical corrective saccades during horizontal HITs is also suggestive of diffuse cerebellar lesions. Lesions involving the vestibular nucleus, medial longitudinal fasciculus, and cerebellum may show decreased or increased gains of the VOR during vertical HITs. Defining the differences in patterns observed during abnormal HITs may help practitioners localize the responsible lesions in both central and peripheral vestibulopathy.
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Affiliation(s)
- Jeong-Yoon Choi
- From the Department of Neurology (J.-Y.C., J.-S.K.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam; and Research Administration Team (H.-J.K.), Seoul National University Bundang Hospital, Korea
| | - Hyo-Jung Kim
- From the Department of Neurology (J.-Y.C., J.-S.K.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam; and Research Administration Team (H.-J.K.), Seoul National University Bundang Hospital, Korea
| | - Ji-Soo Kim
- From the Department of Neurology (J.-Y.C., J.-S.K.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam; and Research Administration Team (H.-J.K.), Seoul National University Bundang Hospital, Korea.
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Zee DS. A neurologist and ataxia: using eye movements to learn about the cerebellum. CEREBELLUM & ATAXIAS 2018; 5:2. [PMID: 29445510 PMCID: PMC5804057 DOI: 10.1186/s40673-018-0081-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 01/25/2018] [Indexed: 11/22/2022]
Abstract
The cerebellum, its normal functions and its diseases, and especially its relation to the control of eye movements, has been at the heart of my academic career. Here I review how this came about, with an emphasis on epiphanies, "tipping points" and the influences of mentors, colleagues and trainees. I set a path for young academicians, both clinicians and basic scientists, with some guidelines for developing a productive and rewarding career in neuroscience.
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Affiliation(s)
- David S. Zee
- Departments of Neurology, Ophthalamology, Otolaryngology-Head and Neck Surgery, and Neuroscience, The Johns Hopkins University School of Medicine, The Johns Hopkins Hospital, Path 2-210, Baltimore, MD 21287 USA
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Zamergrad MV, Grachev SP, Gergova AA. Acute vestibular disorder in the elderly: stroke or peripheral vestibulopathy. Zh Nevrol Psikhiatr Im S S Korsakova 2018; 118:46-49. [DOI: 10.17116/jnevro201811806246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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