Clinical value of the video head impulse test in patients with vestibular neuritis: a systematic review

Video head impulse test in subacute and chronic stroke survivors: new perspectives for implementation of assessment in rehabilitation

INTRODUCTION

The Video Head Impulse Test (vHIT) is a safe and reliable assessment of peripheral vestibular function. Many studies tested its accuracy in clinical settings for differential diagnosis and quantification of the vestibulo-oculomotor reflex (VOR) in various disorders. However, the results of its application after lesions of the CNS are discordant and have never been studied in rehabilitation. This study aims to assess the VOR performance in a sample of stroke survivors.

METHODS

This is a cross-sectional study on 36 subacute and chronic stroke survivors; only persons with first-ever stroke and able to walk independently, even with supervision, were included. We performed VOR assessments for each semicircular canal by vHIT and balance assessments by the Berg Balance Scale and the MiniBESTest scale.

RESULTS

Two hundred and sixteen semicircular canals were assessed using the Head Impulse paradigm (in both the vertical and horizontal planes), while 72 semicircular canals were assessed using the Suppressed Head Impulse paradigm (horizontal plane). There was a high prevalence of participants with dysfunctional canals, particularly for the left anterior and right posterior canals, which were each prevalent in more than one-third of our sample. Furthermore, 16 persons showed an isolated canal dysfunction. The mean VOR gain for the vertical canals had confidence intervals out of the normal values (0.74-0.91 right anterior; 0.74-0.82 right posterior; 0.73-0.87 left anterior).

CONCLUSION

Our findings suggest that peripheral vestibular function may be impaired in people with stroke; a systematic assessment in a rehabilitation setting could allow a more personalized and patient-centred approach.

Vestibular Decompensation Following COVID-19 Infection in a Person With Compensated Unilateral Vestibular Loss: A Rehabilitation Case Study

BACKGROUND AND PURPOSE

Surgical removal of a vestibular schwannoma (vestibular schwannoma resection; VSR) results in a unilateral vestibular hypofunction with complaints of dizziness and imbalance. Although the anatomic lesion is permanent, recovery of balance and diminution of dizziness occurs through central neurophysiologic compensation. Compensation of the system is maintained through daily activity. Unfortunately, interruption of stimulus, such as decreased activities due to illness, can cause decompensation. Decompensation is described as the return of symptoms consistent with that experienced during the initial insult/injury (eg, dizziness, oscillopsia, balance difficulty). This case study describes a reoccurrence of vestibular dysfunction in a person with a history of VSR following hospitalization and protracted recovery from a COVID-19 infection. It further documents her recovery that may be a result of vestibular rehabilitation.

CASE DESCRIPTION

A 49-year-old woman (M.W.) with a surgical history of VSR (10 years prior) and a medical history of significant COVID-19 infection, resulting in an intensive care unit stay and prolonged use of supplemental oxygen, presented to physical therapy with persistent dizziness and imbalance. The video head impulse test confirmed unilateral vestibular hypofunction.

INTERVENTION

M.W. attended biweekly vestibular rehabilitation for 6 weeks and completed daily home exercises.

OUTCOMES

At discharge, M.W. demonstrated improvements in patient-reported outcomes (Dizziness Handicap Inventory), functional testing (MiniBEST, 2-Minute Walk Test), and gaze stability measures (video head impulse testing, dynamic visual acuity).

DISCUSSION

Vestibular decompensation preluded by a COVID-19 infection caused a significant decrease in functional mobility. Vestibular rehabilitation targeted at gaze and postural stability effectively reduced symptoms and facilitated recovery to M.W.'s pre-COVID-19 level of function. Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A458 ).

