Evaluation Of Vestibular Function Research Articles

Vestibular-evoked myogenic potential abnormalities in Parkinson's disease with freezing of gait.

Vestibular dysfunction is closely associated with the pathophysiology of Parkinson's disease (PD) accompanied by freezing of gait (FOG); however, evidence supporting this clinical association is lacking. Vestibular-evoked myogenic potentials (VEMPs) have been widely acknowledged as a crucial electrophysiological parameter in the clinical evaluation of vestibular function. The present study investigated the possible correlation of FOG occurrence with VEMP observations in patients diagnosed with PD. Altogether, 95 idiopathic PD patients were recruited into the present cross-sectional study. All patients underwent motor and non-motor assessments using serial scales. In addition, the electrophysiological vestibular evaluation was conducted, which included cervical (cVEMP) and ocular VEMP (oVEMP) assessments. Furthermore, the correlations of bilateral c/oVEMP absence with clinical phenotypes, especially FOG, among the PD patients were analyzed. Among the 95 patients with PD, 44 (46.3%) had bilateral oVEMP absence and 23 (24.2%) had bilateral cVEMP absence, respectively. The proportions of patients with bilateral oVEMP absence (77.8% vs 30.9%, p = 0.004) and bilateral cVEMP absence (44.4% vs 19.5%, p = 0.035) were higher in the patient group exhibiting FOG than in the group without FOG. Following the adjustment of confounding variables, bilateral oVEMP absence (OR = 8.544, p = 0.007), rather than bilateral cVEMP absence, was shown to independently predict FOG occurrence in patients with PD. The close correlation between bilateral oVEMP absence and FOG in PD patients sheds new light on the possible role of central vestibular/upper brainstem dysfunction in FOG development in patients with PD.

Evaluation of vestibular functions in patients with obstructive sleep apnea syndrome

Background To determine the anatomical proximity of the vestibular nuclei to the respiratory nuclei and the effect of susceptibility of the posterior labyrinth to a hypoxic state on the vestibular system. Objective It was aimed to evaluate the possible effects of periodic hypoxia on vestibular reflexes and proprioceptive perception in patients with obstructive sleep apnea syndrome (OSAS). Material and methods The study was conducted with 40 patients diagnosed with moderate and severe OSAS and 21 healthy individuals. All individuals were evaluated with Dizziness Handicap Inventory, ocular vestibular evoked myogenic potential (oVEMP), cervical vestibular evoked myogenic potential (cVEMP), video head impulse test (vHIT), videonystagmography (VNG) and sportKAT 3000. Results In the vHIT, a statistically significant difference was found between the groups in terms of anterior and posterior semicircular canal vestibulo-ocular reflex gains (p < .05). A negative correlation was found between the lateral gain asymmetry and RALP gain asymmetry and the awake blood oxygen level in the OSAS groups. There was a statistically significant difference between the groups in terms of wave response rates cVEMP 100 dB nHL and oVEMP 100–110 dB nHL (p < .05). Conclusion and Significance It was concluded that vestibular reflexes and proprioceptive perception were affected due to periodic/chronic hypoxia in patients with moderate and severe OSAS.

Evaluation of Vestibular Functions in a Case of Vestibular Migraine With Successful Treatment With Erenumab.

This is the first report of vestibular examinations before and after the successful treatment of vestibular migraine (VM), a common cause of recurrent vertigo, with calcitonin gene-related peptide (CGRP) receptor inhibitor. We evaluated a 42-year-old female with VM and concomitant probable Meniere's disease, whose headache and dizziness have improved promptly with the administration of erenumab, a CGRP receptor inhibitor. The sensorineural hearing loss in pure-tone audiometry, dysfunctions shown in vestibular examinations (cervical and ocular vestibular evoked myogenic potentials), and mild endolymphatic hydrops shown in gadolinium-enhanced inner ear magnetic resonance imaging, all in the right ear, revealed no change compared with those observed before treatment. This case suggests that VM may be treated by blocking CGRP in the trigeminal ganglion, which suppresses the effects on the vestibular nucleus; herein, no effects were observed in the inner ear despite the clear amelioration of dizziness.

