Acute Peripheral Vestibulopathy Research Articles

Thyroid Axis and Vestibular Physiopathology: From Animal Model to Pathology.

A recent work of our group has shown the significant effects of thyroxine treatment on the restoration of postural balance function in a rodent model of acute peripheral vestibulopathy. Based on these findings, we attempt to shed light in this review on the interaction between the hypothalamic-pituitary-thyroid axis and the vestibular system in normal and pathological situations. Pubmed database and relevant websites were searched from inception through to 4 February 2023. All studies relevant to each subsection of this review have been included. After describing the role of thyroid hormones in the development of the inner ear, we investigated the possible link between the thyroid axis and the vestibular system in normal and pathological conditions. The mechanisms and cellular sites of action of thyroid hormones on animal models of vestibulopathy are postulated and therapeutic options are proposed. In view of their pleiotropic action, thyroid hormones represent a target of choice to promote vestibular compensation at different levels. However, very few studies have investigated the relationship between thyroid hormones and the vestibular system. It seems then important to more extensively investigate the link between the endocrine system and the vestibule in order to better understand the vestibular physiopathology and to find new therapeutic leads.

The Quix Test: Identifying Vestibular Dysfunction in the “Dizzy Patient” (P7-4.004)

<h3>Objective:</h3> Our objective was to validate the sensitivity and specificity of the Quix test in the identification of peripheral vestibular dysfunction in the “dizzy” patient and compare it to other conventional tests performed in the routine practice of the evaluation of “dizziness.” <h3>Background:</h3> The complaint of dizziness has ominous implications lending itself to accidental death and increased morbidity and mortality. The evaluation of a dizzy patient can be confounding due to its myriad of potential etiologies, many of which are present comorbidly. Acute peripheral vestibulopathy is a common cause of dizziness. Current conventional tests for vestibular dysfunction offer maximum sensitivity ranging from 50–75% (Cohen, 2019). We developed a modified version of the Quix test in an effort to increase sensitivity. <h3>Design/Methods:</h3> 158 patients were evaluated at a balance disorders clinic. Each patient underwent a comprehensive neurological examination and six assessments that detect vestibular dysfunction: a nystagmus test, a head impulse test, a Romberg test, a Quix test, a tandem stance/walk, and a sitting past-pointing test. Posturography, Dix-Hallpike maneuver, and videonystagmography were performed. Results were analyzed to determine the sensitivity of the vestibular tests in detecting dysfunction. <h3>Results:</h3> The association between the Quix test and vestibular dysfunction was assessed with a chi-square test. The model was statistically significant, χ2 = 4.3175 and p = 0.0377 &lt; .05 = α. The sensitivity was 85.7%, and the specificity was 33.3%. Although specificity was low, a number of patients were found to have benign positional vertigo on clinical examination by a balance therapist. Other conventional tests were not statistically significant predictor variables of vestibular abnormality. <h3>Conclusions:</h3> A positive Quix test helps identify vestibular dysfunction in the “dizzy patient.” It is cost-effective, time-efficient, and easily administered with minimal training. The Quix test is more sensitive than other conventional tests and can serve as a critical screening tool. <b>Disclosure:</b> Ms. Schusterman has nothing to disclose. Mr. Kuder has nothing to disclose. Miss Walker has nothing to disclose. Ms. Lee has nothing to disclose. Ms. Canut has nothing to disclose. Mr. Thompson has nothing to disclose. Charles Maitland has nothing to disclose. Dr. Gaillard has nothing to disclose. Dr. Solatikia has nothing to disclose.

Effect of Convergence on the Horizontal Vestibulo-Ocular Reflex in Normal Volunteers, Unilateral Acute and Subacute Peripheral Vestibulopathy and in One Patient with an Unilateral Pontine Tegmentum Lesion (P15-12.001)

Effect of Convergence on the Horizontal Vestibulo-Ocular Reflex in Normal Volunteers, Unilateral Acute and Subacute Peripheral Vestibulopathy and in One Patient with an Unilateral Pontine Tegmentum Lesion (P15-12.001)

L-Thyroxine Improves Vestibular Compensation in a Rat Model of Acute Peripheral Vestibulopathy: Cellular and Behavioral Aspects.

