Understanding Factors That Cause Benign Paroxysmal Positional Vertigo, Ménière Disease, and Vestibular Neuritis: A Two-Sample Mendelian Randomization Study

OBJECTIVES

Vertigo is a prevalent clinical symptom, frequently associated with benign paroxysmal positional vertigo (BPPV), Ménière disease (MD), and vestibular neuritis (VN), which are three common peripheral vestibular disorders. However, there is a relative lack of research in epidemiology and etiology, with some existing studies presenting discrepancies in their conclusions. We conducted a two-sample Mendelian randomization (MR) analysis to explore potential risk and protective factors for these three peripheral vestibular disorders.

DESIGN

Based on genome-wide association studies, we executed a univariable MR to investigate the potential associations between 38 phenotypes and MD, BPPV, and VN. We used the inverse variance weighted method as the primary MR result and conducted multiple sensitivity analyses. We used false discovery rate (FDR) correction to control for type I errors. For findings that were significant in the univariable MR, a multivariable MR analysis was implemented to ascertain direct effects. In addition, we replicated analyses of significant results from the univariable MR to enhance the robustness of our analyses.

RESULTS

For BPPV, both alcohol consumption (odds ratio [OR] = 0.57, 95% confidence interval [CI] = 0.43 to 0.76, FDR Q = 0.004) and educational attainment (OR = 0.77, 95% CI = 0.68 to 0.88, FDR Q = 0.003) were found to decrease the risk. The genetic prediction analysis identified major depression (OR = 1.75, 95% CI = 1.28 to 2.39, FDR Q = 0.008) and anxiety (OR = 5.25, 95% CI = 1.79 to 15.42, FDR Q = 0.036) increased the risk of MD. However, the impact of major depression on MD could be influenced by potential horizontal pleiotropy. Systolic blood pressures (OR = 1.03, 95% CI = 1.02 to 1.04, FDR Q = 4.00 × 10-7) and diastolic blood pressures (OR = 1.05, 95% CI = 1.03 to 1.07, FDR Q = 2.83 × 10-6) were associated with an increased risk of VN, whereas high-density lipoprotein (OR = 0.77, 95% CI = 0.67 to 0.89, FDR Q = 0.009) and urate (OR = 0.75, 95% CI = 0.63 to 0.91, FDR Q = 0.041) reduces the risk of VN. Only the relationship between urate and VN was not replicated in the replication analysis. Multivariable MR showed that the protective effect of education on BPPV was independent of Townsend deprivation index. The protective effect of high-density lipoprotein against VN was independent of triglycerides and apolipoprotein A1. The risk impacts of systolic and diastolic blood pressures on VN exhibited collinearity, but both are independent of chronic kidney disease and estimated glomerular filtration rate. The impacts of anxiety and severe depression on MD demonstrated collinearity.

CONCLUSIONS

Our study identified the risk association between systolic and diastolic blood pressure with VN and the protective influence of high-density lipoprotein on VN, which may support the vascular hypothesis underlying VN. Furthermore, we observed an elevated risk of MD associated with anxiety. The potential protective effects of education and alcohol consumption on BPPV need further exploration in subsequent studies to elucidate specific mechanistic pathways. In summary, our MR study offers novel insights into the etiology of three peripheral vestibular diseases from a genetic epidemiological standpoint.

Association of Peripheral Vestibular Disorder with Diabetes: A Population-Based Study

BACKGROUND

This study aimed to investigate the association of peripheral vestibular disorders with type 1 and type 2 diabetes using a population-based dataset.

METHODS

The data for this study were obtained from Taiwan's Longitudinal Health Insurance Database 2010. The sample consisted of 150,916 patients who were newly diagnosed with peripheral vestibular disorders as cases and 452,748 propensity-score-matching controls without peripheral vestibular disorders. We utilized multivariate logistic regression models to quantitatively evaluate the association between peripheral vestibular disorders and diabetes while considering factors such as sex, age, geographic location, monthly income, urbanization level of the patient's residence, coronary heart disease, hypertension, and hyperlipidemia.

RESULTS

The chi-squared test indicates that diabetes was more common in the peripheral vestibular disorder group compared to controls (20.6% vs. 15.1%, p < 0.001). Of all sampled patients, the adjusted odds ratio for diabetes was 1.597 (95% CI = 1.570~1.623) for those with peripheral vestibular disorders when compared to controls, while patients with Ménière's disease, benign paroxysmal positional vertigo, unilateral vestibulopathy, and other peripheral vestibular disorders had respective adjusted odds ratios of diabetes at 1.566 (95% CI = 1.498~1.638), 1.677 (95% CI = 1.603~1.755), 1.592 (95% CI = 1.504~1.685), and 1.588 (95% CI = l.555~1.621) in comparison to controls.

CONCLUSIONS

Our research has revealed an association between diabetes and an increased susceptibility to peripheral vestibular disorders.

Epidemiology and Comorbidities of Vestibular Disorders: Preliminary Findings of the AVOCADO Study

INTRODUCTION

Studies on incidence and prevalence of vestibular disorders tend to focus on small pockets of patients recruited from specialized clinics and often exclude measures of vestibular function. The objectives of the study were to characterize patients with common vestibular disorders, estimate the prevalence of common vestibular disorders, and ascertain whether patients with vestibular disorders experience increased risks of falls and morbidity.

MATERIALS AND METHODS

This retrospective cohort study includes both inpatient and outpatient routine clinical care data culled from a nationally representative, population-based sample. Patients were included if their record in the TriNetX Diamond Cohort comprised at least one vestibular function test or vestibular diagnosis. The main outcome measures were diagnosis with a vestibular disorder, a fall, or a common medical comorbidity (e.g., diabetes, cerebrovascular disease).

RESULTS

The cohort includes n = 4,575,724 patients, of which 55% (n = 2,497,136) had a minimum of one vestibular diagnosis. Patients with vestibular diagnoses were 61.3 ± 16.6 years old (mean ± standard deviation), 67% women, 28% White race (69% unknown race), and 30% of non-Hispanic or Latino ethnicity (66% unknown ethnicity). The prevalence of vestibular disorders was estimated at 2.98% (95% confidence interval [CI]: 2.98-2.98%). Patients with vestibular diagnoses experienced a significantly greater odds of falls (odds ratio [OR] = 1.04; 95% CI: 1.02-1.05), cerebrovascular disease (OR = 1.42; 95% CI: 1.40-1.43), ischemic heart disease (OR = 1.17; 95% CI: 1.16-1.19), and diabetes (OR = 1.14; 95% CI: 1.13-1.15), among others.

