Use of HINTS in the acute vestibular syndrome. An Overview

The acute vestibular syndrome: prevalence of new hearing loss and its diagnostic value

OBJECTIVES

To assess the prevalence of new hearing losses in patients with acute vestibular syndrome (AVS) and to start to evaluate its diagnostic value for the differentiation between peripheral and central causes.

DESIGN

We performed a cross-sectional prospective study in AVS patients presenting to our Emergency Department (ED) from February 2015 to November 2020. All patients received an MRI, Head-impulse test, Nystagmus test and Test of skew ('HINTS'), caloric testing and a pure-tone audiometry.

RESULTS

We assessed 71 AVS patients, 17 of whom had a central and 54 a peripheral cause of dizziness. 12.7% had an objective hearing loss. 'HINTS' had an accuracy of 78.9% to diagnose stroke, whereas 'HINTS' plus audiometry 73.2%. 'HINTS' sensitivity was 82.4% and specificity 77.8% compared to 'HINTS' plus audiometry showing a sensitivity of 82.4% and specificity of 70.4%. The four patients with stroke and minor stroke had all central 'HINTS'. 55% of the patients did not perceive their new unilateral hearing loss.

CONCLUSIONS

We found that almost one-eighth of the AVS patients had a new onset of hearing loss and only half had self-reported it. 'HINTS' plus audiometry proved to be less accurate to diagnose a central cause than 'HINTS' alone. Audiometry offered little diagnostic accuracy to detect strokes in the ED but might be useful to objectify a new hearing loss that was underestimated in the acute phase. Complete hearing loss should be considered a red flag, as three in four patients suffered from a central cause.

Video head impulse test in stroke: a review of published studies

Accurate and timely diagnosis of posterior circulation stroke in patients with acute dizziness is a challenge that can lead to misdiagnosis and significant harm. The present review sought to identify and describe published research on the clinical application of vHIT in posterior circulation stroke. vHIT, a portable device, has gained prominence in evaluating peripheral vestibular disorders and offers potential applications in diagnosing neurological disorders, particularly posterior circulation stroke. Several studies have shown that vHIT can differentiate between stroke and vestibular neuritis based on VOR gain values, with high sensitivity and specificity. The manuscript also discusses vHIT's performance in differentiating between types of posterior circulation stroke, such as PICA, AICA, and SCA strokes. While vHIT has demonstrated promise, the review emphasizes the need for further research to validate its use as a tool to rule out stroke in acute dizziness patients in the emergency department. In conclusion, the manuscript underscores the potential of vHIT as a valuable addition to the diagnostic arsenal for acute dizziness, particularly in the context of posterior circulation stroke. It calls for further research and wider adoption of vHIT in clinical settings to improve patient care and reduce unnecessary costs associated with misdiagnoses.

Feasibility of video-based real-time nystagmus tracking: a lightweight deep learning model approach using ocular object segmentation

Background

Eye movement tests remain significantly underutilized in emergency departments and primary healthcare units, despite their superior diagnostic sensitivity compared to neuroimaging modalities for the differential diagnosis of acute vertigo. This underutilization may be attributed to a potential lack of awareness regarding these tests and the absence of appropriate tools for detecting nystagmus. This study aimed to develop a nystagmus measurement algorithm using a lightweight deep-learning model that recognizes the ocular regions.

Method

The deep learning model was used to segment the eye regions, detect blinking, and determine the pupil center. The model was trained using images extracted from video clips of a clinical battery of eye movement tests and synthesized images reproducing real eye movement scenarios using virtual reality. Each eye image was annotated with segmentation masks of the sclera, iris, and pupil, with gaze vectors of the pupil center for eye tracking. We conducted a comprehensive evaluation of model performance and its execution speeds in comparison to various alternative models using metrics that are suitable for the tasks.

Results

The mean Intersection over Union values of the segmentation model ranged from 0.90 to 0.97 for different classes (sclera, iris, and pupil) across types of images (synthetic vs. real-world images). Additionally, the mean absolute error for eye tracking was 0.595 for real-world data and the F1 score for blink detection was ≥ 0.95, which indicates our model is performing at a very high level of accuracy. Execution speed was also the most rapid for ocular object segmentation under the same hardware condition as compared to alternative models. The prediction for horizontal and vertical nystagmus in real eye movement video revealed high accuracy with a strong correlation between the observed and predicted values (r = 0.9949 for horizontal and r = 0.9950 for vertical; both p < 0.05).

Conclusion

The potential of our model, which can automatically segment ocular regions and track nystagmus in real time from eye movement videos, holds significant promise for emergency settings or remote intervention within the field of neurotology.

Quantifying Induced Nystagmus Using a Smartphone Eye Tracking Application (EyePhone)

BACKGROUND

There are ≈5 million annual dizziness visits to US emergency departments, of which vestibular strokes account for over 250 000. The head impulse, nystagmus, and test of skew eye examination can accurately distinguish vestibular strokes from peripheral dizziness. However, the eye-movement signs are subtle, and lack of familiarity and difficulty with recognition of abnormal eye movements are significant barriers to widespread emergency department use. To break this barrier, we sought to assess the accuracy of EyePhone, our smartphone eye-tracking application, for quantifying nystagmus.

METHODS AND RESULTS

We prospectively enrolled healthy volunteers and recorded the velocity of induced nystagmus using a smartphone eye-tracking application (EyePhone) and then compared the results with video oculography (VOG). Following a calibration protocol, the participants viewed optokinetic stimuli with incremental velocities (2-12 degrees/s) in 4 directions. We extracted slow phase velocities from EyePhone data in each direction and compared them with the corresponding slow phase velocities obtained by the VOG. Furthermore, we calculated the area under the receiver operating characteristic curve for nystagmus detection by EyePhone. We enrolled 10 volunteers (90% men) with an average age of 30.2±6 years. EyePhone-recorded slow phase velocities highly correlated with the VOG recordings (r=0.98 for horizontal and r=0.94 for vertical). The calibration significantly increased the slope of linear regression for horizontal and vertical slow phase velocities. Evaluating the EyePhone's performance using VOG data with a 2 degrees/s threshold showed an area under the receiver operating characteristic curve of 0.87 for horizontal and vertical nystagmus detection.

CONCLUSIONS

We demonstrated that EyePhone could accurately detect and quantify optokinetic nystagmus, similar to the VOG goggles.

Do monosymptomatic stroke patients with dizziness present a vestibular syndrome without nystagmus? An underestimated entity

BACKGROUND AND PURPOSE

Vestibular symptoms are common in emergency department (ED) patients and have various causes, including stroke. Accurate identification of stroke in patients with vestibular symptoms is crucial for timely management. We conducted a prospective cross-sectional study from 2015 to 2019 to determine stroke prevalence and associated symptoms in ED patients with vestibular symptoms, aiming to improve diagnosis and outcomes.

METHODS

As part of the DETECT project, we screened 1647 ED patients with acute vestibular symptoms. Following a retrospective analysis of 961 head and neck magnetic resonance imaging (MRI) scans, we included 122 confirmed stroke cases and assessed them for vestibular signs and symptoms.

RESULTS

Stroke prevalence in dizzy patients was 13% (122/961 MRI scans). Most patients (95%) presented with acute vestibular symptoms with or without nystagmus, whereas 5% had episodic vestibular syndrome (EVS). Nystagmus was present in 50% of stroke patients. Eighty percent had a purely posterior circulation stroke, and nystagmus was absent in 46% of these patients. Seven patients (6%) had lesions in both the anterior and posterior circulation. Vertigo was experienced by 52% regardless of territory.

