Clinical characteristics of patients with dizziness/vertigo showing a dissociation between caloric and video head impulse test results

ObjectiveTo explore the clinical characteristics of patients with dizziness/vertigo who showed a dissociation between the results of the caloric test and video head impulse test (vHIT).MethodsA total of 327 patients who complained of dizziness/vertigo were continuously included. All patients underwent both the horizontal vHIT (h-vHIT) and caloric tests. Of the 327 patients, 69 patients showed a dissociation between the results of the two tests, 4 patients were excluded because the interval between the two tests exceeded 7 days. Finally, 65 patients were included in the analysis.ResultsAmong the 65 patients, 55 (84.6%) patients showed a positive caloric test (+) with a negative h-vHIT (-), and 10 (15.4%) patients showed a negative caloric test (-) with a positive h-vHIT (+). Peripheral and central lesions were identified in 50 (90.9%) and 5 (9.1%) patients, respectively, in the caloric test (+)/h-vHIT (-) group; and central lesions were found in 6 (60%) patients in caloric test (-)/h-vHIT (+) group. The etiologies were unilateral peripheral vestibular dysfunction (n = 25), Meniere's disease (MD, n = 10), sudden hearing loss with vertigo (SHLV, n = 7), benign paroxysmal positional vertigo (n = 5), vestibular neuritis (n = 2), autoimmune inner ear disease (n = 1), vestibular migraine (VM, n = 3), multiple sclerosis (n = 1), and multiple system atrophy (n = 1) in the caloric test (+)/h-vHIT (-) group, which were SHLV (n = 3), MD (n = 1), VM (n = 1), episodic ataxia type 2 (n = 1), cerebellopontine angle tumor (N = 1), Parkinson's disease (n = 1), Persistent postural perceptual dizziness (n = 1), and posterior circulation ischemia (n = 1) in the caloric test (-)/h-vHIT (+) group.ConclusionDissociation between the results of caloric test and h-vHIT is not uncommon. A positive caloric test with a negative h-vHIT occurred more frequently, and these patients mostly had peripheral vestibular lesions; while a negative caloric test with a positive h-vHIT was unusual, these patients had both peripheral and central lesions.

Lesion Location and Possible Etiology of Acute Unilateral Vestibulopathy

Objective

Acute unilateral vestibulopathy (AUVP) is quite common in clinical practice, but lesion localization and etiological diagnosis of AUVP remain the current clinical challenges, and have always been the focus for researchers. The study aimed to explore the lesion site and possible etiology of AUVP.

Methods

This study is a retrospective study. Twenty-three AUVP patients who attended the neurology outpatient clinics of our hospital from January 2020 to March 2022 were included. Clinical data of patients including baseline data, cardiovascular risk factors, immunological test results and infection indicators were collected. Vestibular function tests, including video head impulse test (vHIT), caloric testing, vestibular evoked myogenic potentials (VEMPs) and post-contrast delayed 3D-FLAIR MRI, were performed.

Results

Among 32 AUVP patients included, there were 10 males and 13 females, with a male-to-female ratio of 1:1.3, and an average age of 42.13 ± 14.57 years (range 19-76 years old). Acute persistent vertigo and relapsing-remitting vertigo accounted for 39.1% (9/23) and 60.9% (14/23) of the patients, respectively. Possible etiologies included cardiovascular risk factors (n = 11), abnormal immunological indicators (n = 8), and evidence of infection (n = 3). About 57.1% (12/21) of the patients showed abnormal vHIT (including reduced gain in horizontal canal (HC) in 14.3%, anterior canal (AC) in 4.8%, both the AC and HC in 19%, both the HC and posterior canal (PC) in 14.3%, and all three canals in 9.5% of cases). Probable entire vestibular nerve damage was found in 38.1% of the patients, only 9.5% of the patients followed the innervation pattern of the entire vestibular nerve, these patients had abnormal vHIT and VEMP results, and were considered to have definite entire vestibular nerve damage. Probable superior vestibular nerve (SVN) damage was found in 47.6% of the patients, but only 4.8% (1/21) of the patients followed the innervation pattern of SVN, with reduced VOR gains for AC and HC and abnormal oVEMP results, and were considered to have definite SVN damage. 3D-FLAIR MRI revealed high signal intensity in the SVN and vestibule in 4.8% (1/21) and 19% (4/21) of the patients, respectively.

