Scuba Diving-Induced Inner-Ear Pathology: Imaging Findings of Superior Semicircular Canal and Tegmen Tympani Dehiscence

BACKGROUND Superior semicircular canal dehiscence is an inner-ear pathology which presents with vertigo, disequilibrium, and hearing loss. Although the exact etiology of superior semicircular canal dehiscence is unknown, it is thought that an increase in middle-ear pressure disrupts a thin overlying temporal bone. Superior semicircular canal dehiscence is frequently seen in association with dehiscence of the tegmen tympani, which overlies the middle ear. Here, we present a case report of a 52-year-old Puerto Rican man with vertigo, dizziness, vomiting, and mild hearing loss associated with superior semicircular canal and tegmen tympani dehiscence after performing improper scuba diving techniques. CASE REPORT A 52-year-old Puerto Rican man presented to the emergency department with vertigo, dizziness, vomiting, and mild hearing loss in the right ear. The symptoms began shortly after scuba diving with inadequate decompression techniques on ascent. He was treated with recompression therapy with mild but incomplete improvement in symptoms. Bilateral temporal magnetic resonance imaging was suggestive of segmental dehiscence of the right superior semicircular canal and tegmen tympani. High-resolution computed tomography of the temporal bone confirmed right superior semicircular canal and tegmen tympani dehiscence with an intact left inner ear. CONCLUSIONS The increased inner-ear pressure that occurs during scuba diving can lead to dehiscence of the superior semicircular canal and tegmen tympani, causing vertigo and hearing loss. Performance of improper diving techniques can further increase the risk of dehiscence. Therefore, appropriate radiologic evaluation of the inner ear should be performed in such patients.

Periodic vertigo and downbeat nystagmus while supine: Dysfunction of Purkinje cells coding gravity

Cerebellar nodulus and uvula and their connections with the vestibular nuclei form the so-called velocity-storage circuit. Lesions involving the velocity-storage circuit give rise to positional vertigo and nystagmus. Herein, we present a 32-year-old man with cerebellar nodulus and uvular hemorrhage who showed periodic vertigo and downbeat nystagmus in the supine position. To explain this unusual pattern, we adopted velocity-storage model with a lesion on the neural connection between the gravity and inertia estimators, resulting in periodic neural impulses and a gravity bias in a specific position. This report expands the spectrum of central positional nystagmus due to dysfunction of the velocity-storage mechanism.

Vertigo: Streamlining the Evaluation through Symptom Localization

Vertigo is defined as the illusion of internal or external motion. The evaluation of a patient with vertigo in the primary care setting should not necessarily focus on providing a specific diagnosis. Rather, the physician should aim to localize the lesion. This practice streamlines the workup of patients. This article provides detailed information regarding appropriate organ system-based clinical history and the clinical workup of vertigo. Additional signs and symptoms that can facilitate appropriate referral and treatment are highlighted. Although disorder-specific treatments exist the mainstay of therapy for vertigo-induced pathology is physical therapy.

The Value of Subjective Visual Vertical in Diagnosis of Vestibular Migraine

OBJECTIVE

To study the value of the subjective visual vertical (SVV) in the diagnosis of vestibular migraine (VM).

METHODS

This study recruited 128 VM patients and 64 age-matched normal subjects. We detected the SVV during the interval between attacks in both groups, in sitting upright, and the head tilted at 45° to the left or right. We then examined the correlation between the SVV results with the vestibular evoked myogenic potential (VEMP) and canal paresis (CP).

RESULTS

It was found there was a significant difference in SVV at the upright position between VM patients and normal controls (P=0.006) and no significant difference was found at the tilts of 45° to the left or right between the two groups. The SVV results at the upright position were significantly correlated with cervical VEMP (P=0.042) whereas not significantly correlated with CP and VEMP. There existed no significant difference in the conformity to the Müller effect (M effect) between the two groups. ROC analysis exhibited that the sensitivity, specificity of SVVs at the upright were 67.200% and 62.500% respectively. The diagnostic value of SVV at the upright position was significantly higher than that at tilts of 45° to the left and right (P=0.006). Nonetheless the diagnostic accuracy was relatively low.

CONCLUSION

Abnormality in SVV possibly stems from the lasting functional disorder of cerebellar or high-level cortical centers in VM patients or is linked to the vestibular compensation. The SVV is of low diagnostic value for VM and the value of SVV in VM warrants further study.

Prevalence and Risk Factors of White Matter Lesions in Tibetan Patients Without Acute Stroke

Background and Purpose—

Studies on the prevalence and risk factors of white matter lesions (WMLs) in Tibetans living at high altitudes are scarce. We conducted this study to determine the prevalence and risks of WMLs in Tibetan patients without or with nonacute stroke.

Methods—

We undertook a retrospective analysis of medical records of patients treated at the People’s Hospital of Tibetan Autonomous Region and identified a total of 301 Tibetan patients without acute stroke. WML severity was graded by the Fazekas Scale. We assessed the overall and age-specific prevalence of WMLs and analyzed associations between WMLs and related factors with univariate and multivariate methods.

Results—

Of the 301 patients, 87 (28.9%) had peripheral vertigo, 83 (27.3%) had primary headache, 52 (17.3%) had a history of stroke, 36 (12.0%) had an anxiety disorder, 29 (9.6%) had epilepsy, 12 (4.0%) had infections of the central nervous system, and 3 (1.0%) had undetermined diseases. WMLs were present in 245 (81.4%) patients, and 54 (17.9%) were younger than 40 years. Univariate analysis showed that age, history of cerebral infarction, hypertension, the thickness of the common carotid artery intima, and plaque within the intracarotid artery were related risks for WMLs. Ordered logistic analysis showed that age, history of cerebral ischemic stroke, hypertension, male sex, and atrial fibrillation were associated with WML severity.

Conclusions—

Risk factors for WMLs appear similar for Tibetans residing at high altitudes and individuals living in the plains. Further investigations are needed to determine whether Tibetans residing at high altitudes have a higher burden of WMLs than inhabitants of the plains.

Hereditary Angioedema Type 1 with Recurrent Dizziness

A 41-year-old woman presented with recurrent dizziness. After an attack of dizziness, she felt edematous sensations in her hands. However, according to photographs taken during the attack, the edema on the back of the patient's hands and fingers appeared mild. Laboratory examinations revealed a low C4 and C1 inhibitor (INH) activity. A direct sequencing analysis of C1INH revealed a pathogenic gene mutation. Based on these results, she was diagnosed with hereditary angioedema (HAE) type 1. These findings indicate that HAE can cause recurrent dizziness, and it should therefore be included in the differential diagnosis in patients with recurrent neurologic symptoms, even in the absence of severe edema.