CONCLUSIONS

A stroke was identified in 13% of ED patients presenting with acute vestibular symptoms. In 5%, it was EVS. Most strokes were in the posterior circulation territory; vertigo occurred with similar frequency in anterior and posterior circulation stroke, and absence of nystagmus was common in both.

Developing an implementation intervention for managing acute vertigo in the emergency department

BACKGROUND

There are evidence-based bedside tests for diagnosing acute vertigo, but no evidence-based strategies to support clinicians in implementing them. The purpose of this study was to design an implementation strategy for treating acute vertigo by examining current facilitators and barriers to using these tests in the ED using the principles of implementation science.

METHODS

A survey was developed using the Theoretical Domains Framework and Consolidated Framework for Implementation Research to examine barriers and facilitators for using HINTS+ (head impulse, nystagmus, test of skew, plus hearing) and Dix-Hallpike tests. The survey was sent to emergency clinicians (ECs) in a teaching hospital in London, UK, between May and September 2022. Semistructured interviews were conducted simultaneously, and data examined using direct content analysis. Implementation strategies were then selected based on the Expert Recommendations for Implementing Change framework.

RESULTS

Fifty-one ECs responded to the survey and six ECs volunteered for interview. Less than half reported using the bedside tests to make a diagnosis. The most common barriers were beliefs about complexity, a lack of supporting materials, memory, lack of skills and negative experiences. The interview data revealed negative beliefs about the necessity, validity, safety and practicality. There were also barriers in the ED environment (eg, lack of space). There was a strong perception that the current approach to managing acute vertigo needed to change and ECs view this as part of their professional role and responsibility. Based on clinician input, the authors selected strategies to improve diagnostic efforts, which included guidelines for training, developing vertigo champions, protocols, memory aids, audit and feedback.

CONCLUSION

This study found several barriers to managing acute vertigo such as memory constraints, and inadequate supporting materials and training, although a robust desire for change. The implementation strategy's initial phase is described, which must now be tested.

Objective Neurological Testing Methods Used to Follow Up Vestibular Neuritis Depending on Different Factors

Purpose

We analyze the impact of different factors on clinical performance and prognosis in vestibular neuritis (VN) and explore indicators that could accurately reflect changes in patients' symptoms at different stages.

Methods

We observed patients with VN during the acute and recovery phases. Clinical symptoms, vertigo-related scales, neurological examination, vestibular function tests (caloric test, video head impulse test (vHIT), vestibular evoked myogenic potential (VEMP)), and the history of disease (underlying diseases, glucocorticoid therapy) were recorded at onset and at 4 and 12 weeks after onset in VN patients. Multiple linear regression analysis was used to identify vestibular function tests that had a linear regression relationship with the subjective quantitative results.

Results

At 4 weeks after onset, the group without underlying disease had better improvement in EEV, gain, and UW than the group with underlying disease (P < 0.05). There was a significant difference in the change in DHI, EEV, gain of the affected horizontal semicircular canal in the vHIT and unilateral weakness (UW) between the glucocorticoid treatment group and the no glucocorticoid treatment group (P < 0.05), and glucocorticoid treatment group was better. The change value in the gain of horizontal canals in the vHIT was mainly positively and linearly correlated with the EEV scores (P<0.001). Possible dynamic correlation between vHIT results and vestibular symptoms.

Conclusion

The absence of underlying disease and the receipt of glucocorticoid therapy significantly contributed to the improvement of objective vestibular function tests in the short term, while the improvement of subjective vertigo may correlate with the different objective measures and questionnaire. We believe that the improvement of the affected horizontal semicircular canal gain value in the vHIT can be used as a reference indicator of the degree of improvement of vestibular symptoms with superior vestibular neuritis.

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.

Evaluating patients with vertigo

ABSTRACT

Dizziness and vertigo are among the most common complaints in medicine. Patients often provide vague descriptions of symptoms, making clinicians' jobs challenging. However, a patient with vertigo also can be one of the most rewarding encounters of a clinician's day. In most cases, a focused history and bedside vestibular testing provide enough information to make a diagnosis and identify patients for appropriate referral. Canalith repositioning maneuvers often resolve symptoms, leaving patients and clinicians satisfied.

Development of a model to predict the risk of cerebral infarction in acute vestibular syndrome

Objectives

This study aimed to develop a model to predict the risk of cerebral infarction in acute vestibular syndrome and assist emergency physicians in quickly identifying patients with cerebral infarction.

Materials and methods

We looked at 262 patients who were split into cerebral infarction and peripheral vertigo groups. Stepwise regression and Lasso's approach were used to screen for variables, and Boothstrap's method was used to evaluate the model's discrimination and calibration. The model's performance was compared against TriAGe+, ABCD2, and PCI scores using the area under the receiver operator characteristic curve. Clinical decision-making was aided by the use of clinical impact and decision curves.

Results

In the end, nine risk factors were chosen for model 2, and ten risk factors were chosen for model 1. Model 2 was adopted as the final model. The areas under the receiver operator curve value of the model2 were 0.910(P = 0.000), much higher than the areas under the receiver operator curve value of the TriAGe + scores system and that of the PCI scores system. The clinical decision curve shows that when the threshold probability is 0.05, using the nomogram to predict cerebral infarction has more benefits than either the treat-all-patients scheme or the treat-none scheme. The clinical impact curve shows that when the threshold probability is 0.6 the model predicts disease occurrence in general agreement with the occurrence of the real disease.

Conclusion

This study model can help emergency room physicians quickly triage and treat patients by accurately identifying cerebral infarction patients.

Effects of saccade delay, side of deficit, and training on detection of catch-up saccades during head-impulse test in virtual-reality-enhanced mannequin

In this study, a training simulator for the examination of dizzy patients based on a virtual-reality-enhanced mannequin (VREM) was developed to evaluate the detection of catch-up saccades during head impulse test (HIT) and the effect of training in VREM. For novices (n = 35), 2 trials were conducted before and after a training session. Experts (n = 7) were submitted to an evaluation session. In each trial, a left or a right horizontal canal deficit with an overt catch-up saccade (delay between 110 and 320 ms) was randomly presented. Participants scored the difficulty in performing the maneuver, in recognizing the saccades, and the self-confidence in the diagnosis using a visual analogue scale (VAS). Saccade delay significantly influenced the performance. Training significantly improved the sensitivity in the residents (69.1% before to 97.9% after the training, p < 0.001, Fisher's exact test, n = 560 tests), surpassing experts' performances (p < 0.001, versus 87% in experts, Fisher's exact test). The specificity also increased to the expert level (78% before to 95% after the training, and 95% in experts, p < 0.001, Fisher's exact test). The VAS showed a decrease difficulty to execute the HIT, with an increase in the confidence after training. VREM improved the HIT execution performance and the confidence in novice practitioners.

Dizziness in a tertiary neurological department: A cross-sectional study

BACKGROUND AND OBJECTIVE

Dizziness is a common and challenging symptom, which can be caused by different pathophysiological mechanisms and might affect a large number of population. However, up to now, there have been limited research on the characteristics of dizziness as the chief complaint in hospitalized patients in the Department of Neurology. Thus, the aim of this study was to investigate the hospitalized patients with dizziness as their chief complaint in the Department of Neurology.

METHODS

In this cross-sectional study, we conducted a retrospective document analysis of hospitalized patients admitted to a tertiary neurological department with the symptom of dizziness during the period of September 2019 to December 2020. We included 211 patients with dizziness as their chief complaint from 1841 patients admitted to this tertiary neurological department during that period.

