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Martellucci S, Castellucci A, Malara P, Mandalà M. Cerebellar Cavernous Angioma With Symptomatic Hemorrhage Mimicking Different Sequential Peripheral Vestibular Disorders. J Clin Neurol 2024; 20:339-341. [PMID: 38713079 PMCID: PMC11076198 DOI: 10.3988/jcn.2023.0437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 11/17/2023] [Accepted: 12/05/2023] [Indexed: 05/08/2024] Open
Affiliation(s)
- Salvatore Martellucci
- Department of Surgical Science, ENT Unit, Santa Maria Goretti Hospital, Latina, Italy.
| | - Andrea Castellucci
- ENT Unit, Department of Surgery, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Pasquale Malara
- Audiology & Vestibology Service, Centromedico, Bellinzona, Switzerland
| | - Marco Mandalà
- Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
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Michailidou E, Korda A, Wyss T, Bardins S, Schneider E, Morrison M, Wagner F, Caversaccio MD, Mantokoudis G. The value of saccade metrics and VOR gain in detecting a vestibular stroke. J Vestib Res 2024; 34:49-61. [PMID: 38160379 DOI: 10.3233/ves-230083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVE A normal video Head Impulse Test is the gold standard in the emergency department to rule-in patients with an acute vestibular syndrome and a stroke. We aimed to compare the diagnostic accuracy of vHIT metrics regarding the vestibulo-ocular reflex gain and the corrective saccades in detecting vestibular strokes. METHODS Prospective cross-sectional study (convenience sample) of patients presenting with acute vestibular syndrome in the emergency department of a tertiary referral centre between February 2015 and May 2020. We screened 1677 patients and enrolled 76 patients fulfilling the inclusion criteria of acute vestibular syndrome. All patients underwent video head impulse test with automated and manual data analysis. A delayed MRI served as a gold standard for vestibular stroke confirmation. RESULTS Out of 76 patients, 52 were diagnosed with acute unilateral vestibulopathy and 24 with vestibular strokes. The overall accuracy of detecting stroke with an automated vestibulo-ocular reflex gain was 86.8%, compared to 77.6% for cumulative saccade amplitude and automatic saccade mean peak velocity measured by an expert and 71% for cumulative saccade amplitude and saccade mean peak velocity measured automatically. Gain misclassified 13.1% of the patients as false positive or false negative, manual cumulative saccade amplitude and saccade mean peak velocity 22.3%, and automated cumulative saccade amplitude and saccade mean peak velocity 28.9% respectively. CONCLUSIONS We found a better accuracy of video head impulse test for the diagnosis of vestibular strokes when using the vestibulo-ocular reflex gain than using saccade metrics. Nevertheless, saccades provide an additional and important information for video head impulse test evaluation. The automated saccade detection algorithm is not yet perfect compared to expert analysis, but it may become a valuable tool for future non-expert video head impulse test evaluations.
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Affiliation(s)
- Efterpi Michailidou
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Thomas Wyss
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Stanislav Bardins
- Institute of Medical Technology, Brandenburg University of Technology Cottbus - Senftenberg, Cottbus, Germany
| | - Erich Schneider
- Institute of Medical Technology, Brandenburg University of Technology Cottbus - Senftenberg, Cottbus, Germany
| | - Miranda Morrison
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Franca Wagner
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marco D Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
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Tarnutzer AA, Gold D, Wang Z, Robinson KA, Kattah JC, Mantokoudis G, Tehrani ASS, Zee DS, Edlow JA, Newman-Toker DE. Impact of Clinician Training Background and Stroke Location on Bedside Diagnostic Test Accuracy in the Acute Vestibular Syndrome - A Meta-Analysis. Ann Neurol 2023; 94:295-308. [PMID: 37038843 PMCID: PMC10524166 DOI: 10.1002/ana.26661] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/24/2023] [Accepted: 03/30/2023] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Acute dizziness/vertigo is usually due to benign inner-ear causes but is occasionally due to dangerous neurologic ones, particularly stroke. Because symptoms and signs overlap, misdiagnosis is frequent and overuse of neuroimaging is common. We assessed the accuracy of bedside findings to differentiate peripheral vestibular from central neurologic causes. METHODS We performed a systematic search (MEDLINE and Embase) to identify studies reporting on diagnostic accuracy of physical examination in adults with acute, prolonged dizziness/vertigo ("acute vestibular syndrome" [AVS]). Diagnostic test properties were calculated for findings. Results were stratified by examiner type and stroke location. RESULTS We identified 6,089 citations and included 14 articles representing 10 study cohorts (n = 800). The Head Impulse, Nystagmus, Test of Skew (HINTS) eye movement battery had high sensitivity 95.3% (95% confidence interval [CI] = 92.5-98.1) and specificity 92.6% (95% CI = 88.6-96.5). Sensitivity was similar by examiner type (subspecialists 94.3% [95% CI = 88.2-100.0] vs non-subspecialists 95.0% [95% CI = 91.2-98.9], p = 0.55), but specificity was higher among subspecialists (97.6% [95% CI = 94.9-100.0] vs 89.1% [95% CI = 83.0-95.2], p = 0.007). HINTS sensitivity was lower in anterior cerebellar artery (AICA) than posterior inferior cerebellar artery (PICA) strokes (84.0% [95% CI = 65.3-93.6] vs 97.7% [95% CI = 93.3-99.2], p = 0.014) but was "rescued" by the addition of bedside hearing tests (HINTS+). Severe (grade 3) gait/truncal instability had high specificity 99.2% (95% CI = 97.8-100.0) but low sensitivity 35.8% (95% CI = 5.2-66.5). Early magnetic resonance imaging (MRI)-diffusion-weighted imaging (DWI; within 24-48 hours) was falsely negative in 15% of strokes (sensitivity 85.1% [95% CI = 79.2-91.0]). INTERPRETATION In AVS, HINTS examination by appropriately trained clinicians can differentiate peripheral from central causes and has higher diagnostic accuracy for stroke than MRI-DWI in the first 24-48 hours. These techniques should be disseminated to all clinicians evaluating dizziness/vertigo. ANN NEUROL 2023;94:295-308.
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Affiliation(s)
- Alexander A. Tarnutzer
- Neurology, Cantonal Hospital of Baden, Baden, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Daniel Gold
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD
| | - Zheyu Wang
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine
- Johns Hopkins Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD
| | - Karen A. Robinson
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD
| | | | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ali S. Saber Tehrani
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD
| | - David S. Zee
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD
| | - Jonathan A. Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - David E. Newman-Toker
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD
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Wang W, Ji J, Wang C, Wang Y. Topography and etiologies of cerebellar infarcts presenting as isolated acute vestibular syndrome. Neurol Sci 2022; 43:5969-5976. [DOI: 10.1007/s10072-022-06249-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 06/28/2022] [Indexed: 11/28/2022]
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Vestibular Autorotation Test: The Differences in Peripheral and Central Acute Vestibular Syndrome. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:8180013. [PMID: 35996402 PMCID: PMC9392635 DOI: 10.1155/2022/8180013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/21/2022] [Accepted: 06/27/2022] [Indexed: 11/17/2022]
Abstract
Objective To evaluate the difference between the vestibular autorotation test (VAT) in the peripheral and central acute vestibular syndrome (AVS). Methodology. Patients with AVS diagnosed by clinical manifestation admitted to the third affiliated hospital of Qiqihar Medical College from January 2019 to January 2021 were enrolled and divided into peripheral AVS (peripheral group) and central AVS (central group) according to the results of the MRI examination. Results A total of 332 patients with AVS were recruited, including 282 patients in the peripheral group and 50 patients in the central group. The horizontal gain of both groups showed a downward trend at 2–6 Hz. There was no significant change in the horizontal phase between the two groups at 2–6 Hz. The horizontal gain of the two groups was stable at 2–6 Hz with no significant changes in the horizontal phase between 2–6 Hz in both groups. The central group showed a significantly lower proportion of gain increase coupled with loss and a strikingly higher proportion of gain increase without a loss than in the peripheral group (all P < 0.001). Conclusion The increased horizontal and vertical gain of VAT in patients with AVS is of high value in the diagnosis of ACS. Significant differences in the results of VAT in patients with central and peripheral AVS could provide a reference for diagnosis.
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Araki K, Takeuchi R, Katada F, Fukutake T. Rotatory Vertigo Caused by a Small Hemorrhage in the Superior Temporal Gyrus. Intern Med 2020; 59:3067-3069. [PMID: 32759590 PMCID: PMC7759698 DOI: 10.2169/internalmedicine.5112-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Rotatory vertigo is known to have not only peripheral causes, e.g., Meniere's disease, vestibular neuritis, and benign paroxysmal positional vertigo, but also central causes, e.g., stroke, hemorrhage, and tumor. In most cases, central rotatory vertigo is caused by a lesion in the brainstem or cerebellum, but rare cases with a cerebral lesion have also been reported. We herin describe a unique case with acute rotatory vertigo following a small hemorrhage in the left superior temporal gyrus, which probably led to a dysfunction of the visual-vestibular system.
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Comolli L, Goeldlin M, Gaschen J, Kammer C, Sauter TC, Caversaccio MD, Kalla R, Fischer U, Mantokoudis G. [Dizziness and vertigo in a tertiary ENT emergency department]. HNO 2020; 68:763-772. [PMID: 32221628 DOI: 10.1007/s00106-020-00857-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Although vestibular symptoms are amongst the most frequent reasons for seeking emergency medical help, many patients remain undiagnosed. OBJECTIVE In this cross-sectional study, we investigated the spectrum of vertigo and dizziness in a tertiary ear, nose, and throat (ENT) emergency department (ED). Furthermore, we investigated the attendant symptoms, clinical signs, and the diagnostic tests performed. METHODS We screened all ED reports from 01/2013 to 12/2013 for adult patients with vestibular symptoms referred to the ENT department. RESULTS In total, we found 2596 cases with reported vestibular symptoms in the ED as a main or accompanying complaint. Of these, 286 were referred to the ENT specialist directly (n = 98) or via other major medical specialties (n = 188). Benign paroxysmal positional vertigo (BPPV) was the most frequent diagnosis in our study (n = 46, 16.1%), followed by vestibular neuritis (n = 44, 15.4%), otitis media (n = 20, 7%), and 9 patients (3.1%) had an ischemic stroke or a transient ischemic attack. In 70 (24.5%) cases, dizziness was not further specified. CONCLUSION BPPV is the most frequent diagnosis seen in the ED; however, physicians need to document nystagmus more precisely and perform diagnostic tests systematically, in order to make an accurate diagnosis. To avoid misdiagnoses, ED physicians and ENT specialists should be able to recognize central signs in patients with an acute vestibular syndrome. Every fourth patient does not receive a definitive diagnosis. Diagnostic ED workup for patients with dizziness needs further improvement.
