Increased risk of ischemic stroke in patients with benign paroxysmal positional vertigo: a 9-year follow-up nationwide population study in taiwan

A Rare Presentation of Multicanal Benign Paroxysmal Positional Vertigo in a Premenopausal Woman With Osteopenia: A Case Report

We report a case of non-traumatic, multicanal benign paroxysmal positional vertigo (BPPV) in a premenopausal, osteopenic 35-year-old female with corresponding low bone mineral density. Dix-Hallpike and supine roll tests confirmed unilateral posterior canal (PC) BPPV from 2012-2014, and later, a rare presentation of multicanal BPPV with specifically ipsilateral horizontal canals (HC) and anterior canals (AC) affected in 2015. Heel scans displayed T-scores within the osteopenia range in 2012 until levels normalized one year later. Despite treatment with indicated canalith repositioning treatments (CRTs), symptoms continued to persist. Complete resolution of symptoms occurred in 2016, which is most likely due to self-treatment with daily 5000 IU vitamin D in 2015. This case emphasizes the rare presentation of unilateral single-canal BPPV to multi-canal BPPV, along with the importance of vitamin D treatment in preventing the recurrence of symptoms.

Global research trends in benign paroxysmal positional vertigo: a bibliometric analysis

Background

Benign paroxysmal positional vertigo is the most common disease in which vertigo is the main clinical manifestation, and it has become a global medical problem, affecting a wide range of areas and seriously affecting the quality of human life.

Objective

This article presents an analysis of the current characteristics of BPPV-related research and summarizes the current hot topics and trends, with the goal of inspiring future research into the prevention and treatment of BPPV, thereby improving the differential diagnosis and prevention of peripheral vertigo.

Methods

A bibliometric approach was used to collect 1,219 eligible studies on BPPV from four databases-PubMed, Embase, Scopus, and Web of Science-published between 1974 and 2022. The characteristics and status of the accumulated scientific output were processed using R and VOSviewer so that we could visualize any trends or hotspots.

Results

The results showed a significant increase in the annual number of publications, with an average annual growth rate of 21.58%. A possible reason for the especially pronounced peak in 2021 was an increase in the prevalence of BPPV as a result of COVID-19. The new coronavirus became a focus of research in 2021. A total of 3,876 authors (of whom 1,097 were first authors) published articles in 307 different journals; 15.7% of the articles were published in Acta Oto-Larygologica, Otology and Neurotology, and Frontiers in Neurology. Acta Oto-Laryngologica was well ahead of the other journals in terms of growth rate and number of articles published. American scholars generated the largest number of articles overall, and the USA was involved in the greatest number of international collaborations, followed by Italy and China. The themes of the research centered around three topics, namely the treatment of BPPV, its influencing factors, and diagnosis.

Conclusions

There has been a major increase in BPPV-related research over the last 50 years, leading to an increase in related articles and rapid development of the field. Key directions for future research include the improvement of individualized treatment for residual symptoms after initial treatment of BPPV among the elderly; effective control of comorbidities such as osteoporosis; and secondary inner ear disease, such as Ménière's disease.

Recurring benign paroxysmal positional vertigo after successful canalith repositioning manoeuvers

Benign baroxysmal positional vertigo (BPPV) represents the most common peripheral vestibular dysfunction encountered in clinical practice. Although canalith repositioning procedures (CRPs) are a relatively successful treatment for BPPV, many patients suffer from recurrences. Several studies have demonstrated that various pathological conditions (diabetes, hypertension, endolymphatic hydrops, low vitamin D levels) as well as delayed BPPV treatment using CRP, multiple canal involvement may be associated with recurrence of BPPV. We evaluated the history of 1,428 patients (558 males and 870 females, age range 10-92 years) suffering from BPPV. Of 1,428 cases, 820 (77%) did not relapse in the following 20 years. Mean age and gender did not differ significantly between groups with and without recurrence. Regarding risk factors for BPPV recurrence, age, female gender, migraine, hypertension, diabetes mellitus, hyperlipidaemia, osteoporosis, vascular diseases, and vitamin D deficiency may be associated with recurrent BPPV and should be kept in mind. Osteoporosis, vitamin D deficiency as well as thyroid dysfunction should be evaluated in postmenopausal women. Treatment of these comorbidities may help to reduce the risk of BPPV recurrence.

Examining Migraine as a Predictor of Benign Paroxysmal Positional Vertigo Onset, Severity, Recurrence, and Associated Falls

Introduction: The comorbidity of migraine and benign paroxysmal positional vertigo (BPPV) is well-established, yet the impact of migraine on the BPPV phenotype remains understudied.

Methods: A retrospective analysis of patients at a tertiary dizziness/vertigo clinic diagnosed with BPPV from 2015 and 2020 was conducted. The study's primary outcomes were the age of BPPV onset, Dizziness Handicap Index (DHI), BPPV recurrence, and dizziness-related falls.

