Content Validity of the Modified Functional Scale for the Assessment and Rating of Ataxia (f-SARA) Instrument in Spinocerebellar Ataxia

The functional Scale for the Assessment and Rating of Ataxia (f-SARA) assesses Gait, Stance, Sitting, and Speech. It was developed as a potentially clinically meaningful measure of spinocerebellar ataxia (SCA) progression for clinical trial use. Here, we evaluated content validity of the f-SARA. Qualitative interviews were conducted among individuals with SCA1 (n = 1) and SCA3 (n = 6) and healthcare professionals (HCPs) with SCA expertise (USA, n = 5; Europe, n = 3). Interviews evaluated symptoms and signs of SCA and relevance of f-SARA concepts for SCA. HCP cognitive debriefing was conducted. Interviews were recorded, transcribed, coded, and analyzed by ATLAS.TI software. Individuals with SCA1 and 3 reported 85 symptoms, signs, and impacts of SCA. All indicated difficulties with walking, stance, balance, speech, fatigue, emotions, and work. All individuals with SCA1 and 3 considered Gait, Stance, and Speech relevant f-SARA concepts; 3 considered Sitting relevant (42.9%). All HCPs considered Gait and Speech relevant; 5 (62.5%) indicated Stance was relevant. Sitting was considered a late-stage disease indicator. Most HCPs suggested inclusion of appendicular items would enhance clinical relevance. Cognitive debriefing supported clarity and comprehension of f-SARA. Maintaining current abilities on f-SARA items for 1 year was considered meaningful for most individuals with SCA1 and 3. All HCPs considered meaningful changes as stability in f-SARA score over 1-2 years, 1-2-point change in total f-SARA score, and deviation from natural history. These results support content validity of f-SARA for assessing SCA disease progression in clinical trials.

New Anti-CGRP Medications in the Treatment of Vestibular Migraine

Background

Vestibular migraine (VM) is a condition associated with migraine headache, vertigo, dizziness, and balance disturbances. Treatment options are limited. It is unknown if new calcitonin gene-related peptide (CGRP) migraine medications have efficacy in treating VM.

Methods

We retrospectively reviewed all patients with VM who were prescribed one of the new CGRP medications between January 2016 and July 2020. In total, 28 patients met the inclusion criteria. We specifically evaluated the “older” CGRP medications including erenumab, galcanezumab, fremanezumab, and ubrogepant. Medical records for subsequent visits were assessed to monitor improvement described by patients.

Results

Of the 28 patients identified, three were lost to follow up. For the remaining 25 patients, we divided the patients based on a scale of “significant improvement,” “moderate improvement,” “mild improvement,” or “no improvement.” In total 21 of 25 patients demonstrated some level of improvement in their VM symptoms with 15 having moderate to significant improvement.

Conclusion

Results demonstrated a trend toward improvement, suggesting that the CGRP medications appear to be a decent treatment option for VM. A prospective study evaluating CGRP medications in patients with VM would provide further information about this treatment option.

Coding and Reimbursement for Vestibular Tests by the U.S. Centers for Medicare and Medicaid Services (CMS)

Coding and insurance reimbursement is a part of the healthcare system in the United States but is subject to periodic modifications. In addition to changes in the evaluation and management (E/M) codes that took effect in 2021, there are some differences in coding for some diagnostic vestibular function test procedures. Two new codes for vestibular myogenic evoked potential testing were added and previous codes for auditory evoked potential codes 92585 and 92586, which some facilities had used to bill for vestibular myogenic evoked potential testing, have been eliminated. This article outlines the current state of coding and reimbursement by CMS for vestibular procedures.

Approach to the History and Evaluation of Vertigo and Dizziness

PURPOSE OF REVIEW

This article reviews a method of obtaining the medical history of patients presenting with dizziness, vertigo, and imbalance. By combining elements of the history with examination, the goal is to identify patterns and an effective differential diagnosis for this group of patients to help lead to an accurate diagnosis.

RECENT FINDINGS

Studies over the past dozen years have changed the historical approach to patients with dizziness from one based primarily on how the patient describes the sensation of dizziness. This older approach can lead to misdiagnosis, so a preferred method puts greater emphasis on whether the dizziness is acute or chronic, episodic or continuous, or evoked by or brought on by an event or circumstance so that a pattern may be derived that better narrows the differential diagnosis and focused examination can further narrow to a cause or causes.

SUMMARY

Dizziness is a common symptom of many possible causes. This article will help clinicians navigate gathering the history and examination to formulate a working diagnosis in patients affected by dizziness.

Tinnitus, Hyperacusis, Otalgia, and Hearing Loss

PURPOSE OF REVIEW

This article reviews the causes of tinnitus, hyperacusis, and otalgia, as well as hearing loss relevant for clinicians in the field of neurology.

RECENT FINDINGS

Important causes of unilateral and bilateral tinnitus are discussed, including those that are treatable or caused by serious structural or vascular causes. Concepts of hyperacusis and misophonia are covered, along with various types of neurologic disorders that can lead to pain in the ear. Hearing loss is common but not always purely otologic.