Conclusion

The majority of AUVP patients had a relapsing-remitting course and had vestibular function test results that did not follow the innervation pattern of the vestibular nerve. Post-contrast delayed 3D-FLAIR MRI revealed damage to the vestibule in some patients, suggesting that damage to the labyrinth itself in AUVP deserves clinical attention. The majority of the AUVP patients had cardiovascular risk factors and abnormal systemic immunological indicators, which might be the possible etiologies of AUVP.

Postural stability in patients with vestibular migraine and probable vestibular migraine in the absence of acute vestibular symptoms

PURPOSE

To investigate postural stability in patients with vestibular migraine (VM) and probable vestibular migraine (PVM) in the absence of acute vestibular symptoms.

METHODS

We retrospectively reviewed the medical records at our balance disorder clinic. The 30 consecutive VM patients and 25 consecutive PVM patients enrolled in this study all underwent foam posturography. 194 healthy control subjects with no history of dizziness or balance dysfunction was also enrolled. Multiple regression analyses were performed to see whether subjects' age, sex, or diagnosis (VM, PVM and control) were associated with the posturographic findings. Dependent variables were the mean velocity of the center of pressure movement (velocity) and the area enclosed by the center of pressure movement (area) in Fixed/Open, Fixed/Closed, Foam/Open and Foam/Closed conditions, the Romberg's ratio in Velocity/Fixed, Velocity/Foam, Area/Fixed and Area/Foam conditions, and the foam ratio in Velocity/Open, Velocity/Closed, Area/Open and Area/Closed. Independent variables were sex (male, female), age, and diagnosis (VM, PVM and control).

RESULTS

VM and PVM patients showed significantly increased velocity and area compared to healthy controls with and without foam rubber. VM and PVM patients showed significantly lower foam ratios compared to healthy controls in velocity and area, both with open and closed eyes. On the other hand, there were no significant differences in velocity or area, Romberg's ratio or foam ratio between VM patients and PVM patients in any conditions.

CONCLUSIONS

Both VM and PVM patients had more postural instability than healthy controls. There were no differences in postural stability between VM and PVM patients.

Assessment and management of vestibular migraine within ENT

OBJECTIVE

Vestibular migraine is a newly recognised and debilitating condition. This article aims to provide an overview of what is known of vestibular migraine, delineating its diagnostic criteria and presenting some initial management strategies to aid ENT professionals in delivering optimal care when patients first present to the otolaryngology clinic.

METHOD

Although traditionally underdiagnosed, there are now clearly defined diagnostic criteria to aid accurate diagnosis of vestibular migraine.

RESULTS

A detailed history and clinical examination are the cornerstone of the diagnostic process, but supportive evidence is required from appropriate audio-vestibular tests and imaging.

CONCLUSION

This is a unique condition that commonly initially presents to ENT. This article provides a summary of diagnostic and management strategies to facilitate early diagnosis and first-line treatment that can be employed in general ENT settings, which may be particularly useful given the limited availability of specialist audio-vestibular medicine and neuro-otology services.

Prevalence and Contributing Factors of Anxiety and Depression in Patients with Vestibular Migraine

Objective: Anxiety and depression are psychiatric comorbidities potentially associated with dizziness and migraine, which can influence disease state, prognosis, and clinical outcomes. Vestibular migraine (VM) is a disease that causes repeated vestibular symptoms in people with a history of migraines. We investigated the prevalence and contributing factors of anxiety and depression in patients with VM. Methods: A total of 74 patients with VM were enrolled in this study. All patients underwent pure-tone audiometry, the examination of spontaneous nystagmus, Dix-Hallpike maneuver or supine-roll test, video head impulse test, and caloric testing on the day of the visit. We used the Hospital Anxiety and Depression Scale (HADS) to assess the symptoms of anxiety and depression. Dizziness Handicap Inventory was used to measure the intensity of vestibular symptoms. The participants were divided into normal and abnormal groups based on their HADS anxiety and depression scores, and demographic and clinical factors were analyzed. To identify factors associated with anxiety and depression, multivariate logistic regression analyses were performed. Results: A total of 36 (48.6%) patients demonstrated clinically relevant anxiety levels, and 24 (32.4%) demonstrated depression. Twenty-five (33.8%) patients were diagnosed with peripheral vestibular dysfunction. In the multivariable analyses, peripheral vestibular dysfunction and severe intensity vestibular symptoms were significantly associated with anxiety and depression. None of migraine features were significantly associated with anxiety and depression. Conclusion: The prevalence of anxiety in patients with VM is considerably higher than in the depression. VM patients with peripheral vestibular dysfunction are particularly susceptible to anxiety and depression. Therefore, timely screening for vestibular function and psychiatric disorders in VM patients should be considered.