DISCUSSION

Vestibular disorders affect an estimated 3% of the U.S. population, after weighting. Patients with these disorders are at greater risk for many common, consequential medical conditions.

Clinical Significance of Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio in Acute Unilateral Vestibulopathy

BACKGROUND AND PURPOSE

The neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) have been identified as useful biomarkers for assessing the inflammatory response and for predicting the prognosis of various diseases. This study aimed to determine the clinical significance and effects on prognostic prediction of NLR and PLR in acute unilateral vestibulopathy (AUV).

METHODS

We retrospectively recruited 128 patients who were diagnosed with AUV from July 2016 to April 2021, and compared NLR and PLR values between these patients with AUV and age- and sex-matched healthy subjects. We also analyzed the correlations of various clinical parameters with NLR and PLR.

RESULTS

NLR and PLR in the AUV group were 3.41±2.80 (mean±standard deviation) and 128.86±67.06, respectively, with only NLR being significantly higher than that in the control group (1.55±0.60, p<0.001). The gain asymmetry of the horizontal vestibulo-ocular reflex (VOR) was slightly larger in patients with high NLR (n=52) than in those with normal NLR (n=76) (41.9%±20.2% vs. 33.6%±17.4%, p=0.048). However, the hospitalization period, preceding infection, canal paresis, and absolute horizontal VOR gain did not differ between patients with high and normal NLR and PLR values. The correlation analyses also revealed that none of the clinical parameters were significantly correlated with NLR or PLR. At 3-month follow-up examinations, NLR and PLR did not differ significantly between patients with and without function recovery of the horizontal VOR.

CONCLUSIONS

This study found a high NLR in AUV, suggesting an acute inflammatory status in the vestibular organ. However, the usefulness of NLR and PLR as prognostic markers remains unclear.

Increased prevalence of peripheral vestibular disorder among patients with Fabry disease

BACKGROUND

Although peripheral vestibular disorder is a non-fatal complication of Fabry disease, fatalities have been reported in some case reports and case series. To date, no studies have examined the relative risk of peripheral vestibular disorder in patients with Fabry disease compared to the general population without the condition. Due to the high prevalence of Fabry disease in East Asia and the potential shared pathogenic pathways between Fabry disease and vasculopathy, we conducted a study using a nationwide population-based dataset to compare the prevalence of peripheral vestibular disorder between patients with Fabry disease and matched comparison patients.

METHODS

Data was sourced from Taiwan's Longitudinal Health Insurance Database 2010. this study consists of 11,668 sampled patients, 2917 study patients with Fabry disease and 8751 propensity-score-matching comparison patients. We conducted multiple logistic regression analysis to study the association between peripheral vestibular disorder and Fabry disease.

RESULTS

The study identified notable differences in the prevalence of various vestibular disorders between the study and comparison groups. Specifically, there was a 7.2% increased prevalence of peripheral vestibular disorder in the study group (28.3%) compared to the comparison group (20.9%), Meniere's disease (5.4% vs. 3.7%), benign paroxysmal positional vertigo (5.1% vs. 3.3%), and other/ unspecified peripheral vestibular dizziness (15.6% vs. 11.8%) (all p < 0.001). The odds ratios for PVD, MD, BPPV, and other PVD were 1.44 (95% CI = 1.29-1.60), 1.50 (95% CI = 1.23-1.83), 1.59 (95% CI = 1.30-1.95), and 1.40 (95% CI = 1.24-1.58), respectively, among the Fabry disease group relative to the comparison group after adjusting for age, monthly income, geographic location, urbanization level, hyperlipidemia, diabetes, coronary heart disease, and hypertension.

CONCLUSION

This study found that patients with Fabry disease had increased prevalence of peripheral vestibular disorder.

Pharmacological Treatment of Acute Unilateral Vestibulopathy: A Review

There have been few investigations on the epidemiology, etiology, and medical management of acute unilateral vestibulopathy (AUV). Short-term pharmaceutical resolutions include vestibular symptomatic suppressants, anti-emetics, and some cause-based therapies. Anticholinergics, phenothiazines, antihistamines, antidopaminergics, benzodiazepines, and calcium channel antagonists are examples of vestibular suppressants. Some of these medications may show their effects through multiple mechanisms. In contrast, N-acetyl-L-leucine, Ginkgo biloba, and betahistine improve central vestibular compensation. Currently, AUV pathophysiology is poorly understood. Diverse hypotheses have previously been identified which have brought about some causal treatments presently used. According to some publications, acute administration of anti-inflammatory medications may have a deleterious impact on both post-lesional functional recovery and endogenous adaptive plasticity processes. Thus, some authors do not recommend the use of corticosteroids in AUV. Antivirals are even more contentious in the context of AUV treatment. Although vascular theories have been presented, no verified investigations employing anti-clotting or vasodilator medications have been conducted. There are no standardized treatment protocols for AUV to date, and the pharmacological treatment of AUV is still questionable. This review addresses the most current developments and controversies in AUV medical treatment.

Effects of vestibular rehabilitation training combined with anti-vertigo drugs on vertigo and balance function in patients with vestibular neuronitis: a systematic review and meta-analysis

Objective

To investigate the effects of vestibular rehabilitation training (VRT) combined with anti-vertigo drugs on vertigo and balance function in patients with vestibular neuronitis (VN).

Data sources

PubMed, EMBASE, The Cochrane Library, Web of Science, CNKI, Wan Fang Data, VIP, and CBM were searched until July 13, 2023.

Participants

Patients with vestibular neuronitis participated in the study.