SUMMARY

Tinnitus and hearing loss are common symptoms that are sometimes related to a primary neurologic disorder. This review, tailored to neurologists who care for patients who may be referred to or encountered in neurology practice, provides information on hearing disorders, how to recognize when a neurologic process may be involved, and when to refer to otolaryngology or other specialists.

Autoimmune Vestibulocerebellar Syndromes

Autoimmune disorders affecting the vestibular end organs, vestibular pathways, vestibular nuclei, and vestibulocerebellum are often underrecognized as a cause of chronic dizziness and ataxia. Autoantibodies specific for cell-surface, synaptic, and intracellular neural antigens serve as biomarkers of these disorders. This article describes the epidemiology, clinical presentation, diagnostic considerations, imaging findings, treatment, and prognosis of autoimmune disorders, in which the vestibulocerebellar syndrome is the main or presenting clinical presentation. Antibodies specific for intracellular antigenic targets described in the article are PCA-1 (Purkinje cell cytoplasmic antibody type 1, also known as anti-Yo), ANNA-1 (antinuclear neuronal antibody type 1, also known as anti-Hu), ANNA-2 (antinuclear neuronal antibody type 2, also known as anti-Ri), Ma1/2 (anti-Kelch-like 11/12 antibody), Kelch-like 11, amphiphysin, CV2 (collapsin response 2, also known as collapsin response mediator protein-5 [CRMP5]), VGCC (voltage-gated calcium channel), GAD65 (glutamic acid decarboxylase 65-kDa isoform), AP3B2 (adaptor protein 3B2, also known as anti-Nb), MAP1B (microtubule-associated protein 1B antibody, also known as anti-PCA-2), and neurochondrin antibodies. Antibodies targeting cell-surface or synaptic antigenic targets described in the article include DNER (delta/notchlike epidermal growth factor related receptor; antigen to anti-Tr), CASPR2 (contactin-associated proteinlike 2), septin-5, Homer-3, and mGluR1 (metabotropic glutamate receptor 1). The vestibulocerebellar presentation is largely indistinguishable among these conditions and is characterized by subacute onset of cerebellar symptoms over weeks to months. The diagnosis of autoimmune vestibulocerebellar syndromes is based on a combination of clinical and serological features, with a limited role for neuroimaging. Subtle eye movement abnormalities can be an early feature in many of these disorders, and therefore a meticulous vestibulo-ocular examination is essential for early and correct identification. Cancer occurrence and its type are variable and depend on the autoantibody detected and other cancer risk factors. Treatment comprises immunotherapy and cancer-directed therapy. Acute immunotherapies such as intravenous immunoglobulin, plasma exchange, and steroids are used in the initial phase, and the use of long-term immunosuppression such as rituximab may be necessary in relapsing cases. Outcomes are better if immunotherapy is started early. The neurologic prognosis depends on multiple factors.

Bilateral Vestibular Dysfunction Associated With Chronic Exposure to Military Jet Propellant Type-Eight Jet Fuel

We describe three patients diagnosed with bilateral vestibular dysfunction associated with the jet propellant type-eight (JP-8) fuel exposure. Chronic exposure to aromatic and aliphatic hydrocarbons, which are the main constituents of JP-8 military aircraft jet fuel, occurred over 3–5 years’ duration while working on or near the flight line. Exposure to toxic hydrocarbons was substantiated by the presence of JP-8 metabolite n-hexane in the blood of one of the cases. The presenting symptoms were dizziness, headache, fatigue, and imbalance. Rotational chair testing confirmed bilateral vestibular dysfunction in all the three patients. Vestibular function improved over time once the exposure was removed. Bilateral vestibular dysfunction has been associated with hydrocarbon exposure in humans, but only recently has emphasis been placed specifically on the detrimental effects of JP-8 jet fuel and its numerous hydrocarbon constituents. Data are limited on the mechanism of JP-8-induced vestibular dysfunction or ototoxicity. Early recognition of JP-8 toxicity risk, cessation of exposure, and customized vestibular therapy offer the best chance for improved balance. Bilateral vestibular impairment is under-recognized in those chronically exposed to all forms of jet fuel.

Vestibular evoked myogenic potential testing: Payment policy review for clinicians and payers

Purpose of review

A recent American Academy of Neurology Evidence-Based Practice Guideline on vestibular myogenic evoked potential (VEMP) testing has described superior canal dehiscence syndrome (SCDS) and evaluated the merits of VEMP in its diagnosis. SCDS is an uncommon but now well-recognized cause of dizziness and auditory symptoms. This article familiarizes health care providers with this syndrome and the utility and shortcomings of VEMP as a diagnostic test and also explores payment policies for VEMP.

Recent findings

In carefully selected patients with documented history compatible with the SCDS, both high-resolution temporal bone CT scan and VEMP are valuable aids for diagnosis. Payers might be unfamiliar with both this syndrome and VEMP testing.