Results: In our cohort of 255 BPPV patients, 44.7% had a history of migraine. Those with migraine had an earlier age of BPPV onset than individuals without migraine (60.2 vs. 65.4, p = 0.0018). Migraineurs and non-migraineurs did not differ in their DHI (44.7 vs. 41.6, p= 0.44), recurrence rates (48.3% vs. 40.4%, p= 0.21), and falls (32.5% vs. 37.6%, p = 0.39). Among individuals with horizontal canal BPPV, a higher proportion of migraineurs experienced falls than non-migraineurs (50.0% vs. 6.3%, p = 0.02).

Conclusions: Migraineurs experience BPPV at a younger age than those without migraine. This finding suggests that migraine, which has been shown to cause inner ear damage, predisposes individuals to developing BPPV earlier. Migraine was also associated with a higher rate of falls among patients with horizontal canal BPPV, indicating that a migraine history may impact the phenotype of BPPV.

The influence of cerebral small vessel diseases on the efficacy of repositioning therapy and prognosis of benign paroxysmal positional vertigo

Background: Although vascular risk factors have been found to be closely related to the development of benign paroxysmal positional vertigo (BPPV), the relationship between BPPV and cerebral small vessels diseases (CSVDs) has rarely been discussed in literature. This study set out to investigate the efficacy of repositioning therapy and prognosis among BPPV patients with CSVDs. Methods: We enrolled 553 BPPV patients who had undergone brain MRI, and categorized them into two groups based on the presence or absence of CSVDs. After controlling for other confounders using a propensity score matching (PSM) approach, we compared the incidence of recurrence and residual dizziness (RD). Then, we analyzed the recurrence rate and RD incidence in 176 BPPV patients with CSVDs, and assessed potential risk factors. Results: White matter hyperintensity (WMH, 72.2%) and lacunar infarction (LI, 65.9%) were the two CSVDs that were present in the highest proportion among the BPPV patients. The incidence of RD in patients with CSVDs was significantly higher compared to subjects without CSVDs. Patients with RD (n=100, 56.8%) were older, had more severe WMH, and had a higher incidence of brain atrophy; age and higher Fazekas score were independent risk factors. Among the recurrent patients (n=61, 34.7%), the ages were older, the Fazekas score of WMH was higher, and number of LIs was increased; age was the sole independent risk factor. Conclusion: BPPV patients with a combination of CSVD comorbidities, especially elderly patients with WMHs, are more likely to develop RD, which needs to be paid more attention.

Nystagmus Parameters of Supine Roll Test Correlates With Prognosis After Repositioning Maneuver in Horizontal Semicircular Canal Benign Paroxysmal Positional Vertigo

Background: Positional nystagmus induced by supine roll test is characteristic for diagnosing horizontal semicircular canal benign paroxysmal positional vertigo (HC-BPPV). In this study, we aimed to explore the value of nystagmus parameters in by supine roll test (SRT) as prognostic factors in HC-BPPV.

Methods: We retrospectively analyzed the nystagmus parameters of 813 patients diagnosed with HC-BPPV by the SRT model in the SRM-IV system through video nystagmography. Then we used the computer-controlled canalith repositioning procedure (CCRP) mode for treatment. Based on the outcomes, patients were divided into either the cured group or the resistant group. The 1:1 propensity score matching (PSM) was applied to minimize potential selection bias. Then univariable and multivariable analyses were performed to identify the association of nystagmus parameters and the efficacy of CCRP.

Results: Among the 813 patients, 99 (12.2%) were classified in the resistant group. The right side of HC-BPPV patients was twice the number of the left side patients (537 vs. 276). PSM is used to pair resistant patients to the cured patients, in which 99 pairs were successfully matched. Results of univariate and multivariate analyses showed that patients in the resistant group have longer latency in the affected side [odds ratio (OR) = 1.231 (1.110–1.366); P < 0.001] and slower slow phase velocity (SPV) in the healthy side [OR = 0.957 (0.917–0.999); P = 0.045].

Conclusion: Nystagmus parameters may represent the characteristics of canalith. HC-BPPV patients with a longer latency in the affected side and slower SPV on the healthy side during SRT have a higher risk of HC-BPPV persisting after a single CCRP.

Increased Risk of Neurodegenerative Dementia after Benign Paroxysmal Positional Vertigo

The aim of the present study was to estimate the risk of dementia in patients with benign paroxysmal positional vertigo (BPPV), using a population cohort. Data from the Korean National Health Insurance Service-National Sample Cohort for the population ≥60 years of age from 2002 to 2013 were collected. A total of 11,432 individuals with dementia were matched for age, sex, income, region of residence, hypertension, diabetes, and dyslipidemia with 45,728 individuals comprising the control group. The crude (simple) and adjusted odds ratios (ORs) of dementia in BPPV patients were analyzed using non-conditional logistic regression analyses. Subgroup analyses were conducted according to age and sex. A history of BPPV characterized 5.3% (609/11,432) of the dementia group and 2.6% (1,194/45,728) of the control group (p < 0.001). The adjusted OR of dementia for BPPV was 1.14 (95% CI = 1.03–1.26, p = 0.009). In subgroup analyses according to age and sex, males had higher ORs of dementia for BPPV. BPPV increases the risk of dementia in the 60 years of age or older population.