Prospective analysis of video head impulse tests in patients with acute posterior circulation stroke

Background

Video head impulse tests (vHITs), assessing the vestibulo-ocular reflex (VOR), may be helpful in the differential diagnosis of acute dizziness. We aimed to investigate vHITs in patients with acute posterior circulation stroke (PCS) to examine whether these findings could exhibit significant abnormalities based on lesion locations, and to evaluate diagnostic value of vHIT in differentiating dizziness between PCS and vestibular neuritis (VN).

Methods

We prospectively recruited consecutive 80 patients with acute PCS and analyzed vHIT findings according to the presence of dorsal brainstem stroke (DBS). We also compared vHIT findings between PCS patients with dizziness and a previously studied VN group (n = 29). Receiver operating characteristic (ROC) analysis was performed to assess the performance of VOR gain and its asymmetry in distinguishing dizziness between PCS and VN.

Results

Patients with PCS underwent vHIT within a median of 2 days from stroke onset. Mean horizontal VOR gain was 0.97, and there was no significant difference between PCS patients with DBS (n = 15) and without (n = 65). None exhibited pathologic overt corrective saccades. When comparing the PCS group with dizziness (n = 40) to the VN group (n = 29), patients with VN demonstrated significantly lower mean VOR gains in the ipsilesional horizontal canals (1.00 vs. 0.57, p < 0.001). VOR gain and their asymmetry effectively differentiated dizziness in the PCS from VN groups, with an area under the ROC curve of 0.86 (95% CI 0.74-0.98) and 0.91 (95% CI 0.83-0.99, p < 0.001), respectively.

Conclusion

Significantly abnormal vHIT results were rare in patients with acute PCS, even in the presence of DBS. Moreover, vHIT effectively differentiated dizziness between PCS and VN, highlighting its potential for aiding differential diagnosis of acute dizziness.

Vestibular and Oculomotor Findings in Vestibular Migraine Patients

BACKGROUND

Vestibular migraine (VM) is the most frequent etiology of recurrent spontaneous episodic vertigo. Vestibular and oculomotor abnormalities have been described in VM; however, the diagnosis is currently based on symptoms. The objective of this study was to determine the most frequent abnormalities in videonystagmography (VNG), caloric testing (Cal) and video head impulse test (vHIT) in patients with VM.

METHODS

A retrospective cohort study was conducted, including all VM and probable VM patients seen from January 2021 to July 2022. Demographics, auditory symptoms and results via VNG, Cal and vHIT were evaluated. VNG results were compared with a control group.

RESULTS

Sixty patients, 81.7% with VM and 18.3% with probable vestibular migraine, were included. VNG revealed the following abnormalities: 21.7% spontaneous nystagmus; 33.3% positional nystagmus, mostly central; 26.7% optokinetic nystagmus; 56.7% smooth pursuit abnormalities and 70% saccade test abnormalities, mostly velocity and latency. An abnormal unilateral caloric response was seen in 22.9%, while vHIT revealed a low gain in at least one canal in 21.7%, and saccades were seen in at least one canal with normal gains in 18.3%. Concordant results between Cal and lateral vHIT were seen in 77.1% of cases.

CONCLUSIONS

Although VM is a clinical diagnosis, vestibular and oculomotor abnormalities are commonly seen. The most frequent oculomotor findings were an abnormal saccade test, abnormal smooth pursuit and central positional nystagmus.

Vestibular migraine or Meniere's disease: a diagnostic dilemma

Meniere's disease (MD) represents one of the vertigo disorders characterized by triad symptoms (recurrent vertigo, fluctuating hearing loss, tinnitus or ear fullness). The diagnosis of MD relies on the accurate and detailed taking of medical history, and the differentiation between MD and vestibular migraine (VM) is of critical importance from the perspective of the treatment efficacy. VM is a highly prevalent vertigo condition and its typical symptoms (headache, vestibular symptoms, cochlear symptoms) mimic those of MD. Furthermore, the misdiagnosis in MD and VM could lead to VM patients mistakenly receiving the traumatic treatment protocol designed for MD, and sustaining unnecessary damage to the inner ear. Fortunately, thanks to the advances in examination technologies, the barriers to their differentiation are being gradually removed. These advances enhance the diagnostic accuracy of vertigo diseases, especially VM and MD. This review focused on the differentiation of VM and MD, with an attempt to synthesize existing data on the relevant battery of differentiation diagnosis (covering core symptoms, auxiliary tests [audiometry, vestibular tests, endolymphatic hydrops tests]) and longitudinal follow-up. Since the two illnesses are overlapped in all aspects, no single test is sufficiently specific on its own, however, patterns containing all or at least some features boost specificity.

