Vertical components of head-shaking nystagmus in vestibular neuritis, Meniere's disease and migrainous vertigo

Meniere's disease is a manifestation of migraine

PURPOSE OF REVIEW

To discuss the theory that Meniere's disease (MD) is a variation of otologic migraine rather than an isolated inner ear condition.

RECENT FINDINGS

In contrast to the approximately 12% of the general population suffering from migraine headaches, 51-60% of patients with MD experience migraine headaches. While pathognomonic for MD, endolymphatic hydrops has also been identified in patients with vestibular migraine. Treatment with the integrative neurosensory rehabilitation approach (diet and lifestyle changes, magnesium and riboflavin supplementation, and when needed, prophylactic medication) to treat the underlying migraine process has been highly effective in patients with MD.

SUMMARY

MD can be understood as a manifestation of migraine such that patients with MD can be effectively treated with migraine therapies.

Characteristics and Possible Mechanisms of Direction-Reversing Nystagmus During Positional Testing in Patients With Benign Paroxysmal Positional Vertigo

OBJECTIVES

The occurrence of direction-reversing nystagmus during positional testing in patients with benign paroxysmal positional vertigo (BPPV) is not uncommon. Further in-depth analysis of the characteristics and possible mechanisms of direction-reversing nystagmus will help us to diagnose and treat BPPV more precisely. The study aimed to analyze the incidence and characteristics of direction-reversing nystagmus during positional testing in BPPV patients, evaluate the outcomes of canalith repositioning procedure for these patients, and further explore the possible mechanism of reversal nystagmus in BPPV patients.

STUDY DESIGN

Retrospective study.

SETTING

Single-center study.

PATIENTS

A total of 575 patients with BPPV who visited the Vertigo Clinic of our hospital between April 2017 and June 2021 were enrolled.

MAIN OUTCOME MEASURES

Dix-Hallpike and supine roll tests were performed. The nystagmus was recorded using videonystagmography. The characteristics of direction-reversing nystagmus and the possible underlying mechanism were analyzed.

RESULTS

Patients with BPPV who showed reversal nystagmus accounted for 9.39% (54 of 575) of all BPPV patients visiting our hospital during the same period, of which 5.57% (32 of 575) had horizontal semicircular canal BPPV (HC-BPPV), and 3.83% (22 of 575) had posterior semicircular canal BPPV (PC-BPPV). The maximum slow-phase velocities (mSPVs) of the first-phase nystagmus were greater in HC-BPPV and PC-BPPV patients with reversal nystagmus than those without (p = 0.04 and p = 0.01, respectively). In all HC-BPPV and PC-BPPV patients with reversal nystagmus, the mSPV of the first-phase nystagmus was greater than that of the second-phase nystagmus (p < 0.01). The duration of the second-phase nystagmus was longer than 60 seconds in 93.75% (30 of 32) of the HC-BPPV patients and 77.27% (17 of 22) of the PC-BPPV patients (p = 0.107, Fisher exact test). HC-BPPV and PC-BPPV patients with reversal nystagmus both required more than one canalith repositioning procedure compared with those without (HC-BPPV: 75 versus 28.13%, p < 0.001; PC-BPPV: 59.09 versus 13.64%, p = 0.002).

CONCLUSIONS

The cause of second-phase nystagmus in BPPV patients with direction-reversing nystagmus may be related to the involvement of central adaptation mechanisms secondary to the overpowering mSPV of the first-phase nystagmus.

Vestibular migraine or Meniere's disease: a diagnostic dilemma

Meniere's disease (MD) represents one of the vertigo disorders characterized by triad symptoms (recurrent vertigo, fluctuating hearing loss, tinnitus or ear fullness). The diagnosis of MD relies on the accurate and detailed taking of medical history, and the differentiation between MD and vestibular migraine (VM) is of critical importance from the perspective of the treatment efficacy. VM is a highly prevalent vertigo condition and its typical symptoms (headache, vestibular symptoms, cochlear symptoms) mimic those of MD. Furthermore, the misdiagnosis in MD and VM could lead to VM patients mistakenly receiving the traumatic treatment protocol designed for MD, and sustaining unnecessary damage to the inner ear. Fortunately, thanks to the advances in examination technologies, the barriers to their differentiation are being gradually removed. These advances enhance the diagnostic accuracy of vertigo diseases, especially VM and MD. This review focused on the differentiation of VM and MD, with an attempt to synthesize existing data on the relevant battery of differentiation diagnosis (covering core symptoms, auxiliary tests [audiometry, vestibular tests, endolymphatic hydrops tests]) and longitudinal follow-up. Since the two illnesses are overlapped in all aspects, no single test is sufficiently specific on its own, however, patterns containing all or at least some features boost specificity.