Proteome of normal human perilymph and perilymph from people with disabling vertigo

The vast majority of hearing loss, the most common sensory impairment, and vertigo, which commonly causes falls, both reflect underlying dysfunction of inner ear cells. Perilymph sampling can thus provide molecular cues to hearing and balance disorders. While such "liquid biopsy" of the inner ear is not yet in routine clinical practice, previous studies have uncovered alterations in perilymph in patients with certain types of hearing loss. However, the proteome of perilymph from patients with intact hearing has been unknown. Furthermore, no complete characterization of perilymph from patients with vestibular dysfunction has been reported. Here, using liquid-chromatography with tandem mass spectrometry, we analyzed samples of normal perilymph collected from three patients with skull base meningiomas and intact hearing. We identified 228 proteins that were common across the samples, establishing a greatly expanded proteome of the previously inferred normal human perilymph. Further comparison to perilymph obtained from three patients with vestibular dysfunction with drop attacks due to Meniere's disease showed 38 proteins with significantly differential abundance. The abundance of four protein candidates with previously unknown roles in inner ear biology was validated in murine cochleae by immunohistochemistry and in situ hybridization: AACT, HGFAC, EFEMP1, and TGFBI. Together, these results motivate future work in characterizing the normal human perilymph and identifying biomarkers of inner ear disease.

Sound abnormally stimulates the vestibular system in canal dehiscence syndrome by generating pathological fluid-mechanical waves

Individuals suffering from Tullio phenomena experience dizziness, vertigo, and reflexive eye movements (nystagmus) when exposed to seemingly benign acoustic stimuli. The most common cause is a defect in the bone enclosing the vestibular semicircular canals of the inner ear. Surgical repair often corrects the problem, but the precise mechanisms underlying Tullio phenomenon are not known. In the present work we quantified the phenomenon in an animal model of the condition by recording fluid motion in the semicircular canals and neural activity evoked by auditory-frequency stimulation. Results demonstrate short-latency phase-locked afferent neural responses, slowly developing sustained changes in neural discharge rate, and nonlinear fluid pumping in the affected semicircular canal. Experimental data compare favorably to predictions of a nonlinear computational model. Results identify the biophysical origin of Tullio phenomenon in pathological sound-evoked fluid-mechanical waves in the inner ear. Sound energy entering the inner ear at the oval window excites fluid motion at the location of the defect, giving rise to traveling waves that subsequently excite mechano-electrical transduction in the vestibular sensory organs by vibration and nonlinear fluid pumping.

Vestibular click-evoked myogenic potentials: sensitivity and factors determining abnormality in patients with multiple sclerosis

Vestibular evoked myogenic potential (VEMP) assesses the sacculo-spinal pathway. The aim of our study was to examine sensitivity and factors determining abnormality of VEMP, indicative of brainstem dysfunction, in patients with multiple sclerosis (MS). Thirty healthy subjects and 30 MS patients were examined. All healthy subjects showed a normal biphasic response. Twelve of the 30 MS patients (40%) had abnormal recordings. There was a significant difference between MS patients and control subjects with respect to P13 latency (longer in the MS group) and P13-N23 amplitude (lower in the MS group). VEMP abnormalities were statistically significantly related to the presence of brainstem demyelinative lesions and a weaker correlation was found with disease duration. Clinical signs of vestibular dysfunction at any point during the course of the disease did not seem to affect the chances of obtaining abnormal VEMPs. Although the sensitivity of VEMP in detecting abnormality in MS patients is relatively low, its significance is evident in that it is the only electrophysiological method that is able to detect dysfunction in central vestibular pathways. Multiple Sclerosis 2007; 13: 193–198. http://msj.sagepub.com

White matter lesions and vascular vertigo: clinical correlation and findings on cranial magnetic resonance imaging

OBJECTIVE

Vestibular disorders and anxiety are closely related, probably because they share some neuronal pathways. Ageing and patient comorbidities are important facilitating factors, and multiple vascular risk factors could contribute to the onset of a vestibular syndrome called vascular vertigo. White matter lesions (WMLs) are often seen on magnetic resonance imaging (MRI) scans of elderly people and are related to various geriatric disorders, including dizziness. The cause of this correlation could be the disruption of neuronal networks that mediate higher vestibular cortical function. Numerous neuronal pathways link the vestibular network with limbic structures and the prefrontal cortex modulates anxiety through its connections to the amygdala. These could also explain nausea and sickness. The aim of the present work was to investigate the correlation between WML, vascular vertigo and cognitive functions.

PATIENTS AND METHODS

Our team at the Poliambulanza Foundation Hospital of Brescia studied 90 patients (mean age 75 years) suffering from vascular vertigo with positive WML on MRI, by mapping the lesions and by grading anxiety and sickness symptoms. Furthermore, the same patients were treated with sulodexide (a glycosaminoglycan with antithrombotic activity) for 90 days (500 LSU/day for the first 45 days and 250 LSU/day for the following 45 days) to evaluate the efficacy on the vestibular symptoms.

RESULTS

The results showed that the most frequent WML sites were frontal (n=34) and capsule (n=30) areas. Patients had a significant improvement on anxiety and sickness scores (p=0.0001 and p=0.02 respectively) after sulodexide treatment.

CONCLUSIONS

In patients with vascular vertigo we confirmed the correlation between dizziness and anxiety and showed preliminary data regarding the efficacy of sulodexide in relieving in these patients anxiety and sickness.

Progressive multifocal leukoencephalopathy in a patient without apparent immunosuppression

Progressive multifocal leukoencephalopathy (PML) is a viral demyelinating disease due to the reactivation of the JC virus (JCV), which usually occurs in the context of immunosuppression in HIV infection, malignancy, or in patients on disease modifying therapy for autoimmune diseases, such as multiple sclerosis (MS) and Crohn's disease. Notably, there is growing recognition that PML can occur in patients with transient immune dysfunction. Here, we present a case of a 55-year-old man without history of immunosuppression or evidence of ICL who was diagnosed with PML on brain biopsy. We will discuss the potential etiologies of mild and transient immunosuppression that can lead to PML with non-apparent immunosuppression.

