Estimated incidence and characteristics of vestibular neuritis in Japan: A nationwide survey

OBJECTIVE

To assess the annual incidence of vestibular neuritis (VN) in the Japanese population.

METHODS

We conducted a mail-based survey targeting otolaryngologic clinics and hospitals across Japan to estimate the annual number of patients who were newly-diagnosed with VN during the one-year period of 2021. Using a stratified sampling method, we selected 1,107 departments and asked them to report the number of new patients with VN and their demographics. The total number of VN patients was estimated by multiplying the reported numbers by the reciprocal of the sampling rate and response rate.

RESULTS

The overall survey response rate was 40.5 % (448 departments). The estimated number of newly-diagnosed VN patients in 2021 was 8,861 (95 % confidential interval [CI], 2,290-15,432) The annual incidence of VN was 7.05 per 100,000 population in Japan. The male-to-female ratio of VN patients was 0.96, and the mean age was 60.3 ± 16.1 years (range 11-94 years).

CONCLUSIONS

The annual incidence of VN in Japan in 2021 had almost doubled and the mean age had become older compared to the previous study in 1993 (annual incidence; 3.5 per 100,000 per year; mean age: 45 years).

Diagnostic and therapeutic strategies for vestibular neuritis of the Japan Society for Equilibrium Research

OBJECTIVE

To provide diagnostic and therapeutic strategies for vestibular neuritis in accordance with the Japanese Clinical Practice Guidelines for Vestibular Neuritis 2021.

METHODS

The Committee for Clinical Practice Guidelines for Vestibular Neuritis was entrusted with a review of the relevant scientific literature on the above topic. Clinical Questions (CQs) concerning the treatment of vestibular neuritis were produced, and a search of the literature was conducted to identify studies related to the CQs. The recommendations were based on the literature review and the expert opinion of a subcommittee.

RESULTS

We proposed the diagnostic criteria for vestibular neuritis, as well as answers to CQs, recommendations, and evidence levels for the treatment of vestibular neuritis.

CONCLUSION

The diagnostic criteria for vestibular neuritis were based on clinical history and examination findings after completing the differential diagnosis process. The treatment of vestibular neuritis was divided into acute, subacute, and chronic stages. The Japanese Clinical Practice Guidelines for Vestibular Neuritis 2021 should be used as a reference in the diagnosis and treatment of vestibular neuritis.

Differences in semicircular canal function in the video head impulse test in patients in the chronic stage of sudden sensorineural hearing loss with vertigo and vestibular neuritis

BACKGROUND

Sudden sensorineural hearing loss with vertigo (SHLV) and vestibular neuritis (VN) can result in prolonged dizziness.

OBJECTIVES

This study aimed to compare the video head impulse test (vHIT) of patients with SHLV and VN.

METHODS

Fifteen patients with SHLV and 21 patients with VN who visited the Vertigo/Dizziness Center of our hospital between December 2016 and February 2023 were included. vHIT was performed at the time of admission, and the VOR gain and catch up saccade (CUS) in the three types of semicircular canals (SCCs) were analyzed.

RESULTS

Pathologic vHIT results were observed most frequently in the posterior SCC (73%), followed by lateral (53%) and anterior (13%) SCCs in the SHLV group. In contrast, pathologic vHIT results were observed most frequently in the lateral SCC (100%), followed by the anterior (43%) and posterior SCC (24%) SCCs in the VN group. Pathological vHIT results in the lateral and posterior SCC showed significant differences between the two groups, but for anterior SCC, no significant differences were found.

CONCLUSIONS AND SIGNIFICANCE

Comparison of the two vHIT results revealed differences in the SCC dysfunction patterns. This may be due to the different pathophysiological mechanisms of the two vestibular disorders, which may result in prolonged vertigo.

Instrumental assessment of dynamic postural stability in patients with unilateral vestibular hypofunction during straight, curved, and blindfolded gait

PURPOSE

To characterise dynamic postural stability of gait in patients with vestibular hypofunction (PwVH) using a sensor-based assessment while performing dynamic tasks and to correlate the results of this evaluation with clinical scales.

METHODS

This cross-sectional study involved 22 adults between 18 and 70 years old from a healthcare hospital centre. Eleven patients suffering from chronic vestibular hypofunction (PwVH) and eleven healthy controls (HC) were evaluated through a combined inertial sensor-based and clinical scale assessment. Participants were equipped with five synchronised inertial measurement units (IMUs) (128 Hz, Opal, APDM, Portland, OR, USA): three IMUs were located on the occipital cranium bone, near the lambdoid suture of the head, at the centre of the sternum, and at L4/L5 level, just above the pelvis, and were used to quantify gait quality parameters, while the other two were located slightly above lateral malleoli and used to perform stride and step segmentation. Three different motor tasks were performed in a randomized order: the 10-m Walk Test (10mWT), the Figure of Eight Walk Test (Fo8WT) and the Fukuda Stepping Test (FST). A set of gait quality parameters related to stability, symmetry and smoothness of gait were extracted from IMU data and correlated with the clinical scale scores. PwVH and HC results were compared to test for significant between-group differences.

RESULTS

Significant differences were found for the three motor tasks (10mWT, Fo8WT and FST) when comparing PwVH and HC groups. For the 10mWT and the Fo8WT, significant differences between the PwVH and HC groups were found for the stability indexes. Considering the FST, significant differences between the PwVH and HC groups were also found in the stability and symmetry of gait. A significant correlation was found between the Dizziness Handicap Inventory and gait indices during the Fo8WT.

CONCLUSIONS

In this study, we characterized the dynamic postural stability alterations during linear, curved, and blindfolded walking/stepping in PwVH combining an instrumental IMU-based with traditional clinical scales approach. Combining instrumental and clinical evaluation for dynamic stability of gait alterations in PwVH is useful in thoroughly evaluating the effects of unilateral vestibular hypofunction.

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.

Acute Vertigo in a Patient Following COVID-19 Infection: A Case Report and Literature Review

COVID-19 has infected millions of people worldwide causing millions of deaths. COVID-19 has many serious effects on organs of the body especially the respiratory system causing pneumonia and acute respiratory distress syndrome (ARDS). The disease also has severe complications on other different organs; kidneys and liver which may end in multi-organ failure. Most common symptoms that have been detected in large section of patients were fever, cough and loss of taste or smell and less commonly sore throat, headache and muscle pain. The incidence of vertigo or dizziness is a rare symptom of COVID-19. In this case report, we introduce a 59-year-old male patient suffering from acute vertigo attack after COVID-19 infection. The patient had negative medical history of vertigo and any ear diseases. The patient received REGEN-COV (casirivimab and imdevimab) for COVID-19 and meclizine for vertigo. Vertigo attacks lasted for the two weeks follow up after disappearance of COVID-19 symptoms despite receiving vertigo medication. In conclusion, vertigo may be the sole neurological manifestation of COVID-19. More observational studies should address this symptom and researchers should also focus on identifying the origin of developing vertigo and the direct or indirect mechanisms that SARS-CoV-2 triggers to develop dizziness in general. This research should deliver a clear message, especially to ER physicians to consider proper referral of these patients without underestimating the risk of developing more serious COVID-19 symptoms as ARDS and multi-organ failure if no proper testing and follow-up are provided.

Modern vestibular tests can accurately separate stroke and vestibular neuritis

OBJECTIVES

To separate posterior-circulation stroke (PCS) and vestibular-neuritis (VN) using quantitative vestibular tests.