Evaluation of Vestibular Function in Sleep Disorders

Objectives: The aim of this study was to evaluate dizziness in patients with sleep disorders, objectively identify vestibular function through the vestibulo-ocular reflex (VOR) using the video Head Impulse Test (vHIT), and evaluate the association between these findings.Methods: Among the patients who visited the sleep clinic from June to October 2021, 69 who underwent both polysomnography (PSG) and vHIT were included. Participants completed questionnaires including the Dizziness Handicap Inventory (DHI), Beck Anxiety Inventory, Korean-Beck Depression Inventory-II, Epworth Sleepiness Scale, Insomnia Severity Index (ISI), and Pittsburgh Sleep Quality Index (PSQI). The subjects were classified into four groups: insomnia (n=4), rapid eye movement sleep behavior disorder (RBD) (n=13), obstructive sleep apnea syndrome (OSAS) (n=34), and RBD and OSAS (n=18). Moderate to severe OSAS (n=49) was compared with no OSAS and mild OSAS (n=20).Results: In comparison of the four groups according to sleep disorders, the OSAS patients showed the highest DHI scores and the lowest VOR gain, but statistical significance was not found. Although all VOR gains were within the normal range, the VOR gain of the left posterior semicircular canal was significantly lower in the moderate to severe OSA group than in the no OSA and mild OSA groups (1.02±0.18 vs. 0.94±0.10, &lt;i&gt;p&lt;/i&gt;=0.019). DHI total scores showed no correlation with VOR gain but showed a positive correlation with ISI (r=0.422, &lt;i&gt;p&lt;/i&gt;=0.001) and PSQI (r=0.287, &lt;i&gt;p&lt;/i&gt;=0.022). Among PSG parameters, lowest oxygen saturation (SaO&lt;sub&gt;2&lt;/sub&gt;) and percentage of time with SaO&lt;sub&gt;2&lt;/sub&gt; less than 90% were correlated with the emotional score of DHI (r=-0.245, &lt;i&gt;p&lt;/i&gt;=0.043 and r=0.311, &lt;i&gt;p&lt;/i&gt;=0.010, respectively).Conclusions: Although our study could not objectively confirm vestibular dysfunction in patients with sleep disorders, we found that subjective sleep complaints were associated with dizziness and hypoxic conditions during sleep were associated with emotional aspects of dizziness. This suggests that the treatment of concomitant sleep disorders may improve dizziness.

Evaluation of vestibular function of patients with temporal bone fracture through the video head impulse test (vHIT): Preliminary results

Evaluation of vestibular function of patients with temporal bone fracture through the video head impulse test (vHIT): Preliminary results

Vestibular function in children with cochlear implant: Impact and evaluation.

Over the last 30 years, cochlear implant (CI) has been dedicated to improving the rehabilitation of hearing impairments. However, CI has shown potential detrimental effects on vestibular function. For children, due to atypical symptoms and difficulty in cooperating with vestibular function tests, systematic and objective assessments of vestibular function with CI have been conducted sparsely. This review focuses on the impact of vestibular function in children with CI and summarized the evaluation of vestibular function in children. In addition, some recommended strategies are summarized and proposed.

Myotonia-rectified bone-conducted vibration vestibular evoked myogenic potential in normal adults