Vertigo by Breast Cancer Metastasis 33 Years after Treatment

A 76-year-old woman complained of vertigo for two years. She manifested left deafness, loss of caloric response, and right-beaten nystagmus. An imaging study revealed a tumorous lesion located from the clivus to the left temporal bone with inner ear destruction. A tumor biopsy was performed endonasally and the patient was diagnosed with adenocarcinoma mimicking breast cancer. She had undergone surgery for breast cancer 33 years previously, and the current biopsy specimen showed identical pathology. Breast cancer may metastasize to the skull base; however, metastasis 33 years after surgery is very rare.

Changes in endolymphatic hydrops in patients with Ménière's disease treated conservatively for more than 1 year

CONCLUSION

This study revealed that endolymphatic hydrops (EH) reduced in some cases with Ménière's disease (MD) treated conservatively. It appears that the EH reduction was associated with improvement of the clinical symptoms.

OBJECTIVES

The relationship between the degree of EH and clinical symptoms is not clear at present. The purpose of the present study was to investigate the time course of the relationship in patients with MD treated conservatively.

PATIENTS

Twelve patients with MD treated conservatively for more than 1 year in a university hospital.

METHODS

Twenty ears of 12 patients with MD treated conservatively were evaluated. The presence or absence of vertigo, tinnitus and ear fullness was confirmed when magnetic resonance imaging (MRI) was performed. Using a 3 T MRI scanner, three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) MRI was performed 2 or 3 times 24 hours after intra-tympanic gadolinium injection or 4 hours after intravenous gadolinium injection.

RESULTS

In the three ears in which the symptoms alleviated, EH was reduced in two ears, but EH was reduced in only one of 17 ears in which the symptoms did not alleviate. The Fisher exact test revealed that EH reduction occurred more frequently in ears with alleviation of the symptoms (p < 0.05).

[Pathomorphological change of the atlanto-occipital segment of vertebral artery related with cervical vertigo]

OBJECTIVE

To explore the pathomorphological change of the atlanto-occipital segment of vertebral artery (V3 part) related with cervical vertigo.

METHODS

From June 1999 to November 2011, the pathomorphological change of the atlanto-occipital segment of vertebral artery were observed in 1680 patients with cervical vertigo using 3D-CTA technology. The clinical data of these patients were analyzed. There were 783 males and 897 females, aged from 22 to 70 years old with an average of 52.8 years old. Doppler examination showed vertebral basilar artery flow velocity to speed up or slow down.

RESULTS

The blood vessel of 3360 branches were detected in 1680 patients and 2778 branches were detected out vascular anomaly. And 829 branches were in V1 segment, 421 were in V2, 328 were in V3, 1190 were in V4. The pathomorphological changes in the atlanto-occipital segment (V3) of vertebral artery included angiospasm, congenital absence, abnormal exit, localized stenosis.

CONCLUSION

There are 4 kinds of pathomorphological changes in the atlanto-occipital segment of vertebral artery related with cervical vertigo. The 3D-CTA result can be used to judge prognosis and adopt reasonable treatment for the patients.

Immunogold TEM of otoconin 90 and otolin - relevance to mineralization of otoconia, and pathogenesis of benign positional vertigo

Implementation of the deep-etch technique enabled unprecedented definition of substructural elements of otoconia, including the fibrillar meshwork of the inner core with its globular attachments. Subsequently the effects of the principal soluble otoconial protein, otoconin 90, upon calcite crystal growth in vitro were determined, including an increased rate of nucleation, inhibition of growth kinetics and significant morphologic changes. The logical next step, ultrastructural localization of otoconin 90, by means of immunogold TEM in young mature mice, demonstrated a high density of gold particles in the inner core in spite of a relatively low level of mineralization. Here gold particles are typically arranged in oval patterns implying that otoconin 90 is attached to a scaffold consisting of the hexagonal fibrillar meshwork, characteristic of otolin. The level of mineralization is much higher in the outer cortex where mineralized fiber bundles are arranged parallel to the surface. Following decalcification, gold particles, as well as matrix fibrils, presumed to consist of a linear structural phenotype of otolin, are aligned in identical direction, suggesting that they serve as scaffold to guide mineralization mediated by otoconin 90. In the faceted tips, the level of mineralization is highest, even though the density of gold particles is relatively low, conceivably due to the displacement by the dense mineral phase. TEM shows that individual crystallites assemble into iso-oriented columns. Columns are arranged in parallel lamellae which convert into mineralized blocks for hierarchical assembly into the complex otoconial mosaic. Another set of experiments based on immunogold TEM in young mice demonstrates that the fibrils interconnecting otoconia consist of the short chain collagen otolin. By two years of age the superficial layer of mouse otoconia (corresponding to mid-life human) has become demineralized resulting in weakening or loss of anchoring of the fibrils interconnecting otoconia. Consequently, otoconia detached from each other may be released into the endolymphatic space by minor mechanical disturbances. In humans, benign positional vertigo (BPV) is believed to result from translocation of otoconia from the endolymphatic space into the semi-circular canals rendering their receptors susceptible to stimulation by gravity causing severe attacks of vertigo. The combinations of these observations in humans, together with the presented animal experiments, provide a tentative pathogenetic basis of the early stage of BPV.

[Importance of re-examinations in the diagnosis of benign paroxysmal positional vertigo]

OBJECTIVE

To evaluate the importance of re-examinations in the diagnosis of benign paroxysmal positional vertigo (BPPV) and its clinical characteristics.

METHODS

The medical records of 288 BPPV patients treated during January 2009 to December 2010 were reviewed and analyzed. The definite diagnosis was established by re-examinations.

RESULTS

Among them, 39 (13.5%) were diagnosed by re-examinations or return visits. And 25 patients received a correct diagnosis on the first visit and 14 were diagnosed on return visits. Their ages, gender distribution and the times of particle-repositioning maneuver were the same as the overall profiles. The rate of horizontal semicircular canal BPPV was higher in the 39 re-examined patients than the overall rate (46.15% vs 22.22%). And the latencies decreased during the second examination in 18 patients.

CONCLUSION

Re-examinations and return visits are useful for diagnostic clarifications in the suspected BPPV patients.

Stereological volumetric evaluation of the cerebellum in benign paroxysmal positional vertigo

OBJECTIVE

To evaluate cerebellar volume changes and the asymmetry of patients with benign paroxysmal positional vertigo (BPPV).