Vestibular assessment in sudden sensorineural hearing loss: Role in the prediction of hearing outcome and in the early detection of vascular and hydropic pathomechanisms

Introduction

Predicting hearing outcome in sudden sensorineural hearing loss (SSNHL) is challenging, as well as detecting the underlying pathomechanisms. SSNHL could be associated with vestibular damage since cochleo-vestibular structures share the same vascularization, along with being in close anatomical proximity. Whereas viral inflammations and autoimmune/vascular disorders most likely represent the involved aetiologies, early-stage Menière's disease (MD) can also present with SSNHL. Since an early treatment could beneficially influence hearing outcome, understanding the possible etiology plays a pivotal role in orienting the most appropriate treatment. We aimed to evaluate the extent of vestibular damage in patients presenting with SSNHL with or without vertigo, investigate the prognostic role of vestibular dysfunctions on hearing recovery and detect specific lesion patterns related to the underlying pathomechanisms.

Methods

We prospectively evaluated 86 patients with SSNHL. Audio-vestibular investigation included pure-tone/speech/impedance audiometry, cervical/ocular-VEMPs, vHIT and video-Frenzel examination. White matter lesions (WML) were evaluated on brain-MRI. Patients were followed-up and divided into "SSNHL-no-vertigo," "SSNHL+vertigo" and "MD" subgroups.

Results

Hearing was more impaired in "SSNHL+vertigo" patients who exhibited either down-sloping or flat-type audiograms, and was less impaired in "MD" where low frequencies were mostly impaired (p < 0.001). Otolith receptors were more frequently involved than semicircular canals (SCs). Although the "SSNHL-no-vertigo" subgroup exhibited the lowest vestibular impairment (p < 0.001), 52% of patients developed otolith dysfunctions and 72% developed nystagmus. Only "MD" subjects showed anterior SC impairment and upbeating spontaneous/positional nystagmus. They more frequently exhibited cervical-VEMPs frequency tuning (p = 0.036) and ipsilesional spontaneous nystagmus (p < 0.001). "SSNHL+vertigo" subjects presented with more frequently impaired cervical-VEMPs and posterior SC and with higher number of impaired receptors (p < 0.001). They mainly exhibited contralesional spontaneous and vibration-induced nystagmus (p < 0.05) and only they showed the highest WML score and "vascular" lesion patterns (p < 0.001). Concerning the outcomes, hearing was better in "MD" and worse in "SSNHL+vertigo" (p < 0.001). Hearing recovery was mostly affected by cervical-VEMPs impairment and the number of involved receptors (p < 0.05). Patients with "vascular" lesion patterns presented with the highest HL degree and WML score (p ≤ 0.001), while none of them exhibited a complete hearing recovery (p = 0.026).

Conclusions

Our data suggest that vestibular evaluation in SSNHL can provide useful information on hearing recovery and underlying aetiologies.

[Vertical nystagmus]

The review article provides a definition and classification of different nystagmus types, a comparative description of the central and peripheral vestibular nystagmus. The pathogenetic patterns of up-beating and down-beating nystagmus are accurately described. The features of nystagmus formation in various diseases are discussed, such as Wernicke encephalopathy, Arnold-Chiari anomaly, spinocerebellar ataxia and vestibular migraine. The authors provide their own data on oculomotor disorders in 100 patients with vestibular migraine and migraine with a brain stem aura. This article considers approaches to treatment: surgical and conservative. In conclusion, was noted the possibility of differentiating the central and peripheral vestibular nystagmus by means of clinical study. As well, the differences between vertical nystagmus associated with organic lesions of the brain stem or cerebellum and transient nystagmus with vestibular migraine are highlighted. The authors note the need for in-depth studies of nystagmus in vestibular migraine patients and methods of dealing with it.

Association between vestibular dysfunction and findings of horizontal head-shaking and vibration-induced nystagmus

BACKGROUND

The association between vestibular function and findings of horizontal head-shaking nystagmus (HHSN) and vibration-induced nystagmus (VIN) tests is not well understood.

OBJECTIVE

To investigate the association between function in the five distinct vestibular end organs and findings of these nystagmus tests.

METHODS

We retrospectively reviewed the medical records of 50 patients with vestibular diseases who underwent HHSN testing, VIN testing, video head impulse testing (vHIT), cervical vestibular evoked myogenic potential testing to air-conducted sound (ACS cVEMP) and ocular VEMP testing to ACS (ACS oVEMP). We performed mixed-effects logistic regression analyses to see whether age, sex or the presence of nystagmus in HHSN or VIN have an association with the presence of peripheral vestibular dysfunction on the opposite side to the direction of nystagmus.