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Affiliation(s)
- L Comolli
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Schweiz
| | - M Goeldlin
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Schweiz
| | - J Gaschen
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Schweiz
| | - C Kammer
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Schweiz
| | - T C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Schweiz
| | - M D Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Schweiz
| | - R Kalla
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Schweiz
| | - U Fischer
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Schweiz
| | - G Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Schweiz.
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Cerebellar infarction presenting with isolated positional vertigo: differentiating factors for benign paroxysmal positional vertigo. Neurol Sci 2020; 42:1045-1052. [PMID: 32725450 DOI: 10.1007/s10072-020-04617-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Accepted: 07/19/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Isolated central positional vertigo (CPV) due to cerebellar infarction is often difficult to differentiate from benign paroxysmal positional vertigo (BPPV). Here, we aimed to evaluate whether vascular risk factors and serum vitamin D level can differentiate between positional vertigo types. METHODS A total of 78 consecutive patients were consecutively enrolled from January 2017. All CPV patients had a National Institutes of Health Stroke Scale score of 0 and cerebellar infarctions confirmed by brain MR imaging. Vascular risk factors and serum 25-hydroxyvitamin D levels were compared between the two groups of patients. RESULTS The proportion of men was higher in the CPV than in the BPPV group (p = 0.004). Atrial fibrillation was common in the CPV group on univariate analysis (p = 0.046). However, there were no independent differentiating factors between the two groups. The proportion of patients according to the number of risk factors was significantly different between the two groups (linear by linear association test, p = 0.02). The mean serum 25-hydroxyvitamin D level did not differ. Also, the proportions of vitamin D insufficiency and deficiency did not differ significantly between the two groups. CONCLUSIONS Increased number of vascular risk factors including male sex suggested more CPV than BPPV. However, the serum vitamin D level was below the normal range in both groups. Our results demonstrate that serum vitamin D level has little value in the differential diagnosis of positional vertigo. Efforts to identify differentiating factors are warranted, and accumulating evidences including our research may lead to a diagnostic algorithm for isolated positional vertigo.
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Ataç C, Kısabay A, Çetin Akkoç C, Saruhan G, Çelebisoy N. Vestibular nuclear infarction: Case series and review of the literature. J Stroke Cerebrovasc Dis 2020; 29:104937. [PMID: 32689600 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104937] [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: 02/24/2020] [Revised: 04/15/2020] [Accepted: 05/03/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND AND PURPOSE Acute vestibular syndrome (AVS) is a common cause of emergency admittance and has very rarely been reported due to a vestibular nucleus infarction. Initial magnetic resonance imaging studies (MRIs) including diffusion-weighted images may reveal normal results and even bedside examination tests like HINTS battery which involves head impulse test (HIT), nystagmus and test of skew can be challenging in differing a peripheral vestibulopathy from a central lesion. METHODS Four patients seen in the emergency department with AVS and evaluated with HINTS battery, cervical vestibular-evoked myogenic potentials (cVEMP) and cranial MRI revealing infarcts restricted to vestibular nuclei were evaluated. RESULTS In two patients spontaneous nystagmus beating towards the unaffected side was present. In one patient spontaneous nystagmus changed direction on looking to the affected side. In the fourth gaze evoked nystagmus was present without any spontaneous nystagmus. In all, HIT was positive to the affected side. In three cVEMPs was studied revealing delayed latency, reduced amplitude p13/n23 potentials on the lesioned side in two of them. Initial MRIs including diffusion-weighted images disclosed acute infarction in the area of the vestibular nuclei in two patients, with normal results in the other two. Follow-up MRI's performed 48 hours later revealed vestibular nuclear infarction. CONCLUSION It is not always easy to differentiate small lesions restricted to central vestibular structures from peripheral vestibular lesions both on clinical and radiological grounds. Follow-up cranial MRI is necessary in patients with known vascular risk factors.
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Affiliation(s)
- Ceyla Ataç
- Ceyla Ataç, Izmir Bozyaka Egitim ve Arastirma Hastanesi, Neurology, 35360 İzmir, Ege, Turkey.
| | - Ayşın Kısabay
- Ceyla Ataç, Izmir Bozyaka Egitim ve Arastirma Hastanesi, Neurology, 35360 İzmir, Ege, Turkey
| | - Ceren Çetin Akkoç
- Ceyla Ataç, Izmir Bozyaka Egitim ve Arastirma Hastanesi, Neurology, 35360 İzmir, Ege, Turkey
| | - Gülsüm Saruhan
- Ceyla Ataç, Izmir Bozyaka Egitim ve Arastirma Hastanesi, Neurology, 35360 İzmir, Ege, Turkey
| | - Neşe Çelebisoy
- Ceyla Ataç, Izmir Bozyaka Egitim ve Arastirma Hastanesi, Neurology, 35360 İzmir, Ege, Turkey
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Calic Z, Nham B, Bradshaw AP, Young AS, Bhaskar S, D'Souza M, Anderson CS, Cappelen-Smith C, Cordato D, Welgampola MS. Separating posterior-circulation stroke from vestibular neuritis with quantitative vestibular testing. Clin Neurophysiol 2020; 131:2047-2055. [PMID: 32600960 DOI: 10.1016/j.clinph.2020.04.173] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 03/25/2020] [Accepted: 04/26/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To separate vestibular neuritis (VN) from posteriorcirculation stroke (PCS) using quantitative tests of canal and otolith function. METHODS Video Head-Impulse tests (vHIT) were used to assess all three semicircular canal pairs; vestibulo-ocular reflex (VOR) gain and saccade metrics were examined. Cervical and ocular-Vestibular-Evoked Myogenic Potentials (c- and oVEMP) and Subjective Visual Horizontal (SVH) were used to assess otolith function. RESULTS For controls (n = 40), PCS (n = 22), and VN (n = 22), mean horizontal-canal VOR-gains were 0.96 ± 0.1, 0.85 ± 0.3 and 0.40 ± 0.2, refixation-saccade prevalence was 71.9 ± 41, 90.7 ± 57, 209.2 ± 62 per 100 impulses and cumulative-saccade amplitudes were 0.9 ± 0.4°, 2.4 ± 2.2°, 8.0 ± 3.5°. Abnormality-rates for cVEMP, oVEMP and SVH were 38%, 9%, 72% for PCS, and 43%, 50%, 91% for VN. A gain ≤0.68, refixation-saccade prevalence of ≥135% and cumulative-saccade amplitudes ≥5.3° separated VN from PCS with sensitivities of 95.5%, 95.5%, and 81.8%, and specificities of 68.2%, 86.4% and 95.5%. VOR-gain and saccade prevalence when combined, separated VN from PCS with a sensitivity and specificity of 90.9%. Abnormal oVEMP asymmetry-ratios were of low sensitivity (50%) but high specificity (90.9%) for separating VN from PCS. CONCLUSION vHIT provided the best separation of VN from PCS. VOR-gain, refixation-saccade prevalence and amplitude were effective discriminators of VN from PCS. SIGNIFICANCE vHIT and oVEMP could assist early identification of the aetiology of Acute Vestibular Syndrome in the Emergency Room.
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Affiliation(s)
- Zeljka Calic
- Department of Neurophysiology, Liverpool Hospital, Liverpool, NSW, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Benjamin Nham
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Central Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Andrew P Bradshaw
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Central Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Allison S Young
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Central Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Sonu Bhaskar
- Department of Neurophysiology, Liverpool Hospital, Liverpool, NSW, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Mario D'Souza
- Clinical Research Centre, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Craig S Anderson
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Cecilia Cappelen-Smith
- Department of Neurophysiology, Liverpool Hospital, Liverpool, NSW, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Dennis Cordato
- Department of Neurophysiology, Liverpool Hospital, Liverpool, NSW, Australia; South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia; Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Miriam S Welgampola
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Central Clinical School, University of Sydney, Sydney, NSW, Australia.
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Tong D, Chen X, Wang Y, Wang Y, Du L, Bao J. Acute and episodic vestibular syndromes caused by ischemic stroke: predilection sites and risk factors. J Int Med Res 2020; 48:300060520918039. [PMID: 32326788 PMCID: PMC7218482 DOI: 10.1177/0300060520918039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective This study was performed to investigate the predilection sites of acute vestibular syndrome (AVS) and episodic vestibular syndrome (EVS) caused by acute infarcts. Methods This retrospective cohort study was performed at a stroke center in a tertiary teaching hospital. We diagnosed patients with AVS/EVS caused by acute ischemic stroke using diffusion-weighted imaging (DWI) and magnetic resonance angiography. Results Among all patients with AVS/EVS, 68 had DWI-positive ischemic events and 113 had DWI-negative ischemic events. Of the 68 patients with positive DWI findings, 42.6% had acute infarcts in the anterior circulation and 41.2% had acute infarcts in the posterior circulation. The main stroke predilection sites were the insular cortex (22.1%) and posterior thalamus (11.8%). Large vessel stenosis/occlusion (odds ratio, 0.12; 95% confidence interval, 0.04–0.36) and focal neurological symptoms/signs (odds ratio, 0.27; 95% confidence interval, 0.10–0.72) were significantly associated with the risk of AVS/EVS in patients with acute ischemic stroke. Conclusions The main predilection sites of AVS/EVS caused by ischemic stroke are the insular cortex and posterior thalamus. The risk of AVS/EVS is associated with large vessel stenosis and focal symptoms.
