Role of video-head impulse test in lateralization of vestibulopathy: Comparative study with caloric test

Comparison Between the Video Head Impulse Test and Caloric Irrigation During Acute Vertigo

Caloric irrigation (CI) is the gold standard to investigate peripheral vestibular dysfunction. The video head impulse test (vHIT) is faster and more accessible and may be useful during acute vertigo stroke risk differentiation. Comparative studies between the two methods are needed. The objective of this study was to compare vestibular function data derived from caloric irrigation with that from vHIT. This study included 80 patients with acute onset vertigo who underwent caloric irrigation and vHIT. CI derived sum of slow phase velocities (SPVs) and unilateral weakness (UW) were compared with vHIT vestibulo-ocular reflex (VOR) gain and gain asymmetry (GA) using correlation analyses. Optimal cut offs for vHIT VOR gain and GA were calculated using Youden indexes. There was a strong positive correlation between the asymmetry measures UW and GA whereas the correlation between the sum of SPVs and VOR gain was weaker. The optimal cut offs to diagnose unilateral vestibular weakness were 0.80 for VOR gain and 28% for GA; with specificities for predicting normal caloric irrigation results of 55% and 93%, respectively. In one third of cases the results from caloric irrigation and vHIT dissociated. The results from vHIT correlated with those from CI, still neither test seem to have the accuracy to replace the other. GA appears as an attractive measure in acute vertigo as the high specificity can be used to identify those with a substantial probability of normal vestibular function in need of more comprehensive work-up for central causes. To diagnose vestibular dysfunction, CI remains gold standard.

Clinical evaluation of the vestibular impairment using video head impulse test In children with acute otitis media

OBJECTIVES

The objectives of the present study were to evaluate the vestibular impairment in children with acute otitis media (AOM) and dizziness by using video head impulse test (vHIT) and to compare their results with healthy children.

METHODS

The study included two groups of subjects. The patient group consisted of 34 pediatric patients with AOM and dizziness and the control group consisted of 35 healthy children, age between 4 and 15. The age, gender, mean vHIT gains and gain asymmetry values were compared between groups for each canal. In both groups, mean vHIT gains were compared between the right and left sides. Additionally, mean vHIT gains and the presence of saccades according to AOM stages were analyzed.

RESULTS

The comparison of vHIT gains between affected and unaffected sides in patients revealed a significant decrease only in the anterior canal plane on the affected side. Covert saccades were observed in 32% of the patients. When comparing the AOM stages and the presence of saccades in patients, no difference was detected between stages.

CONCLUSION

vHIT is a useful vestibular test for the evaluation of vestibular impairment in children with an applicability rate of 92% in healthy children and 70% in patients with AOM and dizziness. The patients with AOM and dizziness are presented with a decrease in vHIT gains and the presence of cover saccades only in vertical canal planes, supporting that slight vestibular impairment in these patients may represent pathologic vHIT results only in vertical canal planes.

Usefulness and practical insights of the pediatric video head impulse test

OBJECTIVE

The video head impulse test (vHIT) is a diagnostic tool to examine patients experiencing dizziness by assessing the function of the semicircular canals. vHIT has been widely studied in adults but relatively less so in children. The aim of this study was to evaluate the causes of dizziness and the results of vHIT in children. We also identified factors that affect the vHIT results such as artifacts and technical errors.

STUDY DESIGN

Retrospective review; SETTING: Tertiary care center.

PATIENTS

A total of 39 patients who visited our clinic for dizziness from 2014 to 2017.

MAIN OUTCOME MEASURES

The gain of vestibulo-ocular reflex, refixation saccades, and artifacts were analyzed using vHIT. We analyzed 691 individual vHIT traces and categorized the artifacts into 8 categories.

RESULTS

Twenty-three males and 16 females were included. The mean age was 13.84 ± 2.60 years (range, 7-18). Common causes of dizziness were benign paroxysmal vertigo of childhood (25.6%), vestibular neuritis (20.5%), and vestibular migraine (17.9%). The sensitivity and specificity of vHIT based on the bithermal caloric test results were 40% and 94%, respectively. The analysis of vHIT traces revealed that the children had higher artifact ratios of vHIT than the adults. The main artifacts were high gain and blinking eyes.

