Approaching Acute Vertigo With Diplopia: A Rare Skew Deviation in Vestibular Neuritis

Video head impulse test in stroke: a review of published studies

Accurate and timely diagnosis of posterior circulation stroke in patients with acute dizziness is a challenge that can lead to misdiagnosis and significant harm. The present review sought to identify and describe published research on the clinical application of vHIT in posterior circulation stroke. vHIT, a portable device, has gained prominence in evaluating peripheral vestibular disorders and offers potential applications in diagnosing neurological disorders, particularly posterior circulation stroke. Several studies have shown that vHIT can differentiate between stroke and vestibular neuritis based on VOR gain values, with high sensitivity and specificity. The manuscript also discusses vHIT's performance in differentiating between types of posterior circulation stroke, such as PICA, AICA, and SCA strokes. While vHIT has demonstrated promise, the review emphasizes the need for further research to validate its use as a tool to rule out stroke in acute dizziness patients in the emergency department. In conclusion, the manuscript underscores the potential of vHIT as a valuable addition to the diagnostic arsenal for acute dizziness, particularly in the context of posterior circulation stroke. It calls for further research and wider adoption of vHIT in clinical settings to improve patient care and reduce unnecessary costs associated with misdiagnoses.

Acute unilateral vestibulopathy/vestibular neuritis: Diagnostic criteria

This paper describes the diagnostic criteria for Acute Unilateral Vestibulopathy (AUVP), a synonym for vestibular neuritis, as defined by the Committee for the Classification of Vestibular Disorders of the Bárány Society. AUVP manifests as an acute vestibular syndrome due to an acute unilateral loss of peripheral vestibular function without evidence for acute central or acute audiological symptoms or signs. This implies that the diagnosis of AUVP is based on the patient history, bedside examination, and, if necessary, laboratory evaluation. The leading symptom is an acute or rarely subacute onset of spinning or non-spinning vertigo with unsteadiness, nausea/vomiting and/or oscillopsia. A leading clinical sign is a spontaneous peripheral vestibular nystagmus, which is direction-fixed and enhanced by removal of visual fixation with a trajectory appropriate to the semicircular canal afferents involved (generally horizontal-torsional). The diagnostic criteria were classified by the committee for four categories: 1. "Acute Unilateral Vestibulopathy", 2. "Acute Unilateral Vestibulopathy in Evolution", 3. "Probable Acute Unilateral Vestibulopathy" and 4. "History of Acute Unilateral Vestibulopathy". The specific diagnostic criteria for these are as follows:"Acute Unilateral Vestibulopathy": A) Acute or subacute onset of sustained spinning or non-spinning vertigo (i.e., an acute vestibular syndrome) of moderate to severe intensity with symptoms lasting for at least 24 hours. B) Spontaneous peripheral vestibular nystagmus with a trajectory appropriate to the semicircular canal afferents involved, generally horizontal-torsional, direction-fixed, and enhanced by removal of visual fixation. C) Unambiguous evidence of reduced VOR function on the side opposite the direction of the fast phase of the spontaneous nystagmus. D) No evidence for acute central neurological, otological or audiological symptoms. E) No acute central neurological signs, namely no central ocular motor or central vestibular signs, in particular no pronounced skew deviation, no gaze-evoked nystagmus, and no acute audiologic or otological signs. F) Not better accounted for by another disease or disorder."Acute Unilateral Vestibulopathy in Evolution": A) Acute or subacute onset of sustained spinning or non-spinning vertigo with continuous symptoms for more than 3 hours, but not yet lasting for at least 24 h hours, when patient is seen; B) - F) as above. This category is useful for diagnostic reasons to differentiate from acute central vestibular syndromes, to initiate specific treatments, and for research to include patients in clinical studies."Probable Acute Unilateral Vestibulopathy": Identical to AUVP except that the unilateral VOR deficit is not clearly observed or documented."History of acute unilateral vestibulopathy": A) History of acute or subacute onset of vertigo lasting at least 24 hours and slowly decreasing in intensity. B) No history of simultaneous acute audiological or central neurological symptoms. C) Unambiguous evidence of unilaterally reduced VOR function. D) No history of simultaneous acute central neurological signs, namely no central ocular motor or central vestibular signs and no acute audiological or otological signs. E) Not better accounted for by another disease or disorder. This category allows a diagnosis in patients presenting with a unilateral peripheral vestibular deficit and a history of an acute vestibular syndrome who are examined well after the acute phase.It is important to note that there is no definite test for AUVP. Therefore, its diagnosis requires the exclusion of central lesions as well as a variety of other peripheral vestibular disorders. Finally, this consensus paper will discuss other aspects of AUVP such as etiology, pathophysiology and laboratory examinations if they are directly relevant to the classification criteria.