Incidence of peripheral vestibular disorders in individuals with obstructive sleep apnea

BACKGROUND

Obstructive sleep apnea(OSA) could influence peripheral vestibular function adversely via intermittent hypoxia and its consequences.

OBJECTIVE

This study aimed to evaluate the risk of peripheral vestibular disorders in OSA using a nationwide population-based retrospective cohort study.

METHODS

The National Health Insurance Service-National Sample Cohort represents the entire Korean population from 2002 to 2015. OSA was defined as individuals who had used medical services twice or more under a diagnosis of OSA(G47.33 in ICD-10). A comparison cohort consisted of socio-demographically matched non-OSA subjects in a ratio of 1:4. The incidences of benign paroxysmal positional vertigo(BPPV), Meniere's disease, and vestibular neuritis were evaluated in each cohort.

RESULTS

A total of 2,082 individuals with OSA and 8,328 matched non-OSA subjects were identified. The incidence rates(IRs) of peripheral vertigo in OSA and non-OSA were 149.86 and 23.88 per 10,000 persons, respectively (Ratio of IR, IRR = 6.28, 95%CI 4.89 to 8.08). In multivariable analysis, the risk of peripheral vertigo was significantly higher in OSA(adjusted HR = 6.64, 95%CI 5.20 to 8.47), old age(adjusted HR = 1.03, 95%CI 1.02 to 1.04), female sex(adjusted HR = 1.92, 95%CI 1.48 to 2.50), and comorbidities(adjusted HR = 1.09, 95%CI 1.003 to 1.19). The IRRs of each vestibular disorder in the two groups were 7.32(95%CI 4.80 to 11.33) for BPPV, 3.61(95%CI 2.24 to 5.81) for Meniere's disease, and 9.51(95%CI 3.97 to 25.11) for vestibular neuritis.

CONCLUSIONS

Subjects diagnosed with OSA had a higher incidence of peripheral vestibular disorders than those without OSA, according to national administrative claims data. It is recommended to take peripheral vertigo into account when counseling OSA.

Benign Paroxysmal Positional Vertigo and the Increased Risk of Ischemic Stroke: A Nested Case-Control Study Using a National Cohort Sample

A recent population cohort study reported that benign paroxysmal positional vertigo (BPPV) was a risk factor for ischemic stroke. This study investigated the risk of ischemic and hemorrhagic strokes in patients with BPPV. A nested case-control study used the data from the Korean National Health Insurance Service-National Sample Cohort between 2002 and 2013. We used data of patients aged ≥50 years obtained from the Korean National Health Insurance Service-National Sample Cohort between 2002 and 2013. A total of 15,610 patients with ischemic stroke and 4,923 patients with hemorrhagic stroke were matched for age, sex, income, residential location, hypertension, diabetes, and dyslipidemia with 62,440 and 19,692 controls, respectively. History of BPPV was evaluated in the stroke and control groups. Crude and adjusted odds ratios (ORs) for stroke in patients with BPPV were analyzed using stratified logistic regression analysis. Subgroup analyses were performed for age and sex. Notably, 3.7% (572/15,610) of patients with ischemic stroke and 2.7% (1,702/62,440) of the control subjects reported a history of BPPV (P < 0.001). The adjusted OR for BPPV in patients with ischemic stroke was 1.35 (95% confidence interval (CI) 1.22-1.49, P < 0.001). Patients with ischemic stroke showed higher ORs for BPPV in the subgroup of women. Patients with hemorrhagic stroke did not show a high OR for BPPV. Ischemic stroke patients demonstrated the increased OR for BPPV in subjects aged ≥50 years old.

Structural and Functional Changes in the Cerebellum and Brainstem in Patients with Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is one of the most common peripheral vestibular diseases. Since the peripheral vestibular system connects with the cerebellum via the brainstem, repeated episodic vertigo may result in progressive structural and functional changes in the cerebellum and brainstem. In the present work, voxel-based morphometry (VBM) of T1-weighted images and resting-state functional magnetic resonance imaging (fMRI) in 32 patients with BPPV and 32 matched healthy controls were used to assess cerebellar and brainstem anatomical and spontaneous resting-state brain activity alterations associated with BPPV. We used a spatially unbiased infratentorial template toolbox in combination with VBM to analyze cerebellar and brainstem gray matter volume (GMV), fractional amplitude of low-frequency fluctuations (fALFF), and regional homogeneity (ReHo). Patients with BPPV showed decreased GMV in the right cerebellum posterior lobe/cerebellar tonsil extending to the cerebellum anterior lobe and pons relative to healthy controls. BPPV patients also exhibited significantly higher fALFF values in the right pons and left pons and higher ReHo values in the left cerebellum posterior lobe/Crus2 than the controls. Furthermore, the fALFF z-scores in the pons were positively correlated with the duration of vertigo at baseline and dizziness visual analog scale scores 1 week after canalith repositioning procedures (CRPs). BPPV patients exhibited structural and functional changes in the cerebellum and pons, which may reflect the adaptation and plasticity of these anatomical structures after repeated attacks of episodic vertigo. These results indicate that the changes in pons function may be closely related to residual dizziness after CRPs.