Summary

It is important to raise awareness of VEMP and its possible indications and the rationale for coverage of VEMP testing. Payers may not be readily receptive to VEMP coverage if this test is used in an undifferentiated manner for all common vestibular and auditory symptoms.

Practice guideline: Cervical and ocular vestibular evoked myogenic potential testing: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology

OBJECTIVE

To systematically review the evidence and make recommendations with regard to diagnostic utility of cervical and ocular vestibular evoked myogenic potentials (cVEMP and oVEMP, respectively). Four questions were asked: Does cVEMP accurately identify superior canal dehiscence syndrome (SCDS)? Does oVEMP accurately identify SCDS? For suspected vestibular symptoms, does cVEMP/oVEMP accurately identify vestibular dysfunction related to the saccule/utricle? For vestibular symptoms, does cVEMP/oVEMP accurately and substantively aid diagnosis of any specific vestibular disorder besides SCDS?

METHODS

The guideline panel identified and classified relevant published studies (January 1980-December 2016) according to the 2004 American Academy of Neurology process.

RESULTS AND RECOMMENDATIONS

Level C positive: Clinicians may use cVEMP stimulus threshold values to distinguish SCDS from controls (2 Class III studies) (sensitivity 86%-91%, specificity 90%-96%). Corrected cVEMP amplitude may be used to distinguish SCDS from controls (2 Class III studies) (sensitivity 100%, specificity 93%). Clinicians may use oVEMP amplitude to distinguish SCDS from normal controls (3 Class III studies) (sensitivity 77%-100%, specificity 98%-100%). oVEMP threshold may be used to aid in distinguishing SCDS from controls (3 Class III studies) (sensitivity 70%-100%, specificity 77%-100%). Level U: Evidence is insufficient to determine whether cVEMP and oVEMP can accurately identify vestibular function specifically related to the saccule/utricle, or whether cVEMP or oVEMP is useful in diagnosing vestibular neuritis or Ménière disease. Level C negative: It has not been demonstrated that cVEMP substantively aids in diagnosing benign paroxysmal positional vertigo, or that cVEMP or oVEMP aids in diagnosing/managing vestibular migraine.

Dizziness in the Outpatient Care Setting

PURPOSE OF REVIEW

This article summarizes an approach to evaluating dizziness for the general neurologist and reviews common and important causes of dizziness and vertigo.

RECENT FINDINGS

Improved methods of diagnosing patients with vertigo and dizziness have been evolving, including additional diagnostic criteria and characterization of some common conditions that cause dizziness (eg, vestibular migraine, benign paroxysmal positional vertigo, chronic subjective dizziness). Other uncommon causes of dizziness (eg, superior canal dehiscence syndrome, episodic ataxia type 2) have also been better clarified. Distinguishing between central and peripheral causes of vertigo can be accomplished reliably through history and examination, but imaging techniques have further added to accuracy. What has not changed is the necessity of obtaining a basic history of the patient's symptoms to narrow the list of possible causes.

SUMMARY

Dizziness and vertigo are extremely common symptoms that also affect function at home and at work. Improvements in the diagnosis and management of the syndromes that cause dizziness and vertigo will enhance patient care and cost efficiencies in a health care system with limited resources. Clinicians who evaluate patients with dizziness will serve their patient population well by continuing to manage patients with well-focused workup and attentive care.

Clinical perspectives on medical marijuana (cannabis) for neurologic disorders

The American Academy of Neurology published an evidence-based systematic review of randomized controlled trials using marijuana (Cannabis sativa) or cannabinoids in neurologic disorders. Several cannabinoids showed effectiveness or probable effectiveness for spasticity, central pain, and painful spasms in multiple sclerosis. The review justifies insurance coverage for dronabinol and nabilone for these indications. Many insurance companies already cover these medications for other indications. It is unlikely that the review will alter coverage for herbal marijuana. Currently, no payers cover the costs of herbal medical marijuana because it is illegal under federal law and in most states. Cannabinoid preparations currently available by prescription may have a role in other neurologic conditions, but quality scientific evidence is lacking at this time.

Mal de débarquement syndrome: Review and proposed diagnostic criteria

Mal de débarquement syndrome (MdDS) is a rare cause of imbalance encountered in a neurology practice. However, it consists of classic features that the practicing neurologist should be able to recognize when evaluating a patient with dizziness. It is characterized by a feeling of rocking and swaying, and typically follows prolonged exposure to motion, such as being on a boat or plane. In this review article, we provide the clinical neurologist with the history of this disorder followed by illustrative cases of patients diagnosed with MdDS. Next we present proposed criteria for aiding in diagnosis. Finally, we will discuss a differential diagnosis for the syndrome, insights into the possible pathophysiology, current treatments, and future directions in management.

JCV GCN in a natalizumab-treated MS patient is associated with mutations of the VP1 capsid gene

OBJECTIVE

To describe the clinical, neuroimaging, immunologic, and virologic characteristics of JC virus-associated granule cell neuronopathy (JCV GCN) in a natalizumab-treated patient with multiple sclerosis (MS) who developed immune reconstitution inflammatory syndrome (IRIS) after natalizumab withdrawal.