Unilateral vestibular lesions induce a vestibular syndrome, which recovers over time due to vestibular compensation. The therapeutic effect of L-Thyroxine (L-T4) on vestibular compensation was investigated by behavioral testing and immunohistochemical analysis in a rat model of unilateral vestibular neurectomy (UVN). We demonstrated that a short-term L-T4 treatment reduced the vestibular syndrome and significantly promoted vestibular compensation. Thyroid hormone receptors (TRα and TRβ) and type II iodothyronine deiodinase (DIO2) were present in the vestibular nuclei (VN), supporting a local action of L-T4. We confirmed the T4-induced metabolic effects by demonstrating an increase in the number of cytochrome oxidase-labeled neurons in the VN three days after the lesion. L-T4 treatment modulated glial reaction by decreasing both microglia and oligodendrocytes in the deafferented VN three days after UVN and increased cell proliferation. Survival of newly generated cells in the deafferented vestibular nuclei was not affected, but microglial rather than neuronal differentiation was favored by L-T4 treatment.

Sensorimotor Rehabilitation Promotes Vestibular Compensation in a Rodent Model of Acute Peripheral Vestibulopathy by Promoting Microgliogenesis in the Deafferented Vestibular Nuclei.

Acute peripheral vestibulopathy leads to a cascade of symptoms involving balance and gait disorders that are particularly disabling for vestibular patients. Vestibular rehabilitation protocols have proven to be effective in improving vestibular compensation in clinical practice. Yet, the underlying neurobiological correlates remain unknown. The aim of this study was to highlight the behavioural and cellular consequences of a vestibular rehabilitation protocol adapted to a rat model of unilateral vestibular neurectomy. We developed a progressive sensory-motor rehabilitation task, and the behavioural consequences were quantified using a weight-distribution device. This analysis method provides a precise and ecological analysis of posturolocomotor vestibular deficits. At the cellular level, we focused on the analysis of plasticity mechanisms expressed in the vestibular nuclei. The results obtained show that vestibular rehabilitation induces a faster recovery of posturolocomotor deficits during vestibular compensation associated with a decrease in neurogenesis and an increase in microgliogenesis in the deafferented medial vestibular nucleus. This study reveals for the first time a part of the underlying adaptative neuroplasticity mechanisms of vestibular rehabilitation. These original data incite further investigation of the impact of rehabilitation on animal models of vestibulopathy. This new line of research should improve the management of vestibular patients.

SK Channels Modulation Accelerates Equilibrium Recovery in Unilateral Vestibular Neurectomized Rats.

We have previously reported in a feline model of acute peripheral vestibulopathy (APV) that the sudden, unilateral, and irreversible loss of vestibular inputs induces selective overexpression of small conductance calcium-activated potassium (SK) channels in the brain stem vestibular nuclei. Pharmacological blockade of these ion channels by the selective antagonist apamin significantly alleviated the evoked vestibular syndrome and accelerated vestibular compensation. In this follow-up study, we aimed at testing, using a behavioral approach, whether the antivertigo (AV) effect resulting from the antagonization of SK channels was species-dependent or whether it could be reproduced in a rodent APV model, whether other SK channel antagonists reproduced similar functional effects on the vestibular syndrome expression, and whether administration of SK agonist could also alter the vestibular syndrome. We also compared the AV effects of apamin and acetyl-DL-leucine, a reference AV compound used in human clinic. We demonstrate that the AV effect of apamin is also found in a rodent model of APV. Other SK antagonists also produce a trend of AV effect when administrated during the acute phase of the vertigo syndrome. Conversely, the vertigo syndrome is worsened upon administration of SK channel agonist. It is noteworthy that the AV effect of apamin is superior to that of acetyl-DL-leucine. Taken together, these data reinforce SK channels as a pharmacological target for modulating the manifestation of the vertigo syndrome during APV.