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Affiliation(s)
- DaoMing Tong
- Department of Neurology, the Affiliated Shuyang Hospital, Xuzhou Medical University, Xuzhou, China
| | - XiaoDong Chen
- Department of Neurology, the Suqian First Hospital, Suqian, China
| | - YuanWei Wang
- Department of Neurology, the Affiliated Shuyang Hospital, Xuzhou Medical University, Xuzhou, China
| | - Ying Wang
- Department of Neurology, the Affiliated Shuyang Hospital, Xuzhou Medical University, Xuzhou, China
| | - Li Du
- Department of Neurology, the Affiliated Shuyang Hospital, Xuzhou Medical University, Xuzhou, China
| | - JunJie Bao
- Department of Neurology, the Affiliated Shuyang Hospital, Xuzhou Medical University, Xuzhou, China
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Dao-Ming T, Ye-Ting Z. Acute dizziness with potential life-threatening event: A case series from single ICU. J Vestib Res 2019; 29:191-196. [PMID: 31561400 DOI: 10.3233/ves-190677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Whether the acute dizziness would be associated with potentially life-threatening event, which was previously unknown. METHODS Between Jan 2014 and Dec 2016, We performed a retrospective survey to investigate the clinical data of patients with acute dizziness from an intensive care unit (ICU) in China. Inclusion criteria for all cases were presented with acute dizziness at onset, and then with a potentially life-threatening event. Baseline data and 30-days outcomes were collected. RESULTS Approximately 1.0% of ICU patients had an acute dizziness with potentially life-threatening events. The median age of patients was 60 years (range 23 to 81 years), male: female ratio was 1.8:1. The causes of acute dizziness included focal cerebral hemorrhage in 15 cases (60%), shock in 7cases (28%), and cerebral infarction in 3 cases (12%). The most frequent potentially life-threatening event was acute brain failure (24/25), and the most common cause leading to brain failure was the lesion enlarged (54.2%, including hematoma enlargement in 8 cases, large area infarction or new infarction in 3 cases, and intraventricular hemorrhage in 2 cases). The second potentially life-threatening event was septic shock/secondary sepsis (45.8%). The fatality rate for all life- threatening events was in 64%. Compared with the survival group, the patients with lesion enlarged (56.3% vs. 11.1%, p < 0.05), acute respiratory failure (93.8% vs. 55.6% p < 0.05), lactate level (5.3 mmol/l vs. 1.3 mmol/l, p < 0.05), and Sequential Organ Failure Assessment (SOFA) score (6.9 vs. 3.4, p < 0.0001) in the non-survival group were significantly higher, while late mean arterial blood pressure (84.6 mmHg vs.124 mmHg, p < 0.0001), GCS score (5.0 score vs. 15 score, p < 0.0001) in the non-survival group were significantly lower. CONCLUSION Acute dizziness with potentially life-threatening events accounts for about 1% of adult ICU patients. Acute dizziness in ICU patients is associated with a high risk of death within 30 days of onset.
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Affiliation(s)
- Tong Dao-Ming
- Department of Neurology, Affiliated Shuyang Hospital, Xuzhou Medical University, Jiangsu, China
| | - Zhou Ye-Ting
- Department of Clinical Research, Affiliated Shuyang Hospital, Xuzhou Medical University, Jiangsu, China
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Usui M, Mashiko T, Tsuda M, Suzuki M, Matsuzono K, Ozawa T, Kim Y, Shimazaki H, Koide R, Tanaka R, Fujimoto S. Repetitive Episodic Isolated Vertigo in a Patient with Cerebellar Infarction. J Stroke Cerebrovasc Dis 2019; 28:e98-e99. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.03.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 03/17/2019] [Accepted: 03/31/2019] [Indexed: 10/27/2022] Open
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Lee SA, Lee ES, Kim BG, Lee TK, Sung KB, Hwang K, Lee JD. Acute vestibular asymmetry disorder: a new disease entity in acute vestibular syndrome? Acta Otolaryngol 2019; 139:511-516. [PMID: 31035836 DOI: 10.1080/00016489.2019.1599142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Acute vestibular syndrome (AVS) is characterized by the rapid onset of vertigo, nausea, vomiting and gait unsteadiness, which lasts for days. AIMS/OBJECTIVES We report cases as acute vestibular asymmetry disorder (AVAD), with presentations that mimic vestibular neuritis (VN) but without central lesions. MATERIALS AND METHODS We retrospectively reviewed records of patients presenting with acute spontaneous vertigo lasting more than 24 h from January 2011 to June 2016. Among 341 patients, five showed different findings that did not indicate either VN or stroke. We analyzed the clinical features and vestibular assessments of these patients. RESULTS All five patients showed spontaneous nystagmus continuing for several days. However, head impulse tests (HITs) did not reveal a corrective saccade. Brain magnetic resonance imaging showed no abnormal lesions. The bithermal caloric test revealed directional preponderance without canal paresis. Finally, the slow harmonic test of the rotatory chair revealed unilateral high gain and phase within the normal range, but a significantly asymmetric response was observed. No patients showed recurrence during follow-up. CONCLUSIONS AND SIGNIFICANCE Our study suggests that a normal HIT in AVS is not always a dangerous sign indicating an acute stroke. From our observations, we propose that AVAD would be a new disease entity within AVS.
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Affiliation(s)
- Se A. Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Eek-Sung Lee
- Department of Neurology, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Bo Gyung Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Tae-Kyeong Lee
- Department of Neurology, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Ki-Bum Sung
- Department of Neurology, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
| | - Kyurin Hwang
- Department of Otorhinolaryngology-Head and Neck Surgery, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Jong Dae Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Soonchunhyang University College of Medicine, Bucheon, Republic of Korea
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Lee SJ, Lee SA, Kim BG, Hong HS, Lee JY, Lee JD. Feasibility of magnetic resonance imaging in the differential diagnosis of isolated acute audiovestibular loss. J Vestib Res 2019; 28:385-391. [DOI: 10.3233/ves-190649] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Seung Jae Lee
- Department of Otorhinolaryngology – Head and Neck Surgery, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Se A Lee
- Department of Otorhinolaryngology – Head and Neck Surgery, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Bo Gyung Kim
- Department of Otorhinolaryngology – Head and Neck Surgery, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Hyun Sook Hong
- Department of Radiology, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Ji Ye Lee
- Department of Radiology, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jong Dae Lee
- Department of Otorhinolaryngology – Head and Neck Surgery, Soonchunhyang University College of Medicine, Bucheon, Korea
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Guler A, Karbek Akarca F, Eraslan C, Tarhan C, Bilgen C, Kirazli T, Celebisoy N. Clinical and video head impulse test in the diagnosis of posterior circulation stroke presenting as acute vestibular syndrome in the emergency department. J Vestib Res 2018; 27:233-242. [PMID: 29081427 DOI: 10.3233/ves-170620] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Head impulse test (HIT) is the critical bedside examination which differentiates vestibular neuritis (VN) from posterior circulation stroke (PCS) in acute vestibular syndrome (AVS). Video-oculography based HIT (vHIT) may have aadditional strength in making the differentiation. METHODS Patients admitted to the emergency department of a tertiary-care medical center with AVS were studied. An emergency specialist and a neurologist performed HIT. vHIT was conducted by an neuro-otology research fellow. RESULTS Forty patients 26 male, 14 female with a mean age of 49 years were included in the analyses. Final diagnoses were VN in 24 and PCS in 16 patients.In the VN group, clinical HIT was assessed as abnormal in 19(80%) cases by the emergency specialist and in 20(83%) by the neurologist. In all PCS patients, HIT was recorded as normal both by the emergency specialist and the neurologist (100%).On vHIT, patients with VN had significantly low gain values for both the ipsilesional and contralesional sides when compared with the healthy controls, with significantly lower figures for the ipsilesional side (p < 0.001). All patients in this group had normal DWI-MRI.PCS patients had bilaterally low gain (p < 0.05) on vHIT. However, gain asymmetry was not significant. Subgroup analyses according to presence of brainstem involvement revealed bilateral low gain (p < 0.05) in patients with brainstem infarction (anterior inferior cerebellar artery-posterior inferior cerebellar artery stroke, AICA-PICA stroke) whereas patients with pure cerebellar infarction (posterior inferior cerebellar artery-superior cerebellar artery stroke, PICA-SCA stroke) had gain values similar to healthy controls.With a gain cut-off ≤0.75 and gain asymmetry cut-off ≥17%, as determined by ROC analysis, 100% of PCS patients and 80% of VN patients were correctly diagnosed. CONCLUSIONS Clinical HIT, either performed by an emergency specialist or neurologist is equivalent to vHIT gain and gain asymmetry analysis as conducted by neuro-otologist in the diagnosis of PCS, albeit mislabeling about 20% of VN patients. vHIT does not appear to yield additional diagnostic information. These findings indicate the strength of clinical HIT. Pure gain-based vHIT analysis seems limited and needs to be incorporated with saccade analysis.
