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Duvieusart B, Leung TS, Koohi N, Kaski D. Digital biomarkers from gaze tests for classification of central and peripheral lesions in acute vestibular syndrome. Front Neurol 2024; 15:1354041. [PMID: 38595848 PMCID: PMC11003708 DOI: 10.3389/fneur.2024.1354041] [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: 12/12/2023] [Accepted: 01/29/2024] [Indexed: 04/11/2024] Open
Abstract
Acute vestibular syndrome (AVS) is characterised by a sudden vertigo, gait instability, nausea and nystagmus. Accurate and rapid triage of patients with AVS to differentiate central (potentially sinister) from peripheral (usually benign) root causes is a challenge faced across emergency medicine settings. While there exist bedside exams which can reliably differentiate serious cases, they are underused due to clinicians' general unfamiliarity and low confidence interpreting results. Nystagmus is a fundamental part of AVS and can facilitate triaging, but identification of relevant characteristics requires expertise. This work presents two quantitative digital biomarkers from nystagmus analysis, which capture diagnostically-relevant information. The directionality biomarker evaluates changes in direction to differentiate spontaneous and gaze-evoked (direction-changing) nystagmus, while the intensity differential biomarker describes changes in intensity across eccentric gaze tests. In order to evaluate biomarkers, 24 sets of three gaze tests (left, right, and primary) are analysed. Both novel biomarkers were found to perform well, particularly directionality which was a perfect classifier. Generally, the biomarkers matched or eclipsed the performance of quantitative nystagmus features found in the literature. They also surpassed the performance of a support vector machine classifier trained on the same dataset, which achieved an accuracy of 75%. In conclusion, these biomarkers simplify the diagnostic process for non-specialist clinicians, bridging the gap between emergency care and specialist evaluation, ultimately benefiting patients with AVS.
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Affiliation(s)
- Benjamin Duvieusart
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
- SENSE Research Unit, Department of Clinical and Movement Neurosciences, University College London, London, United Kingdom
| | - Terence S. Leung
- Department of Medical Physics and Biomedical Engineering, University College London, London, United Kingdom
| | - Nehzat Koohi
- SENSE Research Unit, Department of Clinical and Movement Neurosciences, University College London, London, United Kingdom
| | - Diego Kaski
- SENSE Research Unit, Department of Clinical and Movement Neurosciences, University College London, London, United Kingdom
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Li X, Si L, Song N, Wu Y, Zhang M, Feng Y, Yang X. Characteristics and Possible Mechanisms of Direction-Reversing Nystagmus During Positional Testing in Patients With Benign Paroxysmal Positional Vertigo. Otol Neurotol 2023:00129492-990000000-00323. [PMID: 37400137 DOI: 10.1097/mao.0000000000003928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
OBJECTIVES The occurrence of direction-reversing nystagmus during positional testing in patients with benign paroxysmal positional vertigo (BPPV) is not uncommon. Further in-depth analysis of the characteristics and possible mechanisms of direction-reversing nystagmus will help us to diagnose and treat BPPV more precisely. The study aimed to analyze the incidence and characteristics of direction-reversing nystagmus during positional testing in BPPV patients, evaluate the outcomes of canalith repositioning procedure for these patients, and further explore the possible mechanism of reversal nystagmus in BPPV patients. STUDY DESIGN Retrospective study. SETTING Single-center study. PATIENTS A total of 575 patients with BPPV who visited the Vertigo Clinic of our hospital between April 2017 and June 2021 were enrolled. MAIN OUTCOME MEASURES Dix-Hallpike and supine roll tests were performed. The nystagmus was recorded using videonystagmography. The characteristics of direction-reversing nystagmus and the possible underlying mechanism were analyzed. RESULTS Patients with BPPV who showed reversal nystagmus accounted for 9.39% (54 of 575) of all BPPV patients visiting our hospital during the same period, of which 5.57% (32 of 575) had horizontal semicircular canal BPPV (HC-BPPV), and 3.83% (22 of 575) had posterior semicircular canal BPPV (PC-BPPV). The maximum slow-phase velocities (mSPVs) of the first-phase nystagmus were greater in HC-BPPV and PC-BPPV patients with reversal nystagmus than those without (p = 0.04 and p = 0.01, respectively). In all HC-BPPV and PC-BPPV patients with reversal nystagmus, the mSPV of the first-phase nystagmus was greater than that of the second-phase nystagmus (p < 0.01). The duration of the second-phase nystagmus was longer than 60 seconds in 93.75% (30 of 32) of the HC-BPPV patients and 77.27% (17 of 22) of the PC-BPPV patients (p = 0.107, Fisher exact test). HC-BPPV and PC-BPPV patients with reversal nystagmus both required more than one canalith repositioning procedure compared with those without (HC-BPPV: 75 versus 28.13%, p < 0.001; PC-BPPV: 59.09 versus 13.64%, p = 0.002). CONCLUSIONS The cause of second-phase nystagmus in BPPV patients with direction-reversing nystagmus may be related to the involvement of central adaptation mechanisms secondary to the overpowering mSPV of the first-phase nystagmus.