Recurring paroxysmal positional vertigo: evaluation of the vascular factor

To evaluate the effective incidence of vascular factor in the recurrence of benign paroxysmal positional vertigo (BPPV), we studied 50 subjects, 32 affected by idiopathic recurrent BPPV (study group) and 18 healthy subjects (control group). All subjects underwent complete otoneurological balance and haemodynamic evaluation by extracranial colour-coded duplex sonography (ECCS) of vertebral arteries (VA) with indication of arterial flow in ml/min, and retinal fluorangiography (FAG). The ECCS of 19 patients (59.3%) within the study group presented a reduction in vertebral arterial flow, exceeding the limits established by normative values (< 100 ml/min). In all cases, the same side was affected by BPPV, emphasised by vertebral hypoperfusion. The remaining 13 patients (40.6%) showed an arterial vertebral flow entirely within the normative values. The FAG excluded qualitative alterations of the cerebral microcirculation. The ECCS demonstrated that 59.3% of the study group showed a significant reduction in vertebral arterial flow ipsilateral to the semicircular canal affected by BPPV. This increased to 68.75% when the flow difference (D) between both the vertebral arteries were considered and reached 71.8% when vascular risk factors were evaluated. We conclude that reduced perfusion of the vestibular structures makes an already critical situation even more difficult, which can eventually develop into labyrinth suffering. The absence of fluorangiographic signs suggests that the labyrinthine neuroepithelium is much more sensitive to hypoperfusion than the retina. We hypothesise that this ischaemic situation could degenerate utricular macula, otolith detachment, leading to the development of recurrent BPPV. This risk situation for the labyrinth can also be revealed by the evaluation of three parameters: presence of vascular risk factors, reduction of vertebral flow < 100 ml/min and the difference in flow between the 2 vertebral arteries > 29 ml/min.

Risk Factors for the Occurrence of Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-Analysis

Background and Purpose: The lifetime prevalence of benign paroxysmal positional vertigo (BPPV) is high, especially in the elderly. Patients with BPPV are more susceptible to ischemic stroke, dementia, and fractures, severely reducing quality of life of patients. Many studies have analyzed risk factors for the occurrence of BPPV. However, the results of these studies are not identical. We performed this meta-analysis to determine potential risk factors associated with the occurrence of BPPV.

Methods: PubMed, EMBASE, and the Cochrane Library (January 2000 through March 2020) were systematically searched for eligible studies analyzing risk factors for the occurrence of BPPV. Reference lists of eligible studies were also reviewed. We selected observational studies in English with a control group and sufficient data. Pooled odds ratios (ORs) or the mean differences (MDs) and 95% confidence intervals (CIs) were calculated to measure the impacts of all potential risk factors. Heterogeneity among studies was evaluated using the Q-test and I² statistics. We used the random-effect model or the fixed-effect model according to the heterogeneity among the included studies.

Results: We eventually included 19 studies published between 2006 and 2019, including 2,618 patients with BPPV and 11,668 participants without BPPV in total. In this meta-analysis, the occurrence of BPPV was significantly associated with female gender (OR = 1.18; 95% CI, 1.05–1.32; P = 0.004), serum vitamin D level (MD = −2.12; 95% CI, −3.85 to −0.38; P = 0.02), osteoporosis (OR = 2.49; 95% CI, 1.39–4.46; P = 0.002), migraine (OR = 4.40; 95% CI, 2.67–7.25; P < 0.00001), head trauma (OR = 3.42; 95% CI, 1.21–9.70; P = 0.02), and total cholesterol level (MD = 0.32; 95% CI, 0.02–0.62; P = 0.03).

Conclusion: Female gender, vitamin D deficiency, osteoporosis, migraine, head trauma, and high TC level were risk factors for the occurrence of BPPV. However, the effects of other risk factors on BPPV occurrence need further investigations.

Demographic data and seasonal variation in peripheral vestibular disorders in ENT practices in Germany

AIM

The aim of this study was to analyze the demographic data pertaining to and seasonal variation in specific vestibular disorders in ear, nose, and throat (ENT) practices in Germany based on data from a representative nationwide practice database.

METHOD

The study sample included patients from 116 ENT practices in Germany who received an initial diagnosis (ICD-10 code) of Meniere's disease (MD, H81.0), benign paroxysmal positioning vertigo (BPPV, H81.1), or vestibular neuronitis (VN, H81.2) between January 2014 and December 2016. Collected parameters included age, sex, and month of diagnosis. Seasonal variation was analyzed for younger vs. older patients (≤50 vs. >50 years of age). Two univariate Poisson regression models were fitted to estimate the association between the month of diagnosis and the number of diagnosed patients per practice.

RESULTS

A total of 20,720 patients were available for analysis. The average case numbers for MD, BPPV, and VN were 0.8 patients, 2.7 patients, and 1.5 patients per practice per month, respectively. The mean ages of female vs. male patients were 55 and 56 years (MD), 59 and 60 years (BPPV), and 58 and 57 years (VN), respectively. The proportions of female patients with these diagnoses were 62%, 70%, and 61%, respectively. All diagnoses were evenly distributed throughout the years in all age groups. No seasonal variation was observed.