Acute Vestibular Syndrome in Cerebellar Infarction: A Case Report

Introduction: Acute vestibular syndrome (AVS) is characterized by rapid onset of vertigo, nausea and vomiting, and gait unsteadiness in association with head motion intolerance and nystagmus, lasting days to weeks. Although the majority of AVS patients have acute peripheral vestibulopathy, some may also have brainstem or cerebellar strokes. Cerebellar infarctions sometimes only cause vertigo. The Head Impulse Test, skew deviation, and nystagmus testing provide for great sensitivity and specificity in distinguishing between peripheral vestibular impairment and stroke. Case: A 41-year-old male patient suffered from acute-onset vertigo and dizziness about 5 hours before admission, which started when he started doing his morning routine. Patients also feel gait unsteadiness and almost fall to the left side. There was no weakness in extremities, skew face or slurred speech. Patient's neurological status showed the cerebellar examination was positive left dysmetria, left dysdiadochokinesia, the Romberg test open eye fell to the left, normal Head Impulse Test (HIT), with horizontal bidirectional nystagmus and negative skew deviation test. Cerebellum infarction was discovered using computed tomography imaging. After passing through the acute stroke period, patients are offered symptomatic therapy in the form of betahistine, antiplatelet medication, and vestibular rehabilitation planning. On the tenth day after the onset, the patient's symptoms began to improve. Conclusion: Proper diagnosis of acute vestibular syndrome will guide the necessary tests. The HINTS oculomotor test at the bedside can detect acute vestibular stroke. Keywords: acute vestibular syndrome, vertigo, cerebellum, HINTS

Breaking a dogma: acute anti-inflammatory treatment alters both post-lesional functional recovery and endogenous adaptive plasticity mechanisms in a rodent model of acute peripheral vestibulopathy

BackgroundDue to their anti-inflammatory action, corticosteroids are the reference treatment for brain injuries and many inflammatory diseases. However, the benefits of acute corticotherapy are now being questioned, particularly in the case of acute peripheral vestibulopathies (APV), characterized by a vestibular syndrome composed of sustained spinning vertigo, spontaneous ocular nystagmus and oscillopsia, perceptual-cognitive, posturo-locomotor, and vegetative disorders. We assessed the effectiveness of acute corticotherapy, and the functional role of acute inflammation observed after sudden unilateral vestibular loss.MethodsWe used the rodent model of unilateral vestibular neurectomy, mimicking the syndrome observed in patients with APV. We treated the animals during the acute phase of the vestibular syndrome, either with placebo or methylprednisolone, an anti-inflammatory corticosteroid. At the cellular level, impacts of methylprednisolone on endogenous plasticity mechanisms were assessed through analysis of cell proliferation and survival, glial reactions, neuron’s membrane excitability, and stress marker. At the behavioral level, vestibular and posturo-locomotor functions’ recovery were assessed with appropriate qualitative and quantitative evaluations.ResultsWe observed that acute treatment with methylprednisolone significantly decreases glial reactions, cell proliferation and survival. In addition, stress and excitability markers were significantly impacted by the treatment. Besides, vestibular syndrome’s intensity was enhanced, and vestibular compensation delayed under acute methylprednisolone treatment.ConclusionsWe show here, for the first time, that acute anti-inflammatory treatment alters the expression of the adaptive plasticity mechanisms in the deafferented vestibular nuclei and generates enhanced and prolonged vestibular and postural deficits. These results strongly suggest a beneficial role for acute endogenous neuroinflammation in vestibular compensation. They open the way to a change in dogma for the treatment and therapeutic management of vestibular patients.

Study of the Comorbidity Between Cases of Acute Peripheral Vestibulopathies and COVID-19.

An infective etiology of acute peripheral vestibulopathy (APV) has long been hypothesized. In the context of coronavirus disease 2019 (COVID-19), we examined the possible comorbidity between these two entities. APV is the second most common cause of vestibular disorders and results from a sudden and unilateral loss of vestibular inputs. The characteristic signs and symptoms include sudden and prolonged vertigo, absence of auditory symptoms, and absence of other neurological symptoms. An infective etiology of APV has long been hypothesized on the basis of its association with respiratory tract infections and its frequent occurrence in epidemics. Possible comorbidity with herpes simplex virus type 1 reactivation or influenza virus infection has also been proposed. This study was designed to assess the possible comorbidity between APV and COVID-19. Quantification of the number of hospital admissions for APV over the period from February to May 2020 was carried out in 5 French hospitals. A comparison with 2018 and 2019 entries over the same period was made. Comorbidity between APV and COVID-19 infection was investigated. No significant increase in admission for APV was noticed over the examination period. No significant difference was noticed among hospitals located in COVID-19 high- and low-risk zones for SARS-CoV-2. No significant increase in the severity of the APV cases was noticed. No case of comorbidity between APV and SARS-CoV-2 infection was reported. Based on our observations, no correlation was made between APV and COVID-19. Based on our observations, COVID-19 is not statistically correlated with APV.