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Affiliation(s)
- Xiang Li
- Department of Neurology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, PR China
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Abstract
Aims of the present article are: 1) assessing vestibular contribution to spatial navigation, 2) exploring how age, global positioning systems (GPS) use, and vestibular navigation contribute to subjective sense of direction (SOD), 3) evaluating vestibular navigation in patients with lesions of the vestibular-cerebellum (patients with downbeat nystagmus, DBN) that could inform on the signals carried by vestibulo-cerebellar-cortical pathways. We applied two navigation tasks on a rotating chair in the dark: return-to-start (RTS), where subjects drive the chair back to the origin after discrete angular displacement stimuli (path reversal), and complete-the-circle (CTC) where subjects drive the chair on, all the way round to origin (path completion). We examined 24 normal controls (20-83 yr), five patients with DBN (62-77 yr) and, as proof of principle, two patients with early dementia (84 and 76 yr). We found a relationship between SOD, assessed by Santa Barbara Sense of Direction Scale, and subject's age (positive), GPS use (negative), and CTC-vestibular-navigation-task (positive). Age-related decline in vestibular navigation was observed with the RTS task but not with the complex CTC task. Vestibular navigation was normal in patients with vestibulo-cerebellar dysfunction but abnormal, particularly CTC, in the demented patients. We conclude that vestibular navigation skills contribute to the build-up of our SOD. Unexpectedly, perceived SOD in the elderly is not inferior, possibly explained by increased GPS use by the young. Preserved vestibular navigation in cerebellar patients suggests that ascending vestibular-cerebellar projections carry velocity (not position) signals. The abnormalities in the cognitively impaired patients suggest that their vestibulo-spatial navigation is disrupted.NEW & NOTEWORTHY Our subjective sense-of-direction is influenced by how good we are at spatial navigation using vestibular cues. Global positioning systems (GPS) may inhibit sense of direction. Increased use of GPS by the young may explain why the elderly's sense of direction is not worse than the young's. Patients with vestibulo-cerebellar dysfunction (downbeat nystagmus syndrome) display normal vestibular navigation, suggesting that ascending vestibulo-cerebellar-cortical pathways carry velocity rather than position signals. Pilot data indicate that dementia disrupts vestibular navigation.