METHODS

We obtained longitudinal clinical data as well as MRI and proton magnetic resonance spectroscopy from this patient with MS. We measured JCV-specific cellular immune response in his peripheral blood by intracellular cytokine staining and sequenced a fragment of JCV VP1 capsid gene detected in his CSF. We contrast our findings with the first recently reported case.

RESULTS

This patient presented with worsening cerebellar symptoms and progressive cerebellar atrophy without new MS lesions on MRI after 63 months of natalizumab monotherapy. JCV DNA was detected in his CSF by PCR and harbored novel GCN-type mutations in the VP1 gene. He developed IRIS upon discontinuation of natalizumab and plasma exchange, which manifested itself by a worsening of clinical symptoms and contrast enhancement in the cerebellum on MRI. Treatment with corticosteroids resulted in resolution of IRIS, as demonstrated by proton magnetic resonance spectroscopy. The patient had a strong JCV-specific T-cell response in his peripheral blood and remains alive after 15 months from onset of symptoms, although with significant disability. He did not have MS relapse on glatiramer acetate.

CONCLUSIONS

JCV GCN should be considered in patients on natalizumab presenting with progressive cerebellar symptoms and cerebellar atrophy, and is associated with mutations in the JCV VP1 gene. Natalizumab withdrawal may be complicated by JCV GCN IRIS, and require treatment with corticosteroids.

Diagnosis and management of epilepsy associated with hypothalamic hamartoma: an evidence-based systematic review

The main objective was to review the evidence for management of epilepsy associated with hypothalamic hamartomas. We performed a systemic review of the literature through July 2012 that studied patients with hypothalamic hamartomas and related epilepsy. Articles meeting selection criteria were rated according to the American Academy of Neurology classification of evidence scheme. Recommendations were linked to the strength of the evidence and as follows: (a) precocious puberty is associated more with the pedunculated type and epilepsy typified by gelastic seizures with the sessile form of hypothalamic hamartomas (class III); (b) significant behavioral and cognitive deficits are associated with patients with hypothalamic hamartomas (class III); (c) video electroencephalography (EEG) findings are extremely variable particularly across the different ages and do not affect surgical outcome (class III); d) various surgical techniques (transcallosal and endoscopic resection) resulted in 49% to 54% seizure freedom, 15% with a pterional approach as well as about 40% with radiosurgery (class III).

A prescription for the Epley maneuver: www.youtube.com?

OBJECTIVES

Video-sharing Web sites are being used for information about common conditions including dizziness. The Epley maneuver (EM) is a simple and effective treatment for benign paroxysmal positional vertigo (BPPV) of the posterior canal. However, the maneuver is underused in routine care. In this study, we aimed to describe and analyze the available information about the EM on youtube.com.

METHODS

A YouTube search was performed on August 31, 2011, for videos that demonstrated the entire EM. Detailed data were abstracted from each video and corresponding Web site. Videos were rated on the accuracy of the maneuver by 2 authors, with differences resolved by adjudication. Comments posted by viewers were assessed for themes regarding video use.

RESULTS

Of the 3,319 videos identified, 33 demonstrated the EM. The total number of hits for all videos was 2,755,607. The video with the most hits (802,471) was produced by the American Academy of Neurology. Five of the videos accounted for 85% of all the hits. The maneuver demonstration was rated as accurate in 64% (21) of the videos. Themes derived from the 424 posted comments included patients self-treating with the maneuver after reviewing the videos, and providers using the videos as a prescribed treatment or for educational purposes.

CONCLUSION

Accurate video demonstration of the Epley maneuver is available and widely viewed on YouTube. Video-sharing media may be an important way to disseminate effective interventions such as the EM. The impact of video Web sites on outcomes and costs of care is not known and warrants future study.

Anxiety in a dizzy patient: the importance of communication in improving outcome

Most patients with dizziness have a benign self-limited condition, often of labyrinthine origin; however, some develop a more intractable form of dizziness that can be challenging to evaluate. In many of these patients, brain imaging, vestibular testing, and clinical examination are normal, but the patient is significantly impaired. Many such patients have coexisting anxiety, which can make it difficult to determine whether the anxiety is a reaction to the dizziness or its primary cause. A careful history, including an assessment of the impact of symptoms on quality-of-life, social, and work-related issues is critical, and effective patient communication is essential. The following case exemplifies how a high-functioning person can become severely limited because of the complex intertwining of several types of dizziness with anxiety.

Positional dizziness

PURPOSE

This article reviews the most common conditions that are caused by changes in head or body positions. Practical clinical methods to help distinguish vestibular from nonvestibular and central from peripheral vestibular positional dizziness are discussed. This article also reviews the treatment methods of selected canal variants of benign paroxysmal positional vertigo (BPPV).

RECENT FINDINGS

Two recent evidence-based guidelines have established canalith repositioning maneuvers (Epley and Semont maneuvers) as safe and highly effective in the treatment of posterior canal BPPV. Recent studies suggest the Gufoni and the Lempert roll (barbecue) maneuvers are effective in treating lateral canal forms of BPPV.

