Vestibular paroxysmia: Clinical features and imaging findings; a literature review

Vestibular paroxysmia: a systematic review

The key symptoms of vestibular paroxysmia (VP) due to neurovascular cross-compression (classical VP) or compression of the eighth nerve by space-occupying cerebellar-pontine angle processes (secondary VP) are frequent short attacks of vertigo and dizziness with unsteadiness which last seconds to minutes. They can be accompanied by unilateral auditory symptoms such as tinnitus or hyperacusis. Head movements and hyperventilation can induce nystagmus and VP attacks that most often occur spontaneously. VP is diagnosed in 3% of patients in a tertiary vertigo care center and very rarely affects children. The mean age of first appearance is 47 to 51 years with equal sex distribution. A combination of high-resolution MRI sequences (with constructive interference in steady-state/fast imaging employing steady-state, 3D-CISS/ FIESTA) of the cerebello-pontine may support the diagnosis although the beneficial treatment with sodium channel blockers is the most reliable clinical sign for classical VP, secondary VP and idiopathic VP (without verification of a causative pathology). Because of the frequency, shortness, and audiovestibular symptomatology of the attacks, the differential diagnosis to other conditions such as paroxysmal brainstem attacks, vestibular epilepsy, rotational vertebral artery compression syndrome or "near"-narrowed internal auditory canal syndrome is only relevant in exceptional cases. However, imaging of the posterior fossa including the inner ear is mandatory to distinguish between classical, secondary and idiopathic VP forms. Randomized controlled trials for medical treatment are still needed. Practical therapy of choice is medical treatment with sodium channel blockers (carbamazepine, oxcarbazepine, lacosamide). A microsurgical decompression is effective in secondary VP but is the ultimate therapy in cases with classical or idiopathic VP when medication is not tolerated.

Vestibular epilepsy: clinical and electroencephalographic characteristics with the proposed diagnostic criteria

BACKGROUND

Focal seizures may encompass vestibular sensations in their symptomatology. When these manifestations occur in isolation or constitute the predominant symptom, they prompt consideration for diagnosing recurrent paroxysmal vertigo. However, the characterization of "vestibular epilepsy" remains debated and underexplored. Our objective is to characterize the clinical and electrophysiological criteria of vestibular epilepsy.

METHODS

We retrospectively analyzed data from a cohort of outpatients treated in the epileptology department of Marseille University Hospital. The study focused on patients presenting with vestibular symptoms without focal abnormalities on brain MRI, and with interictal epileptic abnormalities on wake or sleep EEG.

RESULTS

31 patients (15 men and 16 women) were included in the study. Visual, auditory, and dysautonomic symptoms were frequently associated with vestibular symptoms. The mean time to diagnosis was 3 years. The duration of attacks was generally short, ranging from a few seconds to a few minutes, with variable frequency. Most patients responded well to antiseizure medication. Some patients showed interictal phenomena, such as permanent instability, raising the possibility of inter/postictal disturbances. Seizures could be triggered by peripheral vestibular stimuli. Interictal EEG abnormalities were observed only during sleep in 25% of patients and predominated in the posterior temporoparietal regions.

DISCUSSION

We propose clinical-electro-radiological criteria for defining vestibular epilepsy. These diagnostic criteria overlap with the criteria for vestibular paroxysmia, suggesting the possibility of a single nosological entity.

Vestibular Paroxysmia: A Four-Case Report

Vestibular paroxysmia (VP) is a rare vestibular syndrome classified as a neurovascular compression disorder. It arises from chronic compression of the vestibulocochlear nerve caused by a vascular loop, leading to demyelination via ephaptic transmission. The diagnosis primarily relies on a thorough medical history that meets specific criteria. The differentiation between definite and probable VP is based on the response to medications such as carbamazepine or oxcarbazepine. In this report, we present four patients over the age of 40 who experienced recurrent, brief episodes of vertigo, either spontaneously or triggered by head movements. These patients had undergone various treatments without success. Subsequent MRI scans revealed neurovascular compression of the VIII cranial nerve, prompting the prescription of oxcarbazepine, which resulted in a positive response in all cases. Although the differential diagnoses for these symptoms are limited, the rarity of VP can complicate diagnosis. Therefore, a trial of treatment should be considered in appropriate cases.

Clinical features and outcome of 10 dogs with suspected idiopathic vestibular epilepsy

BACKGROUND

In humans, vestibular epilepsy (VE) is described as focal seizures with transient signs of vestibular disease. In dogs, 2 cases of vestibular episodes, called vestibular paroxysmia, are reported.

HYPOTHESIS/OBJECTIVES

The objective of this study was to define the clinical features, phenotypical manifestation, and outcome of suspected VE in dogs.

ANIMALS

Ten dogs with recurrent vestibular episodes.

METHODS

Retrospective study. Medical records between 2009 and 2023 were reviewed, and dogs with a normal neurological examination, a history of transient signs of vestibular disease, absence of abnormalities detected on blood exams and brain magnetic resonance imaging (MRI) or computed tomography (CT), besides a minimum 10-month follow-up were included. Clinical improvement was defined as a ≥50% reduction in frequency or the cessation of clinical signs after the onset of antiseizure medications (ASMs).