CONCLUSIONS

The demographic data of MD and BPPV patients are comparable to those found by previous large-scale epidemiologic studies. However, no seasonal variation was demonstrated for any vestibular disorder in this large sample.

Seasonality and Cardio-Cerebrovascular Risk Factors for Benign Paroxysmal Positional Vertigo

Background: Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo, especially in the elderly. Several studies have revealed a possible seasonality to BPPV. However, whether the seasonality of BPPV also exists in China is unclear. The characteristics of cardio-cerebrovascular risk factors for BPPV in the cold season have not yet been investigated. Objectives: (1) To investigate the seasonality of BPPV; (2) To explore the relationship between cardio-cerebrovascular risk factors and seasonality of BPPV. Methods: A retrospective observational study was performed in Beijing Tiantan Hospital from Jan 2016 to Dec 2018. The study included 1,409 new-onset BPPV patients aged 18-88 years. The demographic data, onset time, and medical history of BPPV were collected. The meteorological data, including temperature, atmospheric pressure, rainfall, and insolation, was obtained from Beijing Meteorological service. The x ² goodness of fit test was used to evaluate whether BPPV patients' numbers were significantly different among different months of the year. The Spearman correlation was used to detect the correlation between numbers of BPPV patients diagnosed monthly with each climatic parameter. The chi-square test for linear-by-linear association were used to investigate the relationship between cardio-cerebrovascular risk factor and seasonality of BPPV. Results: November to next March is the top 5 months with higher BPPV patient numbers (P < 0.001). The numbers of BPPV diagnosed monthly were conversely correlated with temperature and rainfall (r = -0.736, P = 0.010; r = -0.650, P = 0.022, respectively), positively correlated with atmospheric pressure (r = 0.708, P = 0.010), but no significant correlated with insolation. BPPV in the cold season (including January, February, March, November, and December) had a higher proportion, accounting for 54.2% of all BPPV patients. Among BPPV patients with ≥2, 1, and none cardio-cerebrovascular risk factors, the cold season accounted for 57.0, 56.0, 49.8%, respectively. As the number of cardio-cerebrovascular risk factors increased, the proportion of patients in the cold season of BPPV increased (P = 0.025). Conclusions: BPPV patients are seen more in the months with low temperature, low rainfall, and high atmospheric pressure. Compared with the non-cold season, BPPV patients have more risk factors for cardio-cerebrovascular diseases in the cold season.

Stroke and osteoporosis: a Taiwan cohort study

Background

Osteoporosis and stroke are major health problems that have potentially overlapping pathophysiological mechanisms. The aim of this study was to estimate osteoporosis risk in Taiwan patientswho had a stroke.

Method

This study retrieved data contained in the Taiwan National Health Insurance Research Database for a population-based sample of consecutive patients either hospitalised for stroke or treated for stroke on an outpatient basis. A total of 7550 newly diagnosed patientswho had a stroke were enrolled during 1996–2010. Osteoporosis risk in these patients was then compared with a matched group of patients who had not had a stroke randomly selected from the database at a ratio of 1:4 (n=30 200). The relationship between stroke history and osteoporosis risk was estimated with Cox proportional hazard regression models.

Results

During the follow-up period, osteoporosis developed in 1537 patients who had a stroke and in 5830 patients who had not had a stroke. The incidence of osteoporosis for cohorts with and without stroke was 32.97 and 14.28 per 1000 person-years, respectively. After controlling for covariates, the overall risk of osteoporosis was 1.82-fold higher in the stroke group than in the non-stroke group. The relative osteoporosis risk contributed by stroke had apparently greater impact among male gender and younger age groups.

Conclusion

History of stroke is a risk factor for osteoporosis in Taiwan. Much attention to stroke-targeted treatment modalities might minimise adverse outcomes of osteoporosis.

Bone mineral density and serum 25-hydroxyvitamin D in subtypes of idiopathic benign paroxysmal positional vertigo

Although the etiology of benign paroxysmal positional vertigo (BPPV) is idiopathic in most cases, the association of osteoporosis or vitamin D deficiency with BPPV has attracted much interest recently. While it is generally accepted that osteoporosis or vitamin D deficiency is related to the occurrence and/or recurrence of BPPV, the difference in serum vitamin D level and bone mineral density (BMD) among different subtypes of BPPV has not been investigated. We aimed to compare T-score of BMD score and serum 25-hydroxyvitamin D level among idiopathic BPPV patients with a different subtype. This study included 117 consecutive patients with idiopathic BPPV (26 men and 91 women; mean age, 55 ± 11 years; age range, 25 to 78 years) who underwent blood sampling for serum 25-hydroxyvitamin D level measurement and bone mineral densitometry of the anterior-posterior lumbar spine and femur between April 2018 and February 2019. Among 117 patients, 49 were diagnosed with posterior semicircular canal (PSCC) BPPV, 24 were diagnosed with lateral semicircular canal (LSCC) canalolithiasis, and 44 were diagnosed with LSCC cupulolithiasis. The mean T-score of BMD was -1.5 ± 0.9 in PSCC BPPV, -1.5 ± 1.3 in LSCC canalolithiasis, and -1.5 ± 1.1 in LSCC cupulolithiasis, which was not significantly different (p = 0.998, One-way ANOVA test). The mean level of 25-hydroxyvitamin D was 22.5 ± 10.6 ng/ml in PSCC BPPV, 26.8 ± 16.0 ng/ml in LSCC canalolithiasis, and 25.4 ± 9.6 ng/ml in LSCC cupulolithiasis, which was not significantly different (p = 0.262, One-way ANOVA test). The proportion of osteoporosis/osteopenia or vitamin D deficiency/insufficiency did not show significant difference among idiopathic BPPV patients with different subtypes, and findings of this study indicate that either serum level of vitamin D or T-score of BMD is not a distinguishable characteristic among different subtypes of BPPV.