[The six most frequent peripheral vestibular syndromes]

Three forms of peripheral vestibular disorders, each with its typical symptoms and clinical signs, can be differentiated functionally, anatomically and pathophysiologically: 1. inadequate unilateral paroxysmal stimulation or rarely inhibition of the peripheral vestibular system, e. g., BPPV, Menière's disease, vestibular paroxysmia or syndrome of the third mobile windows; 2. acute unilateral vestibulopathy leading to an acute vestibular tone imbalance manifesting as an acute peripheral vestibular syndrome; and 3. loss or impairment of function of the vestibular nerve and/or labyrinth: bilateral vestibulopathy. For all of these diseases, current diagnostic criteria by the Bárány-Society are available with a high clinical and scientific impact, also for clinical trials. The treatment depends on the underlying disease. It basically consists of 5 principles: 1. Explaining the symptoms and signs, pathophysiology, aetiology and treatment options to the patient; this is important for compliance, adherence and persistence. 2. Physical therapy: A) For BPPV specific liberatory maneuvers, depending on canal involved. Posterior canal: The new SémontPLUS maneuver is superior to the regular Sémont and Epley maneuvers; horizontal canal: the modified roll-maneuver; anterior canal the modified Yacovino-maneuver; 3. Symptomatic or causative drug therapy. There is still a deficit of placebo-controlled clinical trials so that the level of evidence for pharmacotherapy is most often low. 4. Surgery, mainly for the syndrome of the third mobile windows. 5. Psychotherapeutic measures for secondary functional dizziness.

Instrumental assessment of dynamic postural stability in patients with unilateral vestibular hypofunction during straight, curved, and blindfolded gait

PURPOSE

To characterise dynamic postural stability of gait in patients with vestibular hypofunction (PwVH) using a sensor-based assessment while performing dynamic tasks and to correlate the results of this evaluation with clinical scales.

METHODS

This cross-sectional study involved 22 adults between 18 and 70 years old from a healthcare hospital centre. Eleven patients suffering from chronic vestibular hypofunction (PwVH) and eleven healthy controls (HC) were evaluated through a combined inertial sensor-based and clinical scale assessment. Participants were equipped with five synchronised inertial measurement units (IMUs) (128 Hz, Opal, APDM, Portland, OR, USA): three IMUs were located on the occipital cranium bone, near the lambdoid suture of the head, at the centre of the sternum, and at L4/L5 level, just above the pelvis, and were used to quantify gait quality parameters, while the other two were located slightly above lateral malleoli and used to perform stride and step segmentation. Three different motor tasks were performed in a randomized order: the 10-m Walk Test (10mWT), the Figure of Eight Walk Test (Fo8WT) and the Fukuda Stepping Test (FST). A set of gait quality parameters related to stability, symmetry and smoothness of gait were extracted from IMU data and correlated with the clinical scale scores. PwVH and HC results were compared to test for significant between-group differences.

RESULTS

Significant differences were found for the three motor tasks (10mWT, Fo8WT and FST) when comparing PwVH and HC groups. For the 10mWT and the Fo8WT, significant differences between the PwVH and HC groups were found for the stability indexes. Considering the FST, significant differences between the PwVH and HC groups were also found in the stability and symmetry of gait. A significant correlation was found between the Dizziness Handicap Inventory and gait indices during the Fo8WT.

CONCLUSIONS

In this study, we characterized the dynamic postural stability alterations during linear, curved, and blindfolded walking/stepping in PwVH combining an instrumental IMU-based with traditional clinical scales approach. Combining instrumental and clinical evaluation for dynamic stability of gait alterations in PwVH is useful in thoroughly evaluating the effects of unilateral vestibular hypofunction.

Dynamic change of vestibular function and the long-term prognosis of vestibular neuritis

AIM

To comprehensively evaluate the dynamic change of vestibular function during long-term follow-up of vestibular neuritis, as well as the co-relationship with the outcomes of vestibular neuritis (VN), which provides the recommendations for vestibular function tests during the course of VN.

METHODS

A prospective cohort study was conducted on 16 patients with acute VN. Caloric test, vHIT, rotatory chair tests, VEMP, dizziness handicap inventory (DHI) score, and dynamic dizzy scales (VAS-DD) was first performed within 7 days of neuritis onset, which were further re-evaluated during the 6-12 months of follow-up. The dynamic changes on multiple objective vestibular examinations were analyzed during the acute and recovery stage of VN. We further evaluated the co-relationship between the vestibular dysfunction scales and the prognosis of VN.

