Acute Peripheral Vestibular Disorders Research Articles

A Basilar Artery Dissection Mimicking Acute Labyrinthitis in A 15-Year-Old Girl

Basilar artery dissection (BAD) is a rare cause of vertigo in children. A 15-year-old girl presented with sudden vertigo and unilateral hearing loss. Magnetic resonance imaging revealed posterior circulation infarction caused by BAD. After antiplatelet therapy, intratympanic injections of dexamethasone and vestibular rehabilitation, her symptoms improved. We report this case of BAD, which might be mistaken for acute peripheral vestibular disorders in the early stage.

Anchoring the Self to the Body in Bilateral Vestibular Failure.

Recent findings suggest that vestibular information plays a significant role in anchoring the self to the body. Out-of-body experiences of neurological origin are frequently associated with vestibular sensations, and galvanic vestibular stimulation in healthy participants anchors the self to the body. Here, we provide the first objective measures of anchoring the self to the body in chronic bilateral vestibular failure (BVF). We compared 23 patients with idiopathic BVF to 23 healthy participants in a series of experiments addressing several aspects of visuo-spatial perspective taking and embodiment. In Experiment 1, participants were involved in a virtual “dot-counting task” from their own perspective or the perspective of a distant avatar, to measure implicit and explicit perspective taking, respectively. In both groups, response times increased similarly when the avatar’s and participant’s viewpoint differed, for both implicit and explicit perspective taking. In Experiment 2, participants named ambiguous letters (such as “b” or “q”) traced on their forehead that could be perceived from an internal or external perspective. The frequency of perceiving ambiguous letters from an internal perspective was similar in both groups. In Experiment 3, participants completed a questionnaire measuring the experienced self/body and self/environment “closeness”. Both groups reported a similar embodied experience. Altogether, our data show that idiopathic BVF does not change implicit and explicit perspective taking nor subjective anchoring of the self to the body. Our negative findings offer insight into the multisensory mechanisms of embodiment. Only acute peripheral vestibular disorders and neurological disorders in vestibular brain areas (characterized by strong multisensory conflicts) may evoke disembodied experiences.

Integrated approach to the treatment of patients with chronic peripheral vestibular hypofunction

Chronic vertigo is often a consequence of acute peripheral vestibular disorder. The syndrome is caused by the failure of the central nervous system to adequately adapt to the loss of vestibular function in one of the labyrinths. Special exercises (vestibular rehabilitation therapy) are required for the development of adequate central compensation. The treatment requires an individual approach, initial assessment of physical fitness, comorbidities, especially pathology of the eye, musculoskeletal system, cognitive function, which determine the duration of treatment and adequacy of vestibular compensation. Timely and reasonable selection of a vestibular rehabilitation programme, sometimes in combination with medications that stimulate the central compensation processes, could help to achieve restoration of balance and stabilization of the changing visual acuity.

Dorsal Medullary Infarction: Distinct Syndrome of Isolated Central Vestibulopathy.

The characteristics of infarctions restricted to the dorsal medulla have received little attention. This study aimed to define the distinct clinical features of dorsal medullary infarction. Of the 172 patients with a diagnosis of medullary infarction at Seoul National University Bundang Hospital from 2003 to 2014, 18 patients with isolated dorsal medullary infarction were subjected to analyses of clinical and laboratory findings. All patients presented acute isolated vestibular syndrome with dizziness/vertigo and imbalance. Almost all patients (17/18, 94%) showed the signs from involvements of the vestibular nuclei, nucleus prepositus hypoglossi, or inferior cerebellar peduncle, which included direction-changing gaze-evoked nystagmus (n=12), negative head-impulse tests (n=8), skew deviation (n=7), central patterns of head-shaking nystagmus (n=6), and spontaneous nystagmus (n=2). Initial magnetic resonance imagings including diffusion-weighted images were negative in 7 patients (39%). Twelve patients (67%) showed a progression and developed additional neurological abnormalities, but the neurological outcomes were favorable. The presence of central vestibular signs allows bedside differentiation of isolated vestibular syndrome because of dorsal medullary infarction from acute peripheral vestibular disorders. Because initially false-negative magnetic resonance imagings and subsequent progression are frequent in dorsal medullary infarction, early recognition through scrutinized evaluation is important for proper managements.