[A role of vascular risk factors in the development of peripheral vestibulopathy]

The development of peripheral vestibular disorders are often thought to be associated with vascular mechanisms, taking into account terminal type of inner ear blood supply and other predisposing factors. A number of studies indicates a high frequency of vascular risk factors in the patients with vestibular neuronitis and benign paroxysmal positional vertigo (BPPV). According to other results, migraine is widely spread among patients with Meniere's disease and BPPV. However currently there is no evidence for casual relationship between vascular factors and development of peripheral vestibulopathy. The only exclusion is labyrinthine infarction, which develops as a result of posterior circulation disorder. More research is needed in this area.

Clinical Characteristics and Risk Factors for the Recurrence of Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) manifests itself as a paroxysm of vertigo and nystagmus lasting several seconds, which is self-limiting. The clinical characteristics and risk factors for the recurrence of BPPV in different ages have not yet been investigated.

Materials and Methods: A retrospective observational study was conducted in the Department of Neurology in Beijing Tiantan Hospital from July 2009 to June 2015. The study included 1,012 patients aged 18–93 years. All patients received the definitive diagnosis and canalith repositioning maneuvers treatment and finally accomplished follow-up. Demographic variables, potential recurrence risk factors, neurological examination, and laboratory indexes were assessed.

Data Analyses: The t-test or chi-squared test was first performed for group comparison, then logistic regression analysis was used to investigate the risk factors of BPPV recurrence.

Results: The 1-year recurrence rates of BPPV patients after reposition maneuvers were, respectively, 22.79% (aged 18–45 years), 23.92% (aged 45–60 years), 28.89% (over 60 years). The recurrence rates among the three groups have no statistically significant difference. Logistic regression analysis shows that women BPPV patients have more recurrence risks than do men. Ménière's disease (odds ratio = 6.009, 95% confidence interval: 2.489–14.507, p < 0.001), hypertension (odds ratio = 1.510, 95% confidence interval: 1.095–2.084, p = 0.012), migraine (odds ratio = 2.534, 95% confidence interval: 1.164–5.516, p = 0.019), and hyperlipemia (odds ratio = 1.419, 95% confidence interval: 1.024–1.968, p = 0.036) were risk factors for the recurrence of BPPV in patients.

Conclusion: We conclude that Ménière's disease, hypertension, migraine, and hyperlipemia may be independent risk factors for the recurrence of BPPV in patients, but aging does not increase the recurrence risk.

Evaluation of BPPV with vertebral artery values

OBJECTIVES

The aim of this study was to investigate the association between benign paroxysmal positional vertigo (BPPV) and vertebral artery (VA) flow rates and diameters by using Doppler ultrasonography in patients with BPPV. Additionally, we aimed to investigate the abnormalities of VA values obtained by extracranial color-coded duplex sonography in BPPV, which could be accepted as a precursor lesion for posterior cerebral ischemic stroke.

MATERIALS AND METHODS

Between September 2017 to February 2018, 50 patients diagnosed with BPPV were enrolled in this study. Otorhinolaryngology medical examination and medical history assessment were performed at the otorhinolaryngology clinic. Afterward, neurologic examination and ultrasonography of VAs was undertaken in the neurology clinic of University of Gaziantep Medical Faculty.

RESULTS

The types of BPPV found were as follows: right posterior in 27 (54%), right lateral in 4 (8%), left posterior in 16 (32%), and left lateral in 3 (6%), respectively. The most common variables found in the BPPV were smoking (26%), hypertension (26%), and hyperlipidemia (22%).

CONCLUSION

VA flow rates and diameters were found to be affected at the site of BPPV. These findings might suggest that BPPV could be related to an atherosclerotic milieu and may be a precursor clinical condition for future intracranial atherosclerotic diseases.

