Evaluation Of Vertigo Research Articles

Abbreviated MRI in the evaluation of dizziness: report turnaround times and impact on length of stay compared to CT, CTA, and conventional MRI.

Neuroimaging is often used in the emergency department (ED) to evaluate for posterior circulation strokes in patients with dizziness, commonly with CT/CTA due to speed and availability. Although MRI offers more sensitive evaluation, it is less commonly used, in part due to slower turnaround times. We assess the potential for abbreviated MRI to improve reporting times and impact on length of stay (LOS) compared to conventional MRI (as well as CT/CTA) in the evaluation of acute dizziness. We performed a retrospective analysis of length of stay via LASSO regression for patients presenting to the ED with dizziness and discharged directly from the ED over 4 years (1/1/2018-12/31/2021), controlling for numerous patient-level and logistical factors. We additionally assessed turnaround time between order and final report for various imaging modalities. 14,204 patients were included in our analysis. Turnaround time for abbreviated MRI was significantly lower than for conventional MRI (4.40h vs. 6.14h, p < 0.001) with decreased impact on LOS (0.58h vs. 2.02h). Abbreviated MRI studies had longer turnaround time (4.40h vs. 1.41h, p < 0.001) and was associated with greater impact on ED LOS than non-contrast CT head (0.58h vs. 0.00h), however there was no significant difference in turnaround time compared to CTA head and neck (4.40h vs. 3.86h, p = 0.06) with similar effect on LOS (0.58h vs. 0.53h). Ordering both CTA and conventional MRI was associated with a greater-than-linear increase in LOS (additional 0.37h); the same trend was not seen combining CTA and abbreviated MRI (additional 0.00h). In the acute settings where MRI is available, abbreviated MRI protocols may improve turnaround times and LOS compared to conventional MRI protocols. Since recent guidelines recommend MRI over CT in the evaluation of dizziness, implementation of abbreviated MRI protocols has the potential to facilitate rapid access to preferred imaging, while minimizing impact on ED workflows.

Acute Neurological Emergencies: Using Neurology-Trained Standardized Patients To Promote Active Learning in a Case-Based Simulation Curriculum for Neurology Clerkship Students (P9-2.004)

<h3>Objective:</h3> To describe the impact of using live, neurology-trained standardized patients (SPs) in a case-based simulation curriculum for clerkship students. <h3>Background:</h3> Simulation in neurology is limited by the inadequacy of manikins to portray neurologic exam findings. We designed a simulation curriculum using live, neurology-trained resident SPs residents for clerkship students to (1) practice taking a neurologic history, (2) perform a neurologic exam, and (3) recognize and triage neurological emergencies. <h3>Design/Methods:</h3> Two scenarios were developed: (1) evaluation of dizziness and management of acute stroke and (2) treatment of new-onset seizure. Monthly sessions involved 4–5 students. Residents SPs mimicked expected exam findings. Pre- and post-session surveys evaluated students’ self-rated knowledge, clinical skills, and confidence in gathering a history, performing a neurological exam, presenting a case, and recognizing, working up, and managing strokes and seizures. Students also rated the overall session quality and provided feedback about the experience. Paired t-tests were performed for quantitative items. <h3>Results:</h3> 54 students participated. Post-session, students reported significantly higher self-confidence in all neurological knowledge domains and clinical skills (p&lt;0.003 for all). Over 90% of students agreed sessions met the learning objectives, the course was valuable, and the simulation was a safe learning environment and would improve their clinical performance. 94% would recommend the session to others. Over 80% agreed the simulation was realistic, well-organized, and an effective way to practice teamwork and clinical skills. In open responses, students reported they appreciated evaluating neurologic emergencies, performing the exam with a trained SP, and making treatment decisions. Students wanted more cases and time; they suggested smaller groups. <h3>Conclusions:</h3> A simulation curriculum with neurology residents portraying the patient increased students’ knowledge, clinical skills, and self-confidence in recognizing and managing acute neurological emergencies. Resident SPs were cited as the most effective educational component. Future research should evaluate the sustainability of benefits gained and assess clinical skills objectively. <b>Disclosure:</b> Dr. Gheihman has nothing to disclose. Dr. Harrold has nothing to disclose. The institution of Dr. Howard has received research support from Genentech. The institution of Dr. Howard has received research support from Novartis. Dr. Howard has received personal compensation in the range of $50,000-$99,999 for serving as a Clinical Fellow with National Multiple Sclerosis Society. Dr. Albin has received personal compensation in the range of $5,000-$9,999 for serving as an Editor, Associate Editor, or Editorial Advisory Board Member for Continuum: Life Long Learning in Neurology. Dr. Albin has received research support from American Academy of Neurology. Dr. Albin has received publishing royalties from a publication relating to health care. Dr. Albin has received personal compensation in the range of $500-$4,999 for serving as a Instructor with Resuscitation Leadership Academy. Dr. Kaplan has received personal compensation in the range of $500-$4,999 for serving as a Consultant for Novartis . Dr. Kaplan has received personal compensation in the range of $500-$4,999 for serving as a Consultant for EMD Serono .

