Phenotypes and clinical subgroups in vestibular migraine: a cross-sectional study with cluster analysis

OBJECTIVE

The aim of this multicentric cross-sectional study was to collect phenotypes and clinical variability on a large sample of 244 patients enrolled in different university centers in Italy, trying to differentiate subtypes of VM.

BACKGROUND

VM is one of the most frequent episodic vertigo characterized by a great clinical variability for duration of attacks and accompanying symptoms. Diagnosis is based only on clinical history of episodic vertigo in 50% of cases associated with migrainous headache or photo/phonophobia.

METHODS

We enrolled in different university centers 244 patients affected by definite VM according to the criteria of the Barany Society between January 2022 and December 2022. An audiometric examination and a CNS MRI were performed before inclusion. Patients with low-frequency sensorineural hearing loss were not included, as well as patients with an MRI positive otherwise that for microischemic lesions. Patients were asked to characterize vestibular symptoms choosing among (multiple answers were allowed): internal vertigo, dizziness, visuo-vestibular symptoms/external vertigo; onset of vertigo and duration, neurovegetative, and cochlear accompanying symptoms (hearing loss, tinnitus, and fullness during attacks) were collected as well as migrainous headache and/or photo/phonophobia during vertigo; autoimmune disorders were also analyzed. A bedside examination was performed including study of spontaneous-positional nystagmus with infrared video goggles, post head shaking ny, skull vibration test, and video head impulse test.

RESULTS

We included 244 subjects, 181 were females (74.2%). The age of onset of the first vertigo was 36.6 ± 14.5 while of the first headache was 23.2 ± 10.1. A positive correlation has been found between the first headache and the first vertigo. The mean duration of vertigo attacks was 11 ± 16 h. We carried on a cluster analysis to identify subgroups of patients with common clinical features. Four variables allowed to aggregate clusters: age of onset of vertigo, duration of vertigo attacks, presence of migrainous headache during vertigo, and presence of cochlear symptoms during vertigo. We identified 5 clusters: cluster 1/group 1 (23 subjects, 9.4%) characterized by longer duration of vertigo attacks; cluster 2/group 2 (52 subjects, 21.3%) characterized by absence of migrainous headache and cochlear symptoms during vertigo; cluster 3/group 3 (44 subjects, 18%) characterized by presence of cochlear symptoms during vertigo but not headache; cluster 4/group 4 (57 subjects, 23.4%) by the presence of both cochlear symptoms and migrainous headache during vertigo; cluster 5/group 5 (68 subjects, 27.9%) characterized by migrainous headache but no cochlear symptoms during vertigo.

CONCLUSION

VM is with any evidence a heterogeneous disorder and clinical presentations exhibit a great variability. In VM, both symptoms orienting toward a peripheral mechanism (cochlear symptoms) and central ones (long lasting positional non-paroxysmal vertigo) may coexist. Our study is the first published trying to characterize subgroups of VM subjects, thus orienting toward different pathophysiological mechanisms.

Phenotypes, bedside examination, and video head impulse test in vestibular migraine of childhood compared with probable vestibular migraine and recurrent vertigo in childhood

Introduction

Vestibular impairment and vertigo in the pediatric population have an estimated prevalence ranging between 0.4% and 5.6% and are a topic of interest in recent years. The Bárány Society has recently reclassified migraine-related vertigo syndromes as vestibular migraine of childhood (VMC), probable vestibular migraine of childhood (probable VMC), and recurrent vertigo of childhood (RVC).

Methods

Applying the criteria established by the Bárány Society, we retrospectively analyzed data on 95 pediatric patients suffering from episodic vertigo that were recruited from 2018 to 2022. In applying the revised criteria, 28 patients had VMC, 38 had probable VMC, and 29 had RVC.

Results

Visuo-vestibular symptoms (external vertigo) or internal vertigo were reported by 20 of 28 VMC patients (71.4%) compared to 8 of 38 probable VMC patients (21%) (P < .001). None of the RVC patients reported external vertigo. Duration of vertigo was demonstrably longer in the VMC patients than in the probable VMC (P < .001) and RVC (P < .001) patients. Cochlear symptoms were reported by 28.6% of VMC patients and by 13.1% of probable VMC patients. No cochlear symptoms were reported by any RVC patients. Familial cases for headache and episodic vertigo showed no significant difference between groups.

Discussion

The most frequent finding during bedside examination in all three groups was central positional nystagmus. Differences in the duration of attacks and in accompanying symptoms may underline different pathophysiological mechanisms.