Isolated cerebellar nodulus infarction: Two case reports and literature review

BackgroundIsolated cerebellar nodulus infarction (ICNI) is rare and has great clinical similarity with acute peripheral vestibulopathy (APV), from which it is difficult to distinguish. We report two cases of ICNI followed by a literature review to identify the discriminant clinical elements that differentiate ICNI from APV. MethodsWe describe in detail our 2 cases. Besides, a literature search in Medline via PubMed and Scopus was performed up to May 17, 2020. Clinical characteristics, mainly of well-described cases, were extracted and analyzed. ResultsOur search yielded 43 total publications, among which 13 were selected, including 23 patients. Spontaneous or positional rotatory vertigo with unidirectional spontaneous horizontal nystagmus, associated with the postural imbalance and unilateral lateropulsion or fall on Romberg’s test, was the most common clinical picture. According to our literature review, the discriminant clinical elements which differentiate ICNI from APV were direction-changing gaze-evoked nystagmus, bilateral lateropulsion or fall on Romberg’s test, and normal horizontal head impulse test. Our two patients reported a positional fleeting abnormal visual perception of spatial orientation of objects. We proposed this symptom as a discriminant clinical element. ConclusionThe ICNI constitutes a difficult differential diagnosis of APV. Through our two patients reported here, we proposed a supplementary discriminant symptom helpful for the clinical diagnosis.

Radiographic Horizontal Gaze Deviation in Stroke and Acute Peripheral Vestibulopathy: a Systematic Review (1742)

Radiographic Horizontal Gaze Deviation in Stroke and Acute Peripheral Vestibulopathy: a Systematic Review (1742)

Atypical Presentation of Acute Vestibular Syndrome with Ramsay Hunt Syndrome

Ramsay Hunt syndrome is an acquired paralysis of the face specifically caused by a varicella-zoster virus infection in the facial nerve. Other cranial nerves including vestibulo-cochlear disturbance can be affected. Herein we reported a case of Ramsay Hunt syndrome with atypical vestibular syndrome. Although central vestibular signs including direction changing post head-shaking nystagmus or normal head impulse test are generally meaningful, clinicians need to be careful to interpret them because some findings can be observed not only in cases of central disorders but also in peripheral disorders. Clinical findings such as distinct ear pain and close observation of vesicles are important to diagnose Ramsay Hunt syndrome. Keywords: Ramsay Hunt syndrome; Varicella-zoster virus infection; Acute peripheral vestibulopathy; Direction changing head-shaking nystagmus 중심 단어: Ramsay Hunt 증후군, 수두대상포진바이러스, 급성 ì „ì •ë³‘ì¦, 방향변환성 두진후안진

Vestibular migraine presenting with acute peripheral vestibulopathy: Clinical, oculographic and vestibular test profiles

To describe clinical, oculographic and vestibular test profiles in patients with vestibular migraine (VM) who presented with acute peripheral vestibulopathy. VM was diagnosed according to Bárány Society or Neuhauser criteria. Neuro-otological examination, video-head impulse tests (v-HIT), cervical and ocular vestibular-evoked myogenic potentials (cVEMP/oVEMP), subjective visual horizontal (SVH) and audiometry were undertaken. Ten patients presented with prolonged vertigo. All had primary position unidirectional horizontal spontaneous nystagmus (mean slow-phase velocity 9.6 ± 7.0°). Horizontal canal vestibulo-ocular reflex was reduced in all (mean gain 0.54 ± 0.2) with refixation saccades (cumulative amplitude 6.4 ± 3.2°). Abnormality rates for cVEMP, oVEMP and SVH were 30%, 80%, 78%, respectively. Magnetic resonance imaging brain was normal in all patients. Patients were followed up over 6 months to 8 years with no change in the final diagnosis. VM can rarely present as an acute peripheral vestibulopathy with findings that mimic vestibular neuritis and should be considered in the differential diagnosis of acute prolonged vertigo.