RESULTS

Of all 1841 hospitalized patients, those with dizziness as the chief complaint accounted for 11.5% and most of their past medical history included hypertension, diabetes, cerebrovascular diseases, dyslipidemia, and coronary heart disease. Among these 211 patients, dizziness was more common in women than in men (p = .004). More patients presented with vertigo (40.8%) and light-headedness (39.8%) than disequilibrium (17.1%) and pre-syncope (2.4%). Nausea (48.3%), vomiting (34.1%), headache (13.3%), walking unsteadily (13.3%), and ear symptoms (12.8%) were the most common concomitant symptoms. Dix-Hallpike test (24.6%) and Romberg's sign (11.4%) were positive in these dizzy patients. Nystagmus (2.4%), vision changes (1.4%), and hearing disorders (8.5%) were relatively rare symptoms. Common auxiliary examinations were performed, such as magnetic resonance imaging (60.2%), computed tomography (31.8%), carotid duplex ultrasound (30.8%), and echocardiography (28.0%). Benign paroxysmal positional vertigo (24.2%) and stroke/transient ischemic attack (19.0%) were confirmed to be common causes of dizziness. Note that 97.2% of dizzy patients were in improved recovery after treatment.

CONCLUSION

The diagnosis and management of dizziness remain a challenge for clinicians. Vertigo and light-headedness were the most common symptoms among different types of dizziness. Benign paroxysmal positional vertigo and stroke/transient ischemic attack were among the leading causes for common dizziness disorders. The prognosis of most dizzy patients was good.

Isolated transient vertigo due to TIA: challenge for diagnosis and therapy

As a prevalent vertigo disease in the clinic, isolated transient vertigo can present as a vertigo episode without focal signs and always free of symptoms on presentation. Previous studies showed a part of isolated transient vertigo events had a high risk of stroke during follow-up. However, how to discern posterior circulation ischemia become a great challenge for clinicians, especially in emergency, neurology, and ENT departments. Routine besides, hematological, and imaging examinations are often difficult provide a clear etiological diagnosis. Hence, this article reviews current knowledge about the epidemiology, risk factors, offending lesions, and clinical manifestation of transient ischemic attack (TIA) presenting as isolated transient vertigo. In addition, we summarize several advances in besides examinations, serum biomarkers, and imaging technologies to better identify stroke events. Finally, the current situation of therapy was briefly retrospected. Here we present a critical clinical puzzle that needs to be solved in the future. Of note, there is a still lack of high-quality studies in this field. The article reviews the keys to the diagnosis of isolated transient vertigo due to TIA and provides us with more methods to screen for high-risk stroke populations.

Effectiveness and reliability of the four-step STANDING algorithm performed by interns and senior emergency physicians for predicting central causes of vertigo

BACKGROUND

For emergency physicians (EPs), acute vertigo is a challenging complaint and learning a reliable clinical approach is needed. STANDING is a four-step bedside algorithm that requires (1) identifying spontaneous nystagmus with Frenzel glasses or, alternatively, a positional nystagmus; (2) characterizing the nystagmus direction; (3) assessing the vestibuloocular reflex (head impulse test); and (4) assessing the gait. The objective was to determine its accuracy for diagnosing central vertigo when using by naïve examiners as such as interns and its agreement with senior EPs.

METHODS

This was a prospective 1-year diagnostic cohort study among patients with vertigo, vestibulovisual symptoms, or postural symptoms seen by 20 interns trained in the four-step examination. The algorithm was performed first by an intern and second by a senior EP and categorized as either worrisome when indicating a central diagnosis and benign or inconclusive when indicating a peripheral diagnosis. The reference test was diffusion-weighted brain magnetic resonance imaging.

RESULTS

Among 312 patients included, 57 had a central diagnosis including 33 ischemic strokes (10.5%). The main etiology was benign paroxysmal positional vertigo (32.7%). The likelihood ratios were 4.63 and 10.33 for a worrisome STANDING, 0.09 and 0.01 for a benign STANDING, and 0.21 and 0.35 for an inconclusive STANDING, for interns and senior EPs, respectively. The algorithm showed sensitivities of 84.8% (95% CI 75.6%-93.9%) and 89.8% (95% CI 82.1%-97.5%), negative predictive values of 96.2% (95% CI 93.7%-98.6%) and 97.5% (95% CI 95.5%-99.5%), specificities of 88.9% (95% CI 85.1%-92.8%) and 91.3% (95% CI 87.8%-94.8%), and positive predictive values of 64.1% (95% CI 53.5%-74.8%) and 70.7% (95% CI 60.4%-81.0%), respectively. The agreement between interns and senior EPs was very substantial (B-statistic coefficient: 0.77) and almost perfect for each step: (1) 0.87, (2) 0.98, (3) 0.95, and (4) 0.99.

CONCLUSIONS

With a single training session, the algorithm reached high accuracy and reliability for ruling out central causes of vertigo in the hands of both novices and experienced EPs. A future multicenter randomized controlled trial should further its impact on unnecessary neuroimaging use and patient's satisfaction.

Dizziness Evaluation and Characterisation of Patients with Posterior Circulation Stroke in the Emergency Department; a Case Series Study

Introduction

Dizziness is a common scenario in the Emergency Departments (EDs). Among dizziness underlying causes, the posterior circulation stroke is especially relevant due to its mobimortality and concerning misdiagnosis rates. Therefore, we conducted this study to assess dizziness evaluation and baseline characteristics of patients with PS in the ED.

Methods

We conducted a 3-year retrospective observational study on PS cases confirmed by magnetic resonance imaging (MRI). Concretely, we analysed the demographic profile of these patients, the initial PS clinical presentation, and diagnostic workup (with emphasis on dizziness evaluation) performed at the ED.

Results

During the study period, 85 cases were registered. Risk factors for cardiovascular disease were present in 85.5% and previous visits to the ED due to dizziness were recorded in 16.5%. The main clinical presentation was dizziness, concretely as an acute vestibular syndrome (38.8%) with additional neurological signs or symptoms (80%). Evaluation by the otolaryngologist on call was requested in less than 10% of the cases and included the HINTS protocol use with a sensitivity of 100% for central nervous system underlying causality. A brain CT study was always performed with a sensitivity of 27%. However, 96.47% of patients were primarily admitted to the Neurology hospitalization ward and MRI was always performed in a mean time of 3.21 days confirming the diagnosis.

Conclusions

Dizziness is the most frequent symptom of PS. Patients usually present an AVS (associated with additional N-SS or not) and HINTS bedside examination is the most adequate protocol to differentiate a PS from other AVS causes until the diagnostic confirmation via MRI. Interestingly, mainly otolaryngologists seem to use HINTS. However, the use of CT is widespread despite its poor value.

Diagnosing and localizing the acute vestibular syndrome - Beyond the HINTS exam

When assessing the acutely dizzy patient, the HINTS 'Plus' (Head Impulse, Nystagmus, Test of Skew, 'Plus' a bedside assessment of auditory function) exam is a crucial component of the bedside exam. However, there are additional ocular motor findings that can help the clinician distinguish peripheral from central etiologies and enable accurate localization, especially when the patient has acute dizziness, vertigo and/or imbalance but without spontaneous nystagmus. We will review the literature on these findings which are 'beyond HINTS' and include saccades/ocular lateropulsion, smooth pursuit, and provocative maneuvers including head-shaking and positional testing (not part of the HINTS exam). Additionally, we will expound on the localizing value of nystagmus, ocular alignment and the ocular tilt reaction (parts of the HINTS exam). The paper has been organized neuroanatomically, based on brainstem and cerebellar structures that have been reported to cause the acute vestibular syndrome.

Role of incubitus truncal ataxia, and equivalent standing grade 3 ataxia in the diagnosis of central acute vestibular syndrome

INTRODUCTION AND OBJECTIVES

acute vestibular syndrome is a diagnostic challenge, requiring a rapid and precise diagnosis to take therapeutic actions. Truncal ataxia, inability to sit still, and Babinski flexor dysergy were evaluated. Material anf methods: 52 patients with central pathology (stroke in aica and pica territory) and vestibular neuritis were prospectively studied. MRI of the brain was used as the gold standard.