Book Review: Diagnostic Vestibular Pocket Guide: Evaluation of Dizziness, Vertigo, and Imbalance: Julie A. Honaker; San Diego: Pleural Publishing, 2021.

Book Review: Diagnostic Vestibular Pocket Guide: Evaluation of Dizziness, Vertigo, and Imbalance: Julie A. Honaker; San Diego: Pleural Publishing, 2021.

Video Occulography-Assisted Diagnosis of BPPV and Comparison of Pre- and Post-Intervention Dizziness Handicap Inventory Score

AbstractBenign paroxysmal positional vertigo (BPPV) is a commonly recognized vestibular disorder which is characterized by brief periods of vertigo and a characteristic nystagmus. The nystagmus is often difficult to appreciate with naked eyes and hence video oculography is a helpful tool. Dizziness Handicap Inventory is an objective way to assess the impact of vertigo on quality of life. Objective Our study here aims at diagnosing undiagnosed, difficult and missed cases of BPPV using video-oculography and managing it with repositioning manoeuvre. This study also aims at measuring Dizziness Handicap Inventory Scores pre and post repositioning manoeuvre. We also observed the association between Vitamin D levels and the occurrence of BPPV. Methods and Materials One hundred and twenty-six patients were enrolled in the age group of 18-70 years. After recognizing patients with BPPV, vertigo evaluation was performed. Those patients with suggestive history and suspicion of multiple canal involvement were taken for video-oculography. Results Forty-four patients were in age group of 50-60 years, having female predominance. 35.71% cases which were missed on clinical examination were correctly diagnosed using video-oculography. The mean pre-intervention DHI was 41.29 ± 15.90 which lowered down to 14.84 ± 11.52 in post-intervention period. The highest DHI scores were seen in multi-canal BPPV involving lateral and posterior semi-circular canals. Conclusion With the help of vide-oculography we could diagnose more cases of anterior and multi canal BPPV which are often missed. Maximum number of participants had insufficient levels of Vitamin-D and in our opinion correcting it would reduce the occurrence and recurrence rate..

The efficacy of Epley and Semont maneuvers in posterior semicircular canal benign paroxysmal positional vertigo treatment: A short-term comparative study

OBJECTIVE: This study aimed to compare the effectiveness of the Epley maneuver with the Semont maneuver in the treatment of posterior semicircular canal benign paroxysmal positional vertigo and observe differences in the resolution time of symptoms in the short-term follow-up. METHODS: Sixty patients with posterior semicircular canal benign paroxysmal positional vertigo (23 males, 37 females; median age: 44.9 years; range, 14 to 80 years) were included in the prospective randomized comparative study conducted in our clinic between April 2019 and October 2019. Diagnosis and treatment maneuvers were performed under videonystagmography examination. Participants were randomly selected after the diagnostic tests for the Epley maneuver and the Semont maneuver treatment groups. RESULTS: In the evaluation of vertigo with videonystagmography, 25 (83.3%) patients in the Epley maneuver group and 20 (66.6%) patients in the Semont maneuver group recovered in the one-week follow-up, and 28 (93.3%) patients in the Epley maneuver group and 24 (80%) patients in the Semont maneuver group recovered in the two-week follow-up. All patients in the Epley maneuver group recovered at the end of one month; four patients in the Semont maneuver group still had vertiginous symptoms (100% vs. 86.6%, p=0.04). There was a statistically significant difference between the Epley and Semont groups regarding visual analog scores at the one-week, two-week, and one-month follow-ups (p=0.002, p&lt;0.001, p=0.001, respectively). CONCLUSION: The Epley maneuver was significantly more effective than the Semont maneuver in resolving vertigo in the short-term treatment of posterior semicircular canal benign paroxysmal positional vertigo.