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Affiliation(s)
- Athena Zachou
- Neuro-otology Unit, Department of Brain Sciences, Imperial College London, Charing Cross Hospital Campus, London, United Kingdom
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, Greece
| | - Adolfo M Bronstein
- Neuro-otology Unit, Department of Brain Sciences, Imperial College London, Charing Cross Hospital Campus, London, United Kingdom
- 1st Department of Neurology, Eginition Hospital, National and Kapodistrian University of Athens, Greece
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Strupp M, Bisdorff A, Furman J, Hornibrook J, Jahn K, Maire R, Newman-Toker D, Magnusson M. Acute unilateral vestibulopathy/vestibular neuritis: Diagnostic criteria. J Vestib Res 2022; 32:389-406. [PMID: 35723133 PMCID: PMC9661346 DOI: 10.3233/ves-220201] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This paper describes the diagnostic criteria for Acute Unilateral Vestibulopathy (AUVP), a synonym for vestibular neuritis, as defined by the Committee for the Classification of Vestibular Disorders of the Bárány Society. AUVP manifests as an acute vestibular syndrome due to an acute unilateral loss of peripheral vestibular function without evidence for acute central or acute audiological symptoms or signs. This implies that the diagnosis of AUVP is based on the patient history, bedside examination, and, if necessary, laboratory evaluation. The leading symptom is an acute or rarely subacute onset of spinning or non-spinning vertigo with unsteadiness, nausea/vomiting and/or oscillopsia. A leading clinical sign is a spontaneous peripheral vestibular nystagmus, which is direction-fixed and enhanced by removal of visual fixation with a trajectory appropriate to the semicircular canal afferents involved (generally horizontal-torsional). The diagnostic criteria were classified by the committee for four categories: 1. "Acute Unilateral Vestibulopathy", 2. "Acute Unilateral Vestibulopathy in Evolution", 3. "Probable Acute Unilateral Vestibulopathy" and 4. "History of Acute Unilateral Vestibulopathy". The specific diagnostic criteria for these are as follows:"Acute Unilateral Vestibulopathy": A) Acute or subacute onset of sustained spinning or non-spinning vertigo (i.e., an acute vestibular syndrome) of moderate to severe intensity with symptoms lasting for at least 24 hours. B) Spontaneous peripheral vestibular nystagmus with a trajectory appropriate to the semicircular canal afferents involved, generally horizontal-torsional, direction-fixed, and enhanced by removal of visual fixation. C) Unambiguous evidence of reduced VOR function on the side opposite the direction of the fast phase of the spontaneous nystagmus. D) No evidence for acute central neurological, otological or audiological symptoms. E) No acute central neurological signs, namely no central ocular motor or central vestibular signs, in particular no pronounced skew deviation, no gaze-evoked nystagmus, and no acute audiologic or otological signs. F) Not better accounted for by another disease or disorder."Acute Unilateral Vestibulopathy in Evolution": A) Acute or subacute onset of sustained spinning or non-spinning vertigo with continuous symptoms for more than 3 hours, but not yet lasting for at least 24 h hours, when patient is seen; B) - F) as above. This category is useful for diagnostic reasons to differentiate from acute central vestibular syndromes, to initiate specific treatments, and for research to include patients in clinical studies."Probable Acute Unilateral Vestibulopathy": Identical to AUVP except that the unilateral VOR deficit is not clearly observed or documented."History of acute unilateral vestibulopathy": A) History of acute or subacute onset of vertigo lasting at least 24 hours and slowly decreasing in intensity. B) No history of simultaneous acute audiological or central neurological symptoms. C) Unambiguous evidence of unilaterally reduced VOR function. D) No history of simultaneous acute central neurological signs, namely no central ocular motor or central vestibular signs and no acute audiological or otological signs. E) Not better accounted for by another disease or disorder. This category allows a diagnosis in patients presenting with a unilateral peripheral vestibular deficit and a history of an acute vestibular syndrome who are examined well after the acute phase.It is important to note that there is no definite test for AUVP. Therefore, its diagnosis requires the exclusion of central lesions as well as a variety of other peripheral vestibular disorders. Finally, this consensus paper will discuss other aspects of AUVP such as etiology, pathophysiology and laboratory examinations if they are directly relevant to the classification criteria.