VOR gain of lateral semicircular canal using video head impulse test in acute unilateral vestibular hypofunction: A systematic review

Introduction

Acute unilateral vestibular hypofunction is characterized by sudden onset of vertigo or dizziness, vomiting/nausea, gait instability, and nystagmus. This is commonly described as an acute vestibular syndrome and usually attributed to vestibular neuritis; however, up to 25% of acute vestibular syndrome is caused by a stroke of posterior circulations. The video head impulse test is a recent tool in the vestibular test battery that assesses the vestibule-ocular reflex by measuring the VOR gain and recording overt and covert saccades, these findings have been found to be helpful in the diagnosis of various vestibular disorders.

Method

A literature search was conducted in databases, including PubMed Central, PubMed, and Web of Science. All the articles that define video head impulse test (vHIT), acute vestibular hypofunction, and vestibular neuritis were considered for the preliminary search. No limits were placed on the date of publication. The searches were limited to studies with full-text availability, published in English, and including human subjects. Search words such as "head impulse test," "video head impulse test," "vestibular ocular reflex," "acute vestibular syndrome," "acute vestibular hypofunction," "vestibular neuritis," and "vHIT in central vestibular disorders" were entered into different databases in different combinations using boolean operators such as AND, OR, and NOT.

Results

Searches across different databases, including Web of Science, PubMed Central, and PubMed, resulted in a total of 1,790 articles. Title screening was done for all the articles. Out of the 1,790 articles, we found that 245 articles were related to vestibular hypofunction i.e., 1,545 articles were removed at this stage. A further 56 duplicate articles were removed. This led to a final screening of 189 articles. The exclusion criteria included unavailability of full text, studies reported in languages other than English, case reports, reviews, and articles including participants having other comorbid conditions. This final screening led to 133 articles being excluded, which led to the full-text screening of 56 articles. After screening the full-text articles as per the eligibility criteria, 21 articles were found to be eligible for the systematic review. Among the remaining studies, six articles were excluded due to different specific reasons. A total of 15 articles were included in this systematic review. The mean VOR gain for the patients with vestibular neuritis was 0.48 ± 0.14 for the ipsilesional ear, whereas the mean VOR gain was > 0.80 in the contralesional ear for all the patients with acute vestibular neuritis. In patients with PICA lesions, the VOR gain for the ipsilesional ear was 0.90 (range 0.87-0.94) and for the contralesional ear was 0.88 (range 0.84-0.93). In patients with AICA lesions, the mean VOR gain was variable. Based on the above mean VOR gain findings, the authors propose the following adjective description scale of VOR of the lateral canal using vHIT: normal VOR gain above 0.80, mild VOR gain loss for 0.70-0.79, moderate loss for 0.69-0.4, severe loss for 0.39-0.2, and profound loss for < 0.2.

Caloric and video head impulse test dissociated results in dizzy patients

Introduction

We are now able to detect abnormalities for any semicircular canal with the use of the video head impulse test (vHIT). Prior to the vHIT, the gold standard for unilateral canal paresis of the lateral canal was considered the caloric test. Clinical cases where the caloric test and vHIT are discordant are not uncommon.

Methods

Retrospective study. All consecutive cases of dizziness seen from 11/2020 to 12/2021 for which the patient underwent both caloric and vHIT tests performed within 10 days, were reviewed. Patients with discordant results were included. We evaluated the caloric response, vHIT gains for all canals and saccades, with and without gain abnormalities.

Results

We included 74 cases of dizziness with dissociated results. The most common finding was a normal caloric response with abnormal vHIT results (60.8%); the main abnormal finding on vHIT was the presence of saccades. In this group, 37.7% of patients had normal gains and refixation saccades. In addition, the most found low gain was for the posterior canal. The main diagnosis in this group was vestibular migraine. For the group with unilateral caloric paresis and normal vHIT gain in the lateral canal, the main diagnosis was Ménière's disease.

