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Strupp M, Bisdorff A, Furman J, Hornibrook J, Jahn K, Maire R, Newman-Toker D, Magnusson M. Acute unilateral vestibulopathy/vestibular neuritis: Diagnostic criteria. J Vestib Res 2022; 32:389-406. [PMID: 35723133 PMCID: PMC9661346 DOI: 10.3233/ves-220201] [Citation(s) in RCA: 63] [Impact Index Per Article: 31.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This paper describes the diagnostic criteria for Acute Unilateral Vestibulopathy (AUVP), a synonym for vestibular neuritis, as defined by the Committee for the Classification of Vestibular Disorders of the Bárány Society. AUVP manifests as an acute vestibular syndrome due to an acute unilateral loss of peripheral vestibular function without evidence for acute central or acute audiological symptoms or signs. This implies that the diagnosis of AUVP is based on the patient history, bedside examination, and, if necessary, laboratory evaluation. The leading symptom is an acute or rarely subacute onset of spinning or non-spinning vertigo with unsteadiness, nausea/vomiting and/or oscillopsia. A leading clinical sign is a spontaneous peripheral vestibular nystagmus, which is direction-fixed and enhanced by removal of visual fixation with a trajectory appropriate to the semicircular canal afferents involved (generally horizontal-torsional). The diagnostic criteria were classified by the committee for four categories: 1. "Acute Unilateral Vestibulopathy", 2. "Acute Unilateral Vestibulopathy in Evolution", 3. "Probable Acute Unilateral Vestibulopathy" and 4. "History of Acute Unilateral Vestibulopathy". The specific diagnostic criteria for these are as follows:"Acute Unilateral Vestibulopathy": A) Acute or subacute onset of sustained spinning or non-spinning vertigo (i.e., an acute vestibular syndrome) of moderate to severe intensity with symptoms lasting for at least 24 hours. B) Spontaneous peripheral vestibular nystagmus with a trajectory appropriate to the semicircular canal afferents involved, generally horizontal-torsional, direction-fixed, and enhanced by removal of visual fixation. C) Unambiguous evidence of reduced VOR function on the side opposite the direction of the fast phase of the spontaneous nystagmus. D) No evidence for acute central neurological, otological or audiological symptoms. E) No acute central neurological signs, namely no central ocular motor or central vestibular signs, in particular no pronounced skew deviation, no gaze-evoked nystagmus, and no acute audiologic or otological signs. F) Not better accounted for by another disease or disorder."Acute Unilateral Vestibulopathy in Evolution": A) Acute or subacute onset of sustained spinning or non-spinning vertigo with continuous symptoms for more than 3 hours, but not yet lasting for at least 24 h hours, when patient is seen; B) - F) as above. This category is useful for diagnostic reasons to differentiate from acute central vestibular syndromes, to initiate specific treatments, and for research to include patients in clinical studies."Probable Acute Unilateral Vestibulopathy": Identical to AUVP except that the unilateral VOR deficit is not clearly observed or documented."History of acute unilateral vestibulopathy": A) History of acute or subacute onset of vertigo lasting at least 24 hours and slowly decreasing in intensity. B) No history of simultaneous acute audiological or central neurological symptoms. C) Unambiguous evidence of unilaterally reduced VOR function. D) No history of simultaneous acute central neurological signs, namely no central ocular motor or central vestibular signs and no acute audiological or otological signs. E) Not better accounted for by another disease or disorder. This category allows a diagnosis in patients presenting with a unilateral peripheral vestibular deficit and a history of an acute vestibular syndrome who are examined well after the acute phase.It is important to note that there is no definite test for AUVP. Therefore, its diagnosis requires the exclusion of central lesions as well as a variety of other peripheral vestibular disorders. Finally, this consensus paper will discuss other aspects of AUVP such as etiology, pathophysiology and laboratory examinations if they are directly relevant to the classification criteria.