Reliability of two dissociating tests of phoria in artificially created phoria in normal adults

BACKGROUND

The ability of physical therapists (PTs) to accurately identify and reliably measure phoria/tropia is critical in the differential diagnosis of individuals with acute vestibular syndrome and concussion/mild traumatic brain injury.

OBJECTIVES

To determine if PTs may reliably measure phoria and to determine the reliability of two dissociating tests of phoria, the prism neutralized Maddox rod test and modified Thorington method, in normal adults with artificially created phoria.

METHODS

Thirty adults (mean age 24.87 ± 4.74 years) were randomly assigned to wear trial lenses (1, 2, 4, or 6 pd prism left, plain glass right) to create phoria. In sitting and supine, phoria was measured using prism neutralized Maddox rod test and modified Thorington method. Mean, SD, and range of first neutral endpoint were calculated for each examiner. Percentage of trials in agreement (≤ 2 and 4 pd); comparisons within the linear mixed effects regression model; and inter-rater reliability between examiners was calculated with the intra-class correlation coefficient (ICC).

RESULTS

Participants underwent 20 measurements by each examiner. Trial agreement between examiners was 74% (range 13%-100%) in horizontal and 91% (range 63%-100%) in vertical plane. Maddox rod test had significantly different means between two examiners (P < .05). Modified Thorington test had no significant difference. The Maddox rod test had a significant examiner main effect, examiner 2 always scored lower. Inter-rater correlation coefficient for each test was significant at level of P < .01 (ICC ≥ 0.67 ≤ 0.94) except for modified Thorington test in supine, horizontal plane with P < .05 (ICC ≥ 0.38).

CONCLUSION

PTs may reliably measure artificially created phorias using prism neutralized Maddox rod test and modified Thorington method.

Acute vestibular syndrome: is skew deviation a central sign?

Objective

Skew deviation results from a dysfunction of the graviceptive pathways in patients with an acute vestibular syndrome (AVS) leading to vertical diplopia due to vertical ocular misalignment. It is considered as a central sign, however, the prevalence of skew and the accuracy of its test is not well known .

Methods

We performed a prospective study from February 2015 until September 2020 of all patients presenting at our emergency department (ED) with signs of AVS. All patients underwent clinical HINTS and video test of skew (vTS) followed by a delayed MRI, which served as a gold standard for vestibular stroke confirmation.

Results

We assessed 58 healthy subjects, 53 acute unilateral vestibulopathy patients (AUVP) and 24 stroke patients. Skew deviation prevalence was 24% in AUVP and 29% in strokes. For a positive clinical test of skew, the cut-off of vertical misalignment was 3 deg with a very low sensitivity of 15% and specificity of 98.2%. The sensitivity of vTS was 29.2% with a specificity of 75.5%.

Conclusions

Contrary to prior knowledge, skew deviation proved to be more prevalent in patients with AVS and occurred in every forth patient with AUVP. Large skew deviations (> 3.3 deg), were pointing toward a central lesion. Clinical and video test of skew offered little additional diagnostic value compared to other diagnostic tests such as the head impulse test and nystagmus test. Video test of skew could aid to quantify skew in the ED setting in which neurotological expertise is not always readily available.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10692-6.