Discussion

The most common disorders with discordant results were Ménière's disease and vestibular migraine. The caloric test and vHIT are complementary and combining both tests provide greater clinical information. Further research is needed to understand refixation saccades with normal gains.

Dissociation between Caloric and Video Head Impulse Tests in Dizziness Clinics

Vestibular assessment tests such as the video head impulse test (vHIT) for the horizontal semicircular canal, and caloric test (Cal), both evaluate horizontal canal function. One would assume that the outcomes for these tests should lead to concordant results, yet several studies have suggested that dissociation can occur in certain pathological conditions. As this topic remains inconclusive, this review aims to analyze the scientific evidence regarding the patterns of hypofunction observed in vHIT and Cal in different otoneurological diseases. A comprehensive review of the literature regarding dissociation between these tests in common neurotological diseases was carried out. Articles were analyzed when data for vHIT and Cal were described in a way that it was possible to calculate discordance rates; both retrospective and prospective studies were analyzed. In this review, the discordance rates were as follows: 56% in Ménière’s disease, 51.5% in vestibular migraine, 37.2% in vestibular schwannoma, and 20.8% in vestibular neuritis. These results highlight the benefit of using both Cal and vHIT, and that they are complementary tests.

Evaluation of video head impulse test during vertiginous attack in vestibular migraine

Objective

The aim of this study is to evaluate vestibular functions with video head impulse test (VHIT) and to understand the value of VHIT in differential diagnosis in patients with vestibular migraine (VM) during dizziness attack.

Materials and methods

Two groups were enrolled in this study. The first consisted of 84 vestibular migraine patients, and second group of 74 healthy subjects. VHIT was applied to patients with VM during vertigo attack and the results were compared with the VHIT values applied to subjects in the control group.

Results

The mean vestibulo-ocular reflex (VOR) in all semicircular canals in the VM group was lower than healthy individuals, but the results were not statistically significant. Refixation saccades were found in 52.3% of VM patients and in 10.2% of healthy individuals.

Conclusions

When patients with VM were evaluated with VHIT during vertiginous attack, VOR gain values were not different from healthy individuals, but the number of catch-up saccades were higher in VM patients, which indicates peripheral vestibular involvement. For differential diagnosis in patients with VM, vestibular tests should be performed during the vertigo attack. When evaluating VHIT results, the presence of refixation saccades should also be evaluated.

Differential Involvement of Lateral Semicircular Canal and Otolith Organs in Common Vestibular Disorders

Semicircular canal and otolith functions came to be evaluated recently, but comprehensive and comparative analysis of canal and otolith dysfunction in common vestibular disorders is lacking. We aimed to analyze the abnormal rates of canal and otolith function in common vestibular disorders. We enrolled 302 patients who were managed for 2 months in a dizziness clinic. Results of caloric, video head impulse test (vHIT), and cervical and ocular vestibular evoked myogenic potential (cVEMP and oVEMP) tests were analyzed and compared among various diagnoses. Vestibular disorders diagnosed included recurrent vestibulopathy (RV, 27%), vestibular migraine (VM, 21%), benign paroxysmal positional vertigo (BPPV, 17%), Meniere's disease (MD, 11%), vestibular neuritis (VN, 10%), orthostatic dizziness (7%), and central lesions (3%). Lateral canal dysfunction was found most in VN (100%) and less commonly in definite MD (75%), RV (46%) and definite VM (29%). Abnormal caloric results were more common than abnormal vHIT in all disorders. Otolith dysfunction was found more frequently than lateral canal dysfunction in most vestibular disorders except VN. An abnormal cVEMP was more frequent in definite MD than the other disorders. Isolated otolith dysfunction without lateral canal dysfunction was the most found in BPPV, followed by definite VM, RV, and definite MD in decreasing order. Various patterns of involvement in canal and otoliths were revealed in vestibular disorders, suggesting different pathogenesis.

Vestibular and oculomotor function in patients with vestibular migraine

AIM

The purpose of this study was to assess the vestibular and oculomotor function in patients with vestibular migraine (VM). And we also investigate the relationship between testing results and effectiveness of preventive medications in VM.