Trimming of Facial Artery Myomucosal Flap (FAMM) using Indocyanine Green Fluorescence Video-Angiography: Operative Nuances

BACKGROUND

Facial artery myomucosal flap (FAMM) is an intraoral flap pedicled on facial artery used for reconstruction of oral/oropharyngeal defects.¹ Careful assessment of perfusion is essential to avoid flap necrosis, and several options are used for this purpose. Among these, indocyanine green (ICG) fluorescence video-angiography (ICG-VA) represents an innovative tool whose adoption in flap surgery is still at its early days.² METHODS: In this multimedia article, we described the use of ICG-VA for perfusion assessment of a FAMM flap harvested for reconstruction of oral lining after ablation of a cT2cN0 floor-of-mouth (FOM) cancer. The use of ICG-VA was aimed at defining ischemic areas on the flap according to a flap-to-normal mucosa ICG ratio.

RESULTS

After transoral excision of the FOM cancer and subsequent harvesting of a FAMM flap, we used ICG-VA to intraoperatively assess its perfusion. The degree of flap perfusion was expressed point-by-point through flap-to-normal mucosa ICG ratio (percentage); a value of 25-27% was considered as threshold for ischemia.³ Perfusion was documented both with white light modality with "overlay fluorescence" and "black and white SPY fluorescence mode" designed to increase the sensitivity of ICG detection. Small, ischemic areas were detected in the distal part of the flap and were trimmed. At the end of the procedure, an adequate perfusion was evident throughout the whole flap, allowing its safe insetting for left FOM reconstruction. Postoperative course was uneventful.

CONCLUSIONS

ICG-VA represents a reliable tool for intraoperative detection-and trimming-of ischemic areas on reconstructive flaps.

Head and neck pedicled flap autonomization using a new high-resolution indocyanine green fluorescence video-angiography device

In head and neck oncologic surgery a reconstructive phase is often required and pedicled flaps are still a viable option, though they may need a pedicle division performed at a later stage. Several techniques are commonly used for perfusion assessment of the flaps, with indocyanine green (ICG) fluorescence video-angiography representing a promising tool. We used ICG video-angiography to evaluate the perfusion of two of the most commonly adopted pedicled flaps in the head and neck field (the supraclavicular and the paramedian forehead flap) before and after second-stage pedicle division, allowing a safer in-setting. Moreover, the new high-resolution device that we have employed added further accuracy to the traditional video-angiography, providing a real-time flap-to-normal skin ICG ratio. Indeed, ICG video-angiography proved to be a useful tool in head and neck reconstructive surgery and it may allow an earlier second-stage pedicle division.

Spontaneous extracapsular parathyroid adenoma hemorrhage: when surgery is required?

PURPOSE

Spontaneous bleeding is a rare but serious complication of parathyroid adenomas and few cases were reported in the literature. Clinical manifestations and treatment may vary but sometimes an immediate surgery is required. In other cases a conservative approach can be preferred based on clinical stability and patients' conditions. The purpose of this work is to describe our case and to carry out a review of the current literature on this topic.

METHODS

We reported a case of a parathyroid adenoma hemorrhage in an elderly patient describing its management. Moreover, a literature review of 57 cases was carried out, with the aim of collecting data about the most involved parathyroid gland and identifying the most correct management based on clinical manifestations and chosen treatments.

RESULTS

The patients had an age between 29 and 81 years (mean 56.9 ± 16.4 years). Forty-four patients were females (77.2%), whereas 12 were males (21.8%). Based on clinical severity, age, comorbidities and calcemic status, three possible scenarios were identified, each with a recommended management.

CONCLUSIONS

In parathyroid adenoma hemorrhages a careful clinical assessment is crucial to identify emergency conditions requiring immediate intubation, tracheostomy or neck exploration. Elderlies and comorbid patients have a higher risk of perioperative complications and indication for surgery should be evaluated case by case: whenever feasible, a conservative approach should be preferred in these subjects, especially in those with a stable course and without hypercalcemia-related symptoms.

The importance of the patient's perspective in function-sparing parotid surgery for benign neoplasms: clinical reappraisal

Objective

Function-sparing surgery is the cornerstone for the treatment of benign parotid neoplasms. We assessed the incidences and determinants of the main postoperative complications, reappraising their influence on the patient’s quality of life (QoL).

Methods

Patients who underwent parotid surgery for benign neoplasms were reviewed (2016-2019). Parotidectomy Outcome Inventory-8 (POI-8) and condition-specific questionnaires were used to investigate the patient’s perspective.