CONCLUSION

The vHIT results showed a higher percentage of artifacts in children than in the adults. More careful efforts are required to obtain more accurate results during the test, and it is necessary to check for technical errors while interpreting the results.

Comparison of the results of caloric and video head impulse tests in patients with Meniere's disease and vestibular migraine

PURPOSE

To compare the results of video head impulse test (vHIT) and caloric testing (CT) in patients with vestibular migraine (VM) and Ménière's disease (MD) and to investigate the relationship between these two tests.

METHODS

Patients with definite unilateral MD and VM were included in the study. All patients underwent both vHIT and CT. The vestibulo-ocular reflex (VOR) gains of lateral semicircular canals and saccadic waves in vHIT and the canal paresis factor for the CT were examined.

RESULTS

CT was found abnormal in 39 (66.1%) patients with MD and in 17 (34%) patients with VM, while abnormal gain of the lateral canal was obtained in 23 MD (39%) patients and 9 (18%) VM patients. In all, 11.9% of patients with an abnormal vHIT had a normal CT, whereas 33.9% of those with an abnormal CT had a normal vHIT.

CONCLUSION

Loss of VOR detected by caloric testing is more common and severe in MD than VM. Although vHIT is useful and can give complementary information, vestibular testing with the caloric test still seems more sensitive for detecting hVOR pathology.

Changes in Vestibulo-Ocular Reflex Gain After Surgical Plugging of Superior Semicircular Canal Dehiscence

Superior semicircular canal dehiscence (SCD), which is characterized by a “third mobile window” in the inner ear, causes various vestibular and auditory symptoms and signs. Surgical plugging of the superior semicircular canal (SC) can eliminate the symptoms associated with increased perilymph mobility due to the presence of the third window. However, the natural course of vestibular function after surgical plugging remains unknown. Therefore, we explored longitudinal vestibular function after surgery in 11 subjects with SCD who underwent SC plugging using the middle cranial fossa approach. Changes in vestibulo-ocular reflex (VOR) gain in all planes were measured over 1 year with the video head impulse test. We also evaluated surgical outcomes, including changes in symptoms, audiometric results, and electrophysiological tests, to assess whether plugging eliminated third mobile window effects. The mean VOR gain for the plugged SC decreased from 0.81 ± 0.05 before surgery to 0.65 ± 0.08 on examinations performed within 1 week after surgery but normalized thereafter. Four of seven subjects who were able to perform both VOR tests before surgery and immediately after surgery had pathologic values (SC VOR gain < 0.70). Conversely, the mean VOR gain in the other canals remained unchanged over 1 year. The majority of symptoms and signs were absent or markedly decreased at the last follow-up evaluation, and no complications associated with the surgery were reported. Surgical plugging significantly attenuated the air-bone gap, in particular at low frequencies, because of increased bone conduction thresholds and deceased air conduction thresholds. Moreover, surgical plugging significantly increased vestibular-evoked myogenic potential thresholds and decreased the ratio of summating potential to action potential in plugged ears. Postoperative heavily T2-weighted images were available for two subjects and showed complete obliteration of the T2-bright signal intensity in the patent SC lumen in preoperative imaging based on filling defect at the site of plugging. Our results suggest that successful plugging of dehiscent SCs is closely associated with a transient, rather than persistent, disturbance of labyrinthine activity exclusively involved in plugged SCs, which may have clinical implications for timely and individualized vestibular rehabilitation.

Video head impulse test in children with otitis media with effusion and dizziness

OBJECTIVE

The objectives of the study were to evaluate the vestibular impairment in children with otitis media with effusion (OME) and dizziness by using vHIT test, and to compare their results with healthy children.