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Affiliation(s)
- Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, Hospital of the Ludwig Maximilians University, Munich, Marchioninistrasse, Munich, Germany,Corresponding author: Michael Strupp, MD, FRCP, FAAN, FANA, FEAN, Dept. of Neurology and German Center for Vertigo and Balance Disorders, Hospital of the Ludwig Maximilians University, Munich, Marchioninistrasse 15, 81377 Munich, Germany. Tel.: +49 89 44007 3678; Fax: +49 89 44007 6673; E-mail:
| | - Alexandre Bisdorff
- Clinique du Vertige, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg
| | - Joseph Furman
- Department of Otolaryngology, Neurology, Bioengineering and Physical Therapy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeremy Hornibrook
- Departments of Otolaryngology - Head and Neck Surgery, Christchurch Hospital, University of Canterbury and University of Otago, Christchurch, New Zealand
| | - Klaus Jahn
- Department of Neurology, Schoen Clinic Bad Aibling, Bad Aibling, Germany and German Center for Vertigo and Balance Disorders, Ludwig-Maximilians University, Campus Grosshadern, Munich, Germany
| | - Raphael Maire
- Department of Otorhinolaryngology/Head & Neck Surgery, Lausanne University Hospital, Lausanne, Switzerland
| | - David Newman-Toker
- Ophthalmology, Otolaryngology and Emergency Medicine, The Johns Hopkins University School of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Måns Magnusson
- Department of Otorhinolaryngology, Lund University, Lund, Sweden
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Mantokoudis G, Korda A, Zee DS, Zamaro E, Sauter TC, Wagner F, Caversaccio MD. Bruns' nystagmus revisited: A sign of stroke in patients with the acute vestibular syndrome. Eur J Neurol 2021; 28:2971-2979. [PMID: 34176187 PMCID: PMC8456911 DOI: 10.1111/ene.14997] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 06/24/2021] [Indexed: 11/29/2022]
Abstract
Objective Gaze‐evoked nystagmus (GEN) is a central sign in patients with the acute vestibular syndrome (AVS); however, discriminating between a pathological and a physiologic GEN is a challenge. Here we evaluate GEN in patients with AVS. Methods In this prospective cross‐sectional study, we used video‐oculography (VOG) to compare GEN in the light (target at 15° eccentric) in 64 healthy subjects with 47 patients seen in the emergency department (ED) who had AVS; 35 with vestibular neuritis and 12 with stroke. All patients with an initial non‐diagnostic MRI received a confirmatory, delayed MRI as a reference standard in detecting stroke. Results Healthy subjects with GEN had a time constant of centripetal drift >18 s. VOG identified pathologic GEN (time constant ≤ 18 s) in 33% of patients with vestibular strokes, specificity was 100%, accuracy was 83%. Results were equivalent to examination by a clinical expert. As expected, since all patients with GEN had a SN in straight‐ahead position, they showed the pattern of a Bruns’ nystagmus. Conclusions One third of patients with AVS due to central vestibular strokes had a spontaneous SN in straight‐ahead gaze and a pathological GEN, producing the pattern of a Bruns’ nystagmus with a shift of the null position. The localization of the side of the lesion based on the null was not consistent, presumably because the circuits underlying gaze‐holding are widespread in the brainstem and cerebellum. Nevertheless, automated quantification of GEN with VOG was specific, and accurately identified patients in the ED with AVS due to strokes.
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Affiliation(s)
- Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - David S Zee
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ewa Zamaro
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas C Sauter
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Franca Wagner
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marco D Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Lädrach C, Zee DS, Wyss T, Wimmer W, Korda A, Salmina C, Caversaccio MD, Mantokoudis G. Alexander's Law During High-Speed, Yaw-Axis Rotation: Adaptation or Saturation? Front Neurol 2020; 11:604502. [PMID: 33329363 PMCID: PMC7719745 DOI: 10.3389/fneur.2020.604502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 10/02/2020] [Indexed: 11/13/2022] Open
Abstract
Objective: Alexander's law (AL) states the intensity of nystagmus increases when gaze is toward the direction of the quick phase. What might be its cause? A gaze-holding neural integrator (NI) that becomes imperfect as the result of an adaptive process, or saturation in the discharge of neurons in the vestibular nuclei? Methods: We induced nystagmus in normal subjects using a rapid chair acceleration around the yaw (vertical) axis to a constant velocity of 200°/second [s] and then, 90 s later, a sudden stop to induce post-rotatory nystagmus (PRN). Subjects alternated gaze every 2 s between flashing LEDs (right/left or up/down). We calculated the change in slow-phase velocity (ΔSPV) between right and left gaze when the lateral semicircular canals (SCC) were primarily stimulated (head upright) or, with the head tilted to the side, stimulating the vertical and lateral SCC together. Results: During PRN AL occurred for horizontal eye movements with the head upright and for both horizontal and vertical components of eye movements with the head tilted. AL was apparent within just a few seconds of the chair stopping when peak SPV of PRN was reached. When slow-phase velocity of PRN faded into the range of 6-18°/s AL could no longer be demonstrated. Conclusions: Our results support the idea that AL is produced by asymmetrical responses within the vestibular nuclei impairing the NI, and not by an adaptive response that develops over time. AL was related to the predicted plane of eye rotations in the orbit based on the pattern of SCC activation.
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Affiliation(s)
- Claudia Lädrach
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital Bern, Bern, Switzerland
| | - David S Zee
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Thomas Wyss
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital Bern, Bern, Switzerland
| | - Wilhelm Wimmer
- Hearing Research Laboratory, ARTORG Center, University of Bern, Bern, Switzerland
| | - Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital Bern, Bern, Switzerland
| | - Cinzia Salmina
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital Bern, Bern, Switzerland
| | - Marco D Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital Bern, Bern, Switzerland
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