Efficacy of Repositioning Therapy in Patients With Benign Paroxysmal Positional Vertigo and Preexisting Central Neurologic Disorders

With the exception of migraines, benign paroxysmal positional vertigo (BPPV) in patients with preexisting central neurologic disorders (CND) is rarely discussed in the literature. Demographic features of this patient group and the efficacy of repositioning therapy are still unknown. We hypothesized that a CND may alter the function of the central vestibular pathway, thus changing the pattern of BPPV and outcomes of repositioning. In this study, we enrolled 93 consecutive idiopathic BPPV patients and categorized them into two groups according to the presence or absence of a CND. In our series, 31.2% of BPPV cases had a CND. The most common associated CNDs were cerebrovascular disease and migraines. The two groups showed similar age distributions, canal involvement, success rates of repositioning, and cycles of treatment used to achieve complete resolution. The major differences were the proportion of females (89.7%) and a right-side predominance (75.9%) in the CND group. There was a trend of more residual dizziness (RD) after successful repositioning in the CND group, but the difference was not significant. The reason for the female and right-side predominance in the CND group is unclear. We concluded that the efficacy of repositioning therapy was excellent (with a success rate of 80.6% with one cycle and 93.5% within two cycles of treatment) for BPPV with or without a preexisting CND. Clinicians are encouraged to diagnose and treat BPPV in patients with a preexisting CND as early as possible to improve patients' quality of life, avoid complications, and reduce medical costs.

Italian survey on benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common type of peripheral vertigo. BPPV often relapses after the first episode, with a recurrence rate between 15% and 50%. To date both the aetiopathogenetic processes that lead to otoconia detachment and the factors that make BPPV a relapsing disease are still unclear, but recent epidemiological studies have shown a possible association with cardiovascular risk factors. The aim of the present study (Sesto Senso Survey) was to evaluate in the Italian population through an observational survey, the main demographic and clinical characteristics of patients with BPPV (first episode or recurrent) with particular focus on the potential cardiovascular risk factors. The survey was conducted in 158 vestibology centres across Italy on 2,682 patients (mean age 59.3 ± 15.0 years; 39.1% males and 60.9% females) suffering from BPPV, from January 2013 to December 2014. The results showed a high prevalence of cardiovascular risk factors such as high blood pressure (55.8%), hypercholesterolaemia (38.6%) and diabetes (17.7%), as well as a family history of cardiovascular disease (49.4%). A high percentage of patients also had hearing loss (42.9%), tinnitus (41.2%), or both (26.8%). The presence of hypertension, dyslipidaemia and pre-existing cardiovascular comorbidities were significantly related to recurrent BPPV episodes (OR range between 1.84 and 2.31). In addition, the association with diabetes and thyroid/autoimmune disease (OR range between 1.73 and 1.89) was relevant. The survey results confirm the significant association between cardiovascular comorbidities and recurrent BPPV and identify them as a potential important risk factor for recurrence of BPPV in the Italian population, paving the way for the evaluation of new therapeutic strategies in the treatment of this disease.

Age-Related Increases in Benign Paroxysmal Positional Vertigo Are Reversed in Women Taking Estrogen Replacement Therapy: A Population-Based Study in Taiwan

Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vertigo. Numerous investigations have reported an increased BPPV incidence in females and in the aged population. The hormonal characteristics of BPPV patients have not been previously investigated. This study aimed to determine the risk of BPPV in relation to menopause in a population-based study.

Materials and Methods: This retrospective population-based study was designed to use a nationwide longitudinal health insurance database to follow and analyze the incidence of and protective factors against BPPV in a Taiwanese population.

Data Analyses: Univariate and multivariate analyses were performed to calculate the adjusted hazard ratio (aHR) for the incidence of BPPV using Cox-proportional regression models.

Results: In the multivariate analyses, we found that older people (older than 65 years old) were more prone to develop BPPV (aHR: 5.37, 95% CI: 0 4.83–5.97, p < 0.001). The risk of BPPV was analyzed in two specific age subgroups of elderly females. Results revealed that in both age groups (45–65 years old and >65 years old), patients who took estrogen for menopausal syndromes had a significantly lower incidence of BPPV (aHR; 0.01, 95% CI: 0.06–0.23, p < 0.001).

Conclusion: Our study provides a novel etiology and possible treatment method for the prevention of BPPV. Further studies may focus on the pathophysiological mechanism of estrogen in BPPV patients and the development of new drugs for the prevention and treatment of BPPV.

Our experience with 500 patients with benign paroxysmal positional vertigo: Reexploring aetiology and reevaluating MRI investigation

OBJECTIVE

To explore the aetiology of and to evaluate the importance of MRI investigation on the posterior semicircular canal benign paroxysmal positional vertigo in an Irish population.

METHODS

A retrospective observational study of 500 patients with posterior semicircular canal benign paroxysmal positional vertigo, diagnosed and treated by the senior author over a 10-year period. Most patients underwent an MRI brain and inner ear, following the same scan protocol. This included T1 weighted sagittal IR-FSPGR volume, axial T2 weighted, gradient echo T2 weighted and FLAIR sequences plus time of flight cerebral angiography.

RESULTS

The average age of presentation was 56 years; with the overall female to male ratio was 1.6:1, which was largely the net results of 2 age groups. Over 30% of our patients recalled distinct aetiological triggers, of which the top 3 were trauma, infection, and surgery. These accounted for 16%, 6%, and 5%, respectively. More than 25% of the patients were discovered to have abnormal intracranial findings on MRI. The 2 most common non-infarct incidental findings were neoplasia and vascular abnormalities. Although fewer than 20 patients had acute intracranial haemorrhage or malignant tumours, most of them were urgently referred to neurosurgeon due to the life-threatening nature of the condition. One round of particle repositioning manoeuver was successful in treating 84% of the patients, and the 2-year recurrence rate was only 2.2%.

