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

ACR Appropriateness Criteria® Dizziness and Ataxia: 2023 Update

Diagnostic evaluation of a patient with dizziness or vertigo is complicated by a lack of standardized nomenclature, significant overlap in symptom descriptions, and the subjective nature of the patient's symptoms. Although dizziness is an imprecise term often used by patients to describe a feeling of being off-balance, in many cases dizziness can be subcategorized based on symptomatology as vertigo (false sense of motion or spinning), disequilibrium (imbalance with gait instability), presyncope (nearly fainting or blacking out), or lightheadedness (nonspecific). As such, current diagnostic paradigms focus on timing, triggers, and associated symptoms rather than subjective descriptions of dizziness type. Regardless, these factors complicate the selection of appropriate diagnostic imaging in patients presenting with dizziness or vertigo. This document serves to aid providers in this selection by using a framework of definable clinical variants. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Assessment of functional and structural brain abnormalities with resting-state functional MRI in patients with vestibular neuronitis

BACKGROUND

Vestibular neuritis (VN) is a disorder manifesting as acute, isolated, spontaneous vertigo. There are few comprehensive studies on the changes in related functional and structural brain regions.

PURPOSE

To evaluate alterations in spontaneous neural activity, functional connectivity (FC), and gray matter volume (GMV) in patients with VN.

MATERIAL AND METHODS

A total of 24 patients with VN and 22 age- and sex-matched healthy controls underwent resting-state functional magnetic resonance imaging (rs-fMRI) and three-dimensional T1-weighted anatomical imaging. We calculated the amplitude of low frequency fluctuation (ALFF), regional homogeneity (ReHo), and degree centrality (DC) to discern local brain abnormalities. The most abnormal brain region was selected as the region of interest (ROI) for FC analysis based on ALFF and ReHo values after Bonferroni correction. Voxel-based morphometry (VBM) was used to assess differences in GMV.

RESULTS

Patients with VN, compared to healthy controls, showed increased ALFF (P < 0.001), ReHo values (P = 0.002, <0.001), and DC (P = 0.013) in the left lingual gyrus and right postcentral gyrus. FC analysis demonstrated enhanced connectivity between the left lingual gyrus and the left superior frontal gyrus, and decreased connectivity with the right insula gyrus, right and left supramarginal gyrus (P = 0.012, 0.004, <0.001, 0.014). In addition, GMV was reduced in the bilateral caudate (P = 0.022, 0.014).

CONCLUSIONS

Patients with VN exhibit abnormal spontaneous neural activity and changes in ALFF, ReHo, DC, GMV, and FC. Understanding these functional and structural brain abnormalities may elucidate the underlying mechanisms of VN.

Long-term follow-up of patients with vestibular neuritis by caloric testing and directional preponderance calculation

OBJECTIVES

This study focuses on the diagnostic precision of caloric testing in detecting vestibular neuritis (VN).

MATERIALS AND METHODS

In this study, 99 patients (36 men, 63 women, mean age: 44.63 years [Formula: see text] 12.08 SD) with superior VN were involved, and 157 participants with a normal functioning vestibular system were also investigated. All patients underwent a complete neurotological examination, including the caloric test with electronystagmography registration. The canal paresis (CP) and directional preponderance (DP) values were analysed.

RESULTS

A VN on the right side was diagnosed in 31.3% and on the left side in 68.7%. When the CP parameters between the control and VN patients were contrasted, a statistically significant difference was observed (p < 0.00001*, Mann-Whitney U test), indicating higher values in the latter group. The prediction of VN based on the CP value was successful in 71%, and statistical analysis indicated a significant result [p < 0.0001*; OR: 5.730 (95% CI 3.301-9.948)]. The DP values were also significantly higher in the VN group (p < 0.00001*). The prediction of VN according to the DP value was successful in 69.8%. A significant result was also observed in this case [p < 0.001*; OR: 4.162 (95% CI 2.653-8.017)]. When both CP and DP were considered, a predictive value of 84.8% with a significant outcome [p < 0.0001*; OR: 82.7 (95% CI 28.4-241.03)] was detected.

CONCLUSIONS

Including the CP and DP parameters of the caloric test, VN could be detected in around 85%. Therefore, the caloric helps diagnose the disorder, but both parameters must be considered.

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.

Health Promotion Combined with Psychological Care Improves Vestibular Function in Patients with Vestibular Neuritis

This study aimed to explore the effect of health education combined with psychological care on patients with vestibular neuritis and the effect on their vestibular function. One hundred patients with vestibular neuritis admitted to our hospital from January 2019 to December 2020 were enrolled and divided into two groups by the random number: the control group (CG) (n= 53, health education) and the study group (SG) (n= 47, health education + psychological care). The Dizziness Handicap Inventory (DHI) scores, Berg Balance Scale (BBS) scores, depression scores (SDS), anxiety scores (SAS), satisfaction with care, compliance, incidence of falls, quality of life (QOF), and clinical symptom scores were compared between the two groups. Compared with the CG, the SG had a more significant reduction in DHI scores and SDS and SAS scores and a significant increase in BBS scores ( $P<0.05$ ). Compared with the CG, the SG had higher nursing satisfaction and compliance and a lower incidence of falls ( $P<0.05$ ). Nursing efficiency was higher in the SG than in the CG ( $P<0.05$ ). QOF scores were higher in the SG than in the CG ( $P<0.05$ ). Clinical symptom scores were lower in the SG than in the CG ( $P<0.05$ ). Health education combined with psychological care can improve vestibular function and bad mood, reduce the incidence of falls, improve the QOF, and result in high patient satisfaction and compliance, which should be widely promoted.