SUMMARY

Most cases of positional vertigo are of peripheral vestibular origin and can be effectively treated by simple positioning maneuvers. This article reviews the variants of BPPV encountered in clinical practice, including mechanistic cause, differential diagnosis, prognosis, and treatment. Generous use of figures is intended to aid in understanding the most effective treatment maneuver techniques for the more common forms of BPPV. Clinicians who can recognize the types of nystagmus associated with the various canal types of BPPV can usually recognize CNS causes as distinct.

Clinical Practice Guideline

Objective. Sudden hearing loss (SHL) is a frightening symptom that often prompts an urgent or emergent visit to a physician. This guideline provides evidence-based recommendations for the diagnosis, management, and follow-up of patients who present with SHL. The guideline primarily focuses on sudden sensorineural hearing loss (SSNHL) in adult patients (aged 18 and older). Prompt recognition and management of SSNHL may improve hearing recovery and patient quality of life (QOL). Sudden sensorineural hearing loss affects 5 to 20 per 100,000 population, with about 4000 new cases per year in the United States. This guideline is intended for all clinicians who diagnose or manage adult patients who present with SHL.

Purpose. The purpose of this guideline is to provide clinicians with evidence-based recommendations in evaluating patients with SHL, with particular emphasis on managing SSNHL. The panel recognized that patients enter the health care system with SHL as a nonspecific, primary complaint. Therefore, the initial recommendations of the guideline deal with efficiently distinguishing SSNHL from other causes of SHL at the time of presentation. By focusing on opportunities for quality improvement, the guideline should improve diagnostic accuracy, facilitate prompt intervention, decrease variations in management, reduce unnecessary tests and imaging procedures, and improve hearing and rehabilitative outcomes for affected patients.

Results. The panel made strong recommendations that clinicians should (1) distinguish sensorineural hearing loss from conductive hearing loss in a patient presenting with SHL; (2) educate patients with idiopathic sudden sensorineural hearing loss (ISSNHL) about the natural history of the condition, the benefits and risks of medical interventions, and the limitations of existing evidence regarding efficacy; and (3) counsel patients with incomplete recovery of hearing about the possible benefits of amplification and hearing-assistive technology and other supportive measures. The panel made recommendations that clinicians should (1) assess patients with presumptive SSNHL for bilateral SHL, recurrent episodes of SHL, or focal neurologic findings; (2) diagnose presumptive ISSNHL if audiometry confirms a 30-dB hearing loss at 3 consecutive frequencies and an underlying condition cannot be identified by history and physical examination; (3) evaluate patients with ISSNHL for retrocochlear pathology by obtaining magnetic resonance imaging, auditory brainstem response, or audiometric follow-up; (4) offer intratympanic steroid perfusion when patients have incomplete recovery from ISSNHL after failure of initial management; and (5) obtain follow-up audiometric evaluation within 6 months of diagnosis for patients with ISSNHL. The panel offered as options that clinicians may offer (1) corticosteroids as initial therapy to patients with ISSNHL and (2) hyperbaric oxygen therapy within 3 months of diagnosis of ISSNHL. The panel made a recommendation against clinicians routinely prescribing antivirals, thrombolytics, vasodilators, vasoactive substances, or antioxidants to patients with ISSNHL. The panel made strong recommendations against clinicians (1) ordering computerized tomography of the head/brain in the initial evaluation of a patient with presumptive SSNHL and (2) obtaining routine laboratory tests in patients with ISSNHL.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo

Objectives:

This guideline provides evidence-based recommendations on managing benign paroxysmal positional vertigo (BPPV), which is the most common vestibular disorder in adults, with a lifetime prevalence of 2.4 percent. The guideline targets patients aged 18 years or older with a potential diagnosis of BPPV, evaluated in any setting in which an adult with BPPV would be identified, monitored, or managed. This guideline is intended for all clinicians who are likely to diagnose and manage adults with BPPV.

Purpose:

The primary purposes of this guideline are to improve quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary tests such as radiographic imaging and vestibular testing, and to promote the use of effective repositioning maneuvers for treatment. In creating this guideline, the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of audiology, chiropractic medicine, emergency medicine, family medicine, geriatric medicine, internal medicine, neurology, nursing, otolaryngology–head and neck surgery, physical therapy, and physical medicine and rehabilitation.