RESULTS

A combination of grade 2-3 ataxia to differentiate patients with vestibular neuritis from patients with stroke resulted in a 92% sensitivity (95% CI 79-100%), a 67% specificity (95% CI 47-86%). Flexion asynergy had a 70% sensitivity (95% CI 47-92%), and an 88% specificity (95% CI 69-100%). The inability to sit still correlated well with truncal ataxia.

CONCLUSIONS

vestibulospinal signs are useful in the differential diagnosis of acute vestibular syndromes, and the inability to sit is a good substitute for truncal ataxia when it cannot be evaluated.

New onset episodic vertigo as a presentation of vestibular neuritis

Objective

Vestibular neuritis (VN) is a common peripheral cause of acute vestibular syndrome, characterized by sustained vertigo and gait instability, persisting from 1 day to several weeks. With the widespread use of comprehensive vestibular function tests, patients with VN and non-sustained vertigo have drawn attention. In this study, we retrospectively analyzed the clinical presentation of patients with VN and episodic vertigo, aiming to expand the atypical clinical features of VN.

Methods

This retrospective study enrolled 58 patients with VN. Among them, 11 patients with more than 3 remissions per day, each lasting over 1 h were assigned to the episodic vertigo (EV) group, and 47 subjects without significant relief into the sustained vertigo (SV) group. Demographic information, clinical manifestations and data of supplementary examinations were collected and statistically analyzed. These patients were followed up 1 year after discharge to gather prognostic information.

Results

The incidence of spontaneous nystagmus (SN) and proportion of severe vertigo (Dizziness Handicap Inventory questionnaire score >60) in the SV group were significantly higher than those in the EV group. Spearman correlation showed that with a longer disease course, the velocity of overt saccade was smaller (p < 0.05, Rs = −0.263) in all patients with VN.

Conclusion

The non-sustained manifestations in VN overlap with a wider spectrum of other vestibular disorders and stroke-related vertigo, which add an additional layer of complexity to the differential diagnosis of new onset episodic vertigo. By retrospectively analyzing the clinical characteristics and vHIT parameters, our study has expounded on the atypical features and potential pathophysiological mechanism of episodic syndromes in VN. VOR gain and saccades measured by vHIT could be reliable indicators for vestibular rehabilitation process.

A prospective study on the application of HINTS in distinguishing the localization of acute vestibular syndrome

BACKGROUND

Acute vestibular syndrome (AVS) is a common clinical syndrome in neurology clinics and emergency department. Canonical standard for AVS diagnosis requires the presence of persistent vertigo for more than 24 h. HINTS (head impulse-nystagmus-test of skew) is an emerging scheme in the diagnosis of AVS. In this prospective study, we evaluated the specificity and sensitivity of HINTS in distinguishing between central and peripheral AVS.

METHODS

A cohort of 239 cases with complete clinical record was recruited in the study. All patients completed emergency brain CT examination to exclude hemorrhagic stroke. HINTS examination was conducted to distinguish between central AVS and peripheral AVS, and all patients completed head MRI, BAEP and vestibular function examinations within one week. Patients diagnosed as central AVS were subject to angiography (CTA/MRA/DSA), and patients with peripheral AVS were considered for a 3-month follow-up to correct the initial diagnosis.

RESULTS

Patients with central AVS were associated with an elder age, higher incidences of hypertension, atrial fibrillation, family history of stroke and previous history of stroke. Posterior circulation cerebral infarction, vestibular migraine and cerebellitis were the dominant diseases associated with central AVS. The sensitivities of HIT, GE, and TS in the diagnosis of central AVS were 73.5%, 61.2%, and 26.5%, and the specificities were 97.9%, 92.6%, and 93.2% respectively.

CONCLUSIONS

The sensitivity of HINTS for central AVS diagnosis is 89.8% and the specificity is 84.2%. HINTS is an easy-to-operate, low-cost, high-sensitivity and specific examination technique, which is practical in neurology outpatient clinics and emergency departments.

Case Report: Mixed-Cause Vertigo and Sudden Sensorineural Hearing Loss as Presentations of Vertebrobasilar Dolichoectasia

Sudden sensorineural hearing loss (SSNHL) is a syndrome characterized by rapid progression of hearing impairment over seconds to days. While no universally accepted definition exists, it is often defined as a sensorineural hearing loss of 30 decilbles (dB) or more across at least three contiguous frequencies, occurring within 72 hours.

In elderly patients and those with vascular risk factors who develop SSNHL, ischemia of the vertebrobasilar territory is suspected, especially of the anteroinferior cerebellar artery. This is because ischemia that affects this artery produces 79% of SSNHL associated with cerebral infarction. In many cases of ischemia of the vertebrobasilar territory, there is an association with anomalies of the vertebrobasilar circulation, such as vertebral artery hypoplasia or vertebrobasilar dolichoectasia.

Here, we report a case of a 73-year-old man who presented right sudden hearing loss accompanied by acute onset vertigo, a physical exploration compatible with right vestibular dysfunction, and a history of recurrent episodes of syncope in the context of vertebrobasilar dolichoectasia, as diagnosed via magnetic resonance imaging (MRI).

Health Promotion Combined with Psychological Care Improves Vestibular Function in Patients with Vestibular Neuritis

This study aimed to explore the effect of health education combined with psychological care on patients with vestibular neuritis and the effect on their vestibular function. One hundred patients with vestibular neuritis admitted to our hospital from January 2019 to December 2020 were enrolled and divided into two groups by the random number: the control group (CG) (n= 53, health education) and the study group (SG) (n= 47, health education + psychological care). The Dizziness Handicap Inventory (DHI) scores, Berg Balance Scale (BBS) scores, depression scores (SDS), anxiety scores (SAS), satisfaction with care, compliance, incidence of falls, quality of life (QOF), and clinical symptom scores were compared between the two groups. Compared with the CG, the SG had a more significant reduction in DHI scores and SDS and SAS scores and a significant increase in BBS scores ( $P<0.05$ ). Compared with the CG, the SG had higher nursing satisfaction and compliance and a lower incidence of falls ( $P<0.05$ ). Nursing efficiency was higher in the SG than in the CG ( $P<0.05$ ). QOF scores were higher in the SG than in the CG ( $P<0.05$ ). Clinical symptom scores were lower in the SG than in the CG ( $P<0.05$ ). Health education combined with psychological care can improve vestibular function and bad mood, reduce the incidence of falls, improve the QOF, and result in high patient satisfaction and compliance, which should be widely promoted.

Oculo-vestibular signs in experimentally induced migraine attacks: an exploratory analysis

Vestibular symptoms accompanying headache are quite common in migraine patients. Based on the association of vertigo with migraine, vestibular migraine was included in the appendix of the 3rd edition of the International Classification of Headache Disorders as a possible migraine subtype worthy of further investigation. In this post hoc, exploratory analysis, we investigated the occurrence of oculo-vestibular signs (OVSs) during experimentally induced migraine attacks in 24 episodic migraine patients and 19 healthy controls exposed to sublingual nitroglycerin (NTG - 0.9 mg). A comprehensive clinical examination was performed at baseline, at the onset of the migraine-like attack, and immediately before hospital discharge (180 minutes after NTG administration). Three of the 13 migraine patients who developed a spontaneous-like migraine attack during the hospital observation period (23.1%) also developed OVSs during the induction test. Noteworthy, none of the patients with a negative induction test developed OVSs and no OVSs were reported in healthy subjects at any time point. The exploratory nature of our study does not allow to draw definite conclusions on the possible implications of a vestibular dysfunction in migraine pathophysiology. Our results however suggest that NTG administration may lend itself to investigate vestibular dysfunction in migraine, at least in a subset of patients. The present findings represent a starting point for designing future ad hoc and well-powered studies.