METHODS

Patients were prospectively recruited from the emergency room within 72 h of presentation. Video-nystagmography (VNG), three-dimensional video head-impulse testing (vHIT), vestibular-evoked myogenic potentials (VEMPs), and subjective visual-horizontal (SVH) were performed.

RESULTS

There were 128 PCS and 134 VN patients. Common stroke-territories were: posterior-inferior cerebellar artery, basilar-perforators, multi-territory and anterior-inferior cerebellar artery (41.4%, 21.1%, 14.1%, 7.8%). VN included superior, inferior and pan-neuritis (53.3%, 4.2%, and 41.5%). Most VN and stroke patients presented with acute vestibular syndrome (96.6%, 61.7%). In VN, we recorded horizontal (98.5%) or vertical/torsional spontaneous nystagmus (1.5%) and in PCS, absent-nystagmus (53.9%), horizontal (32%) or vertical/torsional (14.1%) nystagmus. The mean slow-phase velocity of horizontal nystagmus was faster in VN than PCS (11.8 ± 7.2 and 5.2 ± 3.0°/s, p < 0.01). Ipsilesional horizontal-canal (HC) vHIT-gain was lower in VN than in stroke (0.47 ± 0.24, 0.92 ± 0.20, p < 0.001). Ipsilesional catch-up saccades occurred earlier, and their amplitude, prevalence, and velocity were greater in VN than PCS (p < 0.01). Ipsilesional SVH deviation > 2.5° occurred more often in VN than in stroke (97.6% and 24.3%, p < 0.01). Abnormal bone-conducted ocular-VEMP asymmetry ratio was more common in VN than PCS (50% and 14.4%, p < 0.01). Using the ten best discriminators (VNG, vHIT, SVH, and oVEMP metrics), VN was separated from PCS with a sensitivity of 92.9% and specificity of 89.8%. Adding VNG and vHIT to the bedside head-impulse-nystagmus-and-test-of-skew (HINTS) test enhanced sensitivity and specificity from 95.3% and 63.4% to 96.5% and 80.6%.

CONCLUSION

Quantitative vestibular testing helps separate stroke from vestibular neuritis and, when used, could improve diagnostic accuracy in the emergency room.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Factors influencing clinical outcome in vestibular neuritis - A focussed review and reanalysis of prospective data

Following vestibular neuritis (VN), long term prognosis is not dependent on the magnitude of the residual peripheral function as measured with either caloric or the video head-impulse test. Rather, recovery is determined by a combination of visuo-vestibular (visual dependence), psychological (anxiety) and vestibular perceptual factors. Our recent research in healthy individuals has also revealed a strong association between the degree of lateralisation of vestibulo-cortical processing and gating of vestibular signals, anxiety and visual dependence. In the context of several functional brain changes occurring in the interaction between visual, vestibular and emotional cortices, which underpin the aforementioned psycho-physiological features in patients with VN, we re-examined our previously published findings focusing on additional factors impacting long term clinical outcome and function. These included: (i) the role of concomitant neuro-otological dysfunction (i.e. migraine and benign paroxysmal positional vertigo (BPPV)) and (ii) the degree to which brain lateralisation of vestibulo-cortical processing influences gating of vestibular function in the acute stage. We found that migraine and BPPV interfere with symptomatic recovery following VN. That is, dizziness handicap at short-term recovery stage was significantly predicted by migraine (r = 0.523, n = 28, p = .002), BPPV (r = 0.658, n = 31, p < .001) and acute visual dependency (r = 0.504, n = 28, p = .003). Moreover, dizziness handicap in the long-term recovery stage continued to be predicted by migraine (r = 0.640, n = 22, p = .001), BPPV (r = 0.626, n = 24, p = .001) and acute visual dependency (r = 0.667, n = 22, p < .001). Furthermore, surrogate measures of vestibulo-cortical lateralisation were predictive of the amount of cortical suppression exerted over vestibular thresholds. That is, in right-sided VN patients, we observed a positive correlation between visual dependence and acute ipsilesional oculomotor thresholds (R² 0.497; p < .001), but not contralateral thresholds (R² 0.017: p > .05). In left-sided VN patients, we observed a negative correlation between visual dependence and ipsilesional oculomotor thresholds (R² 0.459; p < .001), but not for contralateral thresholds (R² 0.013; p > .05). To surmise, our findings illustrate that in VN, neuro-otological co-morbidities retard recovery, and that measures of the peripheral vestibular system are an aggregate of residual function and cortically mediated gating of vestibular input.

Capturing nystagmus in the emergency room: posterior circulation stroke versus acute vestibular neuritis

OBJECTIVES

To compare acute nystagmus characteristics of posterior circulation stroke (PCS) and acute vestibular neuritis (AVN) in the emergency room (ER) within 24 h of presentation.

METHODS

ER-based video-nystagmography (VNG) was conducted, recording ictal nystagmus in 101 patients with PCS (on imaging) and 104 patients with AVN, diagnosed on accepted clinical and vestibular test criteria.

RESULTS

Patients with stroke in the brainstem (38/101, affecting midbrain (n = 7), pons (n = 19), and medulla (n = 12)), cerebellum (31/101), both (15/101) or other locations (17/101) were recruited. Common PCS territories included posterior-inferior-cerebellar-artery (41/101), pontine perforators (18/101), multiple-territories (17/101) and anterior-inferior-cerebellar-artery (7/101). In PCS, 44/101 patients had no spontaneous nystagmus. Remaining PCS patients had primary position horizontal (44/101), vertical (8/101) and torsional (5/101) nystagmus. Horizontal nystagmus was 50% ipsiversive and 50% contraversive in lateralised PCS. Most PCS patients with horizontal nystagmus (28/44) had unidirectional "peripheral-appearing" nystagmus. 32/101 of PCS patients had gaze-evoked nystagmus. AVN affected the superior, inferior or both divisions of the vestibular nerve in 55/104, 4/104 and 45/104. Most (102/104) had primary position horizontal nystagmus; none had gaze-evoked nystagmus. Two inferior VN patients had contraversive torsional-downbeat nystagmus. Horizontal nystagmus with SPV ≥ 5.8 °/s separated AVN from PCS with sensitivity and specificity of 91.2% and 83.0%. Absent nystagmus, gaze-evoked nystagmus, and vertical-torsional nystagmus were highly specific for PCS (100%, 100% and 98.1%).

CONCLUSION

Nystagmus is often absent in PCS and always present in AVN. Unidirectional 'peripheral-appearing' horizontal nystagmus can be seen in PCS. ER-based VNG nystagmus assessment could provide useful diagnostic information when separating PCS from AVN.

Development of a Prototype Video Head Impulse Test System Using an iPhone for Screening of Peripheral Vestibular Dysfunction

Introduction

Head impulse, nystagmus, and test of skew (HINTS) is more accurate for the early diagnosis of occipital fossa stroke than magnetic resonance imaging. However, the head impulse test (HIT) is relatively challenging to perform, as it is subjective. Herein, we developed a prototype video HIT (vHIT) system using an iPhone (Apple, Cupertino, CA, USA) that is compact, easy to operate, and analyzable by our iPhone application.

Methods

The iPhone-vHIT and a vHIT using EyeSeeCam (Interacoustics, Eden Prairie, NM, USA) were performed on a healthy man in his 30s and on a patient with vestibular neuritis who visited the Mejiro University Ear Institute Clinic. For the iPhone-vHIT, eye movements were detected by analyzing high-speed videos captured using an iPhone camera, and head movements were followed using an iPhone gyro sensor. An iPhone fixation brace was used to capture the video without any blurring.