Diagnostic vestibular pocket guide: Evaluation of dizziness, vertigo, and imbalance. Julie A.Honaker. San Diego, CA: Plural Publishing, 2021, 288 pp.

Diagnostic vestibular pocket guide: Evaluation of dizziness, vertigo, and imbalance. Julie A.Honaker. San Diego, CA: Plural Publishing, 2021, 288 pp.

Evaluation of Patients with Vertigo by Cranial Magnetic Resonance Imaging (MRI)

Background: Vertigo is a symptom that neurologists and otologists are confronted with. Magnetic resonance image (MRI) is used for imaging. Objective: To determine the diagnostic yield of MRI in patients with vertigo and to Identify the most common causes. Patients and Methods: This observational study involved 110 vertigo complaining patients attending the MRI unit of Rizgary teaching hospital examined by 0.2 Tesla MRI between June 2007 and September 2008.Collected variables divided into Group 1 (normal MRI) and Group 2 (abnormal MRI) analysed and compared. Results: Group 1= (70%) and Group 2=(30%), abnormal MRI findings in male patients was (59.6%), in female (40.4%,) the commonest abnormalities were cerebellopontine angle (CPA) space occupying lesions (SOL) (9.2%), cerebellar SOL (7.4%), 4th ventricle SOL (7.4%) and deep white matter ischemia (7.4%), most of patients with vascular problems were more than 50 years. In (35.4%) of patients, vertigo was less than one month duration, (50%) of which had abnormal MRI findings. Out of seven patients with normal MRI, 5 patients showed vascular lesion on magnetic resonance angiography (MRA). Conclusion: MRI remains important diagnostic tool for evaluation of vertigo and MRA is necessary when vascular origin is suspected.

Role of electronystagmography as a definitive tool in evaluation of vertigo: a clinical study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Vertigo is one of the most distressing symptoms. It is difficult to identify, practically impossible to measure and not easy to treat. Electronystagmography (ENG) objectively records eye movements and thus tests the functional integrity of vestibulo-ocular reflex and its connections from inner ear to the brain. Hence, this present study was taken to evaluate the role of ENG in the diagnosis of vertigo, to know the peripheral, central and other causes of vertigo and to know the side of lesion. The aim of this study was to evaluate the role of ENG in the diagnosis of vertigo, to know the peripheral, central and other causes of vertigo and to know the side of lesion.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This study included 60 patients who presented with primary complaints of vertigo or dizziness. Patients were subjected to ENG under optimal conditions and the results were obtained in the form of a graphical recordings after analysis of the ENG data.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Of the 60 patients subjected to ENG, a peripheral cause was seen in 33 patients. 21 patients were diagnosed with benign positional paroxysmal vertigo (BPPV), whereas 06 patients showed a central lesion of the vestibular system.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; ENG acts as a useful screening tool to differentiate between peripheral cause of vertigo and central cause of vertigo. It has special significance in localizing the side of the lesion. Hence, ENG has proven to be a useful first line investigation in the diagnosis of vertigo.&lt;/p&gt;

Approach to the History and Evaluation of Vertigo and Dizziness.

This article reviews a method of obtaining the medical history of patients presenting with dizziness, vertigo, and imbalance. By combining elements of the history with examination, the goal is to identify patterns and an effective differential diagnosis for this group of patients to help lead to an accurate diagnosis. Studies over the past dozen years have changed the historical approach to patients with dizziness from one based primarily on how the patient describes the sensation of dizziness. This older approach can lead to misdiagnosis, so a preferred method puts greater emphasis on whether the dizziness is acute or chronic, episodic or continuous, or evoked by or brought on by an event or circumstance so that a pattern may be derived that better narrows the differential diagnosis and focused examination can further narrow to a cause or causes. Dizziness is a common symptom of many possible causes. This article will help clinicians navigate gathering the history and examination to formulate a working diagnosis in patients affected by dizziness.