A Case of Patient with Acute Peripheral Vestibulopathy Involving Isolated Posterior Semicircular Canal

A Case of Patient with Acute Peripheral Vestibulopathy Involving Isolated Posterior Semicircular Canal

Identification and new methods for quantifying new biomarkers of posturo-locomotor instability in a rodent model of acute peripheral vestibulopathy

Introduction Unilateral vestibular lesion results in a typical syndrome characterized by postural imbalance, alteration of locomotion and gaze stabilization as well as cognitive and neurovegetative disorders. One of the main difficulties encountered in the development of new anti-vertigo drugs is the lack of sensitivity in the evaluation of this syndrome. The use of a dynamic weight-bearing device has revealed postural alterations in rats with unilateral vestibular neurectomy (UVN) on the left side (Tighilet et al., 2017). With a new version of this device, we can quantify additional parameters of postural and locomotor equilibrium. The objective of this study is to use this device to set new parameters on our rat model of vestibular pathology. Material and methods We extracted different biomarkers from this device: the support surface, the weight distribution of rats when they are static or dynamic, and the successive positions of rat's barycenter. Results Before UVN, rats show a symmetric distribution of their weight along the lateral axis. In the acute phase after UVN, rats distribute more weight on the right when they are static and then they put more weight on the left side. After UVN, the support surface of the rats increases, and the barycenter distribution show a higher dispersion. Discussion/conclusion This study provides new information on the postural balance pattern observed after vestibular loss in rats. These data show a new way of quantifying the postural deficit associated with vestibular damage and the compensatory strategies adopted. These results could guide us on the validation of pharmacological compounds favoring the balance recovery.

Vertical diplopia as a main manifestation of acute peripheral vestibulopathy

Vertical diplopia as a main manifestation of acute peripheral vestibulopathy

Prediction of Vestibular Imbalance in Acute Peripheral Vestibulopathy by Measuring Horizontal Ocular Deviation on Magnetic Resonance Imaging.

The aim of the study is to evaluate whether horizontal ocular deviation (OD) from MR imaging in the emergency room (ER) reflects vestibular imbalance, by comparing the horizontal OD in patients with acute vestibulopathy to controls. Retrospective review. A total of 69 patients with acute unilateral peripheral vestibulopathy and 30 healthy subjects were included. Horizontal OD was quantified by using the axial T2-weighted fast-spin echo (FSE) images of the brain at 1.5 T. In the study group, the results of VFTs (videonystagmography [VNG], caloric test, rotary chair test, and cervical vestibular evoked myogenic potentials [cVEMP]) were also reviewed. The averaged angle of right and left horizontal ODs was compared between patients with acute unilateral vestibulopathy and healthy controls. Also, the correlation between horizontal OD and results of VFTs was analyzed in the study group. The averaged angle of horizontal OD in study group (23.7° ± 11.6°) was significantly greater than that of control group (4.27° ± 3.7°) (p < 0.05). Horizontal OD significantly correlated with slow phase velocity of spontaneous nystagmus (SN), the value of caloric paresis (CP) on caloric testing, rotary chair gain, asymmetry ratio of rotary chair test and interaural difference (IAD) of cVEMP, regardless of time intervals between magnetic resonance imaging (MRI) and VFTs. Horizontal OD significantly correlated with parameters of VFT which reflect the vestibular imbalance. Therefore, horizontal OD can be used as an indicator of unilateral peripheral vestibular weakness.

Central vertigo.