METHODS

The cerebellar hemispheres` volumetric symmetry were evaluated using a stereological method on MR images. The study included 15 patients with BPPV, and 14 age-, and gender-matched control subjects. The cases were admitted to the Departments of Otolaryngology, Neurology, and Neurosurgery in the Faculty of Medicine, Kocatepe University, Afyonkarahisar, Turkey with the complaint of vertigo between January 2004 and December 2008.

RESULTS

The right hemi cerebellum volumes of the subjects with BPPV and the controls were measured smaller than the left hemi cerebellar volumes, however, there was no statistically significant quantitative evidence detected in terms of cerebellar asymmetry between sagittal and axial plane estimates in the cases with vertigo. There was statistical significance between the right and left cerebellum in both the patient and control groups (p=0.023), however, the difference did not change according to gender. There were no statistically significant age and gender dependent cerebellar atrophy and asymmetry between BPPV and control subjects.

CONCLUSION

There was no cerebellar atrophy and asymmetry between BPPV and age matched control groups. The stereological evaluation of hemi cerebellar symmetry and atrophy in humans is important for both clinicians and anatomists. The technique is simple, inexpensive, and reliable.

[To analyze the etiology of benign paroxysmal positional vertigo]

OBJECTIVE

To analyze the occurrence and probable etiological factors of benign paroxysmal positional vertigo (BPPV).

METHOD

one hundred and twenty four BPPV cases were inquired histories, classified into different groups and analyzed relevant diseases. All patients were taken Caloric tests before Canal repositioning procedure, and compared the differences of unilateral weakness (UW) and semicircular canal involved between BPPV patients with and without relevant diseases.

RESULT

There were 97 (78.2%) patients with relevant diseases while 27 (21.8%) without. Ninety-two (74.2%) patients with abnormal UW. To compare the normal and abnormal UW, posterior canal and lateral canal with abnormal UW values, unilateral or bilateral of abnormal UW values, consistency of abnormal UW side and BPPV side between BPPV patients with and without relevant diseases, there were no significant differences (Chi-square values were 0.000, 0.000, 0.306, 0.027, P>0.05).

CONCLUSION

BPPV patients with relevant diseases are common, which mainly occurs in middle-aged or aged people and female. Otolith ecclesiis and dysfunction of semicircular canal may have the same etiological factors. Caloric tests may do help to analyze the BPPV etiological factors.

A mathematical model of human semicircular canal geometry: a new basis for interpreting vestibular physiology

We report a precise, simple, and accessible method of mathematically measuring and modeling the three-dimensional (3D) geometry of semicircular canals (SCCs) in living humans. Knowledge of this geometry helps understand the development and physiology of SCC stimulation. We developed a framework of robust techniques that automatically and accurately reconstruct SCC geometry from computed tomography (CT) images and are directly validated using micro-CT as ground truth. This framework measures the 3D centroid paths of the bony SCCs allowing direct comparison and analysis between ears within and between subjects. An average set of SCC morphology is calculated from 34 human ears, within which other geometrical attributes such as nonplanarity, radius of curvature, and inter-SCC angle are examined, with a focus on physiological implications. These measurements have also been used to critically evaluate plane fitting techniques that reconcile many of the discrepancies in current SCC plane studies. Finally, we mathematically model SCC geometry using Fourier series equations. This work has the potential to reinterpret physiology and pathophysiology in terms of real individual 3D morphology.

Isolate vertigo crisis revealing an endolymphatic sac tumor

Endolymphatic sac tumors are rare entities that have a destructive potential on the temporal bone. They are aggressive tumors presenting as low-grade papillary adenocarcinoma, but there are no reports of metastasis in the literature. The Von Hippel-Lindau disease is a hereditary condition caused by germinal mutations of the tumor-suppressor VHL-gene. We present the case of an endolymphatic sac tumor associated with the Von Hippel-Lindau disease at a 46-year-old patient revealed by an isolate vertigo crisis, discussing the management of the tumor and the clinical, imaging, genetic and histopathologic features of it.

CONCLUSIONS

Endolymphatic sac tumors have recently been described as part of the Von Hippel-Lindau disease, a genetic disorder involving the development of hypervascular tumors. The treatment depends on the size of the tumor, however surgical approach is the most successful choice and can be associated or not with radiotherapy.

Endolymphatic space imaging in patients with delayed endolymphatic hydrops

CONCLUSION

Magnetic resonance imaging (MRI) after intratympanic gadolinium injection can reveal endolymphatic hydrops (ELH) in patients with delayed ELH (DELH). Patients with contralateral DELH may have bilateral ELH.

OBJECTIVE

DELH has previously been diagnosed based on clinical history, hearing and vestibular examinations. DELH is classified into three types: ipsilateral, contralateral and bilateral indicate the side with the longstanding hearing loss. Ipsilateral DELH occurs in the ear with a profound hearing loss, contralateral DELH in the better hearing ear and bilateral DELH in both ears. Imaging diagnosis of the endolymphatic space may add a new dimension to the diagnosis and treatment of DELH.

PATIENTS AND METHODS

Gadodiamide hydrate was diluted eightfold with saline. The diluted gadodiamide hydrate was injected intratympanically through the tympanic membrane in two patients with ipsilateral DELH and five patients with contralateral DELH. One day after the injection, 3 Tesla MRI was performed to evaluate the endolymphatic space.

RESULTS

ELH was observed in all patients. In three patients who underwent bilateral intratympanic injection of gadolinium and were diagnosed with contralateral DELH, ELH was observed bilaterally. In one of these three patients, ELH was observed in the cochlea on the left and in the vestibule on the right.

[Clinical features of multiple canal involvement in benign paroxysmal positional vertigo]

OBJECTIVE

To describe a series of patients with multiple canal involvement in benign paroxysmal positional vertigo (BPPV), with respect to diagnosis and management.

METHODS

Ninety-five individuals with symptoms of BPPV and positional nystagmus were included in this study. The diagnosis was based on a history of brief episodes of vertigo and the presence of multiple positional nystagmus as confirmed by video-oculographic examination. Patients were treated by means of different particle repositioning manoeuvres according to the affected canal.