Approach to the History and Evaluation of Vertigo and Dizziness

PURPOSE OF REVIEW

This article reviews a method of obtaining the medical history of patients presenting with dizziness, vertigo, and imbalance. By combining elements of the history with examination, the goal is to identify patterns and an effective differential diagnosis for this group of patients to help lead to an accurate diagnosis.

RECENT FINDINGS

Studies over the past dozen years have changed the historical approach to patients with dizziness from one based primarily on how the patient describes the sensation of dizziness. This older approach can lead to misdiagnosis, so a preferred method puts greater emphasis on whether the dizziness is acute or chronic, episodic or continuous, or evoked by or brought on by an event or circumstance so that a pattern may be derived that better narrows the differential diagnosis and focused examination can further narrow to a cause or causes.

SUMMARY

Dizziness is a common symptom of many possible causes. This article will help clinicians navigate gathering the history and examination to formulate a working diagnosis in patients affected by dizziness.

A Practical Approach to Vertigo: A Synthesis of the Emerging Evidence

Vestibular presentations represent a large financial and symptomatic burden of disease^1,2 , while remaining one of the most elusive presentations to accurately and confidently diagnose. A primary cause for this is that the same symptom can be the end-product of numerous aetiologies, and uncertainties can lead to unnecessary investigations and associated increased cost and delays in diagnosis. An effective method to narrow the diagnosis is firstly to determine, from a limited list, which type of vestibular syndrome the patient possesses, and then apply a focussed history and examination to define the most likely aetiology within that syndrome. This review provides a diagnostic approach to the vertiginous patient, outlining the underlying pathophysiology that accounts for the clinical symptoms and signs. With this approach, physicians should be able to diagnose the majority of common vestibular presentations and know when to refer the urgent, complex, or rare cases to sub-specialist neuro-otologists for prompt and appropriate management. This article is protected by copyright. All rights reserved.

Abecedario del examen vestibuloespinal. Revisión bibliográfica

Introducción y objetivo: Durante las largas cuarentenas impuestas en el mundo por la pandemia de COVID-19 los médicos hemos empezado a usar con mayor asiduidad la modalidad de consulta virtual. La neurootología no ha sido una excepción en este contexto y usando el mecanismo de las videollamadas hemos podido dar atención y contención a un buen número de pacientes durante este período. Por esta razón y basados en la experiencia singular de este periodo, hemos diseñado un examen sistemático, basado en pruebas vestíbulo-espinales simples y presentadas en forma nemotécnica (abecedario). Sobre la base de nuestra experiencia y con una revisión de la literatura se intenta demostrar la etiología y topografía vestibular de los hallazgos. Método: Revisión narrativa. Para la búsqueda de la bibliografía se utilizó la metodología de revisión sistemática de documentos en metabuscadores y bases de datos. Periodo analizado del 2001 al 2019, en diversas revistas científicas. Resultados: El examen se dividió en cuatro pasos de acuerdo con las cuatro primeras letras del alfabeto: Ataxia (gradación), Bárány (desviación de los índices), Cefálico (tilt o inclinación cefálica de la cabeza en relación con el tronco) y Desviación (desviación oblicua de los ojos Test de skew). Discusión: Se plantea el uso de la mnemotecnia abecedario para ordenar el examen vestíbulo espinal en los pacientes con afección del sistema vestibular, de manera simple y práctica, permitiendo la modalidad virtual. Conclusiones: Este sencillo abecedario vestíbulo-espinal permite, asociado a un interrogatorio exhaustivo, realizar un examen vestibular eficaz por medios virtuales, separar eficazmente lesiones centrales de periféricas en cuadros vestibulares agudos con alta sensibilidad y especificidad y finalmente hacer un topodiagnóstico del lado de lesión vestibular.