Objective:To study the characteristics of bone-conducted vibration vestibular evoked myogenic potential（BCV-VEMP） in normal adult with and without myotonia rectification, and to provide accurate reference for clinical vestibular function evaluation. Methods:Thirty normal adults（60 ears） aged 20-32 years old were selected to receive BCV-VEMP in a sitting position. BCV-VEMP were induced by B-81 bone-conducted vibrator at 129.5 FL, the P1 latency, N1 latency, P1-N1interval, amplitude, and amplitude asymmetry ratios were recorded in two test conditions. Results:Clear and repeatable waveforms of BCV-cVEMP and BCV-oVEMP were obtained in all normal adults. The P1 and N1 latencies of BCV-cVEMP were（16.00±2.02） ms and（25.04±2.57） ms, respectively, P1-N1 interval was（9.04±1.78） ms. The N1 and P1 latencies of BCV-oVEMP were（10.39±0.81） ms and（15.85±1.00） ms, respectively, iand interval was（5.46±0.86） ms. The amplitudes of BCV-cVEMP and BCV-oVEMP in two test conditions were statistically significant（P<0.05）. The amplitude asymmetry ratios of BCV-cVEMP and BCV-oVEMP after rectification were （17.03±9.14）% and （20.43±11.65）%, respectively. Conclusion:BCV-VEMP is a feasible and reliable tool for vestibular function assessment. The establishment of a normal values such as amplitude and amplitude asymmetry ratio after rectification can provide a more reliable and accurate reference.

Evaluation of vestibular function in cases of hearing loss due to mumps:A report of two cases

Evaluation of vestibular function in cases of hearing loss due to mumps:A report of two cases

Evaluation of Vestibular Function in Patients Affected by Obstructive Sleep Apnea Performing Functional Head Impulse Test (fHIT).

PurposeObstructive sleep apnoea (OSA) is a common disease with significantly related complications. Since a connection between the vestibular nucleus and sleep regulator pathways has been demonstrated, vestibular evaluation in OSA patients was partially studied and none used functional head impulse test (fHIT) for this purpose. This paper aimed at evaluating the vestibular function in patients affected by OSA using fHIT, selecting patients who did not present any other related to cardiovascular, neurological, or metabolic diseases.Patients and MethodsPatients enrolled had a diagnosis of OSA by polysomnography type III and were cataloged according to American Association of Sleep Medicine criteria. Each patient underwent fHIT. Statistical significance was set at 0.05.ResultsA total of 85 patients were enrolled in the study of which 50 had a diagnosis of OSA and were included in the case group, while 35 belonged to the control group. In 88.6% of subjects of the case group was evidenced a vestibular impairment with a substantial difference between the two study groups (p<0.05).ConclusionThe results show that the incidence of vestibular lesions in patients with obstructive sleep apnoea is underestimated and that fHIT can identify these lesions early.

Pulsed infrared stimulation evoked electrical potential in mouse vestibular system

To improve accuracy of VsEP and avoid the inherent limitation of mechanical vibration, we designed an infrared optical stimulation approach to stimulate mouse vestibular system and measured the evoked potential. IR pulses (1871 nm, 30 pps and 100 μs pulse width) were delivered to mice with different vestibular dysfunction levels and the evoked potential was recorded. The result suggests that the amplitude and latency of the IR-evoked potential (IR-VsEP) were significantly associated with vestibular function integrity. Immunofluorescence staining confirmed that magnitude of IR-VsEP decreased was consistent with the loss of HCs. Micro-CT imaging revealed that the optical fiber was orientating towards the vestibular system. Taken together, we found that: 1) IR stimulation can generate VsEP evoked potential in vestibular system (IR-VsEP), which can be potentially used for vestibular function evaluation; 2) intact HCs and fully functional synaptic transmission are crucial for efficient IR-induced vestibular system stimulation.

Prevention of Severe Vestibular Hypofunction after Systemic Gentamicin.

The importance of early evaluation by a neurotologist in patients with infective endocarditis treated with systemic gentamicin and its impact on the patients’ quality of life was evaluated. This is a longitudinal retrospective cohort study of 29 patients who received intravenous gentamicin for the treatment of infective endocarditis. Patients were classified into two groups: group A, before a neurotologist was included in the treatment protocol, and group B, after the inclusion of a neurotologist. The frequency of the different symptoms in each group was measured, and the gain of the vestibulo-ocular reflex (VOR) and its relationship with the presence of oscillopsia. In total, 13 and 16 patients were assigned to groups A and B, respectively. The mean gain of the VOR measured using the video head impulse test in group A was 0.44 in the best side and 0.39 in the worst side. In group B, the mean gain was 0.71 (best side) and 0.64 (worst side) (p < 0.0001). The patients who complained about oscillopsia had a main gain of 0.41 in the best side and 0.35 in the worst side. Evaluation of vestibular function should be included in the infective endocarditis treatment protocol, including the adverse effects of systemic gentamicin.