RESULTS

Ninety-five patients showed multiple positional nystagmus during the examination corresponding to simultaneous multi-canal BPPV. Fourteen patients (14.7%) had bilateral canal BPPV. Six patients had bilateral posterior canal. Six patients had bilateral horizontal canal, and two patients had bilateral anterior canal. Fifty-three patients (55.8%) had torsional, up-beating nystagmus with down-beating nystagmus, which suggested possible affected both of posterior and anterior canals. Twenty patients (21.1%) had torsional up-beating nystagmus and horizontal direction nystagmus, which suggested possible affected both of posterior and horizontal canals. Five patients had down-beating nystagmus with horizontal nystagmus, which suggested affected both of anterior and horizontal canals. Three patients had torsional up-beating with down-beating and horizontal nystagmus, which suggested possible affected multiple canals. Treatment given to the patients varied according to the canal affected, started with the canal that elicited a strong positional nystagmus and vertigo, and 93.7% (89/95) of patients were symptom free or improved.

CONCLUSIONS

It has been found that multi-canal BPPV is not a rate observation in clinic, and most of them affected posterior and anterior canals. Treatment of multi-canal BPPV can be effective using repositioning maneuver.

[Different pathogenesis of benign paroxysmal positional vertigo from the nystagmus during particle repositioning maneuver]

OBJECTIVE

To analyze the nystagmus during particle repositioning maneuver for posterior semicircular canal benign paroxysmal positional vertigo (PC-BPPV), and verify different pathogenesis of benign paroxysmal positional vertigo (BPPV).

METHODS

The chief complains, nystagmus during positioning test and particle repositioning maneuver (PRM) were recorded in detail from 66 PC-BPPV cases during Dec.2007 and Apr.2008, and verifying possible pathogenesis of BPPV was based on nystagmus.

RESULTS

Of all 66 PC-BPPV cases, the four positions of PRM were found in 24 cases presented upward torsional nystagmus at the second or third position, 21 cases presented negative nystagmus except the first position, 7 cases presented intensity horizontal nystagmus during PRM and 14 cases presented downward nystagmus at the second or third position during PRM. Of all 66 cases, 78.8% of them were accord with canalithiasis and cupulolithiasis while the other may be related with otolith organ or nerve disease.

CONCLUSIONS

Besides canalithiasis and cupulolithiasis, part of BPPV may be related with otolith organ or nerve disease.

[Influence of manipulation on arteria vertebralis morphology and blood flow speed of cervical vertigo]

OBJECTIVE

To discuss the influence of manipulation on cervical vertigo arteria vertebralis morphology and blood flow speed.

METHODS

Forty-five patients with cervical vertigo included 27 males and 18 females with an average age of 41.6 years old ranging from 25 to 60. The course of disease was from 2 weeks to 5 years. TCD were applied to test arteria vertebralis blood flow speed and 3D-CTA applied to inspect arteria vertebralis morphology as the observation targets. According to the morphology change different stage localization, the 3-step manipulation were adopt to observe the arteria vertebralis blood flow speed and the morphology influence.

RESULTS

After cervical manipulation, the scoring of vertigo symptoms were improved remarkable (P<0.001); Among the patients of blood flow speed reduced and the patients of blood flow speed increased, the Vm before treament compared with after treament, there were statistical difference (P<0.01). The arteria vertebralis morphology partial patient had changed.

CONCLUSION

The cervical manipulation exceptionally has the bidirectional control action to arteria vertebralis morphology change and blood flow speed in the cervical vertigo, and can cause the partial blood tubular-shaped condition to have the reversal changed.

[Clinical manifestations and imaging features of peripheral vestibular paroxysmia: a report of 7 cases]

OBJECTIVE

To investigate the clinical manifestations and imaging features of peripheral vestibular paroxysmal (PVP).

METHODS

The clinical data, including magnetic resonance tomographic angiography (MRTA), of 7 PVP patients, 1 male and 2 females, aged 40-72, were retrospectively analyzed.

RESULTS

(1) All 7 patients had non-specific cochleovestibular symptoms, e.g., recurrent vertigo and continuous dizziness. (2) The predominant symptom was transient vertigo or dizziness with the sudden change of head position. (3) MRTA showed cross of the cochleovestibular nerve (CNV) and blood vessel in all patients. (4) Carbamazepine and sibelium succeeded to relieve the symptoms.

CONCLUSION

Compression of the cranial nerve VIII by crossing vessel thereon may be the mechanism of PVP which can be identified and diagnosed clinically.

Evaluation of cerebellar asymmetry with vertigo cases: a stereological study

AIM

We aimed to evaluate the relevant methods of stereology to estimate cerebellar asymmetry according to gender in both adult right-handed vertigo cases and healthy cases.

MATERIAL AND METHODS

The study included 14 adult control subjects and 18 patients with vertigo. The volumes of the cerebellar hemispheres were determined on MRI using the point-counting approach of stereological methods.

RESULTS

The mean (+/-SD) of the right cerebellar hemispheres in the patients with vertigo were 52.49+/-5.42 cm3 in males, 50.11+/-4.02 cm3 in females. The mean (+/-SD) of the left cerebellar hemispheres in the patients with vertigo were 53.11+/-3.70 cm3 in males and 49.73+/-4.69 cm3 in females. There was no significant quantitative evidence detected in terms of cerebellar asymmetry between sagittal plane estimates in the cases with vertigo in both genders (p > 0.05). There were no statistically significant differences by genders between vertigo and control subjects (p > 0.05). There was statistical significance only between right and left hemispheres in male control subjects (p=0.039) CONCLUSION: There was no cerebellar asymmetry between control and vertigo cases by gender. The stereological evaluation of cerebellar asymmetry or atrophy in humans in correlation with gender is of importance both for clinicians and anatomists. The technique is simple, reliable, inexpensive and unbiased.

An unusual tumour of the cerebellopontine angle

An unusual tumour of the cerebellopontine angle.

OBJECTIVE

To report an extremely rare case of lipoma of the cerebellopontine angle (CPA).

CASE REPORT

A 33-year-old woman presented with vertigo and tinnitus in the left ear. Her physical examination was unremarkable. Audiometric evaluation was normal in both ears. T1-weighted magnetic resonance imaging (MRI) without fat signal suppression revealed a hyperintense lesion of the left CPA. Based on the neuroimaging findings, the diagnosis was left CPA lipoma. The patient was managed conservatively. After 48 months, follow-up MRI revealed no further growth of the lesion and the patient was symptom free.

CONCLUSION

Lipomas of the CPA should be considered in the differential diagnosis of vertigo and tinnitus. Accurate diagnosis by MRI is critical.