Results

Twenty one studies including 1,415 patients were included in this review for meta-analysis. According to the Physiotherapy Evidence Database (PEDro) quality assessment, four studies received high quality (≥seven scores) and 17 studies received moderate quality (six scores). The meta-analysis showed that VRT combined with anti-vertigo drugs significantly reduced the Dizziness Handicap Inventory (DHI) score, the Vestibular Disorders Activities of Daily Living Scale (VADL) score and the Canal Paresis (CP) score, and improved the overall efficiency and the Berg Balance Scale (BBS) score, promoting vestibular evoked myogenic potentials (VEMPs) returned to normal in VN compared to simple anti-vertigo drugs or VRT alone.

Conclusion

The results of this meta-analysis demonstrate the efficacy and safety of VRT combined with anti-vertigo drugs in patients with VN. Combined therapy can alleviate vestibular dysfunction such as vertigo and vomiting in patients, improve daily activity ability and balance ability, in addition to VRT has fewer adverse reactions, so it is extremely safe. However, there are shortcomings such as lack of long-term follow-up and different frequency and duration of treatment. Therefore, future randomized controlled trials (RCTs) with larger sample sizes and longer-term observations are needed to verify the effectiveness of VRT in combination with anti-vertigo drugs for VN.Systematic Review Registration: https://www.crd.york.ac.uk/prospero/.

Clinical Features and Neurotologic Findings in Patients With Acute Unilateral Peripheral Vestibulopathy Associated With Antiganglioside Antibody

BACKGROUND AND OBJECTIVES

Anecdotal studies have reported the presence of antiganglioside antibodies in acute unilateral peripheral vestibulopathy (AUPV). This study aimed to determine the prevalence, clinical characteristics, and neurotologic findings of AUPV associated with antiganglioside antibodies.

METHODS

Serum antigangliosides were measured in consecutive patients with AUPV according to the Bárány Society criteria during the acute and recovery phases in a referral-based university hospital in South Korea from September 2019 to January 2023. Clinical characteristics and neurotologic findings were compared between those with and without antiganglioside antibodies. The results of video-oculography, video head impulse and bithermal caloric tests, and other neurotologic evaluations including ocular and cervical vestibular-evoked myogenic potentials and subjective visual vertical were compared between the 2. MRIs dedicated to the inner ear were also conducted when considered necessary.

RESULTS

One hundred five patients (mean age ± SD = 60 ± 13 years, 57 male) were included for analyses. During the acute phase, 12 patients (12/105, 11%) were tested positive for serum antiganglioside antibodies, including anti-GQ1b immunoglobulin (Ig) G (n = 5) or IgM (n = 4), anti-GM1 IgM (n = 3), and anti-GD1a IgG (n = 1, including 1 patient with a positive anti-GQ1b antibody). Patients with antiganglioside antibodies showed lesser intensity of spontaneous nystagmus (median [interquartile range] = 1.8 [1.2-2.1] vs 3.4 [1.5-9.5], p = 0.003) and a lesser degree of canal paresis (30 [17-47] vs 58 [34-79], p = 0.028) and gain asymmetry of the vestibulo-ocular reflex for the horizontal semicircular canal during head impulse tests (0.07 [-0.04 to 0.61] vs 0.36 [0.18-0.47], p = 0.032) than those without antibodies. Negative conversion of antibodies and vestibular recovery were observed in most patients (6/8, 75%). Among 30 patients with AUPV with 4-hour delayed 3D fluid-attenuated inversion recovery dedicated to the inner ear, gadolinium enhancement was observed in 18 (18/30, 60%), either in the vestibule (n = 9), semicircular canal (n = 6), or vestibular nerve (n = 5). The positivity rates based on specific antibodies could not be determined due to limited sample sizes.

DISCUSSION

The association between antiganglioside antibodies and AUPV suggests an immune-mediated mechanism in acute vestibular failure and extends the clinical spectrum of antiganglioside antibody syndrome.

Objective Neurological Testing Methods Used to Follow Up Vestibular Neuritis Depending on Different Factors

Purpose

We analyze the impact of different factors on clinical performance and prognosis in vestibular neuritis (VN) and explore indicators that could accurately reflect changes in patients' symptoms at different stages.

Methods

We observed patients with VN during the acute and recovery phases. Clinical symptoms, vertigo-related scales, neurological examination, vestibular function tests (caloric test, video head impulse test (vHIT), vestibular evoked myogenic potential (VEMP)), and the history of disease (underlying diseases, glucocorticoid therapy) were recorded at onset and at 4 and 12 weeks after onset in VN patients. Multiple linear regression analysis was used to identify vestibular function tests that had a linear regression relationship with the subjective quantitative results.

Results

At 4 weeks after onset, the group without underlying disease had better improvement in EEV, gain, and UW than the group with underlying disease (P < 0.05). There was a significant difference in the change in DHI, EEV, gain of the affected horizontal semicircular canal in the vHIT and unilateral weakness (UW) between the glucocorticoid treatment group and the no glucocorticoid treatment group (P < 0.05), and glucocorticoid treatment group was better. The change value in the gain of horizontal canals in the vHIT was mainly positively and linearly correlated with the EEV scores (P<0.001). Possible dynamic correlation between vHIT results and vestibular symptoms.

Conclusion

The absence of underlying disease and the receipt of glucocorticoid therapy significantly contributed to the improvement of objective vestibular function tests in the short term, while the improvement of subjective vertigo may correlate with the different objective measures and questionnaire. We believe that the improvement of the affected horizontal semicircular canal gain value in the vHIT can be used as a reference indicator of the degree of improvement of vestibular symptoms with superior vestibular neuritis.

Higher Cardio-Ankle Vascular Index Values in Patients With Vestibular Neuritis May Indicate a Better Prognosis

BACKGROUND

The presumed etiology of vestibular neuritis (VN), a sudden onset of spontaneous vertigo without auditory or cranial nerve symptoms, includes viral infections and vascular disorders. However, no clinical test for estimating vascular disorders in VN has been reported. Moreover, estimating the etiology of VN is important to predict the prognosis and select appropriate treatment. This study aimed to evaluate the cardio-ankle vascular index (CAVI), which reflects arterial stiffness and elasticity, as an additional indicator for estimating the prognosis and etiology of VN.

MATERIALS AND METHODS

Among 207 consecutive patients with suspected VN, 88 patients diagnosed with definite VN were enrolled. Age, initial and final percent canal paresis (CP) in the caloric test, CAVI, presence or absence of vestibular-evoked myogenic potential asymmetry, and medical history were evaluated using univariate and multivariate analyses.