This review considers recent advances in central vertigo in terms of clinical and laboratory features and pathophysiology. Strokes presenting dizziness-vertigo are more likely to be associated with a misdiagnosis in the emergency setting. The risk of future strokes after discharge is higher in patients diagnosed with peripheral vertigo than in control patients. Strokes and transient ischemic attacks account for one-quarter of acute transient vestibular syndrome. Diagnosis of acute combined central and peripheral vestibulopathy such as anterior inferior cerebellar artery infarction requires additional consideration whenever applying the HINTS (head impulse test, direction-changing gaze-evoked nystagmus, and test of skew). Heat illness and metronidazole have been recognized as new causes of central vestibulopathy. Some new findings have also been added to the clinical and laboratory features of central vertigo. Central vertigo is a heterogeneous group of disorders with diverse clinical spectrums. An integrated approach based on understanding of clinical features, laboratory findings, speculated mechanisms, and limitations of current diagnostic tests will lead to better clinical practice.

Recent Advances in Cerebellar Ischemic Stroke Syndromes Causing Vertigo and Hearing Loss.

Cerebellar ischemic stroke is one of the common causes of vascular vertigo. It usually accompanies other neurological symptoms or signs, but a small infarct in the cerebellum can present with vertigo without other localizing symptoms. Approximately 11% of the patients with isolated cerebellar infarction simulated acute peripheral vestibulopathy, and most patients had an infarct in the territory of the medial branch of the posterior inferior cerebellar artery (PICA). A head impulse test can differentiate acute isolated vertigo associated with PICA territory cerebellar infarction from more benign disorders involving the inner ear. Acute hearing loss (AHL) of a vascular cause is mostly associated with cerebellar infarction in the territory of the anterior inferior cerebellar artery (AICA), but PICA territory cerebellar infarction rarely causes AHL. To date, at least eight subgroups of AICA territory infarction have been identified according to the pattern of neurotological presentations, among which the most common pattern of audiovestibular dysfunction is the combined loss of auditory and vestibular functions. Sometimes acute isolated audiovestibular loss can be the initial symptom of impending posterior circulation ischemic stroke (particularly within the territory of the AICA). Audiovestibular loss from cerebellar infarction has a good long-term outcome than previously thought. Approximately half of patients with superior cerebellar artery territory (SCA) cerebellar infarction experienced true vertigo, suggesting that the vertigo and nystagmus in the SCA territory cerebellar infarctions are more common than previously thought. In this article, recent findings on clinical features of vertigo and hearing loss from cerebellar ischemic stroke syndrome are summarized.

Incidence of dizziness and vertigo in Japanese primary care clinic patients with lifestyle-related diseases: an observational study.

ObjectiveDizziness and vertigo are highly prevalent symptoms among patients presenting at primary care clinics, and peripheral vestibular disorder (PVD) is their most frequent cause. However, the incidence of PVD has not been well documented. This study aimed to investigate the incidence of dizziness, vertigo, and PVD among patients presenting at a primary care clinic.DesignThis was an observational study.Setting and participantsBetween November 2011 and March 2013, we observed 393 patients, all at least 20 years old, who had been treated for chronic diseases such as hypertension, dyslipidemia, and diabetes mellitus for at least 6 months at a primary clinic (Oki Clinic) in Japan.OutcomeThe main outcome of interest was new incidence of dizziness, vertigo, and PVD events. During the 1-year follow-up period, the otorhinolaryngologist diagnosed and reported new PVD events.ResultsThe mean age of the 393 participants at entry was 65.5 years. Of the study participants, 12.7%, 82.4%, and 92.6% had diabetes mellitus, hypertension, and dyslipidemia, respectively. We followed up all the participants (100%). During the 662.5 person-years of follow-up, 121 cases of dizziness or vertigo (dizziness/vertigo) and 76 cases of PVD were observed. The incidence of dizziness/vertigo and PVD was 194.7 (95% confidence interval: 161.6–232.6) per 1,000 person-years and 115.7 (95% confidence interval: 92.2–142.6) per 1,000 person-years, respectively. There were 61 cases of acute peripheral vestibulopathy, 12 of benign paroxysmal positional vertigo, and three of Meniere’s disease among the 76 PVD patients.ConclusionWe reported the incidence of dizziness/vertigo among Japanese primary care clinic patients, which was higher than that usually observed in the general population. Furthermore, we described the incidence of PVD and found that it was a major cause of dizziness/vertigo.