MATERIAL AND METHOD

41 patients with VM were recruited in this study and examined with cervical and ocular vestibular evoked myogenic potential(cVEMP, oVEMP), video head impulse test(vHIT), caloric test and videonystagmography. All patients were treated with preventive medications. We calculated symptomatic improvement and record episodes frequency in patients with VM. Six months later, the effectiveness of preventive medications were evaluated and the relationship between vestibular testing and effectiveness of preventive medications were analyzed further.

RESULTS

In vestibular function testing, 73% of patients with VM showed abnormal results. Abnormal cVEMP, oVEMP, vHIT, and caloric test were found in 20%, 44%, 32% and 56% respectively. The abnormal rate of oVEMP was significantly higher than that of cVEMP(p < 0.05). And the proportion of abnormal caloric test was obviously higher than that of vHIT (p < 0.05). In oculomotor function testing, 42% of the patients with VM showed pathological results which was significantly lower than that of vestibular function testing(p < 0.05). After 6 months follow-up, the proportion of prophylactic medication effectiveness was significantly higher in normal vestibular function testing group compared with the abnormal group (p < 0.05).

CONCLUSION

Abnormal vestibular and oculomotor functions are commonly observed in patients with VM. And these patients with abnormal vestibular function possess a weak effectiveness of preventive medications.

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

•

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

•

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

•

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

Objective

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

Methods

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

Results

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

Conclusion

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

Significance

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

[Labyrinth hydrops and its diagnosis]

The article deals with the basic theories of maze and labyrinth hydrops, which are often used in clinical practice for its diagnosis according to the world literature. Tonal threshold, suprathreshold audiometry, broadband thympanometry, ultrasound tests, test for determination of lateralization of loud sounds, dehydration test, extra-timbanical electrocochleography, method of registration of evoked vestibular myogenic potentials, study of vestibular function (video pulse test, caloric sample), CT of temporal bones with gadolinium, MRI, and other methods are considered. None of these study methods gives an accurate confirmation of the presence of maze hydrops. Only taking into account the history, complaints of the patient, clinical manifestations of the disease and a comprehensive evaluation of the results of all the above methods of study can we speak with confidence about hydropse.

Vestibular mapping in patients with unilateral peripheral-vestibular deficits

OBJECTIVE

To test the hypothesis that patterns of semicircular canal (SCC) and otolith impairment in unilateral vestibular loss depend on the underlying disorders, we analyzed peripheral-vestibular function of all 5 vestibular sensors.

METHODS

For this retrospective case series, we screened the hospital video-head-impulse test database (n = 4,983) for patients with unilaterally impaired SCC function who also received ocular vestibular-evoked myogenic potentials and cervical vestibular-evoked myogenic potentials (n = 302). Frequency of impairment of vestibular end organs (horizontal/anterior/posterior SCC, utriculus/sacculus) was analyzed with hierarchical cluster analysis and correlated with the underlying etiology.

RESULTS

Acute vestibular neuropathy (AVN) (37.4%, 113 of 302), vestibular schwannoma (18.2%, 55 of 302), and acute cochleovestibular neuropathy (6.6%, 20 of 302) were most frequent. Horizontal SCC impairment (87.4%, 264 of 302) was more frequent (p < 0.001) than posterior (47.4%, 143 of 302) and anterior (37.8%, 114 of 302) SCC impairment. Utricular damage (58%, 175 of 302) was noted more often (p = 0.003) than saccular impairment (32%, 98 of 302). On average, 2.6 (95% confidence interval 2.48-2.78) vestibular sensors were deficient, with higher numbers (p ≤ 0.017) for acute cochleovestibular neuropathy and vestibular schwannoma than for AVN, Menière disease, and episodic vestibular syndrome. In hierarchical cluster analysis, early mergers (posterior SCC/sacculus; anterior SCC/utriculus) pointed to closer pathophysiologic association of these sensors, whereas the late merger of the horizontal canal indicated a more distinct state.

CONCLUSIONS

While the extent and pattern of vestibular impairment critically depended on the underlying disorder, more limited damage in AVN and Menière disease was noted, emphasizing the individual range of loss of function and the value of vestibular mapping. Likely, both the anatomic properties of the different vestibular end organs and their vulnerability to external factors contribute to the relative sparing of the vertical canals and the sacculus.

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

SIGNIFICANCE

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

Management of Ménière's Disease: How Does the Coexistence of Vestibular Migraine Affect Outcomes?