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.

Long-Term Evolution of Vestibular Compensation, Postural Control, and Perceived Disability in a Population of Patients with Vestibular Neuritis

Objectives. The aim was to analyze and compare the compensatory process, vestibular dysfunction, postural control, and perceived disability in a population of patients with vestibular neuritis (VN). Material and Methods. This is a prospective and longitudinal study of 67 patients diagnosed with VN. Inclusion criteria were sudden onset of vertigo, unidirectional spontaneous horizontal nystagmus, and impairment in vestibular test. Exclusion criteria were imaging or clinical findings of any neurotologic disorder. All vestibular tests were performed; vHIT, vestibular evoked myogenic potentials (VEMPs), caloric test and computerized dynamic posturography (CDP), dizziness handicap inventory (DHI), and visual analogue scale (VAS) were also performed at every follow up. Results. We observed a correlation between the composite score of CDP and baseline vestibular function elicited either by caloric test, VEMPs, or vHIT. There was a significant correlation between baseline vestibular function and first visit questionnaire scores. The main gain recovery for the horizontal canal was 0.1 ± 0.04 for the first three months. After that, the gain recovery significantly decreased. The presence of covert and overt saccades’, latency and amplitude decreased, respectively, after the 6-month period, when compared to the baseline results. We also observed a decrease in the PR score from 3 months after the vestibular insult until the last follow up. We observed a significant decrease in DHI and VAS from the first visit until the last one. Those patients with an initial HC gain below 0.5 had significantly higher DHI and VAS scores at every follow up. Conclusions. There are different measurements that could become a complete measurement of the state of compensation, postural control, and disability of the patients. There is a time window in which the vestibular restoration could give us clinical insights regarding the management of VN patients.

Acute Unilateral Peripheral Vestibulopathy After COVID-19 Vaccination: Initial Experience in a Tertiary Neurotology Center

Objective

The aim of the present study was to identify patients who developed acute unilateral peripheral vestibulopathy (AUPVP) after COVID-19 vaccination.

Methods

For this single-center, retrospective study, we screened the medical records of our tertiary interdisciplinary neurotology center for patients who had presented with AUPVP within 30 days after COVID-19 vaccination (study period: 1 June−31 December 2021). The initial diagnosis of AUPVP was based on a comprehensive bedside neurotological examination. Laboratory vestibular testing (video head impulse test, cervical and ocular vestibular evoked myogenic potentials, dynamic visual acuity, subjective visual vertical, video-oculography, caloric testing) was performed 1–5 months later.

Results

Twenty-six patients were diagnosed with AUPVP within the study period. Of those, n = 8 (31%) had developed acute vestibular symptoms within 30 days after COVID-19 vaccination (mean interval: 11.9 days, SD: 4.8, range: 6–20) and were thus included in the study. The mean age of the patients (two females, six males) was 46 years (SD: 11.7). Seven patients had received the Moderna mRNA vaccine and one the Pfizer/BioNTech mRNA vaccine. All patients displayed a horizontal(-torsional) spontaneous nystagmus toward the unaffected ear and a pathological clinical head impulse test toward the affected ear on initial clinical examination. Receptor-specific laboratory vestibular testing performed 1–5 months later revealed recovery of vestibular function in two patients, and heterogeneous lesion patterns of vestibular endorgans in the remaining six patients.

Discussion and Conclusions

The present study should raise clinicians' awareness for AUPVP after COVID-19 vaccination. The relatively high fraction of such cases among our AUPVP patients may be due to a certain selection bias at a tertiary neurotology center. Patients presenting with acute vestibular symptoms should be questioned about their vaccination status and the date of the last vaccination dose. Furthermore, cases of AUPVP occurring shortly after a COVID-19 vaccination should be reported to the health authorities to help determining a possible causal relationship.

[The "difficult" patient-Vestibular testing under difficult conditions : Part 1: History taking and clinical neurotological examination]

Der Patient mit dem Leitsymptom Schwindel stellt häufig eine Herausforderung für den Hals-Nasen-Ohren-Arzt dar. Die folgende Artikelserie beleuchtet unterschiedliche Aspekte des „schwierigen“ Schwindelpatienten. Der vorliegende erste Teil widmet sich den Besonderheiten und Fallstricken bei der Anamneseerhebung und der klinisch-neurootologischen Untersuchung. Dabei werden situationsspezifische Lösungsansätze zu folgenden Themen der Anamneseerhebung aufgezeigt: Definition von Erwartungen und Zielen, „ausschweifende“ Anamnese, Beschreibung des Symptoms Schwindel, mehrere Schwindelentitäten bei einem Patienten, Diskrepanz zwischen Symptomschwere und vestibulären Befunden, kognitive Verzerrungen und der Umgang mit Emotionen. Des Weiteren werden praxisbezogene Hinweise für die neurootologische Untersuchung von Patienten mit Halswirbelsäulenproblemen und Augenbewegungsstörungen sowie bei ängstlichen Patienten gegeben.

The HINTS examination and STANDING algorithm in acute vestibular syndrome: A systematic review and meta-analysis involving frontline point-of-care emergency physicians

This systematic review aims to evaluate whether point-of-care emergency physicians, without special equipment, can perform the HINTS examination or STANDING algorithm to differentiate between central and non-central vertigo in acute vestibular syndrome with diagnostic accuracy and reliability comparable to more specialized physicians (neuro-ophthalmologists and neuro-otologists). Previous research has concluded that emergency physicians are unable to utilize the HINTS examination with sufficient accuracy, without providing any appropriate education or training. A comprehensive systematic search was performed using MEDLINE, Embase, the Cochrane CENTRAL register of controlled trials, Web of Science Core Collection, Scopus, Google Scholar, the World Health Organization International Clinical Trials Registry Platform, and conference programs and abstracts from six medical organizations. Of the 1,757 results, only 21 were eligible for full-text screening. Two further studies were identified by a manual search of references and an electronic search for any missed studies associated with the authors. Five studies were included in the qualitative synthesis. For the STANDING algorithm, there were two studies of 450 patients who were examined by 11 emergency physicians. Our meta-analysis showed that emergency physicians who had received prior education and training were able to utilize the STANDING algorithm with a sensitivity of 0.96 (95% confidence interval: 0.87–1.00) and a specificity of 0.88 (0.85–0.91). No data was available for the HINTS examination. When emergency physicians are educated and trained, they can use the STANDING algorithm with confidence. There is a lack of evidence regarding the HINTS examination; however, two ongoing studies seek to remedy this deficit.

Objective measurement of HINTS (Head Impulse, Nystagmus, Test of Skew) in peripheral vestibulopathy

OBJECTIVE

To evaluate how often the positive sign of HINTS (Head-Impulse, Gaze Evoked Nystagmus, Test of Skew) appears in patients with acute peripheral vestibular lesion, HINTS findings were quantitatively measured and analyzed in patients with peripheral vestibulopathy accompanying spontaneous nystagmus.

METHODS

HINTS was evaluated in 14 vertigo patients with spontaneous nystagmus. Horizontal vestibulo-ocular reflex (VOR) gain was measured using the video head impulse test (vHIT). To evaluate gaze-evoked nystagmus (GEN), slow-phase velocities at different points of lateral gaze were measured and plotted, then the slope and its inverse value, the neural integrator time constant, were calculated. Skew deviation was tested using anaglyph filters to simulate the alternate cover test, and the degree and latency of vertical eyeball deviation were measured. The ABCD2 score was calculated to evaluate the risk of stroke.