RESULTS

The presence of HHSN had a significant association with abnormal vHIT in the lateral semicircular canal (LSCC) on the opposite side to the direction of nystagmus. The presence of VIN had a significant association with abnormal vHIT in all the SCCs and abnormal ACS oVEMP on the opposite side to the direction of nystagmus.

CONCLUSIONS

HHSN had an association with LSCC dysfunction alone. VIN had an association with dysfunction in all the SCCs and the utricle.

Clinical implications of head-shaking nystagmus in central and peripheral vestibular disorders: is perverted head-shaking nystagmus specific for central vestibular pathology?

BACKGROUND AND PURPOSE

The patterns of head-shaking nystagmus (HSN) aid in differentiation between central and peripheral vestibular disorders, and perverted HSN (pHSN) has been considered a central sign. The aim was to determine the characteristics of HSN in a large number of patients with either peripheral or central vestibular disorders in a dizziness clinic of a university hospital.

METHODS

The medical records of 7544 dizzy patients were reviewed during a year and 822 patients with a clinical diagnosis of vestibular disorders were recruited. The findings of spontaneous nystagmus (SN) and HSN in these patients were compared with those of healthy controls (n = 48).

RESULTS

A total of 217 of the 822 patients (26.4%) were classified as having a central vestibular disorder, whilst 397 (48.3%) had a peripheral vestibular disorder. In the peripheral vestibular disorder group, SN was observed in 14.1% and HSN in 40.8%, amongst whom 24.1% were the pHSN form. In the central group, SN was observed in 17.5% and HSN in 24.0% of whom 57.7% was pHSN. HSN was more frequently observed in the peripheral vestibular disorder group than in the central group (40.8% vs. 24.0%, P < 0.01). However, the proportion of pHSN was significantly increased in the central group compared to the peripheral vestibular patient group (57.7% vs. 24.1%, P < 0.01).

CONCLUSIONS

Since pHSN is not specific for central vestibular disorders, other clinical features should be considered in pursuing a central lesion in patients with pHSN.

Vestibular training promotes adaptation of multisensory integration in postural control

BACKGROUND

Postural stability depends on the integration of the multisensory system to produce motor outputs. When visual and somatosensory input is reliable, this reduces reliance on the vestibular system. Despite this, vestibular loss can still cause severe postural dysfunction. Training one or more of the three sensory systems through vestibular habituation and adaptation can alter sensory weighting and change postural behavior.

AIM

The purpose of this study was to assess sensory reweighting of postural control processing after combined vestibular activation with voluntary weight shift training in healthy adults.

METHODS

Thirty-three healthy individuals (18-35 y.o.) were randomly assigned to one of three groups: No training (control), visual feedback weight shift training (WST) coupled with an active horizontal headshake (HS) activity to elicit a vestibular perturbation, or the same WST without HS (NoHS). Training was performed 2x/day, every other day (M, W, F), totaling six sessions. Pre- and post- assessments on the Sensory Organization Test (SOT) were performed. Separate between- and within- repeated measures ANOVAs were used to analyze the six SOT equilibrium scores, composite scores, sensory ratios and center of pressure (COP) variables by comparing baseline to post-training. Alpha level was set at p < .05.

RESULTS

There was a significant group x session x condition change (p = .012) in the COP multiscale entropy (MSE) velocity sway in the HS group during SOT conditions 5 and 6. Similarly, COP medio-lateral standard deviation sway (ML Std) showed group x session x visual condition (p = .028), due to HS in condition 6 relative to other two groups.

CONCLUSION

Postural training can alter sensory organization after a visual feedback-vestibular activation training protocol, suggesting a possible sensory reweighting through vestibular adaptation and/or habituation.

SIGNIFICANCE

Translating these findings into a vestibular-impaired population can stimulate the design of a rehabilitation balance protocol.

Vestibular processing during natural self-motion: implications for perception and action

How the brain computes accurate estimates of our self-motion relative to the world and our orientation relative to gravity in order to ensure accurate perception and motor control is a fundamental neuroscientific question. Recent experiments have revealed that the vestibular system encodes this information during everyday activities using pathway-specific neural representations. Furthermore, new findings have established that vestibular signals are selectively combined with extravestibular information at the earliest stages of central vestibular processing in a manner that depends on the current behavioural goal. These findings have important implications for our understanding of the brain mechanisms that ensure accurate perception and behaviour during everyday activities and for our understanding of disorders of vestibular processing.

Direction-Changing and Direction-Fixed Positional Nystagmus in Patients With Vestibular Neuritis and Meniere Disease

Objectives

Direction-changing positional nystagmus (PN) was considered to indicate the presence of benign paroxysmal positional vertigo involving lateral semicircular canal in most cases. We investigated the incidence of PN on the supine head-roll test and compared the characteristics of nystagmus in patients with vestibular neuritis (VN) and Meniere disease (MD).