RESULTS

Pugs were the most prevalent breed (5/10; 50%). In 2 cases, additional generalized tonic-clonic (GTC) seizures were reported. MRI exam was performed in most cases (9/10; 90%), whereas 1 dog underwent a CT scan (1/10; 10%). Electroencephalography (EEG) was carried out in 3 dogs that showed interictal spikes in the fronto-temporal and fronto-parietal areas. All cases received ASMs, with clinical improvement in 10/10 dogs (100%).

CONCLUSION AND CLINICAL IMPORTANCE

The presence of GTC seizures, EEG interictal spikes, and responsiveness to ASMs supported the hypothesis of an epileptic origin of vestibular episodes and thus the existence of VE in these dogs, with a presumed idiopathic cause and apparent favorable outcome.

The "Near"-Narrowed Internal Auditory Canal Syndrome in Adults: Clinical Aspects, Audio-Vestibular Findings, and Radiological Criteria for Diagnosis

INTRODUCTION

Vestibular Paroxysmia (VP) refers to short attacks of vertigo, spontaneous or triggered by head movements, and implies the presence of a compressive vascular loop in contact with the cochleovestibular nerve (CVN). Classically, a narrowed internal auditory canal (IAC) corresponds to a diameter of less than 2 mm on CT, usually associated with a hypoplastic CVN on MRI. The aim of this study was to discuss a distinct clinical entity mimicking VP in relation to a "near"-narrowed IAC (NNIAC) and to propose radiological criteria for its diagnosis.

METHODS

Radiological measurements of the IAC were compared between three groups: the study group (SG, subjects with a clinical presentation suggestive of VP, but whose MRI of the inner ear and pontocerebellar angle excluded a compressive vascular loop) and two control groups (adult and children) with normal vestibular evaluations and no history of vertigo.

RESULTS

59 subjects (18 M and 41 F) were included in the SG. The main symptoms of NNIAC were positional vertigo, exercise- or rapid head movements-induced vertigo, and dizziness. The statistical analysis in the study group showed that the threshold values for diagnosis were 3.3 mm (in tomodensitometry) and 2.9 mm (in MRI) in coronal sections of IAC. Although a significantly lower mean value for axial IAC diameter was found in SG compared with controls, the statistics did not reveal a threshold due to the large inter-individual variations in IAC measurements in normal subjects. There was no significant difference in IAC diameter between the adult and pediatric controls.

CONCLUSIONS

In the present study, we report a new anatomopathological condition that appears to be responsible for a clinical picture very similar-but not identical-to VP in association with the presence of an NNIAC. The diagnosis requires a careful analysis of the IAC's shape and diameters in both axial and coronal planes.

Vestibular paroxysmia associated with congenital vascular malformation: A case report

Vestibular paroxysmia (VP) is an uncommon paroxysmal disease, characterized by vertigo, tinnitus, and postural unsteadiness. The main reason of VP is neurovascular cross compression, while few cases of VP accompanied with congenital vascular malformation were reported. Here, we describe a 22-year-old patient with VP caused by congenital anterior inferior cerebellar artery (AICA) malformation who completely recovered after taking oral medicine. This report shows that VP caused by congenital vascular malformation can occur in adults and that oral medication is effective.

Long-term Prognosis of Vertigo Attacks and Health-related Quality of Life Limitations in Patients With Vestibular Paroxysmia

OBJECTIVE

To explore the long-term course of outcomes in vestibular paroxysmia (VP).

STUDY DESIGN

Cross-sectional observational study with a retrospective collection of baseline data.

SETTING

Tertiary referral center.

PATIENTS

Adult patients who visited the Apeldoorn Dizziness Center between 2010 and 2020 and were diagnosed with definite or probable VP according to the Bárány Society criteria were contacted by telephone to complete a study-specific questionnaire. Baseline data were retrospectively collected from patients electronic medical records to allow comparison between baseline and follow-up data.

MAIN OUTCOME MEASURES

Vertigo attack frequency, use of carbamazepine and health-related quality of life (HRQoL) limitations were the primary outcomes. Secondary outcomes were the number of attack-free years and perceived effect of medication for VP.

RESULTS

Seventy three patients were included, 61 (84%) of whom agreed to participate in the follow-up study. Mean age was 55.0 (SD 13.1) years, 49.2% were females. Mean follow-up was 3.4 years (range 0.4-11.3). At follow-up, 44 responders (72%) still experienced vertigo attacks. Average attack frequency in the past 6 months was 307 (SD 451) at baseline and 153 (SD 279) at follow-up (p = 0.050). At follow-up, 19.7% (n = 12) of the responders reported to use or have used carbamazepine, 58% of patients who (had) used this medication reported a positive perceived effect. Overall, 71% (n = 31) of the responders reported to have limitations in one or more HRQoL items due to their VP.

CONCLUSION

Our study shows a rather unfavorable prognosis in patients with VP in terms of vertigo attacks and HRQoL limitations. After the initial diagnosis follow-up is warranted to monitor clinical outcomes in these patients.