Results

The iPhone-vHIT system obtained vHIT waveforms similar to those of the EyeSeeCam-vHIT system in the healthy man and the patient with vestibular neuritis. The iPhone-vHIT system effectively detected the reduced vestibulo-ocular reflex gain in patients with vestibular neuritis. The iPhone-vHIT system at 120 frames per second was less sensitive to catch-up saccades than the EyeSeeCam.

Conclusion

vHIT systems using a smartphone have been reported but are currently unavailable. At present, the iPhone-vHIT application in this study is the only available smartphone-based vHIT system for screening of peripheral vestibular dysfunction. We believe that the prototype iPhone-vHIT with a high-speed camera will be clinically used to perform the vHIT, even though it only examines the lateral semicircular canal.

Vestibular Schwannoma Presenting as Acute Vertigo Mimicking Vestibular Neuritis

Vestibular schwannoma (VS) is commonly accompanied by hearing loss, tinnitus, and dizziness and tends to be chronically progressive in nature. We report a case of VS presenting as left vestibular neuritis (VN) in a previously healthy 57-year-old patient. Right-beating horizontal-torsional spontaneous nystagmus was observed, and the bedside head impulse test revealed a left catch-up saccade. The bithermal caloric test showed left canal paresis, and pure-tone audiometry revealed an average threshold of 22.5 dB bilaterally. Brain magnetic resonance imaging (MRI) demonstrated a 0.7-cm enhancing mass in the left internal auditory canal, consistent with VS. The patient was administered with high-dose systemic corticosteroids and vestibular suppressants with antiemetic, which relieved acute vertigo. Although dizziness in VS is chronically progressive in nature, VS may present as an acute vestibular syndrome that mimics VN. VS should be considered a potential cause of acute vestibular syndrome, and thorough neurological examination with MRI may be helpful for accurate diagnosis.

Prevalence of stroke in acute vertigo presentations: A UK tertiary stroke centre perspective

The reported prevalence of stroke amongst patients presenting to hospital with acute vertigo and/or imbalance is c. 5%, leading to the pervasive notion amongst emergency and stroke physicians, that stroke is uncommon in this cohort. To interrogate the veracity of this notion, we systematically and retrospectively screened the electronic care records in our institution of patients referred as suspected stroke, to a hyperacute stroke service at a large tertiary referral centre. We screened 24,310 consecutive patients' electronic case records presenting to our hospital as an emergency over a 4-month period, 332 of whom were referred as suspected stroke whose case records were assessed via structured review. Of these 332 cases, 61 presented with a vestibular syndrome, i.e. having at least one of imbalance, dizziness or vertigo. Of the 61 vestibular cases, 38 (62%) were diagnosed as stroke confirmed by imaging in 25/38 or upon clinical grounds only (13/38). None of the 38 vestibular stroke cases received thrombolysis or thrombectomy treatment. In a UK urban population (2.5mn), acute vestibular syndrome cases referred to stroke services have a 50% stroke prevalence. None of the vestibular stroke cases received hyperacute stroke treatment e.g., thrombolysis, due to delay in diagnosis. The high stroke prevalence in our cohort may indicate an excessively high threshold for referring acute vestibular cases for stroke, implying a high number of missed stroke cases. We suggest that early access to vestibular neurologists in acute vestibular cases should improve the proportion of vestibular stroke cases receiving definitive stroke treatment.

Discordant horizontal-torsional nystagmus: a sign of posterior semicircular canal dysfunction

In central as well as peripheral vestibular lesions, right-beating horizontal nystagmus is almost always associated with clockwise (top poles of the eyes beating to the right ear) torsional nystagmus when observed and vice versa (concordant nystagmus). This study aimed to determine the etiologies and mechanisms of horizontal and torsional nystagmus beating in the opposite directions (discordant nystagmus). We reviewed the medical records of 16 consecutive patients with discordant horizontal-torsional nystagmus who had been evaluated at the dizziness clinics of Seoul National University Bundang Hospital (n = 11, from March 2003 to March 2021) and Korea University Medical Center (n = 5, from March 2019 to March 2021). The underlying etiologies included inferior vestibular neuritis (n = 7), Meniere's disease (n = 4), internuclear ophthalmoplegia (n = 3), medullary hemorrhage (n = 1), and normal pressure hydrocephalus (n = 1). The torsional nystagmus decreased during the gaze in the same direction (for instance, during rightward gaze in clockwise nystagmus) and increased during the gaze in the opposite direction. Head-impulse tests (HITs) were positive for the ipsilesional posterior canal (PC) in all 11 patients with unilateral peripheral vestibulopathy and two of the three patients with unilateral central vestibulopathy. Discordant horizontal-torsional nystagmus may be observed in peripheral as well as central lesions. Given the findings of HITs and modulation of spontaneous nystagmus during lateral gazes, discordant horizontal-torsional nystagmus may be ascribed to selective damage of the excitatory or inhibitory pathway from the PC that innervates the ipsilateral superior oblique and contralateral inferior rectus muscles.

The feasibility of SHIMP for judging subjective vertigo and recovery in patients with vestibular neuritis

PURPOSE

We aimed to study the results of the head impulse paradigm (HIMP) and the suppression head impulse paradigm (SHIMP) in patients with acute vestibular neuritis (AVN) to compare dizziness handicap inventory (DHI) scores before and after treatment. We also wanted to investigate the correlation between the HIMP, SHIMP and DHI score and to analyze the factors that affect the recovery with AVN in the short term.

METHODS

The HIMP, SHIMP, and DHI score were assessed in 20 patients with AVN before (T₀) and after treatment (T₁). We collected the following indicators: T₀, T₁-HIMP VOR gain; T₀, T₁-SHIMP VOR gain; the percentage of the anti-compensatory saccades of T₀-SHIMP and T₁-SHIMP on the affected side; T₀-DHI score, T₁-DHI score; and efficacy index (EI). The correlation between HIMP and SHIMP parameters with the DHI score and EI was analyzed, and the factors that affect the recovery of patients with AVN were assessed.

RESULTS

T₀-SHIMP anti-compensatory saccades (%),T₁-SHIMP VOR gain, and T₁-SHIMP anti-compensatory saccades (%) were significantly correlated with the corresponding DHI score and EI (P < 0.05). T₀, T₁-HIMP VOR gain and T₀-SHIMP VOR gain had no correlation with the corresponding DHI score and EI (P > 0.05). T₀-SHIMP anti-compensatory saccades (%) significantly affect EI (P < 0.05).

CONCLUSION

Both HIMP and SHIMP can assess the current vestibular function and recovery of AVN patients, but SHIMP can more accurately reflect the degree of subjective vertigo. At the same time, T₀-SHIMP anti-compensatory saccades (%) can be used as a good index to evaluate the short-term recovery of AVN patients.

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.

White Matter Hyperintensities (WMH) and clinical outcome after vestibular neuritis

OBJECTIVES

Identification of patients at high risk for chronic dizziness after Vestibular Neuritis (VN) would allow these patients to be the target of focused therapies. However, there is a discrepancy between studies with regard to which factors best predict symptom recovery. The present study provides a comprehensive evaluation of Vestibular Neuritis and the major predictors for the development of chronic vestibular insufficiency.