RESULTS

In more than 6 months of follow-up, 44% of the ultralow frequency, 94% of the low-to-mid frequency, and 44% of the high-frequency function of the horizontal semicircular canal returned to normal (p < 0.05). The change degree in symmetry of the rotatory chair test was correlated with the gain of the horizontal semicircular canal on the vHIT and the unilateral weakness (UW) value on the caloric test (p < 0.05). The change in DHI score was correlated with the phase; change in VAS-DD level correlated with the symmetry and TC of the rotatory chair test at VN recovery stage (p < 0.05). There was no significant correlation between the change in DHI score or change in VAS-DD and the degree of vestibular function recovery (p > 0.05).

CONCLUSION

In general, vestibular function improved during the course of VN. The rotatory chair test can be used to evaluate the overall function of the vestibular system and the compensatory state in patients with VN.

Vestibular Rehabilitation Improves Gait Quality and Activities of Daily Living in People with Severe Traumatic Brain Injury: A Randomized Clinical Trial

Neurorehabilitation research in patients with traumatic brain injury (TBI) showed how vestibular rehabilitation (VR) treatments positively affect concussion-related symptoms, but no studies have been carried out in patients with severe TBI (sTBI) during post-acute intensive neurorehabilitation. We aimed at testing this effect by combining sensor-based gait analysis and clinical scales assessment. We hypothesized that integrating VR in post-acute neurorehabilitation training might improve gait quality and activity of daily living (ADL) in sTBI patients. A two-arm, single-blind randomized controlled trial with 8 weeks of follow-up was performed including thirty sTBI inpatients that underwent an 8-week rehabilitation program including either a VR or a conventional program. Gait quality parameters were obtained using body-mounted magneto-inertial sensors during instrumented linear and curvilinear walking tests. A 4X2 mixed model ANOVA was used to investigate session−group interactions and main effects. Patients undergoing VR exhibited improvements in ADL, showing early improvements in clinical scores. Sensor-based assessment of curvilinear pathways highlighted significant VR-related improvements in gait smoothness over time (p < 0.05), whereas both treatments exhibited distinct improvements in gait quality. Integrating VR in conventional neurorehabilitation is a suitable strategy to improve gait smoothness and ADL in sTBI patients. Instrumented protocols are further promoted as an additional measure to quantify the efficacy of neurorehabilitation treatments.