RESULTS

Among 13 patients of peripheral vestibulopathy, 7 showed positive signs in HINTS (normal vHIT: 5, direction-changing GEN: 0, skew deviation: 3). One patient with a cerebellopontine angle tumor presented with both a peripheral and central pattern and showed positive HINTS findings (presence of direction-changing GEN). The mean VOR gain of patients with abnormal vHIT was 0.58±0.29 and 1.10±0.11 in the affected and contralateral side, respectively, while those in patients with normal vHIT were 1.04±0.21 and 1.13±0.12, respectively. The neural integrator time constant calculated from the mean slope of horizontal slow-phase velocity according to horizontal eye position was 42.9 s. The mean vertical eyeball deviation of patients with positive skew was 2.14±1.18° while uncovering the eye on the affected side, and -1.97±1.59° while uncovering the eye on the unaffected side. The median ABCD2 score of 14 patients was 2 (range, 1-3).

CONCLUSIONS

HINTS findings were objectively measured in vertigo patients with spontaneous nystagmus. Although positive findings of HINTS have been recognized as a central sign, 54% (7/13) of cases with peripheral vestibulopathy showed positive HINTS signs. HINTS results should be interpreted carefully considering that a substantial proportion of peripheral vestibulopathy shows a positive HINTS sign.

Identification of Stroke and TIA in Patients With Acute Dizziness, Vertigo or Imbalance in Emergency Departments of Primary Care Hospitals: Early Experiences With a Network-Based Telemedical Approach

Background

Acute dizziness, vertigo, and imbalance are frequent and difficult to interpret symptoms in the emergency department (ED). Primary care hospitals often lack the expertise to identify stroke or TIA as underlying causes. A telemedical approach based on telestroke networks may offer adequate diagnostics and treatment.

Aim

The aim of this study is to evaluate the accuracy of a novel ED algorithm in differentiating between peripheral and central vestibular causes.

Methods

Within the Telemedical Project for Integrative Stroke Care (TEMPiS), a telemedical application including a videooculography (VOG) system was introduced in 2018 in 19 primary care spoke hospitals. An ED triage algorithm was established for all patients with acute dizziness, vertigo, or imbalance of unknown cause (ADVIUC) as a leading complaint. In three predefined months, all ADVIUC cases were prospectively registered and discharge letters analyzed. Accuracy of the ED triage algorithm in differentiation between central and peripheral vestibular cases was analyzed by comparison of ED diagnoses to final discharge diagnoses. The rate of missed strokes was calculated in relation to all cases with a suitable brain imaging. Acceptance of teleconsultants and physicians in spoke hospitals was assessed by surveys.

Results

A total number of 388 ADVIUC cases were collected, with a median of 12 cases per months and hospital (IQR 8–14.5). The most frequent hospital discharge diagnoses are vestibular neuritis (22%), stroke/TIA (18%), benign paroxysmal positioning vertigo (18%), and dizziness due to internal medicine causes (15%). Detection of a central vestibular cause by the ED triage algorithm has a high sensitivity (98.6%), albeit poor specificity (45.9%). One stroke out of 32 verified by brain scan was missed (3.1%). User satisfaction, helpfulness of the project, improvement of care, personal competence, and satisfaction about handling of the VOG systems were rated consistently positive.

Discussion

The concept shows good acceptance for a telemedical and network-based approach to manage ADVIUC cases in the ED of primary care hospitals. Identification of stroke cases is accurate, while specificity needs further improvement. The concept could be a major step toward a broadly available state of the art diagnostics and therapy for patients with ADVIUC in primary care hospitals.

The clinical course of vestibular neuritis from the point of view of the ocular vestibular evoked myogenic potential

Background

Studying otolith functions after unilateral vestibular neuritis using ocular vestibular-evoked myogenic potentials and subjective visual vertical tests could give different results.

Method

A total of 39 patients underwent a vestibular assessment that included the Dizziness Handicap Inventory and horizontal and vertical semicircular canal function testing with video head impulse testing, ocular vestibular-evoked myogenic potential testing, cervical vestibular-evoked myogenic potentials and subjective visual vertical testing.

Results

All patients showed a significant alteration (asymmetry ratio more than 40 per cent) for ocular vestibular-evoked myogenic potentials as well as for subjective visual vertical testing (more than −2° to more than +2°) during the acute phase, whereas after 72 hours from the acute vertigo attack normal values (asymmetry ratio less than 40 per cent) were found in 6 out of 39 patients for ocular vestibular-evoked myogenic potentials and 36 out of 39 for the subjective visual vertical (less than −2° to less than +2°).

Conclusion

Ocular vestibular-evoked myogenic potentials are the most suitable test to evaluate otolith functions in patients with unilateral vestibular neuritis in the acute and sub-acute phase.

Current concepts in acute vestibular syndrome and video-oculography

PURPOSE OF REVIEW

We present here neuro-otological tests using portable video-oculography (VOG) and strategies assisting physicians in the process of decision making beyond the classical 'HINTS' testing battery at the bedside.

RECENT FINDINGS

Patients with acute vestibular syndrome (AVS) experience dizziness, gait unsteadiness and nausea/vomiting. A variety of causes can lead to this condition, including strokes. These patients cannot be adequately identified with the conventional approach by stratifying based on risk factors and symptom type. In addition to bedside methods such as HINTS and HINTS plus, quantitative methods for recording eye movements using VOG can augment the ability to diagnose and localize the lesion. In particular, the ability to identify and quantify the head impulse test (VOR gain, saccade metrics), nystagmus characteristics (waveform, beating direction and intensity), skew deviation, audiometry and lateropulsion expands our diagnostic capabilities. In addition to telemedicine, algorithms and artificial intelligence can be used to support emergency physicians and nonexperts in the future.

SUMMARY

VOG, telemedicine and artificial intelligence may assist physicians in the diagnostic process of AVS patients.

Acute Vertigo After COVID-19 Vaccination: Case Series and Literature Review

Objective: The aim of this study was to present some cases of acute vertigo potentially related to the coronavirus disease 2019 (COVID-19) vaccine and review the available literature about cochleovestibular dysfunction after the COVID-19 vaccination.

Methods: In the period from May to July 2021, we evaluated 33 patients (mean age 54.3 ± 14.1) with “acute vertigo” post COVID-19 vaccination. A detailed medical history was taken on comorbidities, types of vaccines received, and symptoms associated. All patients underwent otoneurological evaluation, such as head impulse test, nystagmus evaluation, test of skew (HINTS) examination. Head shaking test-induced nystagmus, hyperventilation-induced nystagmus, and parossistic positional nystagmus were studied to search for vestibular impairment.

Results: Symptoms included 16 patients (48.5%) with objective vertigo, 14 patients (42.4%) with subjective vertigo, and 3 patients (9.1%) with dizziness. Of the associated ear, nose, and throat (ENT) symptoms, the most expressed was tinnitus (18.2%). Bedside examination showed absent nystagmus in 7 patients (21.2%), 9 patients (27.3%) had horizontal or rotatory nystagmus, 17 patients (51.5%) had a vertical or oblique nystagmus, negative HST, or “central HINTS.”

Discussion and Conclusions: The 9 patients had an evoked nystagmus pathognomonic for benign paroxysmal positional vertigo; in the remaining 17 cases, peripheral vestibular dysfunction could be excluded and central disorder may be suggested. Due to the prevalence of nystagmus of non-peripheral origin, a central nervous system involvement could not be excluded. However, due to the small sample size, a definite cause–effect relationship between vaccination and vertigo cannot be inferred. In light of expected third dose, large-scale and well-designed studies are needed to better define possible adverse reactions of the COVID-19 vaccine.