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Affiliation(s)
- Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, Hospital of the Ludwig Maximilians University, Munich, Marchioninistrasse, Munich, Germany,Corresponding author: Michael Strupp, MD, FRCP, FAAN, FANA, FEAN, Dept. of Neurology and German Center for Vertigo and Balance Disorders, Hospital of the Ludwig Maximilians University, Munich, Marchioninistrasse 15, 81377 Munich, Germany. Tel.: +49 89 44007 3678; Fax: +49 89 44007 6673; E-mail:
| | - Alexandre Bisdorff
- Clinique du Vertige, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg
| | - Joseph Furman
- Department of Otolaryngology, Neurology, Bioengineering and Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeremy Hornibrook
- Departments of Otolaryngology - Head and Neck Surgery, Christchurch Hospital, University of Canterbury and University of Otago, Christchurch, New Zealand
| | - Klaus Jahn
- Department of Neurology, Schoen Clinic Bad Aibling, Bad Aibling, Germany and German Center for Vertigo and Balance Disorders, Ludwig-Maximilians University, Campus Grosshadern, Munich, Germany
| | - Raphael Maire
- Department of Otorhinolaryngology/Head & Neck Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - David Newman-Toker
- Ophthalmology, Otolaryngology and Emergency Medicine, The Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Måns Magnusson
- Department of Otorhinolaryngology, Lund University, Lund, Sweden
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Patel P, Castro P, Koohi N, Arshad Q, Gargallo L, Carmona S, Kaski D. Head shaking does not alter vestibulo ocular reflex gain in vestibular migraine. Front Neurol 2022; 13:967521. [PMID: 36247796 PMCID: PMC9561915 DOI: 10.3389/fneur.2022.967521] [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: 06/13/2022] [Accepted: 08/08/2022] [Indexed: 12/03/2022] Open
Abstract
Vestibular Migraine (VM) is the most common cause of non-positional episodic vestibular symptoms. Patients with VM commonly report increased motion sensitivity, suggesting that vestibular responses to head movement may identify changes specific to VM patients. Here we explore whether the vestibulo-ocular reflex (VOR) gain alters in response to a clinical “headshake” maneuver in patients with VM. Thirty patients with VM in the inter-ictal phase, 16 patients with Benign Positional Paroxysmal Vertigo (BPPV) and 15 healthy controls were recruited. Patients responded to the question “Do you feel sick reading in the passenger seat of a car?” and completed a validated motion sickness questionnaire as a measure of motion sensitivity. Lateral canal vHIT testing was performed before and after headshaking; the change in VOR gain was calculated as the primary outcome. Baseline VOR gain was within normal limits across all participants. There was no significant change in VOR gain after headshaking in any group (p = 0.264). Patients were 4.3 times more likely to be in the VM group than in the BPPV group if they reported nausea when reading in the passenger seat of a car. We postulate that a headshake stimulus may be insufficient to disrupt cortical interactions and induce a change in VOR gain. Alternatively, changes in VOR gain may only be apparent in the acute phase of VM. Reading in the passenger seat of a car was considered uncomfortable in all VM patients suggesting that this specific question may be useful for the diagnosis of VM.
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Affiliation(s)
- Priyani Patel
- Adult Diagnostic Audiology Department, University College London Hospitals, London, United Kingdom
- The Ear Institute, Faculty of Brain Sciences, University College London, London, United Kingdom
| | - Patricia Castro
- Adult Diagnostic Audiology Department, University College London Hospitals, London, United Kingdom
- Department of Brain Sciences, Imperial College London, London, United Kingdom
- Universidad del Desarrollo, Escuela de Fonoaudiologia, Facultad de Medicina Clinica Alemana, Santiago, Chile
| | - Nehzat Koohi
- The Ear Institute, Faculty of Brain Sciences, University College London, London, United Kingdom
- Department of Clinical and Movement Neurosciences, Centre for Vestibular and Behavioural Neuroscience, Institute of Neurology, University College London, London, United Kingdom
| | - Qadeer Arshad
- Department of Clinical and Movement Neurosciences, Centre for Vestibular and Behavioural Neuroscience, Institute of Neurology, University College London, London, United Kingdom
- inAmind Laboratory, Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, United Kingdom
| | - Lucia Gargallo
- Fundación San Lucas para la Neurociencia, Rosario, Argentina
- Cátedra Neurofisiología de la Universidad Nacional de Rosario, Rosario, Argentina
| | - Sergio Carmona
- Fundación San Lucas para la Neurociencia, Rosario, Argentina
- Cátedra Neurofisiología de la Universidad Nacional de Rosario, Rosario, Argentina
| | - Diego Kaski
- The Ear Institute, Faculty of Brain Sciences, University College London, London, United Kingdom
- Department of Clinical and Movement Neurosciences, Centre for Vestibular and Behavioural Neuroscience, Institute of Neurology, University College London, London, United Kingdom
- *Correspondence: Diego Kaski
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Kwon E, Lee JY, Song JM, Kim HJ, Lee JH, Choi JY, Kim JS. Impaired Duration Perception in Patients With Unilateral Vestibulopathy During Whole-Body Rotation. Front Integr Neurosci 2022; 16:818775. [PMID: 35719188 PMCID: PMC9204839 DOI: 10.3389/fnint.2022.818775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 04/22/2022] [Indexed: 12/03/2022] Open
Abstract