OBJECTIVE

To report the incidence of vestibular migraine (VM) in patients with Ménière's disease (MD) and investigate whether management outcomes of MD differ by the association of VM.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care academic center.

PATIENTS

MD patients (n = 251) with/without VM who were managed for 5 years in a dizziness clinic.

MAIN OUTCOME MEASURES

Influence of VM on management outcomes and hearing at the latest follow-up in stepwise management options.

RESULTS

Incidence of VM was 35% in MD patients. VM was more common in women than men (40 vs. 22%) and in probable MD than definite MD (43 vs. 29%). Bilateral MD was more frequent with coexistence of VM than without VM in definite MD (14 vs. 0%) as well as probable MD (24 vs. 7%). At the latest follow-up, preventive medications were effective in controlling vertigo in most (80%) patients (74%/90% in definite/probable MD). Additional intratympanic steroids were required in 16% (20%/10% in definite/probable MD) and intratympanic gentamicin or surgeries in 9 (6%) patients with intractable MD. The percentage of intractable MD did not differ with coexistence of VM, though definite MD showed a significantly higher percentage of intractable MD than probable MD (6 vs. 0%, respectively, p = 0.002). Worsening hearing was more frequent in definite MD than probable MD (19 vs. 4%), and association of VM did not influence the incidence of worsening hearing.

CONCLUSIONS

Coexistence of VM was about 30 to 40% in definite and probable MD, especially frequent in bilateral MD (77%) and women with probable MD (50%), requiring identification of coexisting VM while managing MD patients. Management outcomes and worsening hearing in MD patients are not dependent on the coexistence of VM, when both are managed.

Video head impulse test in vestibular migraine

Introduction

Vestibular migraine as an entity was described in 1999 and its pathophysiology is still not established. Simultaneously with research to better understand vestibular migraine, there has been an improvement in vestibular function assessment. The video-head impulse test is one of the latest tools to evaluate vestibular function, measuring its vestibular-ocular reflex gain.

Objective

To evaluate vestibular function of vestibular migraine patients using video-head impulse test.

Methods

Cross-sectional case-control study homogeneous by age and gender with vestibular migraine patients according to the 2012–2013 Barany Society/International Headache Society diagnostic criteria submitted to video-head impulse test during intercrisis period.

Results

31 vestibular migraine patients were evaluated with a predominantly female group (90.3%) and mean age of 41 years old. Vestibular function was normal in both patient and control groups. Gain values for horizontal canals were similar between the two groups, but gain values for vertical canals were higher in the group with vestibular migraine (p < 0.05). Patients with vestibular migraine felt more dizziness while performing the video-head impulse test than control subjects (p < 0.001).

Conclusions

Patients with vestibular migraine present normal vestibular function during intercrisis period when evaluated by video-head impulse test. Vertical canals, however, have higher gains in patients with vestibular migraine than in control subjects. Vestibular migraine patients feel dizziness more often while conducting video-head impulse test.

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

BACKGROUND

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

AIMS

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Diagnostic Value of Gains and Corrective Saccades in Video Head Impulse Test in Vestibular Neuritis

Objectives We investigated changes in video head impulse test (vHIT) gains and corrective saccades (CSs) at the acute and follow-up stages of vestibular neuritis to assess the diagnostic value of vHIT. Study Design Case series with chart review. Setting Tertiary medical center. Subjects and Methods Sixty-three patients with vestibular neuritis who underwent vHIT at an initial presentation and an approximately 1-month follow-up were included. vHIT gains, gain asymmetry (GA), peak velocities of CS, and interaural difference of CS (CSD) were analyzed. Results Mean vHIT gains increased significantly from the acute stage to the follow-up exam. The mean GA, peak velocities of CS, and CSD had decreased significantly at the follow-up. The incidence of CSs was also significantly decreased at the follow-up. The abnormal rate (87%) considering both gain and CS value was significantly higher than that (62%) considering vHIT gain only at the follow-up, although the abnormal rates did not differ at the acute stage (97% vs 87%). Conclusion The abnormal rates based on both vHIT gains and CS measurements are similar at the acute stage of VN but are considerably higher at the follow-up stage compared with the abnormal rates based on vHIT gains alone. It is thus advisable to check both CS and vHIT gain while performing vHIT to detect vestibular hypofunction.

The clinical utility of vestibular autorotation test in patients with vestibular migraine

OBJECTIVE

To investigate the characteristics and clinical utility of vestibular autorotation test (VAT) in patients with vestibular migraine.