Choice of intravenous thrombolysis therapy in patients with mild stroke complaining of acute dizziness

BACKGROUND

Quick identification of patients with mild ischemic stroke complaining of dizziness from other patients with benign peripheral vestibular disorders who also experience dizziness in the emergency department (ED) may be difficult. Decision-making on intravenous thrombolysis therapy (IVT) in patients whose chief symptoms include acute dizziness or vertigo remains a severe challenge for ED physicians. This study evaluated the diagnosis, treatment processes and the short-term outcomes in patients with mild vestibular stroke in the ED.

METHODS

A total of 89 consecutive patients with mild ischemic stroke primarily presenting with vestibular symptoms, who arrived at ED within 4.5 after onset, and were admitted at the stroke center of Zhejiang Provincial People's Hospital between January 2015 and March 2021 were retrospectively enrolled. Patients treated with IVT (n = 47) were compared to patients without IVT (n = 42) in terms of demographics, onset-to-door time (ODT), baseline clinical characteristics, risk factors of stroke, imaging findings, and short-term outcomes. The correlation between these parameters and IVT decision-making was analyzed.

RESULTS

Patients in IVT group more frequently presented with shorter ODT, focal neurological deficits (dysarthria, facial palsy, hemiglossoplegia, hemiparesis, hemisensory loss), disabling deficits, higher baseline National Institute of Health Stroke Scale (NIHSS) scores, and underwent multi-mode imaging before a decision. A higher proportion of isolated vestibular symptoms, acute transient vestibular syndrome, and vestibulo-vagal symptoms were found in the no-IVT group. There were no differences in demographics between the two groups. ODT was negatively correlated with the decision-making on IVT, and baseline NIHSS scores were positively correlated with the decision-making on IVT.

CONCLUSION

ODT and baseline NIHSS scores were correlated with the IVT decision in mild stroke patients primarily presenting with vestibular symptoms. Severe vestibular symptoms and disabling deficits were weakly associated with IVT decision, while the vestibulo-oculomotor signs and multi-mode imaging did not result as the influencing factors promoting the IVT decision-making for mild vestibular stroke.

Scenarios to improve CT head utilization in the emergency department delineated by critical results reporting

PURPOSE

Increasing use of advanced imaging in the emergency department (ED) has resulted in higher cost without better outcomes. Our goal was to evaluate the yield of CT head exams by scenario to guide efforts at improving patient selection.

METHODS

We performed a retrospective study at an academic medical center over 4 years (1/1/2014-12/31/2017). The chief complaint, imaging order, and exam result text were obtained for all adult ED encounters. For the 50 most common chief complaints leading to CT head exams, the ratio of exams to total encounters and ratio of critical results to imaging studies were calculated. Significant difference in "yield" was assessed via binomial test.

RESULTS

Over 708,145 adult ED encounters, 58,783 CT head exams were ordered, with an overall critical result yield of 8.0%. The three most common chief complaints had higher yield (p < 0.05): altered mental status (9.8%), fall (9.7%), and new headache (10.1%). Lower yield (p < 0.05) was found for 19 chief complaints: dizziness (6.2%), falls in patients > 65 years old (7.1%), syncope (5.3%), seizure with known epilepsy (4.8%), chest pain (3.7%), head injury (4.9%), headache re-evaluation (7.0%), alcohol intoxication (2.5%), fatigue (6.5%), headache-recurrent or in the setting of known migraines (5.2%), hypertension (4.4%), lethargy (5.8%), loss of consciousness (5.3%), migraine (3.2%), psychiatric evaluation (2.9%), near syncope (4.6%), drug problem (3.1%), symptomatically decreased blood sugar (3.2%), and suicidal (1.7%).

CONCLUSION

Our study provides a priority list of low yield scenarios of CT head use for improvement of patient selection.

Update on current diagnosis and treatment of vestibular neuritis

Vertigo is the sensation of self-motion of the head or body when no self-motion is occurring or the sensation of distorted self-motion during an otherwise normal head movement. Representative peripheral vertigo disorders include benign paroxysmal positional vertigo, Ménière disease, and vestibular neuritis. Vestibular neuritis, also known as vestibular neuronitis, is the third most common peripheral vestibular disorder after benign paroxysmal positional vertigo and Ménière disease. The cause of vestibular neuritis remains unclear. However, a viral infection of the vestibular nerve or ischemia of the anterior vestibular artery is known to cause vestibular neuritis. In addition, recent studies on immune-mediated mechanisms as the cause of vestibular neuritis have been reported. The characteristic clinical features of vestibular neuritis are abrupt true-whirling vertigo lasting for more than 24 hours, and no presence of cochlear symptoms and other neurological symptoms and signs. To accurately diagnose vestibular neuritis, various diagnostic tests such as the head impulse test, bithermal caloric test, and vestibular-evoked myogenic potential test are conducted. Various treatments for vestibular neuritis have been reported, which are largely divided into symptomatic therapy, specific drug therapy, and vestibular rehabilitation therapy. Symptomatic therapies include generalized supportive care and administration of vestibular suppressants and antiemetics. Specific drug therapies include steroid therapy, antiviral therapy, and vasodilator therapy. Vestibular rehabilitation therapies include generalized vestibular and customized vestibular exercises.

Automated alternate cover test for 'HINTS' assessment: a validation study

Objective

The alternate cover test (ACT) in patients with acute vestibular syndrome is part of the ‘HINTS’ battery test. Although quantitative, the ACT is highly dependent on the examiner’s experience and could theoretically vary greatly between examiners. In this study, we sought to validate an automated video-oculography (VOG) system based on eye tracking and dedicated glasses.

Methods

We artificially induced a vertical strabismus to simulate a skew deviation on ten healthy subjects, aged from 26 to 66, using different press-on Fresnel prisms on one eye while recording eye position with VOG of the contralateral eye. We then compared the system’s performance to that of a blinded trained orthoptist using conventional, semi-quantitative method of skew measurement known as the alternate prism cover test (APCT) as a gold standard.

Results

We found a significant correlation between the reference APCT and the Skew VOG (Pearson’s R² = 0.606, p < 0.05). There was a good agreement between the two tests (intraclass correlation coefficient 0.852, 95 CI 0.728–0.917, p < 0.001). The overall accuracy of the VOG was estimated at 80.53% with an error rate of 19.46%. There was no significant difference in VOG skew estimations compared with the gold standard except for very small skews.

Conclusions

VOG offers an objective and quantitative skew measurement and proved to be accurate in measuring vertical eye misalignment compared to the ACT with prisms. Precision was moderate, which mandates a sufficient number of tests per subject.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00405-021-06998-w.

Rare Disorders of the Vestibular Labyrinth: of Zebras, Chameleons and Wolves in Sheep's Clothing

The differential diagnosis of vertigo syndromes is a challenging issue, as many - and in particular - rare disorders of the vestibular labyrinth can hide behind the very common symptoms of "vertigo" and "dizziness". The following article presents an overview of those rare disorders of the balance organ that are of special interest for the otorhinolaryngologist dealing with vertigo disorders. For a better orientation, these disorders are categorized as acute (AVS), episodic (EVS) and chronic vestibular syndromes (CVS) according to their clinical presentation. The main focus lies on EVS sorted by their duration and the presence/absence of triggering factors (seconds, no triggers: vestibular paroxysmia, Tumarkin attacks; seconds, sound and pressure induced: "third window" syndromes; seconds to minutes, positional: rare variants and differential diagnoses of benign paroxysmal positional vertigo; hours to days, spontaneous: intralabyrinthine schwannomas, endolymphatic sac tumors, autoimmune disorders of the inner ear). Furthermore, rare causes of AVS (inferior vestibular neuritis, otolith organ specific dysfunction, vascular labyrinthine disorders, acute bilateral vestibulopathy) and CVS (chronic bilateral vestibulopathy) are covered. In each case, special emphasis is laid on the decisive diagnostic test for the identification of the rare disease and "red flags" for potentially dangerous disorders (e. g. labyrinthine infarction/hemorrhage). Thus, this chapter may serve as a clinical companion for the otorhinolaryngologist aiding in the efficient diagnosis and treatment of rare disorders of the vestibular labyrinth.