[Pathogenesis of benign paroxysmal positional vertigo]

OBJECTIVE

To explore the etiological factors of benign paroxysmal positional vertigo (BP-PV).

METHODS

The clinical data of 145 patients with BPPV were retrospectively reviewed. The impacts of gender and age on BPPV were analyzed. The relationship between the onset of BPPV and the internal ear ischemia was also explored.

RESULTS

The abnormality rate of auditory brainstem response (ABR) under high stimulus rate was 59.3% (86/145) in all the patients with, including 22.1% (32/145) in male and 37.2% (54/ 145) in female (P > 0.05). The abnormality rate of ABR under high stimulus rate were 37.9% (55/145) and 21.4% (31/145) in middle-aged (30-55 years) and old ( > 55 years) patients, respectively (P > 0.05).

CONCLUSION

The onset of BPPV may relate to ischemic internal ear but is not relevant with gender and age.

A case of bilateral parietal cortical laminar necrosis with a loss of vertiginous sensation

BACKGROUND

Animal experiments demonstrated that there are vestibular cortical areas at the parietal cortex. Moreover, in humans, recent functional neuroimaging studies revealed that caloric stimulation activated the parietoinsular vestibular cortex and optokinetic stimulation activated the parieto-occipital cortex. These activations indicate that the parietal vestibular areas play some role in nystagmus generation or in spatial information processing in the eye movement tasks.

AIMS OF THE STUDY

The aim of this communication was to present a patient giving some information about parietal cortical function in nystagmus production and vertigo.

CASE

We report a 51-year-old, heavy alcoholic man with Bálint syndrome, constructional disability, limb-kinetic apraxia and ideo-motor apraxia. Brain magnetic resonance imaging demonstrated bilateral parietal cortical laminar necrosis anterior to the parieto-occipital sulci without any involvement of the primary sensory and parietoinsular cortices. Optokinetic nystagmus (OKN) was not elicited whereas cold caloric stimulation fully evoked nystagmus toward the opposite side with oscillopsia when eyes opened. However, he did not feel vertiginous sensation when the eyes were closed.

CONCLUSIONS

These findings suggest that the parietal cortices are indispensable for OKN production and vertiginous sensation.

Cochlear modiolus and lateral semicircular canal in sudden deafness

CONCLUSION

This study demonstrated that precise analysis shows that the inner ear shape in sudden deafness (SD) is different from that in controls in that the fluid-filled area of SD labyrinths is significantly larger than that of controls. Reduced cochlear modiolus area and inner area of the lateral semicircular canal (LSCC) may be associated with insufficient maturation of the inner ear.

OBJECTIVE

The aim of this study was to quantify the morphologies of the cochlea and LSCC using magnetic resonance imaging (MRI) and to evaluate their relationships with clinical symptoms in SD.

SUBJECTS AND METHODS

Twenty-six unilateral SD patients with vertigo, 26 unilateral SD patients without vertigo and a matched control group without hearing loss were studied. The areas of cochlear modioli and LSCCs were traced on the MRI console and compared between SD patients with or without vertigo and control subjects. The ratio of the LSCC fluid-filled area to the total LSCC area was used to index the degree of dysplasia.

RESULTS

The cochlear modiolus area was significantly less in SD ears (4.1+/-0.2 mm2) than in controls (4.3+/-0.4 mm2). The LSCC inner area was significantly less in SD ears (6.9+/-1.7 mm2) than in controls (9.1+/-1.8 mm2). These results suggest that the fluid-filled area of SD labyrinths is significantly larger than controls. Morphology did not differ between affected and contralateral sides or between ears with or without vertigo in SD patients.

Should patients with benign positional vertigo be imaged?

Unexpected intra-cranial pathology is unusually encountered in patients with BPV in the presence of a classically positive Hallpike's response and in the absence of any other neurological signs or symptoms. We carried out a retrospective review to assess the incidence of unexpected intra-cranial pathology in patients with a clinical diagnosis of benign positional vertigo (BPV) and to review the role of radiological imaging in these patients. 145 consecutive patients seen by the senior author with a diagnosis of posterior semi-circular canal BPV over a five-year period were reviewed. In the series of 63 patients who underwent MRI, two cases (3.2%) had cerebral aneurysms, one patient had an epidermoid cyst (1.58%) and one patient had a large right parietal arterio-venous malformation. We would conclude that possible warning signs exist that may alert the clinician to the possibility of unexpected intracranial pathology including failed response to the initial Epley manoeuvre or any asymmetry in hearing. Thus, we would advocate imaging be performed on this sub-group of patients with BPV.

Neuro-otologic applications of MRI

Magnetic resonance imaging (MRI) has increasingly new applications in neuro-otology. The aim of this review was to summarize MRI applications in neuro- otology and make a correlation between neuro-otologic anatomy and MR images. Different MRI techniques have been described in the imaging of different neuro-otologic structures. In particular, we discuss the effectiveness, indications, and techniques of MRI in the demonstration of neuro-otologic tracts and their related pathologies. MRI should be the first choice imaging modality for the evaluation of retrocochlear pathologies.

Benign paroxysmal positional vertigo and its management

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is a common peripheral vestibular disorder encountered in primary care and specialist otolaryngology and neurology clinics. It is associated with a characteristic paroxysmal positional nystagmus, which can be elicited with specific diagnostic positional maneuvers. In recent years, specific therapeutic maneuvers have resulted in its effective treatment. In this paper the current knowledge of the pathogenesis, diagnosis, and treatment of BPPV as well as the authors' own clinical experience in treating such patients are presented.

MATERIAL/METHODS

A retrospective review of the records of 204 patients with BPPV was performed. Epidemiological data and results from the audiological and neuro-otological work-up were recorded. All patients were treated with an appropriate repositioning maneuver, depending on the type of BPPV.

RESULTS

Of the 204 patients, 163 had posterior canal involvement, 19 had horizontal canal involvement, and 6 had the anterior canal variant. Another 11 patients had bilateral posterior canal involvement and 5 had disease of two canals. The canalith repositioning procedure was immediately successful in 165 patients and in 23 more patients proved successful after its repetition in a second session, resulting in a total success rate of 92.1%.

CONCLUSIONS

Most of the patients with BPPV responded very well to treatment. However, differential diagnosis of the type of BPPV was necessary to apply the appropriate canalith repositioning procedure. The canalith repositioning procedure is easy and safe to perform, is noninvasive, can be repeated if needed, and can provide rapid relief of vertigo.