Hemorrhagic stroke after Epley maneuver: a case report

BackgroundThis is the first case to our knowledge of a serious adverse event following the Epley maneuver, which is the treatment of choice for benign paroxysmal positional vertigo (BPPV), the most common vestibular disorder in adults.Case presentationA 77 year old female presented for outpatient evaluation of vertigo at a tertiary otolaryngology clinic. She was found to have BPPV clinically, and elected to have a particle repositioning maneuver (Epley maneuver) performed in clinic. Immediately following Epley maneuver, she had severe nausea and vomiting, with evolving visual changes. A CT angiogram of the brain was performed urgently through the emergency department and demonstrated an acute intraparenchymal hemorrhage in the occipital lobe. After medical stabilization and rehabilitation, the patient continues to have a permanent visual field deficit.ConclusionThe Epley maneuver is safe and effective, and there are no prior reports of serious adverse events associated with its use. This case, in which a patient experienced a hemorrhagic stroke after undergoing the Epley maneuver, is the first and sole case in the medical literature of an Epley-associated serious adverse event. The indirect causation and extreme rarity of this event do not warrant any change to patterns of practice.

The Association Between Vestibular Physical Examination, Vertigo Questionnaires, and the Electronystagmography in Patients With Vestibular Symptoms.

Dizziness makes up a diagnostic and treatment challenge. The diagnostic accuracy of the medical history and vestibular physical examination in cases of vestibular symptoms is not clear. The aim of this study is to determine the association between vestibular physical examination, vestibular questionnaires, and electronystagmography (ENG) test in patients with vestibular symptoms. This is a prospective study of 135 adults with vestibular symptoms. The subjects underwent targeted physical examination and filled vestibular questionnaires, including the Dizziness Handicap Inventory (DHI), before ENG testing. The results of the physical examination and questionnaires were compared with the final ENG findings. Of patients who had normal ENG results, 32.1% (17/52) showed abnormal physical examination, and 48.8% (40/82) of the patient who had normal physical examination showed abnormal ENG results ( P = .46). Among patients with severe disability by DHI, 46.4% (13/28) had an abnormal ENG, and 42.9% (12/28) had a normal ENG ( P = .39). This study did not demonstrate association between vestibular physical examination, vestibular questionnaires, and ENG results. Although history (augmented by questionnaires) and physical examination are the initial steps in the evaluation of vertigo, the current study suggests that they should be complemented by objective testing for evaluation of inner ear origin of vertigo.

Geographic Variation in Use of Vestibular Testing among Medicare Beneficiaries

Objective There is a lack of consensus regarding the indications for vestibular testing in the evaluation of dizziness and balance disorders. Geographic variation in health services utilization is associated with lack of consensus. To understand the variation in current practice, we investigated the patterns of use of vestibular testing and diagnosis codes for dizziness and balance disorders among individuals ≥65 years of age across different regions of the United States. Study Design Cross-sectional study. Setting Medicare administrative claims data. Subjects and Methods Using the Summarized Denominator file, a sample of the US population linked to the Surveillance, Epidemiology, and End Results (SEER)-Medicare files (years 2000-2010), we identified persons who were ≥65 years of age. We used multivariable analyses to determine the factors associated with vestibular testing and diagnoses. Results Of the 231,984 eligible Medicare beneficiaries, 27% were diagnosed with dizziness and balance disorders. Patterns of use of vestibular tests (eye movement recording for spontaneous nystagmus, caloric testing, and rotary chair testing) varied significantly by geographic region. Rotary chair test utilization varied most. We found significant geographic variation in vestibular testing and diagnoses after controlling for age, sex, race, Medicaid participation, and rurality. Conclusions There may be opportunities to improve the consistency and efficiency of care for dizziness and balance disorders. It will be important to define appropriate levels of vestibular diagnostic testing and which tests add sufficient value to justify the costs. Further work is needed to better characterize the causes and consequences of variation in vestibular test utilization.

Evaluation of Vertigo in Pediatric Age Group

Evaluation of Vertigo in Pediatric Age Group

Are there changes in postural regulation across the lifespan?

The purpose was to obtain parameters of postural regulation (n = 1724) of asymptomatic subjects (6–97 years). The maximum postural stability and capacity of postural subsystems were calculated for the age ranges from 34 to 35 years (men) and from 38 to 44 years (women). A significant decline in postural performance was observed in the 40s (men) and 50s (women). Data can be used in the evaluation of dizziness and balance disorders in people of all ages.