Results

The panel made strong recommendations that 1) clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with nystagmus is provoked by the Dix-Hallpike maneuver. The panel made recommendations against 1) radiographic imaging, vestibular testing, or both in patients diagnosed with BPPV, unless the diagnosis is uncertain or there are additional symptoms or signs unrelated to BPPV that warrant testing; and 2) routinely treating BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines. The panel made recommendations that 1) if the patient has a history compatible with BPPV and the Dix-Hallpike test is negative, clinicians should perform a supine roll test to assess for lateral semicircular canal BPPV; 2) clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo; 3) clinicians should question patients with BPPV for factors that modify management including impaired mobility or balance, CNS disorders, lack of home support, and increased risk for falling; 4) clinicians should treat patients with posterior canal BPPV with a particle repositioning maneuver (PRM); 5) clinicians should reassess patients within 1 month after an initial period of observation or treatment to confirm symptom resolution; 6) clinicians should evaluate patients with BPPV who are initial treatment failures for persistent BPPV or underlying peripheral vestibular or CNS disorders; and 7) clinicians should counsel patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The panel offered as options that 1) clinicians may offer vestibular rehabilitation, either self-administered or with a clinician, for the initial treatment of BPPV and 2) clinicians may offer observation as initial management for patients with BPPV and with assurance of follow-up. The panel made no recommendation concerning audiometric testing in patients diagnosed with BPPV.

Disclaimer:

This clinical practice guideline is not intended as a sole source of guidance in managing benign paroxysmal positional vertigo. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgement or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem. ® 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.

Second-generation antiepileptic drugs' impact on balance: a meta-analysis

OBJECTIVE

To systematically review available evidence regarding whether second-generation antiepileptic drugs (AEDs) contribute to the risk of balance disorders.

METHODS

We systematically evaluated data from randomized controlled trials that compared adjunctive therapy with a second-generation AED (gabapentin, lamotrigine, levetiracetam, oxcarbazepine, pregabalin, tiagabine, topIramate, or zonisamide) vs placebo for partial epilepsy and that reported dose-specific rates of ataxia or Imbalance for each group. Random-effects meta-analysis was used to pool ratios (risk ratio [RR]) and associated 95% confidence Intervals to determine whether there was evidence of an overall AED class effect or a dose-response effect and whether there were differences between Individual AEDs.

RESULTS

Sixteen studies met inclusion criteria, representing 4279 individuals randomized to a second-generation AED and 1830 patients to placebo. Pooled analyses of all AEDs demonstrated that they Increase imbalance risk at any dose (RR, 2.73; 95% confidence interval, 2.07-3.61) and at lowest dose (RR, 1.76; 95% confidence interval, 1.26-2.46). The highest dose analysis showed heterogeneity; evaluation of individual AEDs revealed that oxcarbamazepine and topiramate increased imbalance risk at all doses, whereas gabapentin and levetiracetam did not increase imbalance risk at any dose. A dose-response effect was observed for most AEDs.

CONCLUSION

Second-generation AEDs at standard dosages, except for gabapentin and levetiracetam, increase the imbalance risk, and evidence exists for a dose-response effect. The mechanisms, risk factors, and consequences of this risk for individual AEDs warrant further study.

Measuring the effects of antiepileptic medications on balance in older people

BACKGROUND

Dizziness and ataxia are among the most common adverse events associated with antiepileptic medications. Despite this, few studies have attempted to quantitatively assess the effects of antiepileptic therapies on equilibrium. This study was undertaken to prospectively compare quantitative measures of balance in older people taking carbamazepine, gabapentin and lamotrigine.

METHODS

Thirty patients on monotherapy for idiopathic partial or generalized epilepsy were enrolled after giving informed consent. Patients had to be at least 50 years old, able to give consent, and on a stable dose of carbamazepine, gabapentin or lamotrigine for at least 30 days. Since this was a study of asymptomatic patients, all patients had to be without complaint of dizziness or imbalance. Patients with a history of alcohol or drug abuse or any medical or neurological condition expected to adversely affect equilibrium were excluded. Each patient underwent a history and examination, computerized dynamic posturography, the activities-specific balance confidence (ABC) scale, Fregly ataxia battery, and the Berg balance scale. Serum drug levels of carbamazepine were obtained to eliminate patients with toxic levels upon enrollment. Two-tailed paired t-tests were used to determined statistical significance among those on each antiepileptic medication.

RESULTS

Thirty patients were enrolled: 10 on gabapentin, 10 on lamotrigine and 10 on carbamazepine monotherapy for epilepsy. There were no differences in age or sex among those in each treatment group. The average dosages were 1,120 mg/day for those on gabapentin, 335 mg for lamotrigine, and 640 mg for carbamazepine. There were no differences in the activities-specific balance confidence (ABC) or the Berg balance scale scores. All patients had normal vestibular function by quantitative testing. Posturography showed no statistically significant differences. The Fregly ataxia battery includes the sum of timed trials in the sharpened Romberg (SR) position, standing on one leg with eyes closed (SOLEC), and when walking in tandem with eyes closed (WITEC). The patients on lamotrigine exhibited ability to maintain balance in these positions significantly longer than did those on carbamazepine: SR (P<0.05), SOLEC (P<0.05) and WITEC (P<0.05).

CONCLUSIONS

The effects of antiepileptic medications on equilibrium in asymptomatic older people may require more dynamic and challenging measures of equilibrium than are commonly employed in physical therapy to monitor risk of falls. Although the sample size is small, this study suggests that lamotrigine may induce less disequilibrium than does carbamazepine in older people on monotherapy for epilepsy. Further study in this area is needed, particularly given the risks of falling from imbalance in the elderly.