The Usefulness of the TOAST Classification and Prognostic Significance of Pyramidal Symptoms During the Acute Phase of Cerebellar Ischemic Stroke.

Cerebellar stroke is a rare condition with very nonspecific clinical features. The symptoms in the acute phase could imitate acute peripheral vestibular disorders or a brainstem lesion. The aim of this study was to assess the usefulness of the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification in cerebellar stroke and the impact of clinical features on the prognosis. We retrospectively analyzed 107 patients with diagnosed ischemic cerebellar infarction. We studied the clinical features and compared them based on the location of the ischemic lesion and its distribution in the posterior interior cerebellar artery (PICA), superior cerebellar artery (SCA), and anterior inferior cerebellar artery (AICA) territories. According to the TOAST classification, stroke was more prevalent in atrial fibrillation (26/107) and when the lesion was in the PICA territory (39/107). Pyramidal signs occurred in 29/107 of patients and were more prevalent when the lesion was distributed in more than two vascular regions (p = 0.00640). Mortality was higher among patients with ischemic lesion caused by cardiac sources (p = 0.00094) and with pyramidal signs (p = 0.00640). The TOAST classification is less useful in assessing supratentorial ischemic infarcts. Cardioembolic etiology, location of the ischemic lesion, and pyramidal signs support a negative prognosis.

Isolated Vascular Vertigo

Strokes in the distribution of the posterior circulation may present with vertigo, imbalance, and nystagmus. Although the vertigo due to a posterior circulation stroke is usually associated with other neurologic symptoms or signs, small infarcts involving the cerebellum or brainstem can develop vertigo without other localizing symptoms. Approximately 11% of the patients with an isolated cerebellar infarction present with isolated vertigo, nystagmus, and postural unsteadiness mimicking acute peripheral vestibular disorders. The head impulse test can differentiate acute isolated vertigo associated with cerebellar strokes (particularly within the territory of the posterior inferior cerebellar artery) from more benign disorders involving the inner ear. Acute audiovestibular loss may herald impending infarction in the territory of anterior inferior cerebellar artery. Appropriate bedside evaluation is superior to MRIs for detecting central vascular vertigo syndromes. This article reviews the keys to diagnosis of acute isolated vertigo syndrome due to posterior circulation strokes involving the brainstem and cerebellum.

Two Cases of Cerebellar Infarction Masquerading as an Acute Peripheral Vestibular Disorder

Two Cases of Cerebellar Infarction Masquerading as an Acute Peripheral Vestibular Disorder

Correlation between canal paresis and spontaneous nystagmus during early stage of acute peripheral vestibular disorders

Conclusions: This study demonstrates that the resolution period of spontaneous nystagmus (SN) may provide an indication of vestibular dysfunction on a particular day in the primary care setting. Objective: We aimed to predict canal paresis using fundamental observations of SN during the early stage of acute peripheral vestibular disorders. Methods: The study involved 87 patients who had recently experienced their first episode of acute spontaneous vertigo and direction-fixed horizontal nystagmus. Although they did not exhibit any other neurological deficits, they had been hospitalized with severe acute symptoms between 2004 and 2007. A correlation between the resolution period of SN and the results of laboratory caloric testing was reviewed. Results: The receiver operating characteristic analysis showed that the resolution period of SN may be a predictive indicator of unilateral vestibular hypofunction in the acute stage. In about half of the patients, SN disappeared on the third day after their initial visit. However, in 20% of the patients SN still persisted on the eighth day. Among the patients with SN, the prevalence of canal paresis increased with the increase in the resolution period of SN. When SN was observed on the fifth day, the prevalence was approximately 70%.