METHODS

The study population consisted of 30 pediatric patients with OME and dizziness and 30 healthy children, age between 4 and 15. Otoscopic and tympanometric examination and vHIT testing were performed to all subjects. vHIT test parameters were compared between pediatric patients with OME and dizziness and healthy children. Additionally, the differences of the mean vHIT gains between tympanogram types, otoscopic findings and the presence of saccades were analyzed.

RESULTS

The mean vHIT gains and gain asymmetry values of patients with OME and dizziness and healthy children were comparable. No significant difference was observed between the mean vHIT gains of patients with type B and type C2 tympanogram. Covert saccades were observed in 57% of the patients with OME and dizziness. None of the patients had over saccades and none of the healthy children had saccades.

CONCLUSION

Our study is a preliminary study analyzing the vestibular impairment in children with OME and dizziness using vHIT test. Based on our results, it can be assumed that the children with OME and dizziness usually don't have a great vestibular impairment that can be detected with vHIT test. The covert saccades detected in this patient group are accepted as a sign of slight vestibular impairment.

Evaluating the Diagnostic Accuracy of the Head-Impulse Test: A Scoping Review

Importance

Vestibular symptoms rank among the most common complaints in medicine worldwide. Underlying disorders manifested by these symptoms are generally associated with an impairment of the vestibular-ocular reflex and can be assessed with different diagnostic procedures. In recent years, an increasing number of diagnostic test accuracy studies comparing various head-impulse test (HIT) methods with other diagnostic procedures have been published but not systematically reviewed.

Objective

To conduct a scoping review and describe key characteristics of the growing number of diagnostic studies in patients presenting with vestibular symptoms.

Evidence Review

In April 2017, published studies were identified through searches of 4 bibliographic databases: Medline, Science Citation Index Expanded, the Cochrane Library, and ScienceDirect. Studies were included if they provided diagnostic accuracy data (sensitivity and specificity) for any HIT method with reference to any other vestibular test or clinical diagnosis in patients with vestibular symptoms. Study key characteristics were extracted, and the current literature was described narratively. All analysis took place between June 2017 and July 2018.

Findings

We identified a total of 27 diagnostic studies (including 3821 participants). There were disagreements between diagnostic test accuracy data both within and between studies when different HIT methods were compared with other diagnostic procedures. The proportion of correctly identified people having the disease (sensitivity) ranged between 0% and 100% (median, 41%), whereas the proportion of correctly identified people without the disease (specificity) was higher and ranged between 56% and 100% (median, 94%).

Conclusions and Relevance

Based on the studies included in this review, sensitivity, specificity, and, more importantly, the risk of misdiagnosis and associated undertreatment or overtreatment cannot be reliably estimated by HIT methods for patients with vestibular symptoms. We recommend that further diagnostic studies consider (1) multiple possible underlying causes of vestibular symptoms and multiple test thresholds, (2) a representative sample of patients with and without the disease, and (3) reporting guidelines for diagnostic test accuracy studies.

Motor and cognitive performances in pre-lingual cochlear implant adolescents, related with vestibular function and auditory input

BACKGROUND

Information about the role of auditory input and motor control is limited.

OBJECTIVES

Assessment the relationship between auditory and vestibular information with specific motor and cognitive functions.

METHODS

Posturography in 17 Pre-lingual Cochlear Implant Adolescents, (PCIA) age 14.06 ± 3.05 in four sensory conditions was analyzed: (A) eyes open, cochlear implant (CI) on, (B) eyes open, CI off, (C) eyes closed standing on a foam over a platform (ECFP) with CI on, and (D) ECFP, CI off. Gait velocity (GV) was registered by inertial sensors using a 10-meter test. Vestibulo-ocular reflex (VOR) was evaluated with the video head impulse test (VHIT) and visual spatial skill (VS) assessed with the WISC-V test.

RESULTS

SV had no significant difference between conditions A and B (p = .2461). Comparing C and D, SV values decreased when CI was turned on (p = .0036). A significant linear relationship between VOR and GV (p = .0064) generating the VOR gain loss lower gait. Relationship between VOR and VS scores was no significant (p = .685).