RESULTS

Patients with VN with high CAVI had a better prognosis than those with low CAVI. High CAVI was a factor for improvement in percent CP, in addition to younger age and less severe initial percent CP in the Cox proportional hazard model.

CONCLUSION

CAVI can be an additional indicator for estimating the prognosis and etiology of VN. This indicator can potentially be applied to other diseases, including vascular disorders with other etiologies.

Influence of Age and Cardiovascular Risk Factors in Vestibular Neuritis: Retrospective Cohort Study

To analyze the influence of age and cardiovascular risk factors (CVRFs) in the evolution of vestibular neuritis (VN).

METHODS

Retrospective cohort study. VN-diagnosed patients were included and divided into two groups: those with and without CVRFs. We analyzed the mean vestibular-ocular reflex (VOR) gain, measured through the video head impulse test (vHIT) at the diagnosis and one-year follow-up. We conducted a factorial analysis of variance (ANOVA) to evaluate the effect of age, sex, and CVRFs in the mean VOR gain.

RESULTS

Sixty-three VN-diagnosed patients were included. There were no statistically significant differences in the mean VOR gain between both groups. However, in the subgroup analysis, there were statistically significant differences when comparing the mean VOR gain at the one-year follow-up between the group over 55 years of age 0.77 ± 0.20 and the group under 55 years 0.87 ± 0.15 (p = 0.036). Additionally, the factorial ANOVA demonstrated a significant main effect of age group on the mean VOR gain at the one-year follow-up (p = 0.018), and it also found a significant interaction between the factors of gender, age group, HTN (p = 0.043).

CONCLUSIONS

CVRFs do not independently affect the mean VOR gain in VN patients' follow-ups. However, age significantly impacts VOR gain in VN and could be modulated by gender and hypertension.

A Retrospective Study of the Relationship Between Hypertension and Vestibular Disorders in Middle-Aged Women With and Without HIV

BACKGROUND

Patients often conflate the problem of lightheadedness from hypertension (HTN) and vertigo from a vestibular impairment, describing both problems as dizziness. The goal of the study was to learn if there is a relationship between measures of vestibular function and blood pressure.

METHODS

This retrospective study consisted of women who participated in a longitudinal study of the human immunodeficiency virus (HIV) and a control cohort of age-matched women without HIV. We used data from the point in time when participants were tested for vestibular functions with bi-thermal caloric tests and cervical vestibular evoked myogenic potentials; the data also included the blood pressure of the participants.

RESULTS

High odds ratios (1.48 to 2.05) suggest a relationship between HTN and vestibular impairment, although the sample size was too small to reach statistical significance.

CONCLUSION

The data suggest that high blood pressure may be related to vestibular impairments. Clinicians whose patients complain of vertigo and balance disorders consistent with vestibular impairments should consider blood pressure as a related problem during the initial visit.

Research progress on vestibular dysfunction and visual-spatial cognition in patients with Alzheimer's disease

Alzheimer's disease (AD) or vestibular dysfunction may impair visual-spatial cognitive function. Recent studies have shown that vestibular dysfunction is increasingly common in patients with AD, and patients with AD with vestibular impairment show more visual-spatial cognitive impairment. By exploring the relationship and interaction mechanism among the vestibular system, visual-spatial cognitive ability, and AD, this study aims to provide new insights for the screening, diagnosis, and rehabilitation intervention of patients with AD. In contrast, routine vestibular function tests are particularly important for understanding the vestibular function of patients with AD. The efficacy of vestibular function test as a tool for the early screening of patients with AD must also be further studied. Through the visual-spatial cognitive ability test, the "spatial impairment" subtype of patients with AD, which may be significant in caring for patients with AD to prevent loss and falls, can also be determined. Additionally, the visual-spatial cognitive ability test has great benefits in preventing and alleviating cognitive decline of patients with AD.

Cardiovascular risk factors among patients with acute unilateral inner ear hypofunction: A case-control study

Objectives

To assess the prevalence of cardiovascular risk factors (CVRFs) and their impact on acute unilateral inner ear hypofunction (AUIEH), including acute unilateral peripheral vestibulopathy (AUPVP), sudden sensorineural hearing loss (SSNHL) and acute unilateral audiovestibular hypofunction (AUAVH).

Methods

One hundred and twenty-five patients consecutively diagnosed with AUPVP, SSNHL or AUAVH and 250 sex- and age-matched controls were included. Cases presented a mean age of 58.6 ± 14.7 years and included 59 women and 66 men. The correlation between CVRFs (high blood pressure [HBP], diabetes mellitus [DM], dyslipidemia [DLP], cardiocerebrovascular disease [CCVD]) and AUIEH was assessed by multivariate conditional logistic regression analysis.

Results

A higher prevalence of CVRFs was identified in patients than in controls (30 individuals with DM, 53 with HBP, 45 with DLP and 14 with a previous history of CCVD, p < .05). A significantly elevated risk of AUIEH was found in patients with two or more CVRFs (adjusted odds ratio [OR] 5.11; 95% CI 2.23-11.70). Previous CCVD individually predicted AUIEH (OR 8.41; 95% CI 2.36-29.88). Subgroup analysis showed the same tendency for AUPVP and SSNHL.

Conclusion

Acute unilateral inner ear hypofunction patients presented significantly more CVRFs than controls, and the presence of two or more CVRFs was associated with AUIEH. Future studies evaluating vascular risk in AUIEH may include AUPVP and SSNHL patients from the same source population to better characterize risk profiles that can indicate a vascular origin.

Level of Evidence

3b.

Risk of Future Stroke in Patients with a Diagnosis of Peripheral Vertigo in the Emergency Department

BACKGROUND

We evaluated the temporal characteristics of stroke risks in the emergency department patients who had a diagnosis of peripheral vertigo. We also attempted to reveal the stroke risk factor among those with peripheral vertigo.

METHODS

This is a parallel group cohort study in a tertiary referral hospital. After assigning each of matched 4367 patients to the comparative set of peripheral vertigo and appendicitis-ureterolithiasis groups and each of matched 4911 to the comparative set of peripheral vertigo and ischemic stroke groups, we evaluated the relative stroke risk. In addition, to predict the individual stroke risk in patients with peripheral vertigo, any association between the demographic factors and stroke events was evaluated in the peripheral vertigo group.