注視眼振検査を指標とした末梢前庭障害の病状経過把握と急性期治療の検討

Vertigo attacks with severe nausea and vomiting are frequently seen in emergency medical care. The present study was conducted to investigate whether bedside nystagmus observation might provide useful information for prediction of the clinical course during acute hospitalization and for determination of steroid administration in patients with peripheral vestibular disorders. We reviewed the electronystagmography (ENG) records of 38 patients with peripheral vestibular disorder who were hospitalized because of rotary vertigo, severe nausea, and/or vomiting. The patients were diagnosed as having acute peripheral vestibular disorder between January 2004 and February 2006 at the university hospital or its affiliates. Correlations between the withdrawal period duration of spontaneous nystagmus and the results of subsequent laboratory caloric testing by computerized ENG were examined. The 38 patients were divided into the short-decaying and long-lasting groups on the basis of the nystagmus duration. Half of the patients had the short-decaying type of nystagmus; their unidirectional spontaneous nystagmus disappeared within a few days. This group showed a female preponderance (male 2, female 17), recovered quickly from vertigo, and were out of bed within a few days. In contrast, the group with the long-lasting type of nystagmus showed no gender preponderance (male 9, female 10), and also a relatively high incidence of canal paresis on caloric testing (72.2%). Our results suggest that there are at least two types of peripheral vestibular disorders, which we designated as benign paroxysmal spontaneous and vestibular neuritis. We recognized the fact that daily short-time bedside observation of spontaneous nystagmus can provide prognostic information in patients with sudden vertigo at the very first visit. Steroid administration may be recommended when spontaneous nystagmus lasts more than 3 days, because vestibular neuritis would be strongly suspected in such cases.

Predicting Continued Dizziness After an Acute Peripheral Vestibular Disorder

To identify individuals at risk of developing ongoing dizziness 3 months after an acute peripheral vestibular disorder episode, which is usually functionally compensated or even healed within a few weeks. In a prospective longitudinal study, we assessed fear of bodily sensations and cognitions related to anxiety at the time of hospital admission and 3 months later in 43 patients with an episode of vestibular neuritis (VN) or benign paroxysmal positional vertigo (BPPV). All participants were assessed for mental disorders using a structured clinical interview. Only the interaction between fear of bodily sensations within the first 2 weeks after admission and the type of vestibular disorder predicted the extent of dizzy complaints 3 months later; this accounts for 21% of the variance in a multiple regression analysis. Specifically, the prediction was valid only in patients with VN but not in patients with BPPV. Further analysis demonstrated that the interaction was not due to the peripheral vestibular disorder per se but rather determined by the initial severity of dizziness, which was significantly different in BPPV and VN patients. The present study demonstrates that, for the development of persistent psychogenic dizziness after a peripheral vestibular disorder, the fear of bodily sensations is only relevant in interaction with the initial severity of dizziness experienced during the acute organic episode. To prevent development of persistent psychogenic dizziness, we feel that our results indicate the need to screen patients with vestibular disorders for at-risk status and offer them psychological support to deal with their symptoms.

Dissociation between the perception of body verticality and the visual vertical in acute peripheral vestibular disorder in humans

Estimates of the subjective visual and postural vertical were obtained from five patients with acute peripheral vestibular lesions and 20 normal subjects. The visual vertical was assessed by asking the subjects to align a target line to earth vertical by means of remote control. Postural vertical judgments were obtained by exposing them to rotational displacements in the roll plane while sitting on a motor-driven chair and requiring them to align their body to vertical using a joystick control. While the patients showed strong deviations of the visual vertical towards the lesion side, their postural vertical judgments remained veridical. We conclude that the above perceptions are not processed identically and that the participating sensory systems are differently weighted during these tasks.

頭部動揺の角加速度成分に関する研究 遮眼足踏みにおける耳性失調例の検討

Angular acceleration of head movement was measured during stepping in patients with unilateral vestibular disorder (acoustic neurinoma before surgery (pre-AT), 10; acoustic neurinoma after surgery (post-AT), 9; acute peripheral vestibular disorder (APVD), 4).1) In patients with post-AT or APVD, the amplitude of specified angular acceleration toward the affected side was significantly higher than that toward the normal side.2) The amplitude of specified angular acceleration showed a negative correlation with the degree of CP (canal paresis) on the calorigram in patients with pre-AT, but a positive correlation in those with APVD.3) The amplitude of specified angular acceleration showed a negative correlation with the degree of DP (directional preponderance) in Barany's rotation test in all the patients.4) These findings suggest that the function of the semicircular canals and compensation by the vestibular spinal reflex in patients with unilateral vestibular disorder can be detected by measuring the specified angular acceleration during stepping.

Management of acute peripheral vestibular disorders.

The practice of Neurology has always been diverse and challenging. Each day, clinicians face problems, issues, decisions, and conundrums. Texts, lectures, and even practice guidelines often do not provide significant practical help to the clinician. Judgement and experience are often needed. In European Neurology I plan to highlight some of thse common important recurrent practise tissues. I have asked experienced clinicians to share their own individual views and approaches to these issues