Methods

A retrospective review of patients, who were diagnosed with unilateral VN or unilateral definite MD between September 2005 and November 2011, was conducted. Sixty-five VN patients and 65 MD patients were enrolled. Eye movements were recorded for 30–60 seconds at the positions of sitting, head roll to the right, and head roll to the left, and maximum slow-phase eye velocity was calculated. PN was classified as direction-fixed (paretic or recovery) and direction-changing (geotropic or apogeotropic).

Results

Spontaneous nystagmus was observed in 57 patients (87%, the slow-phase eye velocity of 7°/sec±5°/sec) with acute VN, 39 (60%, 2°/sec±1°/sec) with follow-up VN, and 32 (49%, 2°/sec±2°/sec) with MD. Direction-fixed PN was the most common type. Direction-fixed paretic type was most common in acute VN (80%) and follow-up VN (42%), and direction-fixed recovery type was most common in MD (31%). Paretic type was significantly more common in acute VN (80%) than in follow-up VN (42%) and MD (26%), and the recovery type was significantly more common in MD (31%) than in acute VN (3%) and follow-up VN (14%). Direction-changing PN was more common in MD (22%), followed by follow-up VN (14%) and acute VN (9%).

Conclusion

Though direction-fixed paretic PN was most common in VN and MD patients, direction-changing PN could be observed in a few patients (9%–20%) with peripheral vestibular disorders regardless of the duration from the onset of dizziness, suggesting the presence of otolith-related dizziness.

Direction-reversing Nystagmus in Horizontal and Posterior Semicircular Canal Canalolithiasis

OBJECTIVES

To investigate the incidence and characteristics of direction-reversing nystagmus in patients with horizontal (HSCC) and posterior semicircular canal (PSCC) canalolithiasis, and evaluate the effect of direction-reversing nystagmus on the treatment outcome.

STUDY DESIGN

A retrospective study.

METHODS

Between March 2014 and September 2015, 63 and 92 consecutive patients with HSCC and PSCC canalolithiasis, respectively, were enrolled. Positional nystagmus characteristics were examined using video-nystagmography.

RESULTS

In HSCC canalolithiasis, direction-reversing nystagmus was observed in 73% of patients (46 of 63), of which 19 cases were bilateral and 27 unilateral. In patients with bilateral reversal, maximal slow-phase velocity (mSPV) was significantly greater when the head turned to the lesioned side than to the healthy side in both the first and second phase. In all patients with unilateral reversal, direction-reversing nystagmus always occurred in the side of stronger initial nystagmus in a supine roll test. The mean mSPV of first phase nystagmus was significantly greater on the side with reversal than without (p < 0.001). The duration of second-phase nystagmus exceeded 60 seconds in all patients with reversal. Although not statistically significant (p = 0.059), patients presenting with direction-reversing nystagmus required more repositioning maneuver sessions. In contrast to HSCC canalolithiasis, only 4% of patients (4 of 92) with PSCC canalolithiasis exhibited spontaneous reversal of initial nystagmus.

CONCLUSION

The incidence of direction-reversing nystagmus was higher in HSCC canalolithiasis than in PSCC canalolithiasis, and second-phase (direction-reversing) nystagmus in HSCC canalolithiasis has a prolonged duration. Short-term adaptation of the vestibulo-ocular reflex may be responsible for the development of direction-reversing nystagmus.

Envelope statistics of self-motion signals experienced by human subjects during everyday activities: Implications for vestibular processing

There is accumulating evidence that the brain's neural coding strategies are constrained by natural stimulus statistics. Here we investigated the statistics of the time varying envelope (i.e. a second-order stimulus attribute that is related to variance) of rotational and translational self-motion signals experienced by human subjects during everyday activities. We found that envelopes can reach large values across all six motion dimensions (~450 deg/s for rotations and ~4 G for translations). Unlike results obtained in other sensory modalities, the spectral power of envelope signals decreased slowly for low (< 2 Hz) and more sharply for high (>2 Hz) temporal frequencies and thus was not well-fit by a power law. We next compared the spectral properties of envelope signals resulting from active and passive self-motion, as well as those resulting from signals obtained when the subject is absent (i.e. external stimuli). Our data suggest that different mechanisms underlie deviation from scale invariance in rotational and translational self-motion envelopes. Specifically, active self-motion and filtering by the human body cause deviation from scale invariance primarily for translational and rotational envelope signals, respectively. Finally, we used well-established models in order to predict the responses of peripheral vestibular afferents to natural envelope stimuli. We found that irregular afferents responded more strongly to envelopes than their regular counterparts. Our findings have important consequences for understanding the coding strategies used by the vestibular system to process natural second-order self-motion signals.

Clinical Correlation between Perverted Nystagmus and Brain MRI Abnormal Findings

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.