Variation in Orthostatic Vital Sign Testing in an Urban Academic Emergency Department

Orthostatic vital signs are more sensitive than traditional vital signs in the detection of hypovolemia, and they are useful in the evaluation of dizziness and syncope. 1 McGee S Abernethy III, WB Simel DL The rational clinical examination: is this patient hypovolemic?. JAMA. 1999; 281: 1022-1029 Crossref PubMed Scopus (438) Google Scholar , 2 Kessler C Tristano JM De Lorenzo R The emergency department approach to syncope: evidence-based guidelines and prediction rules. Emerg Med Clin North Am. 2010; 28: 487-500 Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar A variety of procedures for measurement of orthostatic vital signs and criteria for a positive test have been proposed. 1 McGee S Abernethy III, WB Simel DL The rational clinical examination: is this patient hypovolemic?. JAMA. 1999; 281: 1022-1029 Crossref PubMed Scopus (438) Google Scholar , 3 Witting MD Gallagher K Unique cutpoints for sitting-to-standing orthostatic vital signs. Am J Emerg Med. 2003; 21: 45-47 Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar , 4 Baraff LJ Schriger DL Orthostatic vital signs: variation with age, specificity, and sensitivity in detecting a 450-mL blood loss. Am J Emerg Med. 1992; 10: 99-103 Abstract Full Text PDF PubMed Scopus (31) Google Scholar , 5 Knopp R Claypool R Leonardi D Use of the tilt test in measuring acute blood loss. Ann Emerg Med. 1980; 9: 72-75 Abstract Full Text PDF PubMed Scopus (59) Google Scholar , 6 Lance R Link ME Padua M et al. Comparison of different methods of obtaining orthostatic vital signs. Clin Nurs Res. 2000; 9: 479-491 Crossref PubMed Scopus (13) Google Scholar , 7 Skinner JE Driscoll SW Porter CB et al. Orthostatic heart rate and blood pressure in adolescents: reference ranges. J Child Neurol. 2010; 25: 1210-1215 Crossref PubMed Scopus (22) Google Scholar , 8 Gorgas DL Barry JD Vital signs measurement. in: Roberts JR Hedges JR Clinical Procedures in Emergency Medicine. 5th ed. Saunders, Philadelphia, PA2010: 1-21 Crossref Google Scholar Michael D. Witting is Associate Professor, Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD. Stacey Chaney Hydorn, Member, Baltimore Metro Chapter of ENA, is Senior Clinical Nurse I, University of Maryland Medical Center, Baltimore, MD.

Yield of CT angiography and contrast-enhanced MR imaging in patients with dizziness.

Dizziness is a common symptom in emergency and outpatient settings. The purpose of our study was to compare the diagnostic and therapeutic efficacy of CTA of the head and neck, contrast-enhanced MR imaging of the brain (CE-MR), and contrast-enhanced MR imaging of the internal auditory canals and temporal bones in patients with isolated dizziness, to determine which of these modalities should be preferred in the evaluation of dizziness. We retrospectively identified patients presenting with dizziness from January 2011 to June 2012 who underwent a CTA, CE-MR, or MRIAC. We excluded patients with signs or symptoms suggestive of other neurologic pathology or a history of an abnormality known to cause dizziness. We calculated the proportion of patients with abnormal findings on a study, tabulated the nature of the abnormality, and reviewed the medical records to determine whether imaging changed management. Two hundred twenty-eight CTAs, 304 CE-MRs, and 266 MRIACs were included. Five patients (2.2%) with CTAs, 4 (1.3%) with CE-MRs, and 4 (1.5%) with MRIACs demonstrated significant findings that related to the history of dizziness or were incidental but judged to be clinically significant. Of these, 3 CTA (1.3%), 2 CE-MR (0.7%), and 3 MRIAC (1.1%) examinations resulted in a change in clinical management. Imaging evaluation of the patient with uncomplicated dizziness is unlikely to identify clinically significant imaging findings and is very unlikely to result in a change in clinical management, with an overall TE of 1.0%. Thus, the routine use of imaging in the evaluation of the patient with dizziness cannot be recommended.