Results

We enrolled 211 patients. Preservation of the posterior branch of the great auricular nerve (GAN) seemed to reduce early dysfunction (87% vs 96%, p = 0.053), but not the late one. Deep lobe dissection and resection of more than one parotid segment favoured first bite syndrome (FBS) and Frey’s syndrome (FS), respectively (16% vs 3%, p = 0.003; 37% vs 15%, p = 0.003). Neither GAN impairment, FBS, nor FS influenced patient QoL. Facial weakness affected 19 patients (9%), being more likely after total parotidectomy (23% vs 7%, p = 0.034). According to POI-8, QoL was mainly jeopardised by fear of revision surgery, especially in females (p= 0.005) and those experiencing early complications (p= 0.004).

Conclusions

Reappraisal of the patient’s perspective after functional parotid surgery is fundamental to tailor preoperative counselling.

Evaluation of a large cohort of adult patients with Ménière's disease: bedside and clinical history

Objective

The purpose of this study was to assess vestibular findings and clinical history in a large cohort of patients affected by Ménière’s disease.

Methods

We retrospectively analysed 511 adult patients fulfilling criteria for definite unilateral Ménière’s disease according to Barany Society. Thorough clinical history, audiometric exam, central nervous system MRI, quantification of serum autoantibodies and complete vestibular function test were performed.

Results

Mean age at clinical record was 55.4 years, while age at onset of the first vertigo attack was 47.4 ± 14.3 years. Ménière’s disease overlapped with migraine in 43.4% of patients. In 31.7% of cases, positivity was found for at least one autoantibody. Forty-nine patients (9.6%) had family history for Ménière’s disease. Bedside examination resulted in 14.7% positivity for video head impulse test, 58.9% for skull vibration-induced nystagmus, 38.7% for the positional test and 23.1% for the post head shaking test. Complete negative examination was reported in 115 cases.

Conclusions

Ménière’s disease was seen to present a characteristic phenotypic pattern in our cohort, confirming the crucial role of thorough anamnesis and bedside examination in diagnosis.

Vertigo without cochlear symptoms: vestibular migraine or Menière disease?

BACKGROUND

Menière's disease (MD) is an inner ear disorder due to raised endolymphatic pressure (hydrops), characterized by cochlear symptoms associated with episodic vertigo. In delayed hydrops, vertigo attacks begin long after the onset of a hearing loss. Few were published on MD in which the onset of vertigo precedes cochlear symptoms by several months. Vestibular migraine (VM) is also a cause of episodic vertigo and an association between migraine and MD was proposed. Purpose of our retrospective work was to assess clinical features associated with MD in which vertigo precedes by months cochlear symptoms.

METHODS

Our sample was composed by 28 subjects reporting episodic vertigo accompanied by migrainous headache or photo-phonophobia, without cochlear symptoms at onset; during follow-up, all patients developed cochlear symptoms leading to a diagnosis of MD. Results of bedside examination were compared with those of 48 VM subjects with diagnosis of VM confirmed in the follow-up. All subjects performed a bedside examination, including head-shaking, positional, and skull vibration test (SVIN).

RESULTS

SVIN was more frequent in MD, while positive positional test in VM. In the entire group of 72 subjects, migrainous headache during vertigo and positive positional test were correlated with a final diagnosis of VM.

CONCLUSIONS

Our data are not inconsistent with the hypothesis that in patients reporting only photo-phonophobia during vertigo attacks and with a positive SVIN, the clinical manifestations may be predictive for evolution toward a MD, while migrainous headache and positive positional tests more frequently are correlated to VM.

Combination of Mustardè cheek advancement flap and paramedian forehead flap as a reconstructive option in orbital exenteration

PURPOSE

To describe a combinatory technique made of Mustardè cheek advancement flap and paramedian forehead flap as a reconstructive option after orbital exenteration.

METHODS

We retrospectively reviewed all patients who underwent orbital exenteration and subsequent reconstruction with this technique at our Head and Neck Department, Divisions of Ophthalmology and Otolaryngology, at San Raffaele Hospital, Milan, Italy.

RESULTS

Three patients were treated with the aforementioned technique, following orbital exenteration due to malignancies. All of them were affected by recurrent diseases arising from the ocular components or periorbital structures: one basal cell carcinoma and two squamous cell carcinomas. Excellent result was achieved considering skin texture and colour match, aesthetic results and intra and post-operative complications (only minor, surgically controlled haemorrhage and minimal dehiscence subsequent to defective healing occurred).