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Affiliation(s)
- Ayse Guler
- Department of Neurology, Ege University School of Medicine, Bornova, Izmir, Turkey
| | - Funda Karbek Akarca
- Department of Emergency, Ege University School of Medicine, Bornova, Izmir, Turkey
| | - Cenk Eraslan
- Department of Radiology, Ege University School of Medicine, Bornova, Izmir, Turkey
| | - Ceyda Tarhan
- Department of Otorhinolaryngology, Ege University School of Medicine, Bornova, Izmir, Turkey
| | - Cem Bilgen
- Department of Otorhinolaryngology, Ege University School of Medicine, Bornova, Izmir, Turkey
| | - Tayfun Kirazli
- Department of Otorhinolaryngology, Ege University School of Medicine, Bornova, Izmir, Turkey
| | - Nese Celebisoy
- Department of Neurology, Ege University School of Medicine, Bornova, Izmir, Turkey
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Kim HA, Yi HA, Lee H. Recent Advances in Cerebellar Ischemic Stroke Syndromes Causing Vertigo and Hearing Loss. THE CEREBELLUM 2017; 15:781-788. [PMID: 26573627 DOI: 10.1007/s12311-015-0745-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Cerebellar ischemic stroke is one of the common causes of vascular vertigo. It usually accompanies other neurological symptoms or signs, but a small infarct in the cerebellum can present with vertigo without other localizing symptoms. Approximately 11 % of the patients with isolated cerebellar infarction simulated acute peripheral vestibulopathy, and most patients had an infarct in the territory of the medial branch of the posterior inferior cerebellar artery (PICA). A head impulse test can differentiate acute isolated vertigo associated with PICA territory cerebellar infarction from more benign disorders involving the inner ear. Acute hearing loss (AHL) of a vascular cause is mostly associated with cerebellar infarction in the territory of the anterior inferior cerebellar artery (AICA), but PICA territory cerebellar infarction rarely causes AHL. To date, at least eight subgroups of AICA territory infarction have been identified according to the pattern of neurotological presentations, among which the most common pattern of audiovestibular dysfunction is the combined loss of auditory and vestibular functions. Sometimes acute isolated audiovestibular loss can be the initial symptom of impending posterior circulation ischemic stroke (particularly within the territory of the AICA). Audiovestibular loss from cerebellar infarction has a good long-term outcome than previously thought. Approximately half of patients with superior cerebellar artery territory (SCA) cerebellar infarction experienced true vertigo, suggesting that the vertigo and nystagmus in the SCA territory cerebellar infarctions are more common than previously thought. In this article, recent findings on clinical features of vertigo and hearing loss from cerebellar ischemic stroke syndrome are summarized.
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Affiliation(s)
- Hyun-Ah Kim
- Department of Neurology, School of Medicine, Keimyung University, 56 Dalseong-ro, Jung-gu, Daegu, 700-712, Republic of Korea.,Brain Research Institute, School of Medicine, Keimyung University, Daegu, Republic of Korea
| | - Hyon-Ah Yi
- Department of Neurology, School of Medicine, Keimyung University, 56 Dalseong-ro, Jung-gu, Daegu, 700-712, Republic of Korea.,Brain Research Institute, School of Medicine, Keimyung University, Daegu, Republic of Korea
| | - Hyung Lee
- Department of Neurology, School of Medicine, Keimyung University, 56 Dalseong-ro, Jung-gu, Daegu, 700-712, Republic of Korea. .,Brain Research Institute, School of Medicine, Keimyung University, Daegu, Republic of Korea.
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Wang MY, Liu YS, Li K, Liu YJ, Wang F. Protective effect of the microcatheter placed at the normal vertebral artery in intracranial stent-assisted angioplasty for vertebral artery stenosis: A case report. Medicine (Baltimore) 2017; 96:e7569. [PMID: 28723788 PMCID: PMC5521928 DOI: 10.1097/md.0000000000007569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE A carefully designed intracranial stent-assisted angioplasty (SAA) is presented here that may prevent subsequent branch artery occlusion. PATIENT CONCERNS A 72-year-old man with a 3-month history of progressive and intermittent vertigo without any obvious trigger, accompanied by nausea. DIAGNOSES Intracranial atherosclerotic disease. INTERVENTIONS the patient underwent intracranial SAA in accordance with the procedure described here. OUTCOMES The patient's paroxysmal vertigo completely subsided, with no complications during the short-term follow-up. LESSONS This novel intracranial SAA procedure is safe and may reduce the risk of subsequent artery occlusion.
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Abstract
The incidence of vertigo in the population is 20% to 30% and one-fourth of the cases are related to central causes. The aim of this study was to evaluate computed tomography angiography (CTA) findings of the vertebrobasilar system in central vertigo without stroke.CTA and magnetic resonance images of patients with vertigo were retrospectively evaluated. One hundred twenty-nine patients suspected of having central vertigo according to history, physical examination, and otological and neurological tests without signs of infarction on diffusion-weighted magnetic resonance imaging were included in the study. The control group included 120 patients with similar vascular disease risk factors but without vertigo. Vertebral and basilar artery diameters, hypoplasias, exit-site variations of vertebral artery, vertebrobasilar tortuosity, and stenosis of ≥50% detected on CTA were recorded for all patients. Independent-samples t test was used in variables with normal distribution, and Mann-Whitney U test in non-normal distribution. The difference of categorical variable distribution according to groups was analyzed with χ and/or Fisher exact test.Vertebral artery hypoplasia and ≥50% stenosis were seen more often in the vertigo group (P = 0.000, <0.001). Overall 78 (60.5%) vertigo patients had ≥50% stenosis, 54 (69.2%) had stenosis at V1 segment, 9 (11.5%) at V2 segment, 2 (2.5%) at V3 segment, and 13 (16.6%) at V4 segment. Both vertigo and control groups had similar basilar artery hypoplasia and ≥50% stenosis rates (P = 0.800, >0.05).CTA may be helpful to clarify the association between abnormal CTA findings of vertebral arteries and central vertigo.This article reveals the opportunity to diagnose posterior circulation abnormalities causing central vertigo with a feasible method such as CTA.
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20
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Hsieh LC, Lin HC, Lee GS. Saccadic entropy of head impulses in acute unilateral vestibular loss. J Formos Med Assoc 2016; 116:790-797. [PMID: 28012675 DOI: 10.1016/j.jfma.2016.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 11/09/2016] [Accepted: 11/24/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND/PURPOSE To evaluate the complexity of vestibular-ocular reflex (VOR) in patients with acute unilateral vestibular loss (AUVL) via entropy analysis of head impulses. METHODS Horizontal head impulse test (HIT) with high-velocity alternating directions was used to evaluate 12 participants with AUVL and 16 healthy volunteers. Wireless electro-oculography and electronic gyrometry were used to acquire eye positional signals and head velocity signals. The eye velocity signals were then obtained through differentiation, band-pass filtering. The approximate entropy of eye velocity to head velocity (RApEn) was used to evaluate chaos property. VOR gain, gain asymmetry ratio, and RApEn asymmetry ratio were also used to compare the groups. RESULTS For the lesion-side HIT of the patient group, the mean VOR gain was significantly lower and the mean RApEn was significantly greater compared with both nonlesion-side HIT and healthy controls (p < 0.01, one-way analysis of variance). Both the RApEn asymmetry ratio and gain asymmetry ratio of the AUVL group were significantly greater compared with those of the control group (p < 0.05, independent sample t test). CONCLUSION Entropy and gain analysis of HIT using wireless electro-oculography system could be used to detect the VOR dysfunctions of AUVL and may become effective methods for evaluating vestibular disorders.
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Affiliation(s)
- Li-Chun Hsieh
- Department of Otolaryngology, Mackay Memorial Hospital, Taipei, Taiwan; Institute of Brain Science, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Audiology and Speech Language Pathology, Mackay Memorial Medical College, Taiwan
| | - Hung-Ching Lin
- Department of Otolaryngology, Mackay Memorial Hospital, Taipei, Taiwan; Department of Audiology and Speech Language Pathology, Mackay Memorial Medical College, Taiwan
| | - Guo-She Lee
- Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Otolaryngology, Taipei City Hospital, Renai Branch, Taipei, Taiwan.
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21
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Loader B, Linauer I, Korkesch S, Krammer-Effenberger I, Zielinski V, Schibany N, Kaider A, Vyskocil E, Tscholakoff D, Franz P. A connection between neurovascular conflicts within the cerebellopontine angle and vestibular neuritis, a case controlled cohort study. ACTA OTORHINOLARYNGOLOGICA ITALICA 2016; 36:421-427. [PMID: 27958603 PMCID: PMC5225799 DOI: 10.14639/0392-100x-766] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 05/21/2016] [Indexed: 12/01/2022]
Abstract
This retrospective, observer blinded case-control study aims to compare the prevalence of neurovascular conflicts (NVCs) of the vestibulocochlear nerve and the anterior inferior cerebellar artery (AICA) in patients presenting with clinical signs of acute vestibular neuritis with and without subsequent objective vestibular function loss (VFL). 58 acute cases of clinically suspected acute vestibular neuritis were investigated with same day cranial MRI at a tertiary referral centre and compared to 61 asymptomatic controls. The prevalence of NVCs in cases with objective VFL were also compared to cases without VFL. Radiologists described the NVC as "no contact" (Grade 0), "contact < 2 mm" (Grade 1), "contact > 2 mm" (Grade 2) and "vascular loop presence" (Grade 3) without knowledge of neurotological data. Neurotological data was collected without knowledge of MRI findings. Vestibular function was tested by bithermic caloric irrigation. 26 cases (45%) showed caloric VFL (Group A), whereas 32 (55%) exhibited no VFL (Group B). Group A included 13 cases with NVCs (50%), Group B included 26 NVC cases (82%) (p = 0.012) and the control group included 16 individuals (26%) (p < 0.001 for comparison of all 3 groups). Group B had a significantly higher NVC-Grading than Group A (p = 0.009). There was no statistically significant association between NVCs and either SNHL or tinnitus (p > 0.05). Our results suggest that patients presenting with clinical signs of acute vestibular neuritis who show symmetrical caloric vestibular function test results have a significantly higher NVC prevalence in the cerebellopontine angle.