METHODS

All subjects (n = 54) with acute vestibular neuritis admitted to the Department of Neurology of Beijing Luhe Hospital affiliated to Capital Medical University from 2018 to 2020 were retrospectively identified . Forty-three subjects who received a 4-test battery as well as 3.0T brain MRI, were included in the study. Patients were divided into two groups: Group 1 with complete recovery and Group 2 without recovery, as determined by symptoms 3 months after the VN episode. In addition, we recruited 21 healthy subjects to characterize the profiles of acute VN .

RESULTS

The total WMH score negatively correlated with a clinical recovery (Phi coefficient = -0.808, p value = 0.000). Statistical regression for predicting the outcome of clinical recovery using cerebral white matter changes as an independent variable was significant (p = 0.004). However, clinical recovery was not associated with the nerve divisions (Phi coefficient = 0.108, p = 0.492), age (p = 0.247) and the grade of nystagmus (p = 0.797)   .

CONCLUSIONS

A 4-test battery provides essential information to identify vestibular nerve dysfunction. Cerebral white matter change on MRI was predictive of chronic vestibular insufficiency after vestibular neuritis.

Three-Dimensional High-Resolution Temporal Bone Histopathology Identifies Areas of Vascular Vulnerability in the Inner Ear

OBJECTIVES

Hypothesized causes of vestibular neuritis/labyrinthitis include neuroinflammatory or vascular disorders, yet vascular disorders of the inner ear are poorly understood. Guided by known microvascular diseases of the retina, we developed 2 hypotheses: (1) there exist vascular vulnerabilities of artery channels in cases of hypothetical nerve swelling for the superior, inferior, and vestibulocochlear artery and (2) there are arteriovenous crossings that could compromise vascular flow in disease states.

METHODS

Two fully mounted and stained temporal bones were used to render three-dimensional reconstructions of the labyrinth blood supply. Using these maps, areas of potential vascular compression were quantified in 50 human temporal bones.

RESULTS

Although inner ear arteries and veins mostly travel within their own bony channels, they may be exposed (1) at the entrance into the otic capsule, and (2) where the superior vestibular vein crosses the inferior vestibular artery. At the entry into the otic capsule, the ratio of the soft tissue to total space for the superior vestibular artery was significantly greater than the inferior vestibular artery/cochleovestibular artery (median 44, interquartile range 34-55 vs. 14 [9-17], p < 0.0001).

CONCLUSIONS

Three-dimensional reconstruction of human temporal bone histopathology can guide vascular studies of the human inner ear. Studies of retinal microvascular disease helped identify areas of vascular vulnerability in cases of hypothetical nerve swelling at the entrance into the otic capsule and at an arteriovenous crossing near the saccular macula. These data may help explain patterns of clinical findings in peripheral vestibular lesions.

Vestibular neuritis after COVID-19 vaccination

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 and presents with pneumonia as the most frequent and serious manifestation. COVID-19 vaccination is an important and urgent interest globally due to COVID-19's rapid spread and high rates of mortality and morbidity. Vestibular neuritis (VN) is an acute vestibular syndrome that causes acute and spontaneous vertigo due to unilateral vestibular deafferentiation, leading to nausea or vomiting and unsteadiness that can last from days to weeks. Reactivation of latent type 1 herpes simplex virus, autoimmune disorders, and microvascular ischemia are hypothesized to be etiologies. Herein, the case of a 54-year-old man who developed VN within three days after COVID-19 vaccination is presented. There have been no reports of VN after vaccination for COVID-19 or other viral diseases. Although the association between VN and COVID-19 vaccination remains unclear, clinicians should be aware that VN may occur as an adverse event of COVID-19 vaccination.

Audiovestibular Symptoms in Patients With Idiopathic Hypertrophic Pachymeningitis: Systematic Literature Review

BACKGROUND AND OBJECTIVE

Hypertrophic pachymeningitis is an infrequent inflammatory disease resulting in thickening and fibrosis of the dura mater. In most cases, the cause in unknown and is called idiopathic hypertrophic pachymeningitis (IHP). Audiovestibular symptoms are infrequent and the pathogenesis is still unclear.

MATERIALS AND METHODS

A systematic literature review of cases with IHP and vestibular symptoms from 2000 to February 2020 was performed. PRISMA Checklist was followed and PubMED database, Web of Science and Cochrane library were searched. We report a case of an adolescent with a diagnosis of vestibular neuritis in the context of IHP attended in our clinic.

RESULTS

We reviewed 5 articles related to IHP and vestibular disorders. A total of 7 cases (5 women and 2 men), with ages between 27 and 68 years with IHP were found. They all had audiovestibular symptoms. In contrast to our patient, uni or bilateral neurosensorial hearing loss was reported in all cases. Furthermore, there is no other case report published describing the association between IHP and vestibular neuritis. High dose steroids improved symptoms in 85.7% of the patients.

CONCLUSION

Vestibular symptoms in IHP are uncommon and the pathogenesis is still debatable. Entrapment of nerves in the internal auditory canal and secondary neuronal damage could be suspected as the main cause of hearing and vestibular loss.

Update on current diagnosis and treatment of vestibular neuritis

Vertigo is the sensation of self-motion of the head or body when no self-motion is occurring or the sensation of distorted self-motion during an otherwise normal head movement. Representative peripheral vertigo disorders include benign paroxysmal positional vertigo, Ménière disease, and vestibular neuritis. Vestibular neuritis, also known as vestibular neuronitis, is the third most common peripheral vestibular disorder after benign paroxysmal positional vertigo and Ménière disease. The cause of vestibular neuritis remains unclear. However, a viral infection of the vestibular nerve or ischemia of the anterior vestibular artery is known to cause vestibular neuritis. In addition, recent studies on immune-mediated mechanisms as the cause of vestibular neuritis have been reported. The characteristic clinical features of vestibular neuritis are abrupt true-whirling vertigo lasting for more than 24 hours, and no presence of cochlear symptoms and other neurological symptoms and signs. To accurately diagnose vestibular neuritis, various diagnostic tests such as the head impulse test, bithermal caloric test, and vestibular-evoked myogenic potential test are conducted. Various treatments for vestibular neuritis have been reported, which are largely divided into symptomatic therapy, specific drug therapy, and vestibular rehabilitation therapy. Symptomatic therapies include generalized supportive care and administration of vestibular suppressants and antiemetics. Specific drug therapies include steroid therapy, antiviral therapy, and vasodilator therapy. Vestibular rehabilitation therapies include generalized vestibular and customized vestibular exercises.

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.

New Onset Vertigo After COVID-19 Infection. A Case Report

In addition to the known pathophysiological sequelae of the SARS-COV-2 virus and its related respiratory symptoms, several studies have recently reported cardiovascular, gastrointestinal, and neurological symptoms of new-onset after a history of infection. Vertigo is a symptom indicating dysfunction of the vestibular system and this report of a 60-year-old female patient points out the possible association between new-onset vertigo and SARS-COV-2 infection. A 60-year-old diabetic and hypertensive female patient with a 9-days history of COVID-19 symptoms presented to the emergency department with acute vertigo attack without nausea or vomiting. A full physical examination showed no other auditory or neurological symptoms and she never experienced vertigo before. Laboratory findings confirmed a current COVID-19 infection. The patient was managed with antihypertensive, anti-vertigo medications, and COVID-19 protocol for mild cases. After discharge, the patient was advised to continue the anti-vertigo drugs and COVID-19 medications. SARS-COV-2 may lead to vestibular neuritis causing vertigo and other related symptoms, but more well-designed observational studies with a large sample size are needed to establish a definite association between COVID-19 and vertigo.