CONCLUSION

The proposed technique can be considered by the head and neck reconstructive surgeon as a good option in extended orbital exenteration.

Protective effect of 4-hydroxy-TEMPO, a low molecular weight superoxide dismutase mimic, on free radical toxicity in experimental pancreatitis

Rats develop acute pancreatitis when infused iv for 3 h with cerulein (10 micrograms/kg/h). Autopsies of the pancreas seen by light microscope show interstitial edema, acinar cells vacuolization, and leukocyte margination in pancreatic capillaries; under electron microscope, severe damage concerning mitochondrial and zymogen granules structures are apparent. Particularly, swelling of the mitochondria and disruption of mitochondrial cristae was observed as well as formation of large vacuoles arising from zymogen granules and liposome fusion. A significant increase of lipid hydroperoxide level in the pancreatic tissue was observed. The purpose of this study was to evaluate the effect of 4-hydroxy-TEMPO--a low-mol-wt superoxide dismutase mimic--in a rat cerulein model of acute pancreatitis, with the expectation that free radical mediated hydroperoxide formation and tissue damage may be reduced significantly. Twenty-one male Wistar rats were divided into three groups: Group 1 (n = 5) served as a control and was infused iv for 3 h with physiologic saline; Group 2 (n = 8) was infused i.v. for 3 h with cerulein 10 micrograms/kg/h; and Group 3 (n = 8) infused i.v. both with cerulein and 4-hydroxy-TEMPO 22.6 mg/kg/h. Pancreatic tissue damage was quantified by measuring lipid hydroperoxide (LOOH) level, the weight of the organ, and by light and electron microscopic examination. 4-hydroxy-TEMPO penetration across cellular membrane barriers was quantified by ESR spectrometric measurements of 4-hydroxy-TEMPO concentration in pancreatic tissue samples and pancreatic juice as well. Administering 4-hydroxy-TEMPO to rats resulted in preventing both lipid hydroperoxide formation and severe morphological damage. 4-hydroxy-TEMPO crossed cellular membrane barriers and was excreted to pancreatic juice. Infusion of 4-hydroxy-TEMPO appears to prevent pancreatic injury caused by free radicals in experimental cerulein pancreatitis.

Local anaesthetic effects on trophoblast membrane fluidity

Previous studies showed that anaesthesia with the barbiturate Thiopental induces an increase in membrane fluidity and a decrease in acetylcholinesterase activity in syncytiotrophoblast plasma membranes (SPM) obtained from placentas after Cesarean section. The aim of the present work was to compare the effect of a local anaesthetic (bupivacaine hydrochloride, trade name Marcaine) on SPM in vivo and to establish whether the anaesthetic is still present in the membrane after tissue preparation. The acetylcholinesterase activity was lower in Marcaine-anaesthetized SPM (27 +/- 3 against 39 +/- 6 in the control). The Marcaine action on the SPM can be ascribed to a competitive inhibition, similar to that reported for Thiopental. Fluorescence studies of the order parameter P showed it to be higher in SPM obtained from control (0.253 +/- 0.012) than in SPM obtained from Marcaine-exposed membranes (0.240 +/- 0.015). The local anaesthetic is still present in the SPM after their preparation (20.1 ng per mg membrane protein). It appears that the local anaesthetic exhibits an effect similar to that of the general anaesthetic, apparently due to binding to the membrane.

A new anthracycline regimen for prolymphocytic leukemia? Study of a case report with flow cytometric implications

A case of prolymphocytic leukemia (PL) is reported, which showed a good response to a new antiblastic schedule (4-epidoxorubicin-asparaginase-dexamethasone) in spite of the resistance to other chemotherapy regimens. However during the course of the disease it was possible to observe the terminal appearance of a small aneuploid cell population in the peripheral blood of the patient and, in the same time, the clinical condition deteriorated considerably. The significance of this neoplastic progression and the pros and cons of aggressive chemotherapy regimens remain to be carefully evaluated in PL and related disorders.

Effect of anesthetics on membrane fluidity tested by two different techniques: EPR spin labels and polarization of perylene fluorescence

We have investigated the effect of n-butanol on the spectroscopic properties of two types of probes, that are usually employed to detect membrane fluidity, in mitochondrial phospholipid vesicles and mitochondrial membranes. Although both a spin label (16-doxylstearate) and the fluorescent probe perylene detect a higher immobilization of the membrane in comparison with phospholipid vesicles, the effect of butanol in the case of the membrane is strikingly different with the two techniques employed, showing increased fluidity in the case of the spin label and decreased fluidity with the fluorescent probe.