Acute unilateral vestibulopathy/vestibular neuritis: Diagnostic criteria

This paper describes the diagnostic criteria for Acute Unilateral Vestibulopathy (AUVP), a synonym for vestibular neuritis, as defined by the Committee for the Classification of Vestibular Disorders of the Bárány Society. AUVP manifests as an acute vestibular syndrome due to an acute unilateral loss of peripheral vestibular function without evidence for acute central or acute audiological symptoms or signs. This implies that the diagnosis of AUVP is based on the patient history, bedside examination, and, if necessary, laboratory evaluation. The leading symptom is an acute or rarely subacute onset of spinning or non-spinning vertigo with unsteadiness, nausea/vomiting and/or oscillopsia. A leading clinical sign is a spontaneous peripheral vestibular nystagmus, which is direction-fixed and enhanced by removal of visual fixation with a trajectory appropriate to the semicircular canal afferents involved (generally horizontal-torsional). The diagnostic criteria were classified by the committee for four categories: 1. "Acute Unilateral Vestibulopathy", 2. "Acute Unilateral Vestibulopathy in Evolution", 3. "Probable Acute Unilateral Vestibulopathy" and 4. "History of Acute Unilateral Vestibulopathy". The specific diagnostic criteria for these are as follows:"Acute Unilateral Vestibulopathy": A) Acute or subacute onset of sustained spinning or non-spinning vertigo (i.e., an acute vestibular syndrome) of moderate to severe intensity with symptoms lasting for at least 24 hours. B) Spontaneous peripheral vestibular nystagmus with a trajectory appropriate to the semicircular canal afferents involved, generally horizontal-torsional, direction-fixed, and enhanced by removal of visual fixation. C) Unambiguous evidence of reduced VOR function on the side opposite the direction of the fast phase of the spontaneous nystagmus. D) No evidence for acute central neurological, otological or audiological symptoms. E) No acute central neurological signs, namely no central ocular motor or central vestibular signs, in particular no pronounced skew deviation, no gaze-evoked nystagmus, and no acute audiologic or otological signs. F) Not better accounted for by another disease or disorder."Acute Unilateral Vestibulopathy in Evolution": A) Acute or subacute onset of sustained spinning or non-spinning vertigo with continuous symptoms for more than 3 hours, but not yet lasting for at least 24 h hours, when patient is seen; B) - F) as above. This category is useful for diagnostic reasons to differentiate from acute central vestibular syndromes, to initiate specific treatments, and for research to include patients in clinical studies."Probable Acute Unilateral Vestibulopathy": Identical to AUVP except that the unilateral VOR deficit is not clearly observed or documented."History of acute unilateral vestibulopathy": A) History of acute or subacute onset of vertigo lasting at least 24 hours and slowly decreasing in intensity. B) No history of simultaneous acute audiological or central neurological symptoms. C) Unambiguous evidence of unilaterally reduced VOR function. D) No history of simultaneous acute central neurological signs, namely no central ocular motor or central vestibular signs and no acute audiological or otological signs. E) Not better accounted for by another disease or disorder. This category allows a diagnosis in patients presenting with a unilateral peripheral vestibular deficit and a history of an acute vestibular syndrome who are examined well after the acute phase.It is important to note that there is no definite test for AUVP. Therefore, its diagnosis requires the exclusion of central lesions as well as a variety of other peripheral vestibular disorders. Finally, this consensus paper will discuss other aspects of AUVP such as etiology, pathophysiology and laboratory examinations if they are directly relevant to the classification criteria.

Video Suppression Head Impulses and Head Impulses Paradigms in Patients with Vestibular Neuritis: A Comparative Study

Background: This study aims to explore the clinical relevance of the Suppression Head Impulse Paradigm (SHIMP) to better understand if it represents an additional clinical value compared to the Head Impulse Paradigm (HIMP) in patients with vestibular neuritis (VN) in different stages of the disease. Methods: From January 2020 to June 2022, patients with unilateral VN were found in a database of an ENT vestibular clinic. Clinical presentation, vestibular test outcomes, therapy, and recovery were examined in medical records. Results: A total of 42 patients (16 Females, mean age 51.06 ± 12.96; 26 Male, mean age 62.50 ± 9.82) met the inclusion criteria and were enrolled in the study. The means of the VOR gain for both paradigms were respectively 0.38 ± 0.12 (SHIMP) and 0.46 ± 0.13 (HIMP) at T0 and 0.55 ± 0.20 (SHIMP) and 0.64 ± 0.19 (HIMP) at T1 for the lesional side. For the HIMP, the gain value <0.76 identified the affected side of VN with 100% sensitivity (92−100) and 100% specificity (91−100). For the SHIMP, the gain value <0.66 identified the affected side of VN with 100% sensitivity (92−100) and 100% specificity (91−100) and an AUC of 1.0 (0.96−1.0, p < 0.0001). Conclusion: The SHIMP paradigm has a diagnostic accuracy equal to the classic HIMP paradigm in patients with VN. The assessment of VOR slow phase velocity and vestibulo-saccadic interaction in patients with VN could be easier with the use of the SHIMPs paradigm. SHIMPs paradigm provides helpful information about the evaluation of VOR slow phase velocity and vestibulo-saccadic interaction as new recovery strategies in patients with VN.