Different time course of compensation of subjective visual vertical and ocular torsion after acute unilateral vestibular lesion

PURPOSE

Time course of the recovery of otolithic dis-function caused by superior vestibular neuritis has been examined in fifteen patients.

METHODS

The subjective visual vertical (SVV) and the ocular cyclotorsion (OT) have been measured four times after the acute episode up to 1 year RESULTS: In most of the patients the SVV tilt returned to control values within few months (3-6 months) after the acute episode, while OT remained out of normal range in almost all patients a year later.

CONCLUSION

The abnormal OT observed after 1 year from the acute episode of vestibular neuritis, suggests that the otolithic receptors remained altered for several months and the OT may be a good indicator of the entity of the residual peripheral otolithic lesion. Moreover, the dissociation between the SVV tilt recovery and that of OT supports the issue that the two signs of the otolithic disfunction are only partially linked each other with centrally or peripherally distinct re-balancing circuits.

Horizontal nystagmus is gravity-dependent in patients with vestibular neuritis

OBJECTIVE

Horizontal nystagmus can be observed in the acute stage of vestibular neuritis, Although the direction of the nystagmus is gravity independent, its intensity can be influenced by gravity. In this study, we compared the slow phase velocity (SPV) of horizontal nystagmus in different head positions in patients with vestibular neuritis to analyze the static effects of gravity on horizontal nystagmus.

METHODS

The study enrolled 22 vestibular neuritis patients with spontaneous horizontal nystagmus (9 men, 13 women; median age 40 years). The deficits were right-sided in 9 patients and left-sided in 13. The nystagmus was recorded in the sitting, supine, right and left ear down positions. The intensity of spontaneous nystagmus in the sitting versus while supine position, and SPV in affected ear down (AED), healthy ear down (HED), and supine positions were compared. The position-induced nystagmus was calculated to quantify the effect of head positions on nystagmus.

RESULTS

The nystagmus intensity in the supine position had no statistic difference than when sitting, with a median value of 6.3°/s and 5.6°/s, respectively(P = 0.355). SPV in AED had a median value of 7.8°/s, which was greater than when supine (P = 0.008) and HED (4.8°/s) (P < 0.001). Position-induced nystagmus in left and right ear-down positions were 1.4°/s and -1.4°/s respectively, which were significantly correlated (Spearman's ρ = -0.848, P < 0.001).

CONCLUSIONS

The nystagmus intensity in vestibular neuritis is gravity dependent; it's greater in AED than in supine and HED, and the effect of head position on nystagmus was nearly symmetrical in left and right ear-down positions.

The spectrum of acute vestibular neuropathy through modern vestibular testing: A descriptive analysis

•

Video head impulse testing and vestibular evoked myogenic potentials show that acute vestibular neuropathy is heterogeneous.

•

Peripheral vestibular pathway vulnerability is approximately inversely correlated with its proportion of afferent fibers.

•

Caloric testing, while useful, should no longer be considered the gold standard for diagnosing acute vestibular neuropathy.

Objective

Acute vestibular neuropathy (AVN), often referred to as vestibular neuritis, is a cranial neuropathy responsible for a significant proportion of cases of acute vertigo. This study describes the spectrum of lesion patterns in AVN as identified by video head impulse testing (vHIT) which assesses the high frequency vestibulo-ocular reflex function of the semicircular canals, and cervical and ocular vestibular evoked myogenic potentials (VEMPs) which assess otolith function.

Methods

We used vHIT and VEMPs to assess 35 patients with vestibular neuropathy in the acute stage.

Results

Unilateral superior division vestibular nerve involvement was the most common variant (57.1%), followed by unilateral superior and inferior division (28.5%), bilateral superior division (8.5%) and unilateral inferior division (5.7%). We observed a partial inverse correlation between the proportion of afferent fibers from an organelle, and the likelihood that the test of that organelle’s function will be abnormal.

Conclusion

vHIT and VEMPs provide more detailed characterization of lesion pattern in AVN than caloric testing.

Significance

Comparison of lesion patterns from neuro-physiological testing with what is known about the proportional distribution of afferent fibers from the vestibular end-organelles suggests a new, neuro-anatomically based insight regarding susceptibility of these pathways to AVN.

[Unclear chronic vertigo syndromes-experiences with an interdisciplinary inpatient diagnostic concept]

Schwindel ist ein häufiges Leitsymptom. Insbesondere Patienten mit chronischen Schwindelsyndromen erleben eine deutliche Beeinträchtigung der Lebensqualität und bei Berufstätigen eine Einschränkung der Arbeitsfähigkeit. Folgen sind finanzielle und kapazitive Belastungen des Gesundheitssystems aufgrund von häufigen Mehrfachuntersuchungen und Krankschreibungen bis hin zur Erwerbsunfähigkeit der Betroffenen. Bei 150 Patienten mit in der ambulanten Diagnostik unklaren chronischen Schwindelsyndromen wurde auf der Grundlage eines strukturierten interdisziplinären stationären Diagnostikkonzepts bei über 90 % der Fälle mindestens eine die Beschwerden begründende Diagnose erhoben. Chronische Schwindelsyndrome sind häufig multifaktoriell bedingt. Bei mehr als der Hälfte der Patienten fanden sich u. a. psychosomatische (Begleit‑)Diagnosen. Zielführende therapeutische Empfehlungen können nur diagnosespezifisch erfolgen, weshalb in dauerhaft unklaren Fällen auch die Abklärung im Rahmen eines interdisziplinären stationären Diagnostikkonzepts sinnvoll und gerechtfertigt sein kann.

Clinical value of the video head impulse test in patients with vestibular neuritis: a systematic review

PURPOSE

The aim of this systematic review was to evaluate the clinical application potential of the video head impulse test (vHIT) in diagnosing vestibular neuritis (VN).

METHODS

An electronic search was conducted in the following databases: Embase, MEDLINE, ScienceDirect, Google scholar, and the Cochrane Database of Systematic Reviews. Clinical studies were included in which an evaluation was made using vHIT either alone or in combination with other tests or bedside algorithms. Evaluations that were carried out using unvalidated tools were excluded. Only studies of patients with VN (superior, inferior, or in toto) were included. Screening of titles, abstracts, full texts, and data extraction were undertaken independently by pairs of reviewers. Included studies were quality appraised using a modified version of the Newcastle-Ottawa scale.

RESULTS

Results were reported according to the preferred reporting items for systematic reviews and meta-analyses. Our search yielded 1309 unique records, 21 of which remained after screening titles and abstracts. Sixteen studies were included, i.e., for a total of 933 patients including 474 patients with a diagnosis of VN.

CONCLUSIONS

The diagnostic value of vHIT is high for VN, as it is a high-frequency measurement tool. vHIT is a useful complement or alternative to caloric and rotational tests as an indicator of lesions of vestibular canal functioning, especially at the time of onset. This tool can provide useful clues about the clinical progress of recovery from the lesion through the value of the vestibulo ocular reflex gain and the consequent evolution of the saccade pattern, which allows the patient to stabilize vision on the retina.

Acute Dizziness, Vertigo, and Unsteadiness

Vestibular symptoms, including dizziness, vertigo, and unsteadiness, are common presentations in the emergency department. Most cases have benign causes, such as vestibular apparatus dysfunction or orthostatic hypotension. However, dizziness can signal a more sinister condition, such as an acute cerebrovascular event or high-risk cardiac arrhythmia. A contemporary approach to clinical evaluation that emphasizes symptom duration and triggers along with a focused oculomotor and neurologic examination can differentiate peripheral causes from more serious central causes of vertigo. Patients with high-risk features should get brain MRI as the diagnostic investigation of choice.