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Affiliation(s)
- B Loader
- Department of Otorhinolaryngology, Head and Neck Surgery, Rudolfstiftung Tertiary Teaching Hospital, Juchgasse, Vienna, Austria
| | - I Linauer
- Department of Otorhinolaryngology, Head and Neck Surgery, Rudolfstiftung Tertiary Teaching Hospital, Juchgasse, Vienna, Austria
| | - S Korkesch
- Department of Otorhinolaryngology, Head and Neck Surgery, Rudolfstiftung Tertiary Teaching Hospital, Juchgasse, Vienna, Austria
| | - I Krammer-Effenberger
- Institute of Diagnostic and Interventional Radiology, Rudolfstiftung Tertiary Teaching Hospital, Juchgasse, Vienna, Austria
| | - V Zielinski
- Department of Otorhinolaryngology, Head and Neck Surgery, Rudolfstiftung Tertiary Teaching Hospital, Juchgasse, Vienna, Austria
| | - N Schibany
- Institute of Diagnostic and Interventional Radiology, Rudolfstiftung Tertiary Teaching Hospital, Juchgasse, Vienna, Austria
| | - A Kaider
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Spitalgasse, Vienna, Austria
| | - E Vyskocil
- Department of Otorhinolaryngology, Head and Neck Surgery, Vienna General Hospital, Medical University of Vienna, Spitalgasse, Vienna, Austria
| | - D Tscholakoff
- Institute of Diagnostic and Interventional Radiology, Rudolfstiftung Tertiary Teaching Hospital, Juchgasse, Vienna, Austria
| | - P Franz
- Department of Otorhinolaryngology, Head and Neck Surgery, Rudolfstiftung Tertiary Teaching Hospital, Juchgasse, Vienna, Austria
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Kim HA, Yi HA, Lee H. Failure of Fixation Suppression of Spontaneous Nystagmus in Cerebellar Infarction: Frequency, Pattern, and a Possible Structure. THE CEREBELLUM 2016; 15:182-9. [PMID: 26082303 DOI: 10.1007/s12311-015-0688-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
To investigate the frequency and pattern of failure of the fixation suppression (FFS) of spontaneous nystagmus (SN) in unilateral cerebellar infarction, and to identify the structure responsible for FFS, 29 patients with acute, mainly unilateral, isolated cerebellar infarction who had SN with a predominantly horizontal component were enrolled in this study. The ocular fixation index (OFI) was defined as the mean slow phase velocity (SPV) of the horizontal component of SN with fixation divided by the mean SPV of the horizontal component of SN without fixation. The OFI from age- and sex-matched patients with vestibular neuritis was calculated and used as the control data. The FFS of SN was only found in less than half (41 %, 12/29) of the patients. Approximately 65 % (n = 7) of the patients with isolated anterior inferior cerebellar artery territory cerebellar infarction showed FFS, whereas only a quarter (n = 3) of the patients with isolated posterior inferior cerebellar artery (PICA) territory cerebellar infarction showed FFS. The proportion of gaze-evoked nystagmus (6/12 [50 %] vs. 2/17 [12 %], p = 0.04) and deficient gain of ipsilesional pursuit (10/12 [83 %] vs. 6/17 [35 %], p = 0.05) was more frequent in the FFS group than in the group without FFS. Lesion subtraction analysis in isolated PICA territory cerebellar infarction revealed that the nodulus was commonly damaged in patients with FFS, compared to that of patients without FFS. Our study shows that FFS of SN due to acute cerebellar infarction is less common than previously thought and the nodulus may be an important structure for the suppression of SN in humans.
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Affiliation(s)
- Hyun-Ah Kim
- Department of Neurology, School of Medicine, Keimyung University, 56 Dalseong-ro, Jung-gu, Daegu, 700-712, Republic of Korea
- Brain Research Institute, School of Medicine, Keimyung University, Daegu, Republic of Korea
| | - Hyon-Ah Yi
- Department of Neurology, School of Medicine, Keimyung University, 56 Dalseong-ro, Jung-gu, Daegu, 700-712, Republic of Korea
- Brain Research Institute, School of Medicine, Keimyung University, Daegu, Republic of Korea
| | - Hyung Lee
- Department of Neurology, School of Medicine, Keimyung University, 56 Dalseong-ro, Jung-gu, Daegu, 700-712, Republic of Korea.
- Brain Research Institute, School of Medicine, Keimyung University, Daegu, Republic of Korea.
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23
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Kim HA, Lee H. Recent Advances in Understanding Audiovestibular Loss of a Vascular Cause. J Stroke 2016; 19:61-66. [PMID: 28030893 PMCID: PMC5307938 DOI: 10.5853/jos.2016.00857] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 08/31/2016] [Accepted: 10/09/2016] [Indexed: 12/22/2022] Open
Abstract
Acute audiovestibular loss is characterized by abrupt onset of prolonged (lasting days) vertigo and hearing loss. Acute ischemic stroke in the distribution of the anterior inferior cerebellar artery (AICA) is known to be the leading cause of acute audiovestibular loss. So far, eight subgroups of AICA territory infarction have been identified according to the patterns of audiovestibular dysfunctions, among which the most common pattern is the combined loss of auditory and vestibular functions. Unlike inner ear dysfunction of a viral cause, which can commonly present as an isolated vestibular (i.e., vestibular neuritis) or cochlear loss (i.e., sudden deafness), labyrinthine dysfunction of a vascular cause rarely results in isolated loss of vestibular or auditory function. As audiovestibular loss may precede the central symptoms or signs of an ischemic stroke in the posterior circulation, early diagnosis and proper management of audiovestiubular loss may provide a window to prevent the progression of infarction to larger areas of the posterior circulation. A clinician should consider the possibility that acute audiovestibular loss may herald impending AICA territory infarction, especially when patients have basilar artery occlusive disease close to the origin of the AICA on brain MRA. This review aims to highlight the recent advances in understanding audiovestibular loss of a vascular cause and to address its clinical significance.
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Affiliation(s)
- Hyun-Ah Kim
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea.,Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
| | - Hyung Lee
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea.,Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
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24
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Han WG, Yoon HC, Kim TM, Rah YC, Choi J. Clinical Correlation between Perverted Nystagmus and Brain MRI Abnormal Findings. J Audiol Otol 2016; 20:85-9. [PMID: 27626081 PMCID: PMC5020575 DOI: 10.7874/jao.2016.20.2.85] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 05/03/2016] [Accepted: 05/09/2016] [Indexed: 11/22/2022] Open
Abstract
Background and Objectives To analyze the clinical correlation between perverted nystagmus and brain magnetic resonance imaging (MRI) abnormal findings and to evaluate whether perverted nystagmus is clinically significant results of brain abnormal lesions or not. Subjects and Methods We performed medical charts review from January 2008 to July 2014, retrospectively. Patients who were suspected central originated vertigo at Frenzel goggles test were included among patients who visited our hospital. To investigate the correlation with nystagmus suspected central originated vertigo and brain MRI abnormal findings, we confirmed whether performing brain MRI or not. Then we exclude that patients not performed brain MRI. Results The number of patients with perverted nystagmus was 15, upbeating was 1 and down-beating was 14. Among these patients, 5 patients have brain MRI abnormal findings. However, 2 patients with MRI abnormal findings were not associated correctly with perverted nystagmus and only 3 patients with perverted nystagmus were considered central originated vertigo and further evaluation and treatment was performed by the department of neurology. Conclusions Perverted nystagmus was considered to the abnormalities at brain lesions, especially cerebellum, but neurologic symptoms and further evaluation were needed for exact diagnosis of central originated vertigo.
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Affiliation(s)
- Won-Gue Han
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University College of Medicine, Seoul, Korea
| | - Hee-Chul Yoon
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University College of Medicine, Seoul, Korea
| | - Tae-Min Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University College of Medicine, Seoul, Korea
| | - Yoon Chan Rah
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University College of Medicine, Seoul, Korea
| | - June Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Korea University College of Medicine, Seoul, Korea
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25
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Clinical evaluation of acute phase nystagmus associated with cerebellar lesions. The Journal of Laryngology & Otology 2016; 130:536-40. [PMID: 27086942 DOI: 10.1017/s0022215116001079] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To determine the characteristics of acute phase nystagmus in patients with cerebellar lesions, and to identify a useful indicator for differentiating central lesions from peripheral lesions. METHODS Acute phase nystagmus and the appearance of neurological symptoms were retrospectively investigated in 11 patients with cerebellar stroke. RESULTS At the initial visit, there were no patients with vertical nystagmus, direction-changing gaze evoked nystagmus or pure rotatory nystagmus. There were four cases with no nystagmus and seven cases with horizontal nystagmus at the initial visit. There were no neurological symptoms, except for vertigo and hearing loss, in any cases at the initial visit. The direction and type of nystagmus changed with time, and neurological symptoms other than vertigo appeared subsequently to admission. CONCLUSION It is important to observe the changes in nystagmus and other neurological findings for the differential diagnosis of central lesions.
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26
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Parthasarathy R, Derksen C, Saqqur M, Khan K. Isolated intermittent vertigo: A presenting feature of persistent trigeminal artery. J Neurosci Rural Pract 2016; 7:161-3. [PMID: 26933370 PMCID: PMC4750321 DOI: 10.4103/0976-3147.165430] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Embryonic carotid – basilar anastomosis when persistent in adult life can present with a variety of neurological symptoms. We present a patient with isolated intermittent vertigo attributable to the embryonic anastomosis and describe the different types of persistent trigeminal artery. A 76-year-old Caucasian man presented with isolated intermittent vertigo and symptoms suggestive of anterior and posterior circulation strokes. Impaired vasomotor reactivity was demonstrated on insonation of the anterior and posterior cerebral arteries in this patient with a persistent left trigeminal artery and 75% stenosis of the left internal carotid artery (ICA). The symptom of intermittent vertigo resolved with carotid endarterectomy. Decreased flow across the stenotic segment of the ICA which subserved the posterior circulation resulted in basilar insufficiency. Hypoperfusion to the flocculonodular lobe supplied by the anterior inferior cerebellar artery is a likely cause for the intermittent vertigo.