The Clinical Use of the Suppression Head Impulse Paradigm in Patients with Vestibulopathy: A Systematic Review

Background: This review aims to explore the potential clinical application of the suppression head impulse paradigm (SHIMP) in patients with unilateral and bilateral vestibulopathy. Methods: An electronic search was conducted by two independent reviewers in the following databases: Embase, MEDLINE (PubMed), and Scopus. The screening of titles, abstracts, and full texts and data extraction were undertaken independently by pairs of reviewers. The included studies were quality appraised using a modified version of the Newcastle–Ottawa Scale. Results: The results were reported following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Our search yielded 935 unique records, of which 16 remained after screening titles and abstracts. A total of 11 studies were included, covering a total of 418 participants (230 patients and 188 healthy participants). Conclusion: SHIMP could be a useful tool to diagnose a VOR alteration in patients with vestibulopathy in both the acute and chronic phases of vestibulopathy.

Video Head Impulse Test (vHIT): Value of Gain and Refixation Saccades in Unilateral Vestibular Neuritis

The aim of this study was to evaluate gain and refixation saccades (covert and overt) using a video head impulse test (vHIT) in the horizontal and vertical planes in patients after the onset of unilateral acute vestibular neuritis (AVN). Thirty-five patients were examined in the acute stage of AVN and at follow-up (range, 6–30 months); a control group of 32 healthy subjects also participated. At onset, the mean gain was significantly lower on the affected side in all of the semi-circular canal planes, mainly in the horizontal canal plane, and saccades (covert and overt) were more prevalent in the horizontal compared to the vertical canal planes. Multi-canal affection occurred more frequently (80% for gain, 71% for saccades) than isolated canal affection. At follow-up, which ranged from 6 to 30 months, the gain was recovered in all of the canals (anterior in 50%, horizontal in 42.8%, and posterior canal in 41.1% of cases), while covert and overt saccades were reduced in the horizontal and vertical planes. However, covert saccades were still recorded in a greater proportion (69%) than overt saccades (57%) in the horizontal plane and at a lower rate in the vertical planes. The compensatory mechanisms after AVN mainly involve the horizontal canal, as the refixation saccades—especially covert ones—were more frequently recorded in the horizontal than vertical canals.

Association Analysis of HIMP and SHIMP Quantitative Parameters in Patients With Vestibular Neuritis and Healthy Participants

Background: The Head Impulse Paradigm (HIMP) and Suppression Head Impulse Paradigm (SHIMP) are objective, quantitative methods that directly test the vestibulo-ocular reflex (VOR) and are increasingly becoming a standard in evaluating patients with vestibular disorders. Objective: The main objective was to assess the correlations between HIMP and SHIMP parameters in patients with superior vestibular neuritis (VN) and healthy participants. Additionally, the correlations between the parameters of each method were analyzed. Methods: A retrospective cohort, non-randomized study was designed. HIMP and SHIMP were performed on 40 patients with VN and 20 healthy participants (40 ears). HIMP and SHIMP parameters were measured and calculated. Pearson's or Spearson's correlations were used to establish the associations among them. Results: A strong positive correlation was found between HIMP and SHIMP gain (Pearson's r = 0.957, p = 0.000), while strong negative correlations were detected between HIMP and SHIMP saccade amplitudes (r = -0.637, p = 0.000) and percentages of overt saccades (r = -0.631, p = 0.000). In HIMP, strong and moderate positive correlations were identified between gain and saccade amplitude (R ² = 0.726, p = 0.000) and gain and saccade percentage (R ² = 0.558, p = 0.000), respectively. By contrast, an extremely weak positive correlation was observed between gain and latency (R ² = 0.053, p = 0.040). In SHIMP, strong and moderate positive correlations were found between gain and saccade percentage (R ² = 0.723, p = 0.000) and gain and saccade amplitude (R ² = 0.525, p = 0.000), respectively, but no correlation was detected between gain and latency (R ² = 0.006, p = 0.490). Conclusions: HIMP and SHIMP-related parameters were highly correlated (inter-method). Within each method (intra-method), moderate to strong correlations in VOR assessment were observed. These results further contribute to our understanding of the relationship between HIMP and SHIMP as well as to the diagnosis.