Antiepileptic drugs and their impact on balance

Antiepileptic drugs (AEDs) are being used with increasing frequency, not only to manage epilepsy, but also in the treatment of other conditions including neuropathic pain, migraine headaches and psychiatric conditions requiring mood stabilization. Although AEDs as a class are commonly prescribed in older patients and those with a predisposition to imbalance, the effect these drugs exert on gait and equilibrium has received very little study. Data from controlled efficacy and safety trials suggests that some AEDs are more apt to affect balance than others, even at therapeutic doses. In particular, phenytoin, primidone and phenobarbital produce more dizziness than some of the newer AEDs such as lamotrigine, levetiracetam and oxcarbazepine. For some of the other new AEDs, the data are simply not sufficient to estimate their effect on balance. This article reviews the current evidence that may guide the clinician in choosing a medication likely to have a low impact on gait and balance. Considering the risks and morbidity associated with imbalance and falls, particularly in the elderly, the direct effects of AEDs on balance should be examined further.

Dizziness and headache: a common association in children and adolescents

Vertigo has long been recognized by the clinician as a frequent accompanying symptom of the adult migraine syndrome. This association has not been so readily identified in the pediatric population, and, as a consequence, children undergo unnecessary evaluations. We reviewed the charts of all children and adolescents referred for vestibular function testing to the Balance Center at the Barrow Neurological Institute between July 1994 and July 2000 (N = 31). Items analyzed included age, gender, symptoms that prompted the referral, test outcomes, family medical history, and final diagnosis. The most common justification for vestibular testing referral was the combination of dizziness and headache. Other less common reasons were "passing out" episodes, poor balance, and blurred vision. Normal test results were obtained from 70% of patients (n = 22). The most common abnormal test outcome was unilateral vestibular dysfunction (n = 5). Bilateral peripheral vestibular dysfunction was present in three patients. One patient had central vestibular dysfunction. The final diagnoses were vestibular migraine (n = 11), benign paroxysmal vertigo of childhood (n = 6), anxiety attacks (n = 3), Meniere's disease (n = 2), idiopathic sudden-onset sensorineural hearing loss (n = 1), vertigo not otherwise specified (n = 1), familial vertigo/ataxia syndrome (n = 1), and malingering (n = 1); in five patients, no definitive diagnosis was established. The stereotypical patient with vestibular migraine was a teenage female with repeated episodes of headache and dizziness, a past history of carsickness, a family history of migraine, and a normal neurologic examination. Patients who fit this profile are likely to have migrainous vertigo. Consequently, a trial of prophylactic migraine medication should be considered for both diagnostic and therapeutic purposes. Brain imaging and other tests are appropriate for patients whose symptoms deviate from this profile.

Recognition and management of horizontal canal benign positional vertigo

OBJECTIVE

We reviewed the features of nystagmus in 24 patients with horizontal canal benign positional vertigo (BPV). Patients were treated with canalith repositioning maneuvers. Our goal was to develop a framework for distinguishing horizontal from posterior canal BPV and to further develop a mechanistic model explaining the horizontal canal variant of BPV.

STUDY DESIGN

The study design was a retrospective case review with prospective treatment outcome and follow-up.

SETTING

The study was performed at a secondary and tertiary referral center for vertigo and dizziness.

PATIENTS

The diagnosis of horizontal canal BPV was based on: 1) recurrent brief episodes of positional vertigo; 2) paroxysmal bursts of horizontal positional nystagmus; and 3) lack of any other identifiable central nervous system disorder to explain the nystagmus. Patient average age was 62 years, and average duration of symptoms was 12 weeks.

INTERVENTIONS

We documented patients' symptoms and the characteristics of nystagmus. We reviewed the effectiveness of several similar canalith repositioning treatments.

MAIN OUTCOME MEASURE

We observed and recorded factors that distinguish horizontal from posterior canal BPV. We monitored the direction of nystagmus, the type of maneuver that evoked the nystagmus, and the response to canalith repositioning.

RESULTS

Symptom description alone was not sufficient to distinguish among canal types of BPV. Horizontal geotropic direction-changing positional nystagmus was observed in 19 of 24 patients. The other patients had ageotropic nystagmus. Both types were distinct from the nystagmus of posterior canal BPV. Response to canalith repositioning was 75% at 1 week of follow-up. Conversion of BPV from one canal to another occurred in some patients, but each canal could be treated individually.

CONCLUSIONS

Patients with positional vertigo should undergo Dix-Hallpike positioning and supine lateral head turns to each side. Paroxysmal positional horizontal nystagmus that changes direction with changes in head position strongly suggests the diagnosis. Canalith repositioning for posterior canal BPV may fail in horizontal BPV. A 360 degrees barbecue rotation toward the presumably healthy ear done two to four times or until nystagmus disappears may result in more rapid resolution of symptoms.

Comparison of static and dynamic posturography in young and older normal people

OBJECTIVE

To measure sway velocity during static and dynamic posturography in "normal" older people and to determine which tests best distinguish young from older subjects.