This study aimed to evaluate vestibular perception in patients with unilateral vestibulopathy. We recruited 14 patients (9 women, mean age = 59.3 ± 14.3) with unilateral vestibulopathy during the subacute or chronic stage (disease duration = 6 days to 25 years). For the evaluation of position perception, the patients had to estimate the position after whole-body rotation in the yaw plane. The velocity/acceleration perception was evaluated by acquiring decisions of patients regarding which direction would be the faster rotation after a pair of ipsi- and contra-lesional rotations at various velocity/acceleration settings. The duration perception was assessed by collecting decisions of patients for longer rotation directions at each pair of ipsi- and contra-lesional rotations with various velocities and amplitudes. Patients with unilateral vestibulopathy showed position estimates and velocity/acceleration discriminations comparable to healthy controls. However, in duration discrimination, patients had a contralesional bias such that they had a longer perception period for the healthy side during the equal duration and same amplitude rotations. For the complex duration task, where a longer duration was assigned to a smaller rotation amplitude, the precision was significantly lower in the patient group than in the control group. These results indicate persistent impairments of duration perception in unilateral vestibulopathy and favor the intrinsic and distributed timing mechanism of the vestibular system. Complex perceptual tasks may be helpful to disclose hidden perceptual disturbances in unilateral vestibular hypofunction.
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Affiliation(s)
- Eunjin Kwon
- Department of Neurology, Chungnam National University Hospital, Daejeon, South Korea
| | - Ju-Young Lee
- Department of Neurology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, South Korea
| | - Jung-Mi Song
- Research Administration Team, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Hyo-Jung Kim
- Research Administration Team, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jong-Hee Lee
- Dizziness Center, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jeong-Yoon Choi
- Dizziness Center, Seoul National University Bundang Hospital, Seongnam-si, South Korea
- Department of Neurology, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seoul, South Korea
- Department of Neurology, Seoul National University College of Medicine, Seongnam-si, South Korea
- *Correspondence: Jeong-Yoon Choi,
| | - Ji-Soo Kim
- Dizziness Center, Seoul National University Bundang Hospital, Seongnam-si, South Korea
- Department of Neurology, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seoul, South Korea
- Department of Neurology, Seoul National University College of Medicine, Seongnam-si, South Korea
- Ji-Soo Kim,
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The clinical application of head-shaking test combined with head-shaking tilt suppression test in distinguishing between peripheral and central vertigo at bedside vs. examination room. Braz J Otorhinolaryngol 2022; 88 Suppl 3:S177-S184. [DOI: 10.1016/j.bjorl.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/20/2022] [Indexed: 11/23/2022] Open
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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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Hyperactive and cross-coupled head impulse signs in recurrent strokes: clinical signs of global cerebellar dysfunction. J Neurol 2021; 269:1698-1700. [PMID: 34608520 DOI: 10.1007/s00415-021-10827-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 09/25/2021] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
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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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Choi SY, Lee MJ, Oh EH, Choi JH, Choi KD. Short-Term Central Adaptation in Benign Paroxysmal Positional Vertigo. Front Neurol 2020; 11:260. [PMID: 32373046 PMCID: PMC7186433 DOI: 10.3389/fneur.2020.00260] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 03/20/2020] [Indexed: 11/14/2022] Open
Abstract
Objective: To elucidate the frequency, underlying mechanisms, and clinical implications of spontaneous reversal of positional nystagmus (SRPN) in benign paroxysmal positional vertigo (BPPV). Methods: We prospectively recruited 182 patients with posterior canal (PC, n = 119) and horizontal canal (HC) BPPV (n = 63) canalolithiasis. We analyzed the maximal slow phase velocity (maxSPV), duration, and time constant (Tc) of positional nystagmus, and compared the measures between groups with and without SRPN. We also compared the treatment outcome between two groups. Results: The frequency of SRPN in PC- and HC-BPPV was 47 and 68%, respectively. The maxSPVs were greater in BPPV with SRPN than without, larger in HC-BPPV than PC-BPPV (114.3 ± 56.8 vs. 57.1 ± 38.1°/s, p < 0.001). The reversed nystagmus last longer in HC-BPPV than PC-BPPV. The Tc of positional nystagmus got shorter in PC-BPPV with SRPN (3.7 ± 1.8 s) than without SRPN (4.5 ± 2.0 s, p = 0.034), while it was longer during contralesional head turning in HC-BPPV with SRPN (14.8 ± 7.5 s) than that of ipsilesional side (7.3 ±2.8 s, p < 0.001). The treatment response did not significantly differ between groups with and without SRPN in both PC- and HC-BPPV (p = 0.378 and p = 0.737, respectively). Conclusion: The SRPN is common in both PC- and HC-BPPV canalolithiasis. The intensity of rotational stimuli may be a major determinant for the development of short-term central adaptation which utilizes the velocity-storage system below a certain velocity limit. The presence of SRPN is not related to treatment outcome in BPPV.