Histology and neuroanatomy suggest a unified mechanism to explain the distribution of lesion patterns in acute vestibular neuropathy

Human temporal bone studies have described the distribution of afferent fibers from each of the five organelles in the labyrinth. Data from vestibular tests in patients with vestibular neuritis can be abnormal in almost any pattern. We propose a unified explanation for these patterns, based on histological and neuroanatomical factors.

Absence of a vergence-mediated vestibulo-ocular reflex gain increase does not preclude adaptation

BACKGROUND

The gain (eye-velocity/head-velocity) of the angular vestibuloocular reflex (aVOR) during head impulses can be increased while viewing near-targets and when exposed to unilateral, incremental retinal image velocity error signals. It is not clear however, whether the tonic or phasic vestibular pathways mediate these gain increases.

OBJECTIVE

Determine whether a shared pathway is responsible for gain enhancement between vergence and adaptation of aVOR gain in patients with unilateral vestibular hypofunction (UVH).

MATERIAL AND METHODS

20 patients with UVH were examined for change in aVOR gain during a vergence task and after 15-minutes of ipsilesional incremental VOR adaptation (uIVA) using StableEyes (a device that controls a laser target as a function of head velocity) during horizontal passive head impulses. A 5 % aVOR gain increase was defined as the threshold for significant change.

RESULTS

11/20 patients had >5% vergence-mediated gain increase during ipsi-lesional impulses. For uIVA, 10/20 patients had >5% ipsi-lesional gain increase. There was no correlation between the vergence-mediated gain increase and gain increase after uIVA training.

CONCLUSION

Vergence-enhanced and uIVA training gain increases are mediated by separate mechanisms and/or vestibular pathways (tonic/phasic). The ability to increase the aVOR gain during vergence is not prognostic for successful adaptation training.

Diagnostic evolution of vestibular neuritis after long-term monitoring

INTRODUCTION

The diagnosis of vestibular neuritis is based on clinical and laboratory findings after exclusion of other disease. There are occasional discrepancies between clinical impressions and laboratory results. It could be the first vertigo episode caused by other recurrent vestibular disease, other than vestibular neuritis.

OBJECTIVE

This study aimed to analyze the clinical features and identify the diagnostic evolution of patients with clinically suspected vestibular neuritis.

METHODS

A total of 201 patients clinically diagnosed with vestibular neuritis were included in this study. Clinical data on the symptoms and signs of vertigo along with the results of vestibular function test were analyzed retrospectively. Patients were categorized in terms of the results of caloric testing (CP - canal paresis) group; canal paresis ≥25%; (MCP -minimal canal paresis) group; canal paresis <25%). Clinical features were compared between the two groups and the final diagnosis was reviewed after long-term follow up of both groups.

RESULTS

Out of 201 patients, 57 showed minimal canal paresis (CP<25%) and 144 showed definite canal paresis (CP≥25%). A total of 48 patients (23.8%) experienced another vertigo episode and were re-diagnosed. Recurring vestibular symptoms were seen more frequently in patients with minimal canal paresis (p=0.027). Repeated symptoms were observed on the same affected side more frequently in the CP group. The proportion of final diagnosis were not different between two groups.

CONCLUSIONS

Patients with minimal CP are more likely to have recurrent vertigo than patients with definite CP. There was no significant difference in the distribution of the final diagnoses between two groups when the vertigo recurs.

Audiovestibular symptoms in patients with idiopathic hypertrophic pachymeningitis: Systematic literature review

BACKGROUND AND OBJECTIVE

Hypertrophic pachymeningitis is an infrequent inflammatory disease resulting in thickening and fibrosis of the dura mater. In most cases, the cause in unknown and is called idiopathic hypertrophic pachymeningitis (IHP). Audiovestibular symptoms are infrequent and the pathogenesis is still unclear.

MATERIALS AND METHODS

A systematic literature review of cases with IHP and vestibular symptoms from 2000 to February 2020 was performed. PRISMA Checklist was followed and PubMED database, Web of Science and Cochrane library were searched. We report a case of an adolescent with a diagnosis of vestibular neuritis in the context of IHP attended in our clinic.

RESULTS

We reviewed 5 articles related to IHP and vestibular disorders. A total of 7 cases (5 women and 2 men), with ages between 27 and 68 years with IHP were found. They all had audiovestibular symptoms. In contrast to our patient, uni or bilateral neurosensorial hearing loss was reported in all cases. Furthermore, there is no other case report published describing the association between IHP and vestibular neuritis. High dose steroids improved symptoms in 85.7% of the patients.

CONCLUSION

Vestibular symptoms in IHP are uncommon and the pathogenesis is still debatable. Entrapment of nerves in the internal auditory canal and secondary neuronal damage could be suspected as the main cause of hearing and vestibular loss.

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.

Consensus on Virtual Management of Vestibular Disorders: Urgent Versus Expedited Care

The virtual practice has made major advances in the way that we care for patients in the modern era. The culture of virtual practice, consulting, and telemedicine, which had started several years ago, took an accelerated leap as humankind was challenged by the novel coronavirus pandemic (COVID19). The social distancing measures and lockdowns imposed in many countries left medical care providers with limited options in evaluating ambulatory patients, pushing the rapid transition to assessments via virtual platforms. In this novel arena of medical practice, which may form new norms beyond the current pandemic crisis, we found it critical to define guidelines on the recommended practice in neurotology, including remote methods in examining the vestibular and eye movement function. The proposed remote examination methods aim to reliably diagnose acute and subacute diseases of the inner-ear, brainstem, and the cerebellum. A key aim was to triage patients into those requiring urgent emergency room assessment versus non-urgent but expedited outpatient management. Physicians who had expertise in managing patients with vestibular disorders were invited to participate in the taskforce. The focus was on two topics: (1) an adequate eye movement and vestibular examination strategy using virtual platforms and (2) a decision pathway providing guidance about which patient should seek urgent medical care and which patient should have non-urgent but expedited outpatient management.

Modern machine-learning can support diagnostic differentiation of central and peripheral acute vestibular disorders

BACKGROUND

Diagnostic classification of central vs. peripheral etiologies in acute vestibular disorders remains a challenge in the emergency setting. Novel machine-learning methods may help to support diagnostic decisions. In the current study, we tested the performance of standard and machine-learning approaches in the classification of consecutive patients with acute central or peripheral vestibular disorders.

METHODS

40 Patients with vestibular stroke (19 with and 21 without acute vestibular syndrome (AVS), defined by the presence of spontaneous nystagmus) and 68 patients with peripheral AVS due to vestibular neuritis were recruited in the emergency department, in the context of the prospective EMVERT trial (EMergency VERTigo). All patients received a standardized neuro-otological examination including videooculography and posturography in the acute symptomatic stage and an MRI within 7 days after symptom onset. Diagnostic performance of state-of-the-art scores, such as HINTS (Head Impulse, gaze-evoked Nystagmus, Test of Skew) and ABCD2 (Age, Blood, Clinical features, Duration, Diabetes), for the differentiation of vestibular stroke vs. peripheral AVS was compared to various machine-learning approaches: (i) linear logistic regression (LR), (ii) non-linear random forest (RF), (iii) artificial neural network, and (iv) geometric deep learning (Single/MultiGMC). A prospective classification was simulated by ten-fold cross-validation. We analyzed whether machine-estimated feature importances correlate with clinical experience.