SUBJECTS

A sample of 30 young (18-39 years) and 82 community-dwelling older (> 75 years) subjects who reported normal balance underwent a battery of balance tests.

MEASUREMENTS

Velocity and frequency of sway, Tinetti gait and balance score, self-reported fear of falling and number of falls.

RESULTS

Mean sway velocity and the ratio of high to low frequency sway velocity were significantly increased in older subjects compared with younger subjects for static and dynamic tests with eyes open and with eyes closed. Measures of anterior-posterior sway velocity during angular tilt of the platform with eyes closed best distinguished young from older subjects (almost three-fourths of older subjects had values greater than 2 standard deviations from the young normal mean). Older subjects who reported falls in the past year did not have a significantly higher sway velocity on static or dynamic tests compared with those who did not report falls. However, subjects who reported a fear of falling had significantly higher sway velocity on dynamic tests with eyes closed compared to those who did not report a fear of falling.

CONCLUSIONS

On average, velocity of sway is higher in older subjects compared with younger subjects, and the difference between young and old is greater with dynamic posturography than with static posturography.

Disequilibrium of unknown cause in older people

Many older people complain of a sense of unsteadiness when standing or walking and many are fearful of falling. The cause of this disequilibrium is often difficult to determine even after thorough clinical evaluation. To better understand the pathogenesis of this symptom in a community-dwelling population, we studied 26 patients > 75 years old who complained of disequilibrium in whom no cause was evident after clinical evaluation. Each patient and each of 26 age-matched controls underwent a comprehensive evaluation that included a history and examination, a questionnaire, functional scales, a gait and balance scale, mini-mental state testing, audiometry, visual acuity, visual tracking, rotational vestibular testing, and quantitative posturography. Although none had Romberg's sign, patients tended to sway more and do poorer on semiquantitative gait and balance testing than did controls. Patients showed few differences from controls for most other measurements. However, 7 patients, designated Group V, had profoundly reduced vestibular function. In the remaining 19 patients (Group D), the average vestibular function was still significantly lower than controls. Sway velocity measured with posturography was increased in the patients compared with controls, particularly in Group V patients. Measures of vestibular function correlated with increased sway velocity both in Group D alone and among all study participants. Quantitative measurement of vestibular function should be considered in older people complaining of disequilibrium, particularly if the cause is not apparent after the initial evaluation.

Progressive multifocal leukoencephalopathy in AIDS: a clinicopathologic study and review of the literature

We reviewed the clinical, radiographic, and pathologic features of 15 patients with the acquired immune deficiency syndrome (AIDS) and progressive multifocal leukoencephalopathy (PML). Brain tissue from 10 autopsy and 6 biopsy specimens was studied using: in situ hybridization (ISH) for JC virus (JCV), immunohistochemistry for human immunodeficiency virus (HIV) p24 antigen, and electron microscopy. Thirteen patients presented with focal neurologic deficits, while 2 presented with a rapid decline in mental status. PML was commonly the initial opportunistic infection of AIDS and produced hemiparesis, dementia, dysarthria, cerebellar abnormalities, and seizures. Magnetic resonance imaging was more sensitive than computed tomography in detecting lesions, and often showed multifocal areas of PML. CD4+ T-cell counts were uniformly low (mean 84/mm3), except in 1 patient who improved on 3'-azido-3'-deoxythymidine (AZT). PML involved the cerebral hemispheres, brain stem, cerebellum, and cervical spinal cord. The distribution of brain involvement was consistent with hematogenous dissemination of the virus. In 2 brain specimens, multiple HIV-type giant cells were present within the regions involved by PML. When co-infection by HIV and papovavirus was present, PML dominated the pathological picture. ISH for JCV showed virus in the nuclei of oligodendrocytes and astrocytes. Occasionally there was staining for JCV in the cytoplasm of glial cells and in the neuropil, the latter possibly a correlate of papovavirus spread between myelin sheaths, as seen by electron microscopy. ISH demonstrated more extensive foci of PML than did routine light microscopy.

Pericardial actinomycosis: case report and review

Pericardial actinomycosis is rare and frequently goes unrecognized during life, a circumstance due in part to a paucity of clinical manifestations and to a low rate of positivity in cultures. We present a case report of pericardial actinomycosis and a review of 18 other cases reported in the literature since 1950. Possible risk factors include aspiration pneumonia, alcohol abuse, and periodontal disease. Actinomyces may cause purulent pericarditis that evolves into cardiac tamponade or constrictive pericarditis. Clues to the identity of the causative organism (e.g., draining sinus tracts and the presence of sulfur granules) are frequently absent, and cultures often fail to yield the organism. Histologic examination of material obtained by biopsy is often necessary to make the diagnosis. Most cases originate from a thoracopulmonary site of actinomycosis and spread directly to the pericardium. Widespread dissemination to extrathoracic organs is uncommon. Treatment consists of high-dose, long-term antimicrobial therapy as well as drainage of the pericardial space.