RESULTS

The peripheral vertigo group had a higher stroke risk than the appendicitis-ureterolithiasis group (HR=1.73, 95% CI=1.18-2.55) but a lower risk than the ischemic stroke group (HR=0.30, 95% CI=0.24-0.37). The stroke risk of the peripheral vertigo group was just below that of small vessel stroke. The stroke risk of the peripheral vertigo group differed markedly by time: higher within seven days, moderate between seven days and one year, and diminished thereafter. Old age (>65), male gender, and diabetes mellitus were the risk factors for stroke in the peripheral vertigo group.

CONCLUSION

Patients with a diagnosis of peripheral vertigo in the ED showed a moderate future stroke risk so that requires a stroke preventive strategy tailored to the timing of symptom onset and individual risk.

Monthly and seasonal variations in vestibular neuritis

Seasonal variations in vestibular neuritis (VN) could support the etiology of viral infection. However, several recent studies revealed no significant seasonal variations in VN. Further studies are necessary to determine the etiology of VN. We analyzed patients with VN to evaluate monthly and seasonal variations. Patients with VN who visited our otorhinolaryngology department or were referred to our department from the emergency department between March 2014 and February 2019 were included retrospectively in this study. Differences among the months and seasons of VN visits were analyzed. Patients were divided into 2 groups according to sex and age (65 years or older and younger than 65 years). Differences among the months and seasons of VN visits were analyzed between groups. There were no significant differences in monthly and seasonal distributions in 248 patients with VN. There were also no significant differences in monthly and seasonal distributions in male and female patients or in older and younger patients. There were no significant differences in monthly or seasonal distributions of patients with VN. Factors other than viruses, such as vascular ischemia, should also be considered in the incidence of VN, especially in older patients.

Cerebral Small Vessel Disease in Elderly Patients With Vestibular Neuritis

Background

Acute audiovestibular loss is a neurotologic emergency of which the etiology is frequently unknown. In vestibular neuritis a viral genesis is expected, although there is insufficient evidence to support viruses as the only possible etiological factor. In sudden deafness, a vascular etiology has been proposed in elderly patients, since cardiovascular risk factors are more frequently present and a higher risk of developing a stroke was seen compared to the general population. So far, very little research has been carried out on vascular involvement in elderly patients with vestibular neuritis. Cardiovascular risk factors have a positive correlation with cerebral small vessel disease, visible as white matter hyperintensities, brain infarctions, microbleeds and lacunes on MRI. The presence of these characteristics indicate a higher risk of developing a stroke.

Aim

We investigated whether elderly patients with vestibular neuritis have a higher prevalence of vascular lesions on MRI compared to a control cohort.

Materials and Methods

Patients of 50-years and older, diagnosed with vestibular neuritis in a multidisciplinary tertiary referral hospital, were retrospectively reviewed and compared to a control cohort. The primary outcome was the difference in cerebral small vessel disease on MRI imaging, which was assessed by the number of white matter hyperintensities using the ordinal Fazekas scale. Secondary outcomes were the presence of brain infarctions on MRI and the difference in cardiovascular risk factors.

Results

Patients with vestibular neuritis (N = 101) had a 1.60 higher odds of receiving a higher Fazekas score than the control cohort (N = 203) (p = 0.048), there was no difference in presence of brain infarctions (p = 1.0). Hyperlipidemia and atrial fibrillation were more common in patients experiencing vestibular neuritis.

Conclusion

We found a positive correlation of white matter hyperintensities and VN which supports the hypothesis of vascular involvement in the pathophysiology of vestibular neuritis in elderly patients. Further prospective research is necessary to confirm this correlation.

Prevalence of cardiovascular risk factors in superior vestibular neuritis: A cross-sectional study following STROBE guidelines

OBJECTIVE

To compare the prevalence of cardiovascular risk factors (CVRF) in patients with superior vestibular neuritis (SVN) versus the general French population, and to examine the possibility of vascular etiology in acute superior vestibular deficit.

MATERIAL AND METHODS

A single-center retrospective study compared the prevalence of hypercholesterolemia, hypertension, diabetes, smoking, cardiovascular disease and atrial fibrillation between patients with SVN and the French general population. Inclusion criteria comprised: rotatory vertigo lasting several days, without hearing impairment or neurological signs, with anterior and lateral semicircular canal involvement on video-Head-Impulse-Test (vHIT). A senior radiologist analyzed superior vestibular nerve and inner ear structure enhancement on cerebellopontine MRI.

RESULTS

One hundred and eighteen cases of SVN were included from May 2016 to February 2020. Statistical analyses concerned 106 cases. The SVN population had significantly less hypercholesterolemia (RR=0.40) than the general French population. There was no significant difference concerning other CVRFs. Superior vestibular nerve enhancement was observed on 84% of MRIs.

CONCLUSION

Prevalence of CVRF was not higher in patients with SVN than in the general population. The present study highlighted involvement of the superior vestibular nerve more than of the anterior vestibular artery in SVN.

Vascular mechanisms in acute unilateral peripheral vestibulopathy: a systematic review

Acute unilateral peripheral vestibulopathy (AUPVP) is a frequent cause of vestibular loss. Several aetiologies have been proposed, but the exact mechanism remains unknown. The aim of this study is a systematic analysis of the literature evaluating the vascular aetiology of AUPVP. A systematic literature search was performed in PubMed, Cochrane Library and Embase, including articles published from January 1^st, 2010 to November 30^th, 2020. Two reviewers independently selected articles investigating a link between AUPVP and vascular disease. The following information was extracted: year of publication, country, level of evidence, assessed vascular risk factors and number of patients. A total of 450 articles was obtained. Eleven articles were retained with 100% agreement between the two reviewers. In a pooled population of 805 patients, the main results were the higher neutrophil to lymphocyte ratio and higher prevalence of vascular risk factors among AUPVP patients. A meta-analysis was not performed because the studies were too heterogeneous in terms of methodology. Indirect arguments for vascular mechanisms in AUPVP were found. These findings indicate that larger prospective well-controlled studies are needed to clarify the vascular aetiology of AUPVP.