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Affiliation(s)
- Seo-Young Choi
- Department of Neurology, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Myung-Jun Lee
- Department of Neurology, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, 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
| | - 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
| | - Kwang-Dong Choi
- Department of Neurology, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
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Kim K, Kim HJ, Choi JY, Liqun Z, Yang X, Kim JS. Cerebellar tuberculous granuloma mimicking benign paroxysmal positional vertigo: progression after initial misdiagnosis. J Neurol 2019; 266:2581-2583. [PMID: 31321516 DOI: 10.1007/s00415-019-09478-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/15/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Kitae Kim
- Department of Neurology, Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hyo-Jung Kim
- Research Administration Team, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jeong-Yoon Choi
- Department of Neurology, Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, Korea, 13620, South Korea
| | - Zhong Liqun
- Department of Neurology, Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine, Beijing, People's Republic of China
| | - Xu Yang
- Department of Neurology, Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Peking, People's Republic of China
| | - Ji-Soo Kim
- Department of Neurology, Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea. .,Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam-si, Gyeonggi-do, Korea, 13620, South Korea.
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Abstract
The acute vestibular syndrome (AVS) is characterized by the rapid onset of vertigo, nausea/vomiting, nystagmus, unsteady gait, and head motion intolerance lasting more than 24 hours. We present 4 patients with AVS to illustrate the pearls and pitfalls of the Head Impulse, Nystagmus, Test of Skew (HINTS) examination.
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Choi JY, Glasauer S, Kim JH, Zee DS, Kim JS. Characteristics and mechanism of apogeotropic central positional nystagmus. Brain 2019; 141:762-775. [PMID: 29373699 DOI: 10.1093/brain/awx381] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 11/23/2017] [Indexed: 11/12/2022] Open
Abstract
Here we characterize persistent apogeotropic type of central positional nystagmus, and compare it with the apogeotropic nystagmus of benign paroxysmal positional vertigo involving the lateral canal. Nystagmus was recorded in 27 patients with apogeotropic type of central positional nystagmus (22 with unilateral and five with diffuse cerebellar lesions) and 20 patients with apogeotropic nystagmus of benign paroxysmal positional vertigo. They were tested while sitting, while supine with the head straight back, and in the right and left ear-down positions. The intensity of spontaneous nystagmus was similar while sitting and supine in apogeotropic type of central positional nystagmus, but greater when supine in apogeotropic nystagmus of benign paroxysmal positional vertigo. In central positional nystagmus, when due to a focal pathology, the lesions mostly overlapped in the vestibulocerebellum (nodulus, uvula, and tonsil). We suggest a mechanism for apogeotropic type of central positional nystagmus based on the location of lesions and a model that uses the velocity-storage mechanism. During both tilt and translation, the otolith organs can relay the same gravito-inertial acceleration signal. This inherent ambiguity can be resolved by a 'tilt-estimator circuit' in which information from the semicircular canals about head rotation is combined with otolith information about linear acceleration through the velocity-storage mechanism. An example of how this mechanism works in normal subjects is the sustained horizontal nystagmus that is produced when a normal subject is rotated at a constant speed around an axis that is tilted away from the true vertical (off-vertical axis rotation). We propose that when the tilt-estimator circuit malfunctions, for example, with lesions in the vestibulocerebellum, the estimate of the direction of gravity is erroneously biased away from true vertical. If the bias is toward the nose, when the head is turned to the side while supine, there will be sustained, unwanted, horizontal positional nystagmus (apogeotropic type of central positional nystagmus) because of an inappropriate feedback signal indicating that the head is rotating when it is not.