RESULTS

Machine-learning methods (e.g., MultiGMC) outperform univariate scores, such as HINTS or ABCD2, for differentiation of all vestibular strokes vs. peripheral AVS (MultiGMC area-under-the-curve (AUC): 0.96 vs. HINTS/ABCD2 AUC: 0.71/0.58). HINTS performed similarly to MultiGMC for vestibular stroke with AVS (AUC: 0.86), but more poorly for vestibular stroke without AVS (AUC: 0.54). Machine-learning models learn to put different weights on particular features, each of which is relevant from a clinical viewpoint. Established non-linear machine-learning methods like RF and linear methods like LR are less powerful classification models (AUC: 0.89 vs. 0.62).

CONCLUSIONS

Established clinical scores (such as HINTS) provide a valuable baseline assessment for stroke detection in acute vestibular syndromes. In addition, machine-learning methods may have the potential to increase sensitivity and selectivity in the establishment of a correct diagnosis.

Platform posturography of patients with peripheral vestibular dysfunction in the non-acute phase of vertigo

OBJECTIVE

Posturography (PG) shows various patterns corresponding to a patient's equilibrium condition; however, PG is not useful for the differential diagnosis of peripheral vestibular diseases (PVDs). The aim of this study was to identify parameters of PG that can distinguish between PVDs.

METHODS

The differences in PG parameters between PVDs were evaluated retrospectively. Two hundred and two patients with Ménière's disease (MD), 154 patients with benign paroxysmal positional vertigo (BPPV), 20 patients with sudden sensorineural hearing loss with vertigo (SSNHLwV), and 31 patients with vestibular neuritis (VN) underwent PG during the non-acute phase of vertigo, from January 2010 to March 2017.

RESULTS

The velocity of body oscillation of BPPV patients with eyes open and closed were significantly faster than those of MD patients with eyes open (p < 0.001) and closed (p = 0.033). The velocity of body oscillation of VN patients with eyes open was significantly faster than that of MD patients with eyes open (p = 0.0083). There were no significant differences among the other PG parameters between PVDs. Although there were significant differences among the velocity with eyes open and closed between males and females (eye open: p = 0.0009, eye close: p < 0.0001), there was no significant difference in the ratio of males to females among PVDs (p = 0.1834). Therefore, the ratio did not influence the difference in velocity among PVDs. Patient age correlated with the velocity with eyes open (p < 0.001) and with eyes closed (p < 0.001). Post-hoc analysis revealed significant differences in patient age, and comparisons of MD and BPPV, MD and SSNHLwV, BPPV and VN, and VN and SSNHLwV. Therefore, we performed multiple regression analysis to determine whether the significant differences in the velocity of body oscillation among PVDs were caused by the difference in age distribution between PVD groups, rather than by differences in the PVDs themselves. There were correlations between age and the velocity of body oscillation with eyes open (p < 0.001) and with eyes closed (p < 0.001). There also were correlations between MD or VN and the velocity of body oscillation with eyes open (p = 0.0194).

CONCLUSION

There were significant differences in the velocity of body oscillation with eyes open between MD and VN patients. The difference between MD and VN was significant regardless of the age distribution. To distinguish between MD and VN, the velocity of body oscillation with eyes open is a useful PG index.

Diagnosis of Patients with Acute Dizziness

Using an algorithmic approach to acutely dizzy patients, physicians can often confidently make a specific diagnosis that leads to correct treatment and should reduce the misdiagnosis of cerebrovascular events. Emergency clinicians should try to become familiar with an approach that exploits timing and triggers as well as some basic "rules" of nystagmus. The gait should always be tested in all patients who might be discharged. Computed tomographic scans are unreliable to exclude posterior circulation stroke presenting as dizziness, and early MRI (within the first 72 hours) also misses 10% to 20% of these cases.

Evidence-based diagnostic use of VEMPs : From neurophysiological principles to clinical application

BACKGROUND

Vestibular evoked myogenic potentials (VEMPs) are increasingly being used for testing otolith organ function.

OBJECTIVE

This article provides an overview of the anatomical, biomechanical and neurophysiological principles underlying the evidence-based clinical application of ocular and cervical VEMPs (oVEMPs and cVEMPs).

MATERIAL AND METHODS

Systematic literature search in PubMed until April 2019.

RESULTS

Sound and vibration at a frequency of 500 Hz represent selective vestibular stimuli for the otolith organs. The predominant specificity of oVEMPs for contralateral utricular function and of cVEMPs for ipsilateral saccular function is defined by the different central projections of utricular and saccular afferents. VEMPs are particularly useful in the diagnosis of superior canal dehiscence and otolith organ specific vestibular dysfunction and as an alternative diagnostic approach in situations when video oculography is not possible or useful.

CONCLUSION

The use of VEMPs is a simple, safe, reliable and selective test of dynamic function of otolith organs.

Separating posterior-circulation stroke from vestibular neuritis with quantitative vestibular testing

OBJECTIVE

To separate vestibular neuritis (VN) from posteriorcirculation stroke (PCS) using quantitative tests of canal and otolith function.

METHODS

Video Head-Impulse tests (vHIT) were used to assess all three semicircular canal pairs; vestibulo-ocular reflex (VOR) gain and saccade metrics were examined. Cervical and ocular-Vestibular-Evoked Myogenic Potentials (c- and oVEMP) and Subjective Visual Horizontal (SVH) were used to assess otolith function.

RESULTS

For controls (n = 40), PCS (n = 22), and VN (n = 22), mean horizontal-canal VOR-gains were 0.96 ± 0.1, 0.85 ± 0.3 and 0.40 ± 0.2, refixation-saccade prevalence was 71.9 ± 41, 90.7 ± 57, 209.2 ± 62 per 100 impulses and cumulative-saccade amplitudes were 0.9 ± 0.4°, 2.4 ± 2.2°, 8.0 ± 3.5°. Abnormality-rates for cVEMP, oVEMP and SVH were 38%, 9%, 72% for PCS, and 43%, 50%, 91% for VN. A gain ≤0.68, refixation-saccade prevalence of ≥135% and cumulative-saccade amplitudes ≥5.3° separated VN from PCS with sensitivities of 95.5%, 95.5%, and 81.8%, and specificities of 68.2%, 86.4% and 95.5%. VOR-gain and saccade prevalence when combined, separated VN from PCS with a sensitivity and specificity of 90.9%. Abnormal oVEMP asymmetry-ratios were of low sensitivity (50%) but high specificity (90.9%) for separating VN from PCS.

CONCLUSION

vHIT provided the best separation of VN from PCS. VOR-gain, refixation-saccade prevalence and amplitude were effective discriminators of VN from PCS.

SIGNIFICANCE

vHIT and oVEMP could assist early identification of the aetiology of Acute Vestibular Syndrome in the Emergency Room.

Suppression Head Impulse Paradigm (SHIMP) in evaluating the vestibulo-saccadic interaction in patients with vestibular neuritis

PURPOSE

Evaluate the potential clinical application of the Suppression Head Impulse Paradigm (SHIMP) in evaluating the vestibulo-saccadic interaction in patients with vestibular neuritis (VN).

METHODS

A retrospective study was performed. Fifteen patients diagnosed with unilateral VN were identified from a database of ENT vestibular clinic from January 2011 to February 2020. Medical records were reviewed to determine clinical presentation, vestibular testing results, treatment, and recovery.