Emerging and distinct video head impulse test responses in elderly with vestibular symptoms

INTRODUCTION

Dizziness has been reported to be the most common symptom in elderly population. Video head impulse test, VHIT, allows clinicians to assess the vestibular function in elderly individuals, during their initial stages of vestibular symptoms. Inferences from VHIT responses were traditionally low vestibulo-ocular reflex gain or a normal vestibulo-ocular reflex gain. However, the possibility of a third and new variant of the vestibulo-ocular reflex gain has not been clinically explored yet.

OBJECTIVES

To determine and report distinct patterns of vestibulo-ocular reflex gain using VHIT in elderly individuals with vestibular symptoms.

METHODS

Retrospective cross-sectional study was done on a group of elderly patients who were above 70 years of age. These individuals were subjected to VHIT during their symptomatic phase. A vestibulo-ocular reflex gain value between 0.80-01.20 (Horizontal plane) was considered normal. The gain above and below this cutoff range was considered abnormal.

RESULTS

39 elderly patients (15 males and 24 females) whose mean age range was 74.71 years were evaluated for the VHIT response. Vestibulo-ocular reflex gain obtained was categorized into three distinct patterns: (i) normal vestibulo-ocular reflex gain, (ii) reduced vestibulo- ocular reflex gain and (iii) increased vestibulo-ocular reflex gain. The mean vestibulo- ocular reflex gain for both left and right horizontal canals varied significantly between the three groups (p < 0.05). No significant effect of age and vestibulo-ocular reflex gain was noted, though vestibulo-ocular reflex gain was higher in 80 years and above age (p > 0.05).

CONCLUSION

Elderly individuals with dizziness may show varying responses with vestibulo-ocular reflex gain during the symptomatic period. The third type of hyperactive vestibule-ocular reflex responses that emerged from the current study were potential indicators of fluid dynamic changes in the inner ear. These responses need to be explored further as it relates to new clinical markers for both peripheral and central vestibular disorders.

Selective Asymmetry of Ocular Vestibular-Evoked Myogenic Potential in Patients with Acute Utricular Macula Loss

OBJECTIVES

We retrospectively evaluated a chart review of 3,525 patients evaluated for any acute disturbance. A total of 1,504 patients with acute vestibular syndrome (AVS) received an instrumental vestibular assessment within 72 h from the onset of the symptoms evaluated using simultaneously a combination of ocular vestibular-evoked myogenic potential (oVEMPs), cervical vestibular-evoked myogenic potential (cVEMPs), video head-impulse test (vHIT), and subjective visual vertical (SVV) were included in this study.

MATERIALS AND METHODS

A total of 41 patients with AVS that showed a normal horizontal canal function tested with vHIT, a normal cVEMP function, unilaterally reduced or absent oVEMP n10, and an altered SVV were enrolled.

RESULTS

We found that although these patients referred acute vertigo and presented spontaneous nystagmus, they showed physiological values of vHIT and a normal saccular function, as shown by symmetrical cVEMPs.

CONCLUSION

Our findings support the hypothesis that a percentage of patients evaluated during an AVS using an instrumental vestibular assessment could present selective utricular macula dysfunction.

Predictors of vertigo in the emergency department: The preved study

BACKGROUND AND PURPOSE

Acute vertigo (sense of motion) can be the sole manifestation of a posterior circulation stroke, and often gets missed in the emergency department (ED). The studies for evaluation of central vertigo have focused on physical exam findings, which require expertise and may not be suitable for rapid triage by a nurse in ED or by paramedics.

METHODS

This cross sectional study included retrospective chart review of patients 18 years of age and older who presented to the Adult ED with acute dizziness or vertigo during the calendar year 2017. All the patients with a diagnosis of central or peripheral vertigo were included in the final analysis. Sensitivity, specificity, Likelihood Ratio of positive result (LR (+)) and Likelihood Ratio of negative result (LR (-)) for central and peripheral vertigo were calculated for risk factors, symptoms and physical examination features. Chi-squared test and univariate logistic regression were used to evaluate statistical correlation and to calculate the prevalence odds ratio (POR).

RESULTS

Two hundred and forty nine out of 505 (49.3%) patients presenting with dizziness had vertigo. Of these, 14 had central vertigo and 163 had peripheral vertigo. Statistically significant variables were: constant symptoms of vertigo (p 0.000- POR 8.7, 95% confidence interval (CI) 2.3-33.1), no change in symptoms with head movement (p 0.000- POR 10.2, 95% CI 3.0-35.4), dysmetria (p 0.000- POR 56.8, 95% CI 5.8-557.1), and unsteady gait (p 0.000- POR 13.3, 95% CI 3.3-54.3). The sensitivity and specificity to detect central vertigo were 100% and 66.4% respectively if the patient had either unsteady gait, constant symptoms, or no change in symptoms with head movement, [VAIN triad (Vertigo- Ataxia, Incessant, or Non-positional)].

CONCLUSIONS

We suggest that triage with VAIN triad can be used to design prospective studies to develop a triage algorithm for the detection of central vertigo in the ED.

Acute vestibular syndrome and hearing loss mimicking labyrinthitis as initial presentation of multiple sclerosis

Acute vestibular syndrome is most often caused by vestibular neuritis or stroke, although demyelinating diseases may be responsible for 4% of all AVS episodes. The authors present the case of a previously healthy 17-year-old female patient complaining of spontaneous vertigo and right-sided hearing loss. Otoneurological examination suggested a peripheral vestibular cause and video head impulse test revealed a reduced vestibulo-ocular reflex gain. The presence of sensorineural hearing loss raised the suspicion of a central cause and prompted imaging evaluation. A brain MRI evidenced demyelinating lesions in the right middle cerebellar peduncle and the patient was ultimately diagnosed with Multiple Sclerosis.

[Ocular movement and nystagmus: basics and clinical diagnosis]

BACKGROUND

Eye movements are one of the most complex motor functions of the central nervous system (CNS). Eye movement disorders including nystagmus occur in diseases of the CNS and the vestibular system. A systematic clinical examination often allows a topodiagnostic classification of the lesion.

OBJECTIVE

The basics of eye movements, the role of the cerebellum, the clinical examination of the oculomotor system, and the most important forms of nystagmus and their diagnostic implications are described.

MATERIALS AND METHODS

A literature analysis assessing eye movements, cerebellar control of eye movements, clinical examination of eye movement, and nystagmus was performed.

RESULTS

In disorders of eye movement, diseases of the oculomotor cranial nerves and the central nervous structures are to be distinguished from diseases of the orbit, eye muscles, and motor end plates. The former result in cranial nerve-related paralysis of extraocular muscles, disturbances of saccadic and smooth pursuit eye movements, vertical or horizontal gaze palsy, internuclear ophthalmoplegia, or impaired gaze holding. Nystagmus in combination with other disturbances of ocular movement is highly related to a lesion within the CNS. Intense nystagmus with a rotatory component that decreases during fixation usually has a peripheral vestibular cause.

CONCLUSION

Clinical examination of eye movements and nystagmus enables the diagnosis of typical eye movement disorders with a strong relation to distinct lesions of the CNS or the peripheral vestibular pathway.