Acute Vestibular Syndrome and ER Presentations of Dizziness

Acute vestibular syndrome (AVS) describes sudden onset, severe, continuous dizziness that persists for more than 24 hours. Its wide differential presents a diagnostic challenge. Vestibular neuritis is the most common cause, but stroke, trauma, medication effects, infectious, and inflammatory causes all present similarly. The TiTrATE model (Timing, Triggers, And Targeted Exam) is systematic way to evaluate these patients, and the HINTS Plus exam (Head Impulse, Nystagmus, Test of Skew, plus hearing loss) is critical in differentiating central and peripheral causes. The importance of recognizing risk factors for stroke and the role of imaging is also discussed.

Sequential Vestibular Neuritis: Report of Four Cases and Literature Review

Background and Objectives

Bilateral sequential vestibular neuritis (BSVN) is a rare condition in which an inflammation or an ischemic damage of the vestibular nerve occurs bilaterally in a sequential pattern. We described four cases of BSVN.

Subjects and Methods

Every patient underwent video-head impulse test during the first and the second episode of vestibular neuritis (VN), furthermore they have been studied with radiological imaging.

Results

Contralateral VN occurred after a variable period from prior event. Vestibular function recovered from the first episode in one case. The other three patients developed contralateral VN. One case was due to a bilateral VN in association with a Ramsay-Hunt syndrome, in another patient clinical records strongly suggested an ischemic etiology, whereas in two cases aetiology remained uncertain. Two patients subsequently developed a benign paroxysmal positional vertigo involving the posterior canal on the side of the latest VN (Lindsay-Hemenway syndrome).

Conclusions

Instrumental vestibular assessment represents a pivotal tool to confirm the diagnosis of VN and BSVN.

Neutrophil-mediated immune response as a possible mechanism of acute unilateral vestibulopathy

OBJECTIVE

This study aimed to investigate the underlying pathogenesis of acute unilateral vestibulopathy (AUV) using gene expression profiling combined with bioinformatics analysis.

METHODS

Total RNA was extracted from the peripheral blood mononuclear cells of ten AUV patients in the acute phase and from ten controls. The differentially expressed genes (DEGs) between these two groups were screened using microarray analysis with the cut-off criteria (|fold changes| > 1.5 and p-value < 0.05). Functional enrichment analysis of DEGs was performed using Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway analysis, and the protein-protein interaction (PPI) network was constructed using the STRING (Search Tool for the Retrieval of Interacting Genes) database.

RESULTS

There were 57 DEGs (50 up-regulated and 7 down-regulated) identified in the AUV group. Functional enrichment analysis showed that most of the up-regulated DEGs were significantly enriched in terms related to the neutrophil-mediated immune pathway. From the PPI network, the top ten hub genes were extracted by calculating four topological properties, and most of them were related to the innate immune system, inflammatory processes and vascular disorders. The complete blood count tests showed that the neutrophil-to-lymphocyte ratio was significantly higher in the 72 AUV patients than in the age-matched controls (2.93±2.25 vs 1.54±0.61, p < 0.001).

CONCLUSIONS

This study showed that the neutrophil-mediated immune pathway may contribute to the development of AUV by mediating inflammatory and thrombotic changes in the vestibular organ.

Balance disorders as potential confounders associated with an increased risk of acute cerebrovascular accidents

PURPOSE

There is a higher risk of stroke after suffering from balance disorders (BDs) such as vertigo or dizziness. The causal relationship remains unclear due to the limited scope of the existing studies and the high prevalence of cardiovascular risk factors (CVRFs) in BD patients. The objective of this study is to clarify the role that BDs seem to have in the development of acute cerebrovascular accidents (ACAs).

METHODS

This is an observational prospective study. The CVRFs and demographic factors of a sample of our population were noted. Five clusters of patients were tracked over the course of 2 years to detect and diagnose BDs and ACAs. The causal relationships between the CVRFs, BDs and ACAs were analyzed in a univariate analysis. A logistic regression multivariant analysis was performed on those variables that reached statistical significance.

RESULTS

The sample included 7886 participants and 31 ACAs were recorded. CVRFs that reached statistical significance included age ≥ 60, hypertension, diabetes mellitus, dyslipidemia, ischemic heart disease, atrial fibrillation and previous ACAs. The relationship between BDs and ACAs always reached statistical significance, regardless of how the BD variable was defined. Five different multivariate analyses were performed, but in none of them did the BD variables significantly reduce the deviance and thus, they were not taken into account when building the final model.

CONCLUSION

This study shows that BDs are probably confounders that are closely linked to other CVRFs and they are also useful red flags to identify patients at a higher risk of suffering from ACAs.

[A follow-Up Study with the Video Head Impulse Test for the patients with vestibular neuritis]

Objective:To detect the impairment degree and recovery process of the semicircular canals of patients with vestibular neuritis（VN） by video head impulse test（vHIT） over different periods. Method:The clinical data of patients with VN, who were diagnosed by Vertigo clinic'physicians in the Department of ENT, Dalian Municipal Central Hospital from Sept. 2018 to Sept. 2019, were analyzed and followed up at 1 and 3 month. The damage degree and recovery process of each semicircular canal function were evaluated by vHIT. Result:During the onset period, 89.7% horizontal semicircular canal HSC, 86.2% anterior semicircular canal ASC and 44.8% posterior semicircular canal PSC were abnormal in 29 patients. 23.8% HSC were back to normal, 75.0% ASC were back to normal, 15.4% PSC were back to normal at 1 month; 47.1% HSC were back to normal, 87.5%ASC were back to normal, 25.0% PSC were back to normal at 3 month. Conclusion:vHIT can effectively and dynamically detect the damage and recovery of the high-frequency region of the semicircular canal in patients with VN; the damaged function of the ASC is best recovered, followed by the HSC.