Vibration-Induced Nystagmus After Acute Peripheral Vestibular Loss

To validate the role of vibration-induced nystagmus (VIN) detecting vestibular asymmetry by comparing several vestibulo-ocular reflex (VOR) parameters in the yaw plane. Prospective validation study for diagnostic test. Tertiary referral center. Seventy-four patients with unilateral vestibular loss of acute onset without a history of fluctuating vestibular function and 24 healthy volunteers. Spontaneous nystagmus, head-shaking nystagmus (HSN), and VIN using a 100 Hz handheld vibrator were recorded using a videonystagmography system. Canal paresis on the caloric test and the time constant (TC) on the step velocity test were examined as parameters of the laboratory test. Correlation analysis between horizontal VOR parameters was performed. Receiver operating characteristic (ROC) curves of these parameters were plotted, and the area under the ROC curve (AUC) was compared according to the lower limiting value of TC on step velocity test as well as the presence of unilateral vestibular loss. VIN was observed in 64 (86%) of 74 patients, and it was directed toward the contralesional side in 98%. VIN showed a significant positive correlation with the canal paresis (r=0.416, p<0.001) and a negative correlation with the TC (r=-0.351, p<0.005). ROC curves of several VOR parameters were compared according to the presence of unilateral vestibular loss. The AUC of VIN was 0.882, and the cutoff intensity of VIN was 2.5 degrees per second. The AUCs of the HSN and spontaneous nystagmus were 0.774 and 0.661, respectively. The lateralization value of VIN was comparable with caloric test and superior to HSN. VIN is a useful vestibular test detecting vestibular asymmetry in the evaluation of dizziness.

Retraction: Clinical Characteristics and Diagnostic Classification of Vertigo in Children

Background and Objectives:Vertigo in children is relatively uncommon. The severity of vertigo in children varies from mild balance disturbance to true vertigo with obvious nystagmus and falling. There is not much concern about vertigo in children, thus only a few articles exist. The purpose of this study is to analyze the clinical characteristics and the results of audiological and vestibular evaluation, to classify the diagnostic causes of vertigo, and to provide the information about vertigo in children. Materials and Methods:A total of 49 patients with vertigo or dizziness who visited Dizziness Clinic in the Department of Otolaryngology at Ajou University Hospital from January 1995 to December 2001 were included in this study. These patients were retrospectively reviewed based on clinical charts. The average age of the patients was 11.9 years, with a minimum of 3 years and a maximum of 15 years. All patients performed questionnaires and pure tone audiometries. Caloric tests and rotational tests were performed in 39 and 40 patients respectively. In selective cases, computed tomography, magnetic resonance imaging, electroencephalogram and hematologic test were performed. Results:Migraine and benign paroxysmal vertigo of childhood (BPVC) were 32.7% and 20.4% in children with vertigo, respectively. Other causes were trauma, Meniere's disease, delayed endolymphatic hydrops, benign positional vertigo, cerebellopontine angle tumor, seizure, otitis media and unknown causes were 16.3%. Audiometry, caloric and rotational chair tests showed abnormal findings in 11 cases (22%), 5 cases (13%) and 30 cases (75%), respectively. Conclusion:Vertigo in children has different causes from adult vertigo, showing migraine and BPVC to be the most frequent causes. The evaluation of vertigo in children should include a complete history (questionnaire) and physical examination, an audiogram, and vestibular function tests. In selective cases, EEG, Hematologic evaluation and scanning of the brain or temporal bone should be performed. (Korean J Otolaryngol 2003;46:105-9)

Longitudinal posturography and rotational testing in children three to nine years of age: Normative data

Objective To obtain normative longitudinal vestibulo-ocular and balance test data in children from ages three to nine years with normal middle ear status. Study Design Prospective, longitudinal cohort. Setting Tertiary care pediatric hospital. Subjects and Methods Three-year-old children were entered and tested yearly. Subjects underwent earth vertical axis rotation testing using sinusoidal and constant velocity stimuli and performed the Sensory Organization Test. Results One hundred forty-eight children were entered, and usable data were collected on 127 children. A linear increase in the vestibulo-ocular reflex gain as children aged was found, without a change in the phase of the response. An age-related linear increase in equilibrium scores, indicating reduced postural sway, was also observed. Conclusion These normative data can be used in the evaluation of dizziness and balance disorders in children.

Migration of an aneurysm clip to the sacral subarachnoid space

A 33-year-old woman was admitted for evaluation of vertigo. An unruptured fusiform aneurysm of left distal posterior inferior cerebellar artery was found and presumed to be the cause of her vertigo. The aneurysm was clipped using three clips and then the vertigo was relieved. However, she developed low back pain 53 months after the operation. On plain radiographic examination, a right-angled clip was found at the sacral level. Cerebral angiography revealed two clips remaining at the previous location and previous aneurysm was no longer visualized. Her symptom of back pain was resolved spontaneously over 2 weeks, and she is doing well without any particular inconvenience for following 72 months. Clip loosening and migration is an extremely rare event in aneurysm surgery. If the aneurysm is secured and symptoms related to a migrated clip is resolved, the removal of one does not seem to be mandatory.