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Affiliation(s)
- Rajsrinivas Parthasarathy
- Department of Neurointerventional Surgery, Institute of Neurosciences, Medanta - The Medicity, Gurgaon, Haryana, India
| | - Carol Derksen
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Maher Saqqur
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Khurshid Khan
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Choi KD, Lee H, Kim JS. Ischemic syndromes causing dizziness and vertigo. HANDBOOK OF CLINICAL NEUROLOGY 2016; 137:317-40. [PMID: 27638081 DOI: 10.1016/b978-0-444-63437-5.00023-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Dizziness/vertigo and imbalance are the most common symptoms of vertebrobasilar ischemia. Even though dizziness/vertigo usually accompanies other neurologic symptoms and signs in cerebrovascular disorders, a diagnosis of isolated vascular vertigo is increasing markedly by virtue of recent developments in clinical neurotology and neuroimaging. It is important to differentiate isolated vertigo of a vascular cause from more benign disorders involving the inner ear, since therapeutic strategies and prognosis differ between these two conditions. Over the last decade, we have achieved a marked development in the understanding and diagnosis of vascular dizziness/vertigo. Introduction of diffusion-weighted magnetic resonance imaging (MRI) has greatly enhanced detection of infarctions in patients with vascular dizziness/vertigo, especially in the posterior-circulation territories. However, well-organized bedside neurotologic evaluation is even more sensitive than MRI in detecting acute infarction as a cause of spontaneous prolonged vertigo. Furthermore, detailed evaluation of strategic infarctions has elucidated the function of various vestibular structures of the brainstem and cerebellum. In contrast, diagnosis of isolated labyrinthine infarction still remains a challenge. This diagnostic difficulty also applies to isolated transient dizziness/vertigo of vascular origin. Regarding the common nonlacunar mechanisms in the acute vestibular syndrome from small infarctions, individual strategies may be indicated to prevent recurrences of stroke in patients with vascular vertigo.
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Affiliation(s)
- K-D Choi
- Department of Neurology, College of Medicine, Pusan National University Hospital, Busan, Korea
| | - H Lee
- Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
| | - J-S Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Gyeonggi-do, Korea.
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Newman-Toker DE, Della Santina CC, Blitz AM. Vertigo and hearing loss. HANDBOOK OF CLINICAL NEUROLOGY 2016; 136:905-21. [PMID: 27430449 DOI: 10.1016/b978-0-444-53486-6.00046-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Symptoms referable to disorders affecting the inner ear and vestibulocochlear nerve (eighth cranial nerve) include dizziness, vertigo, tinnitus, and hearing loss, in various combinations. Similar symptoms may occur with involvement of the central nervous system, principally the brainstem and cerebellum, to which the vestibular and auditory systems are connected. Imaging choices should be tailored to patient symptoms and the clinical context. Computed tomography (CT) should be used primarily to assess bony structures. Magnetic resonance imaging (MRI) should be used primarily to assess soft-tissue structures. Vascular imaging by angiography or venography should be obtained when vascular lesions are suspected. No imaging should be obtained in patients with typical presentations of common peripheral vestibular or auditory disorders. In current clinical practice, neuroimaging is often overused, especially CT in the assessment of acute dizziness and vertigo in the emergency department. Despite low sensitivity for ischemic strokes, CT is often used to rule out neurologic causes. When ischemic stroke is the principal concern in acute vestibular presentations, imaging should almost always be by MRI with diffusion-weighted images, rather than CT. In this chapter, we describe recommended strategies for audiovestibular imaging based on patient symptoms and signs.
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Affiliation(s)
- David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Otolaryngology, Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Charles C Della Santina
- Department of Otolaryngology, Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ari M Blitz
- Neuro-radiology Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Unidentified Bright Objects on Brain Magnetic Resonance Imaging Affect Vestibular Neuritis. Clin Exp Otorhinolaryngol 2015; 8:364-9. [PMID: 26622955 PMCID: PMC4661252 DOI: 10.3342/ceo.2015.8.4.364] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 11/25/2014] [Accepted: 12/22/2014] [Indexed: 11/30/2022] Open
Abstract
Objectives The aim of this study was to investigate the differences in clinical manifestations of in two groups of vestibular neuritis (VN) patients with or without unidentified bright objects (UBOs). Methods A prospective, observational study with 46 patients diagnosed with VN between May 2013 and November 2013 was executed. A caloric test, a cervical vestibular-evoked myogenic potentials (cVEMPs) test, brain magnetic resonance imaging (MRI), spontaneous nystagmus test, head impulse test, and head-shaking nystagmus test were performed. Results Of the patients, 56.5% (n=26) were classified as UBO-positive by MRI. These showed lower caloric weakness and more prominent cVEMP asymmetry compared with the UBO-negative group (P<0.05). Total VN (TVN) was the most common in the UBO-positive group (45.0%), followed by superior VN (SVN, 30.0%), and inferior VN (IVN, 25.0%). However, in the UBO-negative group, SVN (75.0%) was the most common, followed by TVN and IVN (P<0.05). The recovery rate was not influenced by UBOs (P>0.05). Conclusion UBOs on T2-weighted or fluid attenuated inversion recovery MRI may affect the patterns of the vestibular nerve in patients with VN.
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Kim JC, Cha WW, Chang DS, Lee HY. The Effect of Intravenous Dexamethasone on the Nausea Accompanying Vestibular Neuritis: A Preliminary Study. Clin Ther 2015; 37:2536-42. [PMID: 26475420 DOI: 10.1016/j.clinthera.2015.09.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 08/25/2015] [Accepted: 08/25/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE We undertook a preliminary assessment of the efficacy of administering intravenous dexamethasone (DEX) for relieving the nausea and dizziness accompanying vestibular neuritis (VN). METHODS Between November 2013 and October 2014, 26 patients with VN were prospectively enrolled in this study. The patients were randomly assigned to treatment with a combination of 20 mg/d of intravenous metoclopramide, 100 mg of oral dimenhydrinate, and 5 mg/d of intravenous DEX or 20 mg/d of intravenous metoclopramide, 100 mg of oral dimenhydrinate, and intravenous normal saline as a placebo therapy. Patients' subjective assessments of the severity of their nausea and dizziness were recorded using a visual analog scale on the day of admission and 2 days, 3 days, 1 month, and 3 months thereafter. Bedside examinations consisted of spontaneous nystagmus (SPN) assessment, the head shaking nystagmus test, and the head impulse test, which were performed at every follow-up visit. FINDINGS The severity of nausea and dizziness was significantly reduced over time (both P < 0.05). However, there was no significant effect of DEX injection on the severity of nausea or dizziness (P > 0.05). The presence of SPN was solely associated with nausea (hazard ratio = 3.34; 95% CI, 1.85-6.02). IMPLICATIONS The administration of intravenous DEX did not relieve nausea or dizziness any better than a placebo treatment. However, further research is required to confirm whether there is a dose-dependent effect of DEX on the control of nausea or dizziness in VN.
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Affiliation(s)
- Ji Chan Kim
- Department of Otorhinolaryngology, Eulji University Medical Center, Eulji University, Daejeon, South Korea
| | - Wang Woon Cha
- Department of Otorhinolaryngology, Eulji University Medical Center, Eulji University, Daejeon, South Korea
| | - Dong Sik Chang
- Department of Otorhinolaryngology, Eulji University Medical Center, Eulji University, Daejeon, South Korea
| | - Ho Yun Lee
- Department of Otorhinolaryngology, Eulji University Medical Center, Eulji University, Daejeon, South Korea.
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VOR gain by head impulse video-oculography differentiates acute vestibular neuritis from stroke. Otol Neurotol 2015; 36:457-65. [PMID: 25321888 DOI: 10.1097/mao.0000000000000638] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Vestibular neuritis is often mimicked by stroke (pseudoneuritis). Vestibular eye movements help discriminate the two conditions. We report vestibulo-ocular reflex (VOR) gain measures in neuritis and stroke presenting acute vestibular syndrome (AVS). METHODS Prospective cross-sectional study of AVS (acute continuous vertigo/dizziness lasting >24 h) at two academic centers. We measured horizontal head impulse test (HIT) VOR gains in 26 AVS patients using a video HIT device (ICS Impulse). All patients were assessed within 1 week of symptom onset. Diagnoses were confirmed by clinical examinations, brain magnetic resonance imaging with diffusion-weighted images, and follow-up. Brainstem and cerebellar strokes were classified by vascular territory-posterior inferior cerebellar artery (PICA) or anterior inferior cerebellar artery (AICA). RESULTS Diagnoses were vestibular neuritis (n = 16) and posterior fossa stroke (PICA, n = 7; AICA, n = 3). Mean HIT VOR gains (ipsilesional [standard error of the mean], contralesional [standard error of the mean]) were as follows: vestibular neuritis (0.52 [0.04], 0.87 [0.04]); PICA stroke (0.94 [0.04], 0.93 [0.04]); AICA stroke (0.84 [0.10], 0.74 [0.10]). VOR gains were asymmetric in neuritis (unilateral vestibulopathy) and symmetric in PICA stroke (bilaterally normal VOR), whereas gains in AICA stroke were heterogeneous (asymmetric, bilaterally low, or normal). In vestibular neuritis, borderline gains ranged from 0.62 to 0.73. Twenty patients (12 neuritis, six PICA strokes, two AICA strokes) had at least five interpretable HIT trials (for both ears), allowing an appropriate classification based on mean VOR gains per ear. Classifying AVS patients with bilateral VOR mean gains of 0.70 or more as suspected strokes yielded a total diagnostic accuracy of 90%, with stroke sensitivity of 88% and specificity of 92%. CONCLUSION Video HIT VOR gains differ between peripheral and central causes of AVS. PICA strokes were readily separated from neuritis using gain measures, but AICA strokes were at risk of being misclassified based on VOR gain alone.
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Abstract
Isolated vestibular syndrome may occur all along the vestibular pathways from the peripheral labyrinth to the brain. By virtue of recent developments in clinical neurotology and neuroimaging, however, diagnosis of isolated central vestibulopathy is increasing. Here, we review five distinct syndromes of isolated central vestibular syndrome from lesions restricted to the vestibular nuclei, the nucleus prepositus hypoglossi, the flocculus, the tonsil, and the nodulus, and introduce a new vestibular syndrome from isolated involvement of the inferior cerebellar peduncle. Decreased responses to head impulses do not exclude a central lesion as a cause of isolated vestibular syndrome. Brain imaging, including diffusion-weighted magnetic resonance imaging (MRI), may be falsely negative during the acute phase in patients with isolated vestibular syndrome because of a stroke. Central signs should be sought carefully in patients with isolated vertigo, even when the patients show the features of peripheral vestibulopathy and negative MRIs. Recognition of these isolated central vestibular syndromes would aid in defining the lesions responsible for various vestibular manifestations in central vestibulopathy.