The Relationship Between Vestibular Sensory Integration and Prosthetic Mobility in Community Ambulators With Unilateral Lower Limb Amputation

OBJECTIVE

The modified Clinical Test of Sensory Interaction and Balance (mCTSIB) is used to clinically assess vestibular sensory integration (VSI), the process by which the central nervous system integrates vestibular afference to maintain balance. The rate and effects of impaired VSI (IVSI) on prosthetic mobility in people with lower limb amputation (LLA) is unknown. The objective of this study was to use the mCTSIB to classify VSI in active community ambulators with LLA and to examine the relationship between IVSI and prosthetic mobility, as measured by the Component Timed Up and Go (cTUG) test.

METHODS

This was a cross-sectional study with a convenience sample of 130 community ambulators with unilateral LLA. Classification of VSI was determined based on a time-based pass/fail mCTSIB performance. Participants were classified as having normal sensory integration (NSI) if they could balance for 30 seconds in every mCTSIB condition. Participants who failed condition 4 exclusively were classified as IVSI. Prosthetic mobility, as measured by the cTUG, was compared between NSI and IVSI groups.

RESULTS

Of the 130 participants, 29 (22%) were classified as IVSI and 95 (73%) were classified as having NSI. Prosthetic mobility significantly differed between IVSI and NSI groups, with IVSI participants performing all components of the cTUG significantly slower. Medium to large effect sizes were found between groups during cTUG.

CONCLUSIONS

These results suggest that 1 in 5 community ambulators with LLA have IVSI, with associated limitations in balance confidence and prosthetic mobility.

IMPACT

The ability to integrate vestibular information was found to have a strong relationship with prosthetic mobility in active community ambulators with LLA, especially with performing a 180-degree step turn. Physical therapists can use the mCTSIB to classify sensory integration during prosthetic rehabilitation and develop an appropriate balance intervention.

LAY SUMMARY

Active adults with LLA can use information from their senses to maintain their standing balance. Adults with LLA who have difficulty balancing on foam with closed eyes were slower to get in and out of a chair, walk, and perform a 180-degree step turn.

Association of Cervical Spondylosis With Peripheral Vertigo: A Case-Control Study

OBJECTIVES/HYPOTHESIS

This study aimed to assess the association of prior cervical spondylosis (CS) with peripheral vertigo.

STUDY DESIGN

Case-control study.

METHODS

Data were retrieved from the Taiwan Longitudinal Health Insurance Database. A total of 2,570 patients who were newly diagnosed with peripheral vertigo were identified. We compared them with a 3:1 ratio of propensity score-matched patients, 7,710 comparison patients from the same dataset. We performed multivariate logistic regressions to estimate the odds ratio for prior CS occurrence among peripheral vertigo patients versus controls.

RESULTS

Of 10,280 sample patients, 1,739 (16.92%) patients had CS prior to the index date. A significant difference in prior CS between peripheral vertigo patients and controls (19.49% vs. 16.06%, P < .001) was observed. Logistic regression analysis shows that the odds of prior CS was 1.285 for peripheral vertigo patients versus controls (95% confidence interval [CI]: 1.143-1.446) after adjusting for age, sex, urbanization level, monthly income, geographic region, hyperlipidemia, diabetes, coronary heart disease, hypertension, and asthma. Prior CS with myelopathy was not associated with peripheral vertigo. Stratified analysis by age showed that the odds of CS were highest among patients with peripheral vertigo in the 45- to 64-year-old age group (1.442, 95% CI: 1.215-1.712).

CONCLUSIONS

CS is associated with subsequent peripheral vertigo in the Taiwan population, with higher risk among those aged 45 to 64 years.

LEVEL OF EVIDENCE

2b Laryngoscope, 131:E625-E630, 2021.

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

PURPOSE

 Sudden unilateral peripheral vestibular deficit is mostly termed vestibular neuritis (VN), even if its cause or the exact location of the lesion remains unclear. Thus, therapy is mostly symptomatic. We aimed to prove if there is peripheral atrophy after VN with persistent canal paresis.

METHODS

 After approval by the ethics committee and according to the declaration of Helsinki and with informed consent, ten patients with persistent canal paresis after VN and ten age-matched healthy controls were included. High-resolution measurement (in-plane resolution 0.2 mm) of the internal auditory canal (IAC) using a 3 D CISS sequence at 3 Tesla was performed. The course of the pertaining nerves was reconstructed in the 3 D dataset and the measurement was performed at 60 % of the length of the IAC. The cross-sectional areas of the superior (SVN) and inferior vestibular nerve (IVN) were taken independently by two blinded readers.

RESULTS

 The interrater difference regarding the area was 22 %. We found significant atrophy of the SVN with a 24 % smaller area (p = 0.026) and found a smaller ratio of SVN/IVN on the symptomatic side (p = 0.017). Concerning single subject data, only 5 patients showed extensive atrophy of the NVS, while 5 patients did not. The time since symptom onset did not significantly influence the atrophy.

CONCLUSION

 MRI measuring of the area of the NVS after VN could detect atrophy after VN. However, only 5 patients exhibited marked atrophy, while the other 5 patients did not. With the background of stringent inclusion criteria (more than 6 months of symptom duration and proven persistent canal paresis), one has to wonder if there might be different etiologies behind the apparently identical symptoms.

KEY POINTS

  · MRI measuring of the area of the NVS after VN could detect atrophy after VN. · Only half of the 10 researched patients showed atrophy, while the other patients did not. · There are different etiologies to be suspected for VN.

CITATION FORMAT

· Freund W, Weber F, Schneider D et al. Vestibular Nerve Atrophy After Vestibular Neuritis - Results from a Prospective High-Resolution MRI Study. Fortschr Röntgenstr 2020; 192: 854 - 861.

[A role of vascular risk factors in the development of peripheral vestibulopathy]

The development of peripheral vestibular disorders are often thought to be associated with vascular mechanisms, taking into account terminal type of inner ear blood supply and other predisposing factors. A number of studies indicates a high frequency of vascular risk factors in the patients with vestibular neuronitis and benign paroxysmal positional vertigo (BPPV). According to other results, migraine is widely spread among patients with Meniere's disease and BPPV. However currently there is no evidence for casual relationship between vascular factors and development of peripheral vestibulopathy. The only exclusion is labyrinthine infarction, which develops as a result of posterior circulation disorder. More research is needed in this area.