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Affiliation(s)
- Jeong-Yoon Choi
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Stefan Glasauer
- Center for Sensorimotor Research, Department of Neurology, Ludwig-Maximilian University Munich, Munich, Germany.,German Center for Vertigo and Balance Disorders, Ludwig-Maximilian University Munich, Munich, Germany
| | - Ji Hyun Kim
- Department of Neurology, Korea University College of Medicine, Korea University Guro Hospital, Seoul, Korea
| | - David S Zee
- Departments of Neurology, Ophthalmology, Otolaryngology - Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Choi JY, Kim JS. Central positional nystagmus: Characteristics and model-based explanations. PROGRESS IN BRAIN RESEARCH 2019; 249:211-225. [PMID: 31325981 DOI: 10.1016/bs.pbr.2019.04.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
The central vestibular system operates to precisely estimate the rotational velocity and gravity orientation using the inherently ambiguous information from peripheral vestibular system. Therefore, any lesions disrupting this function can generate positional nystagmus. Central positional nystagmus (CPN) can be classified into the paroxysmal (transient) and persistent forms. The paroxysmal CPN has the features suggesting a semicircular canal origin regarding the latency, duration, and direction of nystagmus. Patients with paroxysmal CPN commonly show several different types of nystagmus classified according to the provoking positioning. The persistent form of CPN mostly appears as downbeat nystagmus while prone or supine, or apogeotropic or geotropic horizontal nystagmus when the head is turned to either side while supine. CPN may be ascribed to erroneous neural processing within the velocity-storage circuit that functions in estimating angular head velocity, gravity direction, and inertia. Paroxysmal CPN appears to be post-rotatory rebound nystagmus due to lesions involving the cerebellar nodulus and uvula. In contrast, persistent CPN may arise from erroneous gravity estimation. The overlap of lesion location responsible for both paroxysmal and persistent CPN may account for the frequent coexistence of both forms of nystagmus in a single patient.
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Affiliation(s)
- Jeong-Yoon Choi
- Department of Neurology, Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Ji-Soo Kim
- Department of Neurology, Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, South Korea; Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea.
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16
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Abstract
Dizziness can be due to pathology from multiple physiologic systems, the most common being vestibular. Dizziness may be categorized as vertigo, disequilibrium, lightheadedness, or oscillopsia. Vertigo is an illusion of motion often caused by asymmetrical vestibular input to the brainstem. To evaluate vertigo, it is essential to include the symptom's quality, timing, frequency, trigger, influence from positional changes, and other associations from the history. Oculomotor, otologic, balance testing, positional testing, and nystagmus testing are equally important components of the examination. Two of the most common diagnoses are readily treated with canalith repositioning maneuvers and vestibular rehabilitation exercises.