CONCLUSIONS AND SIGNIFICANCE

Auditory information is a relevant cue when somatosensory and visual inputs are modified and range of vestibular function influence in a dynamic motor activity as gait, facts which must be considered in the neurodevelopment control.

Associations of Video Head Impulse Test and Caloric Testing among Patients with Vestibular Schwannoma

OBJECTIVE

To determine relationships between caloric testing (CT) and video head impulse testing (vHIT) among patients with unilateral vestibular schwannoma (VS). To describe the distribution of CT and vHIT measurements and assess associations with tumor size and self-perceived handicapping effects.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary referral hospital.

SUBJECTS AND METHODS

Subjects were adults with presumed unilateral VS between 2014 and 2017. Interventions were CT and vHIT. Primary outcomes were vHIT value (abnormal <0.8) and CT value (abnormal >25%). Secondary outcomes were tumor size and Dizziness Handicap Inventory scores.

RESULTS

Fifty-one individuals had complete data for CT and vHIT. The odds of abnormal gain increases by 2.18 for every 10% increase in unilateral weakness on CT (range, 1.44-3.34; P < .001). A significant negative correlation between CT and gain exists (r_s = -0.64, P < .001). Odds of observing saccades increased by 2.68 for every 10% increase in unilateral weakness (range, 1.48-4.85; P = .001). This association was larger in magnitude for overt than covert saccades (odds ratios, 2.48 and 1.59, respectively). Tumor size was significantly associated with an increase in caloric weakness (β = 0.135, P < .001). With every 10-mm increase of tumor size, odds of abnormal gain on vHIT increased 4.13 (range, 1.46-11.66; P = .007). Mean Dizziness Handicap Inventory score was 19.7 (σ = 22), without association to caloric weakness, gain, or tumor size.

CONCLUSION

CT and vHIT both effectively assess vestibular function for patients with VS and correlate to tumor size. These findings are important as vHIT has a lower overall cost, improved patient tolerance, and demonstrated reliability.

Bilateral Vestibulopathy in Superficial Siderosis

Background: Superficial siderosis (SS) is a rare condition in which hemosiderin, an iron storage complex, is deposited in neural tissues because of recurrent subarachnoid bleeding. Hemosiderin deposition in the vestibulocochlear nerve (CN VIII), brain, spinal cord and peripheral nerve can cause sensorineural hearing loss (SNHL) and postural imbalance, but much remains unknown about the vestibular manifestations of SS.

Objectives: To report the clinical course, cochleovestibular status, and patterns of vestibulopathy during follow-up of a relatively large case series, and to discuss the possible pathophysiological mechanism of vestibular deterioration.

Methods: Six patients diagnosed with SS by magnetic resonance imaging (MRI) were enrolled. Their medical records and radiological findings were retrospectively reviewed, particularly in terms of progression of the vestibulocochlear manifestations and the radiological characteristics.

Results: All six patients had SNHL. Five of them exhibited progressive hearing loss over years, which was asymmetric in four. On their most recent evaluations, patients showed cerebellar ataxia with combined central and peripheral vestibulopathy on both sides (n = 4), a bilateral peripheral vestibulopathy (n = 1) or isolated central vestibulopathy (n = 1). Notably, the former four patients showed an evolution of isolated central vestibulopathy into combined central and peripheral vestibulopathy. Hypo-intense lesions on T2 weighted MRIs were evident around the cerebellum in all patients, but such lesions were observed around the brainstem in five and the CN VIII in four. The cochlea-vestibular dysfunction generally progressed asymmetrically, but no left-right asymmetry was evident on MRI.

Conclusions: SS typically presents as bilaterally asymmetric, progressive cochleovestibular dysfunction with cerebellar ataxia. The pattern of vestibular dysfunction is usually combined central and peripheral vestibulopathy on both sides. Thus, precise identification of audiovestibular dysfunction and central signs is essential in SS, and patients with SS should undergo regular, comprehensive neurotological evaluation to optimize their treatments and prognosis.