A Case of Isolated Nodular Infarction Mimicking Vestibular Neuritis on the Contralateral Side

Differentiating central vestibulopathy from more common vestibular disorders is crucial because it often necessitates different treatment strategies, and early detection can help to minimize potential complications. Isolated nodular infarct is one of the central brain lesions that can mimic peripheral vertigo. We present a case of isolated nodular infarct that had been misdiagnosed as vestibular neuritis on the contralateral side at the initial evaluation. The patient was successfully treated with anticoagulants and antihyperlipidemic agents. Clinicians should keep in mind that some causes of central vertigo mimic peripheral vestibulopathy at the early stage.

Detection of intralabyrinthine abnormalities using post-contrast delayed 3D-FLAIR MRI sequences in patients with acute vestibular syndrome

PURPOSE

3D-FLAIR sequences with delayed acquisition after contrast medium injection have demonstrated new insights into blood-labyrinthine barrier (BLB) abnormalities in various diseases. The aim of this study was to assess the BLB in patients referred with unilateral acute vestibular syndrome (UAVS).

MATERIALS AND METHODS

In this retrospective multicenter imaging study, we performed 3D-FLAIR and steady-state free precession (SSFP) sequences 4 h after contrast medium administration in 26 healthy volunteers and in 30 patients with UAVS. Two radiologists, blinded to the clinical data, independently assessed the asymmetrical enhancement of the labyrinthine structures and the vestibular nerve on 3D-FLAIR sequences, and the signal of the labyrinthine structures on SSFP sequences. Inter-reader agreement tests were performed.

RESULTS

An asymmetrical enhancement of the semicircular canals was observed in 26 out of 30 ears (86.6%, p < 0.001) and never observed in healthy subjects. An asymmetrical enhancement of the vestibular nerve was never observed in either patients or healthy subjects. An asymmetrical enhancement of the cochlea was observed on the 3D-FLAIR sequence in 6 out of 30 ears only in the patients' group (20%, p = 0.03) and always associated with an enhancement of at least one semicircular canal. A low signal on SSFP sequences was observed only in 11 out of 30 symptomatic ears (36.7%, p < 0.001), involving the utricle in 7 ears and the superior semicircular canal in 4 ears.

CONCLUSION

Patients with typical UAVS presented with semicircular canal enhancement on MRI, while an asymmetrical enhancement of the vestibular nerve was not displayed.

TRIAL REGISTRATION

NCT02529475 KEY POINTS: • Patients with typical vestibular neuronitis presented with semicircular canal enhancement on MRI in 87% of cases. • An enhancement of the vestibular nerve was never displayed.

Correlation between vestibular neuritis and cerebrovascular risk factors

PURPOSE

To investigate the relationship between cerebrovascular risk factors, including carotid plaques, and vestibular neuritis (VN).

MATERIALS AND METHODS

According to the inclusion and exclusion criteria, this retrospective study included 90 VN patients and 74 age- and sex-matched healthy controls from January 2016 to December 2017. All subjects' records of cerebrovascular risk factors, such as age, sex, height, weight, history of hypertension and diabetes mellitus, living habits, serum levels of glucose, lipids, glycosylated haemoglobin (HbA1c), creatinine (CR), albumin (ALB), haemoglobin (HGB); and results of carotid colour Doppler ultrasound, were obtained and compared.

RESULTS

No significant differences in age; sex ratio; body mass index; history of hypertension or diabetes mellitus; or mean serum lipids, glucose, creatinine, haemoglobin or HbA1c were found between patients with VN and healthy controls (all P > 0.05). The mean serum ALB level was significantly lower in VN patients than in healthy controls (40.65 ± 3.77 vs 42.84 ± 4.32, P = 0.001).The prevalence of carotid plaques was significantly higher in VN patients than in healthy controls (36.67% vs. 16.22%, P = 0.003). Regression analyses demonstrated that a high frequency of carotid plaques was associated with VN with an odds ratio of 2.252 (95% CI 1.165-5.458, P = 0.019).

CONCLUSION

A high frequency of carotid plaques may be a risk factor for VN.

Central vertigo

PURPOSE OF REVIEW

This review considers recent advances in central vertigo in terms of clinical and laboratory features and pathophysiology.

RECENT FINDINGS

Strokes presenting dizziness-vertigo are more likely to be associated with a misdiagnosis in the emergency setting. The risk of future strokes after discharge is higher in patients diagnosed with peripheral vertigo than in control patients. Strokes and transient ischemic attacks account for one-quarter of acute transient vestibular syndrome. Diagnosis of acute combined central and peripheral vestibulopathy such as anterior inferior cerebellar artery infarction requires additional consideration whenever applying the HINTS (head impulse test, direction-changing gaze-evoked nystagmus, and test of skew). Heat illness and metronidazole have been recognized as new causes of central vestibulopathy. Some new findings have also been added to the clinical and laboratory features of central vertigo.

SUMMARY

Central vertigo is a heterogeneous group of disorders with diverse clinical spectrums. An integrated approach based on understanding of clinical features, laboratory findings, speculated mechanisms, and limitations of current diagnostic tests will lead to better clinical practice.

Association between smoking and the peripheral vestibular disorder: a retrospective cohort study

Common inner ear diseases include peripheral vestibular disorder (PVD) and hearing impairment. The association between smoking and peripheral vestibular disorder (PVD) is unclear. We examined associations between smoking and new PVD events. In this retrospective study, we consecutively enrolled 393 participants aged ≥20 years [mean age 65.3 years; males 133 (33.8%)] treated for hypertension, dyslipidaemia, or diabetes mellitus at a primary care clinic between November 2011 and March 2013. Participants were categorized as ever-smokers (including current and past -smokers; divided per <30 and ≥30 pack-years), and never-smokers. New PVD events were reported over a 1-year follow-up period. Hazard ratios (HR) for new onset PVD were estimated using the Cox proportional hazard regression model. Compared to never-smokers, the adjusted HR was 2.22 for ever-smokers and 2.70 for all ever-smokers with ≥30 pack-years among all 393 participants. Among male participants, compared to never-smokers, the adjusted HR was 4.41 for ever-smokers with ≥30 pack-years. A smoking history of ≥30 pack-years was strongly associated with the risk of new onset PVD in males but not, females. This study may assist patients with smoking cessation for the prevention of new PVD events among males.