RESULTS

Fifteen patients (7 left ear, 8 right ear, mean age 58.73 ± 10.73, six female) met the inclusion criteria and were enrolled in the study. Significant differences were found in the within-subjects analysis at T1 in DHI score (p = 0.001), VOR gain (p < 0.005), and in the percentages of impulses containing a SHIMPs saccade when the head is passively turned toward the affected side (p = 0.001).

CONCLUSIONS

SHIMPs paradigm provides useful information about the value of vestibulo-saccadic interaction as new recovery strategies in patients with VN.

Electrophysiological and inner ear MRI findings in patients with bilateral vestibulopathy

PURPOSE

Bilateral vestibulopathy (BV) is an uncommon disorder and the etiology remained idiopathic in most cases. Delayed 3D-FLAIR sequences have provided new insights into various inner ear diseases, allowing the evaluation of the endolymphatic space and the permeability of the blood-labyrinthine barrier (BLB). The aim of this study was to assess both the morphology of the endolymphatic space and the permeability of the BLB in patients with BV as evaluated by delayed 3D-FLAIR sequences.

METHODS

In this retrospective study, we performed 3D-FLAIR sequences 4 h after administering contrast media to 42 patients with BV. Two radiologists independently evaluated the morphology of the endolymphatic space (either vestibular atelectasis or endolymphatic hydrops) and the permeability of the BLB.

RESULTS

Morphologic anomalies of the endolymphatic space and vestibular blood-labyrinthine barrier impairment were observed in 59.6% of patients with BV. Bilateral vestibular atelectasis (VA) was found in 21 patients (50%), involving only the utricle and all three ampullas while the saccule was always observed with no sign of collapse: idiopathic BV (n = 19), aminoglycoside administration (n = 1) and few days following abdominal surgery (n = 1). One patient had bilateral vestibular malformation. BLB impairment was observed in five patients (11.9%): paraneoplastic (n = 1), lymphoma (n = 1), autoimmune (n = 1), and vestibular "neuritis" (n = 2). Seventeen patients (40.4%) had normal MRI with no endolymphatic space anomaly or BLB impairment.

CONCLUSION

Patients with BV presented with morphologic anomalies of the endolymphatic space or BLB impairment in 59.6% of patients.

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.

Mean platelet volume, neutrophil- and platelet to lymphocyte ratios are elevated in vestibular neuritis

AIM

To evaluate the alterations in inflammatory markers, NLR and PLR, as well as mean platelet volume (MPV) and the other parameters of complete blood counts (CBC) in adult patients with vestibular neuritis (VN).

METHOD

Designed as a case control study. The records of the patients, who were hospitalized due to an acute onset vertigo, and diagnosed as VN, were analysed retrospectively. The complete blood count (CBC) measures of the patients were statistically compared with the measures of healthy subjects. The correlations between the length of hospitalization and the neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) were also analysed.

RESULTS

One hundred four patients with VN and 138 healthy controls were included. MPV, white blood cell and neutrophil counts, NLR and PLR were significantly higher; while lymphocyte count was significantly lower in the VN group (p < 0.001). There were no correlations between the length of hospitalization and NLR or PLR.

CONCLUSION

The elevations of NLR and PLR support the role of inflammation in VN. The high level of MPV indicates the possible role of the vascular thrombosis in the etiology of VN.

Risk of traffic accidents after onset of vestibular disease assessed with a surrogate marker

OBJECTIVES

To determine if the risk of traffic accidents increases after disease onset in patients with acute vestibular disorders. That could provide a valid rationale for guidelines on driving restrictions.

METHODS

5,260,054 patient data (> 18 years of age) from a statutory health insurer were used to identify traffic injuries in incident cases of Menière's disease (MD) and vestibular neuritis (VN) in 2010-2013. Incident diagnoses were defined as the absence of such diagnoses in the preceding 5 years. Comparators were insured individuals with no such diagnoses throughout 2005-2017. The surrogate for traffic injuries were whiplash injuries coded in ICD-10 as diagnosis of sprain of ligaments of the cervical spine without structural changes.

RESULTS

We identified 4509 incident patients with Menière's disease and 25,448 with vestibular neuritis and 5,102,655 controls with no such diagnoses throughout the observation period. The incidence of traffic injuries was increased for both vestibular disorders prior to the time point of diagnosis-MD 0.72 [0.47; 0.97] and VN 0.66 [0.56; 0.76] compared to controls (0.46 [0.46; 0.47]). The temporal course of incidence in whiplash injuries showed no increase and was 0.64 [0.41; 0.88] for MD at diagnosis and 0.73 [0.48; 0.98] after diagnosis, for VN it was 0.81 [0.70; 0.92] at diagnosis and 0.65 [0.55; 0.74] after diagnosis.

CONCLUSIONS

Although these data were not originally collected to address the research question, they provide a valid body of evidence. There is no rationale for driving restrictions, which substantially interfere with the individuals' quality of life, in patients with incident MD and VN.

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.

An fMRI study of visuo-vestibular interactions following vestibular neuritis

Vestibular neuritis (VN) is characterised by acute vertigo due to a sudden loss of unilateral vestibular function. A considerable proportion of VN patients proceed to develop chronic symptoms of dizziness, including visually induced dizziness, specifically during head turns. Here we investigated whether the development of such poor clinical outcomes following VN, is associated with abnormal visuo-vestibular cortical processing. Accordingly, we applied functional magnetic resonance imaging to assess brain responses of chronic VN patients and compared these to controls during both congruent (co-directional) and incongruent (opposite directions) visuo-vestibular stimulation (i.e. emulating situations that provoke symptoms in patients). We observed a focal significant difference in BOLD signal in the primary visual cortex V1 between patients and controls in the congruent condition (small volume corrected level of p < .05 FWE). Importantly, this reduced BOLD signal in V1 was negatively correlated with functional status measured with validated clinical questionnaires. Our findings suggest that central compensation and in turn clinical outcomes in VN are partly mediated by adaptive mechanisms associated with the early visual cortex.

•

VN clinical status related to V1 response to congruent visuo-vestibular stimuli

•

Reduced V1 BOLD signal during congruent stimulation correlates with subjective dizziness scores

•

No association between V1 BOLD signal and incongruent visuo-vestibular stimulation

•

Changes in V1 activity may reflect cortical adaptive mechanisms following VN

Changes of video head impulse test results in lateral semicircular canal plane by different peak head velocities in patients with vestibular neuritis

BACKGROUND

The peak head velocity influences on the video head impulse test (vHIT) results, but it has been not known how much the difference is.

AIMS

To evaluate the clinical evidence for the superiority of high-velocity compared to low-velocity vHIT.

MATERIAL AND METHODS

vHIT was performed in 30 patients with vestibular neuritis using two peak head velocities (mean 80 vs. 240°/s). vHIT gains and parameters of corrective saccades (CSs) were compared. A vHIT gain of ≤0.8 or a peak CS velocity of ≥100°/s was considered pathologic.

RESULTS

The vHIT gains were significantly lower (mean 0.5 vs. 0.6), and GA was larger (35 vs. 25%) at high-velocity vHIT, compared to low-velocity vHIT. CSs were significantly more frequent (100 vs. 80%) and peak CS velocities were larger (252 vs. 112°/s) at high-velocity vHIT. The abnormal rates based on vHIT gains were higher (90% vs. 73%) and CSs occurred more frequently (100% vs. 80%) at high-velocity vHIT. The abnormal rates based on the peak CS velocity were significantly higher at high-velocity vHIT (100% vs. 57%).

CONCLUSION

High-velocity vHIT is superior to low-velocity vHIT with a difference of 17-20% based on pathologic vHIT gains and presence of CSs.