CONCLUSION

The diagnosis of posterior semicircular canal benign paroxysmal positional vertigo is thought to be relatively easy to make, and the treatment is highly effective. Clinicians should be fully aware of and prepared for the diverse aetiology, and thus have no hesitation in requesting MRI scan as an important investigation.

Association of dementia in patients with benign paroxysmal positional vertigo

OBJECTIVE

We conducted a cohort study to investigate whether benign paroxysmal positional vertigo (BPPV) is correlated with an increased risk of dementia.

METHODS

We established a case cohort comprising 7818 patients aged over 20 years who were diagnosed with BPPV from 2000 to 2010. In addition, we formed a control cohort by randomly selecting 31,272 people without BPPV and matched them with the BPPV patients according to gender, age, and index year. Cox proportional hazard regressions were performed to compute the hazard ratio (HR) of dementia after we adjusted for demographic characteristics and comorbidity.

RESULTS

The prevalence of comorbidity was higher among patients with BPPV than among those without BPPV. In addition, patients with BPPV exhibited a 1.24-fold (95% confidence interval, CI 1.09-1.40; P < 0.001) higher risk of dementia than those without BPPV after we adjusted for age, gender, and comorbidity. An analysis stratified according to demographic factors revealed that women with BPPV exhibited a 1.36-fold (95% CI 1.16-1.59; P < 0.001) higher risk of dementia. Patients with BPPV aged over 65 years exhibited a significantly higher risk of dementia (adjusted HR: 1.26; 95% CI 1.10-1.43; P < 0.001) than those without BPPV.

CONCLUSIONS

Patients with BPPV exhibited a higher risk of dementia than those without BPPV.

Retrospective data suggests that the higher prevalence of benign paroxysmal positional vertigo in individuals with type 2 diabetes is mediated by hypertension

OBJECTIVE

Benign Paroxysmal Positional Vertigo (BPPV) has been linked to comorbidities like diabetes and hypertension. However, the relationship between type 2 diabetes (DM) and BPPV is unclear. The purpose of this retrospective study was to examine the relationship between DM and BPPV in the presence of known contributors like age, gender and hypertension.

METHODS

A retrospective review of the records of 3933 individuals was categorized by the specific vestibular diagnosis and for the presence of type 2 DM and hypertension. As the prevalence of BPPV was higher in people with type 2 DM compared to those without DM, multivariable logistic regressions were used to identify variables predictive of BPPV. The relationship between type 2 DM, hypertension and BPPV was analyzed using mediation analysis.

RESULTS

BPPV was seen in 46% of individuals with type 2 DM, compared to 37% of individuals without DM (p< 0.001). Forty two percent of the association between type 2 DM and BPPV was mediated by hypertension, and supported hypertension as a complete mediator in the relationship between type 2 DM and BPPV.

CONCLUSIONS

Hypertension may provide the mediating pathway by which diabetes affects the vestibular system. Individuals with complaints of dizziness, with comorbidities including hypertension and diabetes, may benefit from a screening for BPPV.

"Positive to Negative" Dix-Hallpike test and Benign Paroxysmal Positional Vertigo recurrence in elderly undergoing Canalith Repositioning Maneuver and Vestibular Rehabilitation

Introduction Benign Paroxysmal Positional Vertigo is the most common cause of dizziness in elderly people. Recent studies have shown that the elderly present higher Benign Paroxysmal Positional Vertigo recurrence and that vertiginous symptomatology remission varies according to comorbidities and the therapeutic techniques applied.

Objective To assess the short-term effectiveness of Vestibular Rehabilitation in addition to Canalith Repositioning Maneuver on positive to negative Dix-Hallpike test, on recurrence and number of maneuvers to achieve a negative test in elderly patients with chronic Benign Paroxysmal Positional Vertigo.

Methods In this randomized controlled trial, 7 older adults (median age: 69 years, range 65–78) underwent Canalith Repositioning Maneuver and Vestibular Rehabilitation for thirteen weeks. Seven older adults (median age: 73 years, range 65–76) in the control group received only Canalith Repositioning Maneuver. The participants were assessed at baseline (T0), one (T1), five (T5), nine (T9), and thirteen weeks (T13). We assessed the differences between the groups by Mann-Whitney and Fisher exact tests, and used the Friedman and Wilcoxon tests to determine the intragroup differences.

Results No significant differences were found between groups for the positive to negative Dix-Hallpike test, recurrence, and number of maneuvers to achieve a negative test. The number of maneuvers to achieve negative Dix-Hallpike test was lower in intragroup comparisons in the experimental group.

Conclusion The findings suggest that additional Vestibular Rehabilitation did not influence the positive to negative Dix-Hallpike test, recurrence, or number of maneuvers to achieve a negative test in elderly patients with chronic Benign Paroxysmal Positional Vertigo.