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Affiliation(s)
- Sharmeen Sorathia
- Ziauddin University College of Medicine, 4/B, Shahrah-e-Ghalib, Block 6, Clifton, Karachi 75600, Pakistan; Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287, USA
| | - Yuri Agrawal
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287, USA
| | - Michael C Schubert
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287, USA; Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287, 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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Abstract
PURPOSE OF REVIEW This review considers recent advances in central vertigo in terms of clinical and laboratory features and pathophysiology. RECENT FINDINGS Strokes presenting dizziness-vertigo are more likely to be associated with a misdiagnosis in the emergency setting. The risk of future strokes after discharge is higher in patients diagnosed with peripheral vertigo than in control patients. Strokes and transient ischemic attacks account for one-quarter of acute transient vestibular syndrome. Diagnosis of acute combined central and peripheral vestibulopathy such as anterior inferior cerebellar artery infarction requires additional consideration whenever applying the HINTS (head impulse test, direction-changing gaze-evoked nystagmus, and test of skew). Heat illness and metronidazole have been recognized as new causes of central vestibulopathy. Some new findings have also been added to the clinical and laboratory features of central vertigo. SUMMARY Central vertigo is a heterogeneous group of disorders with diverse clinical spectrums. 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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Lee SU, Choi JY, Kim HJ, Kim JS. Recurrent spontaneous vertigo with interictal headshaking nystagmus. Neurology 2018; 90:e2135-e2145. [DOI: 10.1212/wnl.0000000000005689] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Accepted: 03/21/2018] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo define a disorder characterized by recurrent spontaneous vertigo (RSV) of unknown etiology and interictal headshaking nystagmus (HSN).MethodsWe characterized HSN in 35 patients with RSV-HSN compared to that recorded in randomly selected patients with compensated vestibular neuritis (VN), vestibular migraine (VM), and Ménière disease (MD).ResultsThe estimated time constant (TC) of the primary phase of HSN was 12 seconds (95% confidence interval [CI] 12–13) in patients with RSV-HSN, which was larger than those in patients with VN (5 seconds, 95% CI 4–5), VM (5 seconds, 95% CI 5–6), or MD (6 seconds, 95% CI 5–6). TCs of the horizontal vestibulo-ocular reflex were also larger during the rotatory chair test in patients with RSV-HSN. Among the 35 patients with RSV-HSN, 7 showed vigorous long-lasting HSN with a peak slow-phase velocity >50.0°/s. In 5 patients (5 of 7, 71%) with vigorous HSN, HSN could have been induced even with headshaking for only 2 to 5 seconds. Long-term prognosis was favorable, with a resolution or improvement of the symptoms in more than half of the patients during the median follow-up of 12 (range 2–58) years from symptom onset. None developed VM, MD, or cerebellar dysfunction during the follow-up.ConclusionThe clinical features and characteristics of HSN in our patients indicate a hyperactive and asymmetric velocity-storage mechanism that gives rise to intermittent attacks of spontaneous vertigo probably when marginal compensation of underlying pathology is disrupted by endogenous or exogenous factors.
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Consensus Paper: Neurophysiological Assessments of Ataxias in Daily Practice. THE CEREBELLUM 2018; 17:628-653. [DOI: 10.1007/s12311-018-0937-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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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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Walther LE. Current diagnostic procedures for diagnosing vertigo and dizziness. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2017; 16:Doc02. [PMID: 29279722 PMCID: PMC5738933 DOI: 10.3205/cto000141] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Vertigo is a multisensory syndrome that otolaryngologists are confronted with every day. With regard to the complex functions of the sense of orientation, vertigo is considered today as a disorder of the sense of direction, a disturbed spatial perception of the body. Beside the frequent classical syndromes for which vertigo is the leading symptom (e.g. positional vertigo, vestibular neuritis, Menière’s disease), vertigo may occur as main or accompanying symptom of a multitude of ENT-related diseases involving the inner ear. It also concerns for example acute and chronic viral or bacterial infections of the ear with serous or bacterial labyrinthitis, disorders due to injury (e.g. barotrauma, fracture of the oto-base, contusion of the labyrinth), chronic-inflammatory bone processes as well as inner ear affections in the perioperative course. In the last years, diagnostics of vertigo have experienced a paradigm shift due to new diagnostic possibilities. In the diagnostics of emergency cases, peripheral and central disorders of vertigo (acute vestibular syndrome) may be differentiated with simple algorithms. The introduction of modern vestibular test procedures (video head impulse test, vestibular evoked myogenic potentials) in the clinical practice led to new diagnostic options that for the first time allow a complex objective assessment of all components of the vestibular organ with relatively low effort. Combined with established methods, a frequency-specific assessment of the function of vestibular reflexes is possible. New classifications allow a clinically better differentiation of vertigo syndromes. Modern radiological procedures such as for example intratympanic gadolinium application for Menière’s disease with visualization of an endolymphatic hydrops also influence current medical standards. Recent methodical developments significantly contributed to the possibilities that nowadays vertigo can be better and more quickly clarified in particular in otolaryngology.
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Kim SH, Kim HJ, Kim JS. Isolated vestibular syndromes due to brainstem and cerebellar lesions. J Neurol 2017; 264:63-69. [DOI: 10.1007/s00415-017-8455-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 03/09/2017] [Accepted: 03/11/2017] [Indexed: 11/28/2022]
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