Relationship between the affected ear in benign paroxysmal positional vertigo and habitual head-lying side during bedrest

OBJECTIVE

To assess the association between the habitual head position during bedrest and the affected ear in benign paroxysmal positional vertigo (BPPV).

STUDY DESIGN

Prospective trial of patients with active BPPV of the posterior semicircular canal, confirmed on physical examination.

METHODS

Seventy-five patients were asked to explain the head position and lying side they were accustomed to before falling asleep in bed.

RESULTS

Fifty patients (67 per cent) habitually adopted a lateral head position during bedrest. The ear affected by BPPV was found to be consistent with the head-lying side during bedrest in 43 cases (86 per cent) (29 cases for the right ear and 14 cases for the left ear).

CONCLUSION

Habitual lateral head-positioning during bedrest can be a major factor leading to the development of BPPV in the ipsilateral ear.

Association Between Cupular Deposits and Otosclerosis

OBJECTIVE

To evaluate whether otosclerosis is an underlying mechanism for the production of cupular deposits and to study the association between cupular deposits and dysequilibrium in otosclerosis.

DESIGN

Retrospective human temporal bone (TB) study. The incidence of cupular deposits in these 70 TBs was analyzed. Correlations between cupular deposits and vestibular symptoms, endosteal involvement of the otosclerotic focus, stapedial fixation, and clinical history of stapes surgery were evaluated.

SETTING

Otolaryngology laboratory in a tertiary academic medical center.

PATIENTS

The study material consisted of 35 human TBs with otosclerosis and 35 age-matched controls.

MAIN OUTCOME MEASURES

Morphometric evaluations of the incidence of cupular deposits, endosteal involvement of the otosclerotic focus, and stapedial fixation were made by light microscopy. Clinical records were reviewed retrospectively for clinical history of stapes surgery and prevalence of vestibular symptoms. The incidence of cupular deposits was compared between the otosclerotic and control groups. Correlations between cupular deposits and vestibular symptoms, endosteal involvement of the otosclerotic focus, stapedial fixation, and clinical history of stapes surgery were evaluated in the subjects with otosclerosis.

RESULTS

The incidence of cupular deposits in TBs with otosclerosis was significantly higher than in those without whereas there was no correlation between the incidence of the deposits and dysequilibrium in cases of otosclerosis. An increase in deposits did not correlate with stapedial fixation, stapes surgery, or endosteal involvement.

CONCLUSIONS

Our results suggest otosclerosis as an underlying mechanism for the production of cupular deposits; however, we did not find an association between these deposits and vestibular symptoms.

Pathological localization of so-called posterior canal BPPV

OBJECTIVE

Based on the hypothesis that the origin of nystagmus is from the posterior canal (PC), the nystagmus in the head hanging and sitting position should be mirror images. To clarify the anatomical origin of positioning nystagmus in BPPV patients, we analyzed the positioning nystagmus of benign paroxysmal positioning vertigo (BPPV) patients three-dimensionally.

METHODS

Twenty-six patients with BPPV participated in this study. The positioning nystagmus was recorded in complete darkness from the patient's left eye by means of an infrared CCD camera. We performed three-dimensional analysis of nystagmus using video image analysis system (VIAS). Subsequently, the rotation axis of the 3D eye movements of the positioning nystagmus was calculated.

RESULTS

Among the 26 patients tested, 20 patients demonstrated the axes of nystagmus in good or relatively good alignment to the PC axis. However, in 11 of these 20 patients there was poor alignment of the axis of nystagmus in the sitting position to the PC axis. In addition, six patients showed axes of nystagmus with poor alignment to the PC in the head hanging position. Among them, two patients exhibited axes of nystagmus in good alignment with the anterior canal, in spite of diagnosis of these patients as PC BPPV by experienced examiner based on the positioning nystagmus test.

CONCLUSION

These results demonstrated that only one-third of patients who were diagnosed as BPPV, could be diagnosed as true BPPV which originates from a PC pathology. Besides the possibility that the pathology may originate from the AC, it is still unclear which part of the inner ear may be the candidate site of origin of the pathology of BPPV in the other 15 patients.

Multiple dehiscence of semicircular canals

Dehiscence of the semicircular canal is an uncommon condition and has been reported to involve the roof of the superior semicircular canal. We describe a case with dehiscence of four semicircular canals and in areas not involving the roof of the superior semicircular canal. Features that assist the diagnosis of this condition are reviewed, along with the current literature.

Cerebellar infarction presenting isolated vertigo: Frequency and vascular topographical patterns

OBJECTIVE

To determine the frequency of cerebellar infarction mimicking vestibular neuritis (VN), the pattern of clinical presentation, and the territory of the cerebellar infarction when it simulates VN.

METHODS

We studied 240 consecutive cases of isolated cerebellar infarction in the territories of the cerebellar arteries diagnosed by brain MRI from the acute stroke registry at the Keimyung University Dongsan Medical Center.

RESULTS

We identified 25 patients (10.4%) with isolated cerebellar infarction who had clinical features suggesting VN. Two types of cerebellar infarction simulating VN were found: isolated spontaneous prolonged vertigo with imbalance as a sole manifestation of cerebellar infarction (n = 24) and isolated spontaneous prolonged vertigo with imbalance as an initial manifestation of cerebellar infarction (n = 1) followed by delayed neurologic deficits 2 days after the onset. The cerebellar infarction territory most commonly involved was the medial branch of the posterior inferior cerebellar artery territory (24/25: 96%), followed by the anterior inferior cerebellar artery territory (1/25: 4%). None of patients with infarcts in the territory of the superior cerebellar artery or multiple cerebellar arteries showed isolated spontaneous prolonged vertigo.

CONCLUSIONS

Cerebellar infarction simulating vestibular neuritis is more common than previously thought. Early recognition of the pseudo-vestibular neuritis of vascular cause may allow specific management.

MRI of the vestibular nerve after selective vestibular neurectomy

CONCLUSION

In patients with Ménière's disease and persisting vertigo attacks after vestibular neurectomy (VNx) MRI of the vestibulocochlear nerve can identify residual vestibular nerve fibres that could be responsible for the vertigo attacks.

OBJECTIVE

To test if MRI of the vestibulocochlear nerve can corroborate the presence of residual vestibular nerve fibres in patients with persisting vertigo attacks and residual vestibular function after VNx.