METHODS

This study included two groups, an experimental group (441 patients) and a control group (65 healthy subjects). Both groups undertook VAT; the parameters evaluated were horizontal gain/phase, vertical gain/phase and asymmetry. The differences in VAT results between the two groups were investigated.

RESULTS

There were no statistical differences between the VAT data of the control group when compared to the reference value from the manufacturer (p > .05). There were statistically significant differences in VAT results between the experimental and control group, namely elevated horizontal gain at frequency 2, 3, 4 and 5 Hz, horizontal phase delay at frequency 2, 4, 5 and 6 Hz, elevated vertical gain at frequency 2 6Hz and vertical phase delay at frequency 4 6Hz.

CONCLUSION

The results of this study using VAT in VM patients demonstrate elevated horizontal gain, vertical gain and delay in horizontal phase, vertical phase. We suggest the application of VAT as a diagnostic tool which may provide objective evidence that can contribute to the diagnosis of VM and also in differential diagnosis.

Efficacy of steroid therapy based on symptomatic and functional improvement in patients with vestibular neuritis: a prospective randomized controlled trial

The aim of this study was to examine the efficacy of methylprednisolone in vestibular neuritis (VN) by objective and subjective measures. This prospective controlled randomized study was conducted at one tertiary hospital. Twenty-nine VN patients were randomized to either the steroid (n = 15) or the control (n = 14) group. The steroid group received methylprednisolone for 2 weeks, whereas control patients did not; both groups underwent regular vestibular exercises and were prescribed a Ginkgo biloba. Vestibular function tests including caloric test, video head impulse test (vHIT), and sensory organization test (SOT) were performed, and dizziness handicap index (DHI) was determined at enrollment; all tests were repeated at 1 and 6 months after enrollment. Both groups showed statistically significant improvements in caloric weakness and vHIT gain at 1- and 6-month follow-up evaluations compared to the initial examination; however, differences were not significant. The rates of normalization of canal paresis at 1 and 6 months were 50 and 64% in the control group and 33 and 60% in the steroid group, respectively, with no differences between the two groups. The rates of vHIT normalization at 1 and 6 months after treatment were 57 and 78% in the control group and 53 and 87% in the steroid group, respectively, with no differences between the two groups. Finally, there were no significant differences in the improvement of composite scores of SOT and the DHI scores between the two groups. In this prospective RCT, methylprednisolone had no additional benefit in patients with VN who underwent vestibular exercises and received a Ginkgo biloba.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier, NCT02098330; Trial title, The Efficacy of Steroid Therapy in Vestibular Neuritis.

Vestibular Function Tests for Vestibular Migraine: Clinical Implication of Video Head Impulse and Caloric Tests

Vestibular migraine (VM) is one of the most common causes of episodic vertigo. We reviewed the results of multiple vestibular function tests in a cohort of VM patients who were diagnosed with VM according to the diagnostic criteria of the Barany Society and the International Headache Society and assessed the efficacy of each for predicting the prognosis in VM patients. A retrospective chart analysis was performed on 81 VM patients at a tertiary care center from June 2014 to July 2015. Patients were assessed by the video head impulse test (vHIT), caloric test, vestibular-evoked myogenic potentials (VEMPs), and sensory organization test (SOT) at the initial visit and then evaluated for symptomatic improvement after 6 months. Complete response (CR) was defined as no need for continued medication, partial response (PR) as improved symptoms but need for continued medication, and no response (NR) as no symptomatic improvement and requiring increased dosage or change in medications. At the initial evaluation, 9 of 81 patients (11%) exhibited abnormal vHIT results, 14 of 73 (19%) exhibited abnormal caloric test results, 25 of 65 (38%) exhibited abnormal SOT results, 8 of 75 (11%) exhibited abnormal cervical VEMP results, and 20 of 75 (27%) exhibited abnormal ocular VEMP results. Six months later, 63 of 81 patients (78%) no longer required medication (CR), while 18 (22%) still required medication, including 7 PR and 11 NR patients. Abnormal vHIT gain and abnormal caloric results were significantly related to the necessity for continued medication at 6-month follow-up (OR = 5.67 and 4.36, respectively). Abnormal vHIT and caloric test results revealed semicircular canal dysfunction in VM patients and predicted prolonged preventive medication requirement. These results suggest that peripheral vestibular abnormalities are closely related to the development of vertigo in VM patients.