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Affiliation(s)
- Sung-Hee Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Korea
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Abstract
Strokes in the distribution of the posterior circulation may present with vertigo, imbalance, and nystagmus. Although the vertigo due to a posterior circulation stroke is usually associated with other neurologic symptoms or signs, small infarcts involving the cerebellum or brainstem can develop vertigo without other localizing symptoms. Approximately 11% of the patients with an isolated cerebellar infarction present with isolated vertigo, nystagmus, and postural unsteadiness mimicking acute peripheral vestibular disorders. The head impulse test can differentiate acute isolated vertigo associated with cerebellar strokes (particularly within the territory of the posterior inferior cerebellar artery) from more benign disorders involving the inner ear. Acute audiovestibular loss may herald impending infarction in the territory of anterior inferior cerebellar artery. Appropriate bedside evaluation is superior to MRIs for detecting central vascular vertigo syndromes. This article reviews the keys to diagnosis of acute isolated vertigo syndrome due to posterior circulation strokes involving the brainstem and cerebellum.
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Affiliation(s)
- Hyung Lee
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
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Choi JH, Kim HW, Choi KD, Kim MJ, Choi YR, Cho HJ, Sung SM, Kim HJ, Kim JS, Jung DS. Isolated vestibular syndrome in posterior circulation stroke: Frequency and involved structures. Neurol Clin Pract 2014; 4:410-418. [PMID: 29443249 DOI: 10.1212/cpj.0000000000000028] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Dizziness/vertigo is a common symptom of posterior circulation stroke and usually accompanies other neurologic symptoms and signs. Although strokes involving the brainstem or cerebellum may produce isolated vestibular syndrome (isolated vertigo or imbalance), the overall frequency and involved structures of isolated vestibular syndrome in the posterior circulation stroke remain uncertain. Isolated vestibular syndrome occurs in approximately 25% of the patients with posterior circulation stroke, and mostly involves the cerebellum, inferior or superior cerebellar peduncles, and caudal lateral or rostral dorsolateral medulla. The occasional negative neuroimaging in patients with acute isolated vascular vertigo highlights the importance of appropriate bedside evaluation in acute vestibular syndrome.
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Affiliation(s)
- Jae-Hwan Choi
- Department of Neurology (J-HC), Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Biomedical Research Institute; Departments of Neurology (H-WK, K-DC, M-JK, YRC, H-JC, S-MS, D-SJ) and Radiology (H-JK), Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute; and Department of Neurology (J-SK), Seoul National University College of Medicine, Seoul National University Bundang Hospital, South Korea
| | - Hyun-Woo Kim
- Department of Neurology (J-HC), Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Biomedical Research Institute; Departments of Neurology (H-WK, K-DC, M-JK, YRC, H-JC, S-MS, D-SJ) and Radiology (H-JK), Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute; and Department of Neurology (J-SK), Seoul National University College of Medicine, Seoul National University Bundang Hospital, South Korea
| | - Kwang-Dong Choi
- Department of Neurology (J-HC), Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Biomedical Research Institute; Departments of Neurology (H-WK, K-DC, M-JK, YRC, H-JC, S-MS, D-SJ) and Radiology (H-JK), Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute; and Department of Neurology (J-SK), Seoul National University College of Medicine, Seoul National University Bundang Hospital, South Korea
| | - Min-Ji Kim
- Department of Neurology (J-HC), Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Biomedical Research Institute; Departments of Neurology (H-WK, K-DC, M-JK, YRC, H-JC, S-MS, D-SJ) and Radiology (H-JK), Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute; and Department of Neurology (J-SK), Seoul National University College of Medicine, Seoul National University Bundang Hospital, South Korea
| | - Yu Ri Choi
- Department of Neurology (J-HC), Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Biomedical Research Institute; Departments of Neurology (H-WK, K-DC, M-JK, YRC, H-JC, S-MS, D-SJ) and Radiology (H-JK), Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute; and Department of Neurology (J-SK), Seoul National University College of Medicine, Seoul National University Bundang Hospital, South Korea
| | - Han-Jin Cho
- Department of Neurology (J-HC), Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Biomedical Research Institute; Departments of Neurology (H-WK, K-DC, M-JK, YRC, H-JC, S-MS, D-SJ) and Radiology (H-JK), Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute; and Department of Neurology (J-SK), Seoul National University College of Medicine, Seoul National University Bundang Hospital, South Korea
| | - Sang-Min Sung
- Department of Neurology (J-HC), Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Biomedical Research Institute; Departments of Neurology (H-WK, K-DC, M-JK, YRC, H-JC, S-MS, D-SJ) and Radiology (H-JK), Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute; and Department of Neurology (J-SK), Seoul National University College of Medicine, Seoul National University Bundang Hospital, South Korea
| | - Hak-Jin Kim
- Department of Neurology (J-HC), Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Biomedical Research Institute; Departments of Neurology (H-WK, K-DC, M-JK, YRC, H-JC, S-MS, D-SJ) and Radiology (H-JK), Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute; and Department of Neurology (J-SK), Seoul National University College of Medicine, Seoul National University Bundang Hospital, South Korea
| | - Ji-Soo Kim
- Department of Neurology (J-HC), Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Biomedical Research Institute; Departments of Neurology (H-WK, K-DC, M-JK, YRC, H-JC, S-MS, D-SJ) and Radiology (H-JK), Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute; and Department of Neurology (J-SK), Seoul National University College of Medicine, Seoul National University Bundang Hospital, South Korea
| | - Dae-Soo Jung
- Department of Neurology (J-HC), Pusan National University Yangsan Hospital, Pusan National University School of Medicine and Biomedical Research Institute; Departments of Neurology (H-WK, K-DC, M-JK, YRC, H-JC, S-MS, D-SJ) and Radiology (H-JK), Pusan National University Hospital, Pusan National University School of Medicine and Biomedical Research Institute; and Department of Neurology (J-SK), Seoul National University College of Medicine, Seoul National University Bundang Hospital, South Korea
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Saber Tehrani AS, Kattah JC, Mantokoudis G, Pula JH, Nair D, Blitz A, Ying S, Hanley DF, Zee DS, Newman-Toker DE. Small strokes causing severe vertigo: frequency of false-negative MRIs and nonlacunar mechanisms. Neurology 2014; 83:169-73. [PMID: 24920847 DOI: 10.1212/wnl.0000000000000573] [Citation(s) in RCA: 151] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Describe characteristics of small strokes causing acute vestibular syndrome (AVS). METHODS Ambispective cross-sectional study of patients with AVS (acute vertigo or dizziness, nystagmus, nausea/vomiting, head-motion intolerance, unsteady gait) with at least one stroke risk factor from 1999 to 2011 at a single stroke referral center. Patients underwent nonquantitative HINTS "plus" examination (head impulse, nystagmus, test-of-skew plus hearing), neuroimaging to confirm diagnoses (97% by MRI), and repeat MRI in those with initially normal imaging but clinical signs of a central lesion. We identified patients with diffusion-weighted imaging (DWI) strokes ≤10 mm in axial diameter. RESULTS Of 190 high-risk AVS presentations (105 strokes), we found small strokes in 15 patients (median age 64 years, range 41-85). The most common vestibular structure infarcted was the inferior cerebellar peduncle (73%); the most common stroke location was the lateral medulla (60%). Focal neurologic signs were present in only 27%. The HINTS "plus" battery identified small strokes with greater sensitivity than early MRI-DWI (100% vs 47%, p < 0.001). False-negative initial MRIs (6-48 hours) were more common with small strokes than large strokes (53% [n = 8/15] vs 7.8% [n = 7/90], p < 0.001). Nonlacunar stroke mechanisms were responsible in 47%, including 6 vertebral artery occlusions or dissections. CONCLUSIONS Small strokes affecting central vestibular projections can present with isolated AVS. The HINTS "plus" hearing battery identifies these patients with greater accuracy than early MRI-DWI, which is falsely negative in half, up to 48 hours after onset. We found nonlacunar mechanisms in half, suggesting greater risk than might otherwise be assumed for patients with such small infarctions.
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Affiliation(s)
- Ali S Saber Tehrani
- From the Department of Neurology (A.S.S.T., J.C.K., J.H.P., D.N.), University of Illinois College of Medicine at Peoria; and Departments of Neurology (G.M., D.F.H., D.S.Z., D.E.N.-T.) and Radiology (A.B., S.Y.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jorge C Kattah
- From the Department of Neurology (A.S.S.T., J.C.K., J.H.P., D.N.), University of Illinois College of Medicine at Peoria; and Departments of Neurology (G.M., D.F.H., D.S.Z., D.E.N.-T.) and Radiology (A.B., S.Y.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Georgios Mantokoudis
- From the Department of Neurology (A.S.S.T., J.C.K., J.H.P., D.N.), University of Illinois College of Medicine at Peoria; and Departments of Neurology (G.M., D.F.H., D.S.Z., D.E.N.-T.) and Radiology (A.B., S.Y.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - John H Pula
- From the Department of Neurology (A.S.S.T., J.C.K., J.H.P., D.N.), University of Illinois College of Medicine at Peoria; and Departments of Neurology (G.M., D.F.H., D.S.Z., D.E.N.-T.) and Radiology (A.B., S.Y.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Deepak Nair
- From the Department of Neurology (A.S.S.T., J.C.K., J.H.P., D.N.), University of Illinois College of Medicine at Peoria; and Departments of Neurology (G.M., D.F.H., D.S.Z., D.E.N.-T.) and Radiology (A.B., S.Y.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ari Blitz
- From the Department of Neurology (A.S.S.T., J.C.K., J.H.P., D.N.), University of Illinois College of Medicine at Peoria; and Departments of Neurology (G.M., D.F.H., D.S.Z., D.E.N.-T.) and Radiology (A.B., S.Y.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sarah Ying
- From the Department of Neurology (A.S.S.T., J.C.K., J.H.P., D.N.), University of Illinois College of Medicine at Peoria; and Departments of Neurology (G.M., D.F.H., D.S.Z., D.E.N.-T.) and Radiology (A.B., S.Y.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel F Hanley
- From the Department of Neurology (A.S.S.T., J.C.K., J.H.P., D.N.), University of Illinois College of Medicine at Peoria; and Departments of Neurology (G.M., D.F.H., D.S.Z., D.E.N.-T.) and Radiology (A.B., S.Y.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - David S Zee
- From the Department of Neurology (A.S.S.T., J.C.K., J.H.P., D.N.), University of Illinois College of Medicine at Peoria; and Departments of Neurology (G.M., D.F.H., D.S.Z., D.E.N.-T.) and Radiology (A.B., S.Y.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - David E Newman-Toker
- From the Department of Neurology (A.S.S.T., J.C.K., J.H.P., D.N.), University of Illinois College of Medicine at Peoria; and Departments of Neurology (G.M., D.F.H., D.S.Z., D.E.N.-T.) and Radiology (A.B., S.Y.), Johns Hopkins University School of Medicine, Baltimore, MD.