MATERIALS AND METHODS

Vestibulocochlear nerve bundles of seven post-VNx unilateral Ménière's patients were imaged using 1.5 Tesla MRI with steady state free precession (SSFP) sequences. Reformatted MR images orthogonal to the vestibulocochlear nerve axis in internal auditory canal were compared on the VNx and intact sides. Vestibular function was assessed with caloric tests, three-dimensional head impulse tests and vestibular evoked myogenic potentials. Of the seven patients only one was asymptomatic (totally free of vertigo); six had continued to experience vertigo attacks, albeit not as long or as severe as before VNx.

RESULTS

On the VNx side, MRI showed intact facial and cochlear nerves in all seven patients. In the six symptomatic patients, although superior and inferior vestibular nerve bulk and signal were reduced, residual bulk suggestive of inferior vestibular nerve was evident, correlating with evidence of residual posterior canal function on impulsive testing in all six symptomatic patients. In the asymptomatic patient, superior and inferior vestibular nerves were absent on MRI and impulsive testing revealed no residual posterior canal function.

Age-related changes on the morphology of the otoconia

OBJECTIVES/HYPOTHESIS

Although there are numerous reports on otoconial morphology using field-emission scanning electron microscopy (FESEM), there are few reports regarding the changes of otoconial morphology with aging. The aim of the current study was to investigate changes in otoconial morphology in rats according to age, using FESEM.

STUDY DESIGN

Laboratory study using experimental animals.

METHODS

We investigated age-related changes in otoconial morphology using FESEM in three groups of rats: young (1 wk old), middle-aged (6 mo old), and aged (23 mo old).

RESULTS

There was great size variation in utricular otoconia in the young and aged rats, but we found no clear regional separation of saccular otoconia in all groups based on size. In the oldest rats, the bodies of many otoconia in both maculae were pitted, fissured, penetrated, and eventually broken into several fragments. However, the terminal facets were smooth and the lines of intersection of facets were sharp, despite the degenerated bodies of the otoconia in this group. Giant otoconia were discovered frequently on the outer margin of the utricular maculae in aged rats. We directly observed weakened or broken linking filaments and otoconial fragments in the aged group.

CONCLUSION

The oldest rats showed the most degeneration of otoconia and linking filaments with otoconial fragments. This study of age-related morphologic changes in otoconia might help us understand the origin of idiopathic benign paroxysmal positional vertigo.

Analysis of the vestibulo-ocular reflex time constant in patients with benign recurrent vertigo associated with head-shaking nystagmus

CONCLUSIONS

When considering benign recurrent vertigo and a similar peripheral vestibular deficiency, the asymmetry of the vestibulo-ocular reflex (VOR) time constant (Tc) is lower in those patients with paretic head-shaking nystagmus (HSN) than in those with reversed HSN or without HSN.

OBJECTIVE

To determine whether the existence of HSN is related to the time constant of the VOR in patients with benign recurrent vertigo (BRV).

PATIENTS AND METHODS

This was a prospective study conducted at a tertiary care center in which patients were subjected to the head-shaking test, the caloric test and rotatory chair impulsive test on the same day. The clinical features of the disease analyzed were the disease duration, frequency of vertigo spells, time since the last vertigo spell and the existence of migraine. The results of the head-shaking test were considered positive when nystagmus appeared after head-shaking had ended. Two groups of patients were established on the basis of these results and the group that displayed HSN was divided according to the direction of nystagmus. In the impulsive test, the time constant of the VOR after ipsilesional and contralesional acceleration was analyzed, as was the symmetry of the response. The differences in the means were calculated.

RESULTS

BRV was diagnosed in 25% of patients suffering recurrent spells of vertigo, of which 33 patients were HSN- and 29 were HSN+. In the latter group, vestibular migraine was frequently observed (83% of the patients), the spells of vertigo were more frequent and the patients were seen closer to the previous spell of vertigo. No differences were observed in the Tc of the VOR between HSN+ and HSN- patients, although the asymmetry of this Tc was higher in HSN- patients than in HSN+ patients. Nevertheless, the differences observed were only significant between paretic and reversed HSN patients and paretic HSN patients and HSN- patients.

Benign paroxysmal positional vertigo due to a simultaneous involvement of both horizontal and posterior semicircular canals

From April 2001 to November 2003, we investigated 8 patients with benign paroxysmal positional vertigo (BPPV) that was suspected to simultaneously affect both the horizontal and posterior semicircular canals (HSCC and PSCC). These cases showed typical vertical-torsional nystagmus induced by the Dix-Hallpike maneuver, followed by a horizontal nystagmus. They also showed a direction-changing geotropic or apogeotropic positional nystagmus triggered by lateral head rotations in the supine position. Using the three-dimensional analysis of the positional nystagmus, the rotation axis of the positional nystagmus had a component perpendicular to the plane of PSCC and another component perpendicular to the plane of HSCC. All these findings suggest that BPPV in these patients was a combination of posterior and horizontal canal BPPV. The observation of a vertical-torsional positional nystagmus should prompt the specialist to perform not only the canalith repositioning procedure, but also to execute lateral head turns in the supine position.

[Brain perfusion disturbances in patients with vertigo -- a study with SPECT]

BACKGROUND AND PURPOSE

The aim of our study was to evaluate brain perfusion in patients with vertigo using the SPECT technique.

METHODS

The study involved a group of 32 patients and was performed in the Neurological Department of the Medical University in Bialystok. Patients with vertigo of peripheral origin like middle ear pathology were excluded from the study. Tomographic pictures were taken with Nucline X-Ring camera after administration of Tc99m-ECD. Perfusion maps were estimated by qualitative and semi-quantitative methods.

RESULTS

In 8 patients (25%) perfusion maps were normal in the hemispheres, cerebellum and subcortical structures. In 10 patients (31.2%) there was a substantial decrease in perfusion in the left temporal region, in 8 patients (25%) -- hypoperfusion was seen in the right temporal region. In 4 patients (12.5%) there was a substantial decrease in perfusion in the cerebellum, in two persons -- in the frontal lobes.

CONCLUSIONS

The results obtained so far confirm the major role of ischemia in etiology of the central origin vertigo and balance disturbances. It involves not only the brainstem and cerebellar structures, but the temporal lobes as well. The test has also proved that the qualitative and semi-quantitative methods of assessing brain perfusion with a SPECT are satisfactory in diagnostics of vertigo.