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Brandt T, Strupp M, Dieterich M. Towards a concept of disorders of "higher vestibular function". Front Integr Neurosci 2014; 8:47. [PMID: 24917796 PMCID: PMC4041089 DOI: 10.3389/fnint.2014.00047] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 05/18/2014] [Indexed: 12/02/2022] Open
Abstract
Background: Vestibular disorders are commonly characterized by a combination of perceptual, ocular motor, postural, and vegetative manifestations, which cause the symptoms of vertigo, nystagmus, ataxia, and nausea. Multisensory convergence and numerous polysynaptic pathways link the bilaterally organized central vestibular network with limbic, hippocampal, cerebellar, and non-vestibular cortex structures to mediate “higher” cognitive functions. Anatomical classification of vestibular disorders: The traditional classification of vestibular disorders is based on the anatomical site of the lesion. While it distinguishes between the peripheral and the central vestibular systems, certain weaknesses become apparent when applied clinically. There are two reasons for this: first, peripheral and central vestibular disorders cannot always be separated by the clinical syndrome; second, a third category, namely disorders of “higher vestibular function”, is missing. These disorders may be caused by peripheral as well as central vestibular lesions. Functional classification: Here we discuss a new concept of disorders of higher vestibular function which involve cognition and more than one sensory modality. Three conditions are described that exemplify such higher disorders: room tilt illusion, spatial hemineglect, and bilateral vestibulopathy all of which present with deficits of orientation and spatial memory. Conclusions: Further elaboration of such disorders of higher multisensory functions with respect to lesion site and symptomatology is desirable. The room tilt illusion and spatial hemineglect involve vestibular and visual function to the extent that both conditions can be classified as either disorders of higher vestibular or of higher visual functions. A possible way of separating these disorders in a first step is to determine whether the causative lesion site affects the vestibular or the visual system. For the vestibular system this lesion site may be peripheral or central. The criterion of “higher function” is fulfilled if cognition or senses other than the primarily affected one come into play.
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Affiliation(s)
- Thomas Brandt
- German Center for Vertigo and Balance Disorders, University of Grosshadern Munich Munich, Germany ; Clinical Neurosciences, University of Grosshadern Munich Munich, Germany
| | - Michael Strupp
- German Center for Vertigo and Balance Disorders, University of Grosshadern Munich Munich, Germany ; Department of Neurology, University of Munich Munich, Germany
| | - Marianne Dieterich
- German Center for Vertigo and Balance Disorders, University of Grosshadern Munich Munich, Germany ; Department of Neurology, University of Munich Munich, Germany ; Munich Cluster of Systems Neurology, SyNergy Munich, Germany
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Recent advances in acute hearing loss due to posterior circulation ischemic stroke. J Neurol Sci 2014; 338:23-9. [DOI: 10.1016/j.jns.2013.12.048] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Revised: 12/28/2013] [Accepted: 12/31/2013] [Indexed: 02/06/2023]
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Brandt T, Strupp M, Dieterich M. Five keys for diagnosing most vertigo, dizziness, and imbalance syndromes: an expert opinion. J Neurol 2013; 261:229-31. [DOI: 10.1007/s00415-013-7190-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Revised: 11/07/2013] [Accepted: 11/08/2013] [Indexed: 11/30/2022]
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Newman-Toker DE, Kerber KA, Hsieh YH, Pula JH, Omron R, Saber Tehrani AS, Mantokoudis G, Hanley DF, Zee DS, Kattah JC. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med 2013; 20:986-96. [PMID: 24127701 DOI: 10.1111/acem.12223] [Citation(s) in RCA: 226] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 04/23/2013] [Accepted: 04/28/2013] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Dizziness and vertigo account for about 4 million emergency department (ED) visits annually in the United States, and some 160,000 to 240,000 (4% to 6%) have cerebrovascular causes. Stroke diagnosis in ED patients with vertigo/dizziness is challenging because the majority have no obvious focal neurologic signs at initial presentation. The authors sought to compare the accuracy of two previously published approaches purported to be useful in bedside screening for possible stroke in dizziness: a clinical decision rule (head impulse, nystagmus type, test of skew [HINTS]) and a risk stratification rule (age, blood pressure, clinical features, duration of symptoms, diabetes [ABCD2]). METHODS This was a cross-sectional study of high-risk patients (more than one stroke risk factor) with acute vestibular syndrome (AVS; acute, persistent vertigo or dizziness with nystagmus, plus nausea or vomiting, head motion intolerance, and new gait unsteadiness) at a single academic center. All underwent neurootologic examination, neuroimaging (97.4% by magnetic resonance imaging [MRI]), and follow-up. ABCD2 risk scores (0-7 points), using the recommended cutoff of ≥4 for stroke, were compared to a three-component eye movement battery (HINTS). Sensitivity, specificity, and positive and negative likelihood ratios (LR+, LR-) were assessed for stroke and other central causes, and the results were stratified by age. False-negative initial neuroimaging was also assessed. RESULTS A total of 190 adult AVS patients were assessed (1999-2012). Median age was 60.5 years (range = 18 to 92 years; interquartile range [IQR] = 52.0 to 70.0 years); 60.5% were men. Final diagnoses were vestibular neuritis (34.7%), posterior fossa stroke (59.5% [105 infarctions, eight hemorrhages]), and other central causes (5.8%). Median ABCD2 was 4.0 (range = 2 to 7; IQR = 3.0 to 4.0). ABCD2 ≥ 4 for stroke had sensitivity of 61.1%, specificity of 62.3%, LR+ of 1.62, and LR- of 0.62; sensitivity was lower for those younger than 60 years old (28.9%). HINTS stroke sensitivity was 96.5%, specificity was 84.4%, LR+ was 6.19, and LR- was 0.04 and did not vary by age. For any central lesion, sensitivity was 96.8%, specificity was 98.5%, LR+ was 63.9, and LR- was 0.03 for HINTS, and sensitivity was 99.2%, specificity was 97.0%, LR+ was 32.7, and LR- was 0.01 for HINTS "plus" (any new hearing loss added to HINTS). Initial MRIs were falsely negative in 15 of 105 (14.3%) infarctions; all but one was obtained before 48 hours after onset, and all were confirmed by delayed MRI. CONCLUSIONS HINTS substantially outperforms ABCD2 for stroke diagnosis in ED patients with AVS. It also outperforms MRI obtained within the first 2 days after symptom onset. While HINTS testing has traditionally been performed by specialists, methods for empowering emergency physicians (EPs) to leverage this approach for stroke screening in dizziness should be investigated.
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Affiliation(s)
| | | | | | - John H. Pula
- University of Illinois College of Medicine at Peoria; Illinois Neurological Institute; Peoria IL
| | - Rodney Omron
- Johns Hopkins University School of Medicine; Baltimore MD
| | | | | | | | - David S. Zee
- Johns Hopkins University School of Medicine; Baltimore MD
| | - Jorge C. Kattah
- University of Illinois College of Medicine at Peoria; Illinois Neurological Institute; Peoria IL
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Abstract
PURPOSE OF REVIEW First, to update the diagnosis, pathophysiology, and treatment of the most frequent peripheral vestibular disorders. Second, to identify those disorders for which the diagnostic criteria are still deficient and treatment trials are still lacking. RECENT FINDINGS Bilateral vestibulopathy can be reliably diagnosed by the head-impulse test, caloric irrigation, and vestibular-evoked myogenic potentials. A new frequent subtype has been described: cerebellar ataxia, neuropathy, and vestibular areflexia syndrome. Benign paroxysmal positioning vertigo can be easily diagnosed and effectively treated. Vestibular neuritis is most likely caused by the reactivation of a herpes simplex type 1 infection; the inferior vestibular nerve subtype is now well established. More evidence is needed that the recovery can be improved by corticosteroids. Endolymphatic hydrops in Menière's disease can be depicted by high-resolution MRI after transtympanic gadolinium injection; a high-dosage and long-term prophylactic treatment with betahistine is evidently effective. Its mechanism of action is most likely an increase in the inner-ear blood flow. Vestibular paroxysmia is now a well established entity; carbamazepine is the treatment of first choice. Superior canal dehiscence syndrome can be reliably diagnosed; the best current treatment option is canal plugging. SUMMARY Although progress has been made in the diagnosis and treatment of most peripheral vestibular disorders, more state-of-the-art trials are needed on the treatment of bilateral vestibulopathy to prove the efficacy of balance training, of vestibular neuritis (in terms of recovery of peripheral vestibular function and central compensation), of vestibular paroxysmia to prove the effects of carbamazepine, and of Menière's disease to find the optimal dosage of betahistine.
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Im S. Anatomy and Physiology of Balance. BRAIN & NEUROREHABILITATION 2013. [DOI: 10.12786/bn.2013.6.2.47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Sun Im
- Department of Rehabilitation Medicine, College of Medicine, The Catholic University of Korea, Korea
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