Evaluation of vestibular function in children with purulent media otitis by computer stabilometry

The aim of the research – assessment of vestibular function in children with acute purulent otitis media by computer static stabilometry compared with typically developed children of the same age.&#x0D; Materials and methods: 22 children with purulent otitis media aged 4 to 7 years and 30 practically healthy peers were examined by static stabilometry on the device “MPFI stabilograph 1” (Kharkiv, Ukraine). Indicators of variation and shape of the pressure center distribution, spectral-correlation indicators of stabilograms, as well as integral indicators of stability (length, velocity and angle of postural oscillations) were taken into account and the equilibrium functions of the two sensory states (open and closed eyes) are calculated in the StabiliS software.&#x0D; Results: purulent otitis media causes posterior displacement of the absolute coordinates of the pressure center. In the state with closed eyes, children with purulent otitis differ from their healthy coevals by 14 of 24 stabilometric parameters, including stabilogram length, speed, angle and amplitude of oscillations, giving way to them in the stability of equilibrium. Children with purulent otitis media are more sensitive to the visual canal of postural control than their coevals. Involvement of visual afferents in postural control significantly improves balance maintenance in children with purulent otitis by reducing deviations of postural oscillations, which is reflected in the probable changes of 9 out of 24 stabilometric parameters compared to control.&#x0D; Conclusions: In preschool age, purulent otitis media leads to latent vestibular dysfunction, which is manifested by a violation of the stability of the vertical posture in a state with closed eyes and is compensated by visual-vestibulo-proprioceptive integration in the process of postural control.

Evaluation of Vestibular Function in Diagnosis of Vestibular Schwannomas.

Vestibular schwannomas (VS) are benign tumors of the vestibular nerve. The common first symptoms are hearing loss and tinnitus, followed by imbalance, vertigo, and facial nerve involvement. The subjective symptoms of VS patients are not consistent with the severity of vestibular lesions and the results of vestibular tests, which often interfere with clinicians' diagnoses. Thus, the main screening and diagnostic methods for VS are audiometry and magnetic resonance imaging (MRI), ignoring the evaluation of vestibular function at the source of pathological lesions. With the development and improvement of vestibular evaluation technology and its wide application in the clinic, modern vestibular examination technology can reflect the severity and frequency of vestibular lesions and compensation from multiple perspectives, providing an objective basis for the diagnosis and treatment of vestibular diseases. In this report, we review the results and characteristics of vestibular tests in VS patients and further clarify the clinical value of vestibular function assessment in the diagnosis and treatment of VS.

Alteration of Vestibular Function in Pediatric Cochlear Implant Recipients.

Background: Vestibular dysfunction is a complication of cochlear implantation (CI). Reports on the evaluation of vestibular function before and after CI are limited, especially in children. We investigated the effect of CI on vestibular function in pediatric patients.Patients and Methods: We routinely evaluated vestibular function before but not immediately after CI. Therefore, patients who underwent sequential bilateral CI were enrolled in this study. Seventy-three children who underwent sequential CI from 2003 to 2020 at our hospital were included. Since the vestibular function of the first implanted ear was evaluated before the second surgery for the contralateral ear, post-CI evaluation timing differed among the cases. The evaluation included a caloric test, a cervical vestibular-evoked myogenic potential (cVEMP) test, and a damped rotation test. The objective variables included the results of these tests, and the explanatory variables included the age at surgery, cause of hearing loss, electrode type, and surgical approach used. The associations of these tests were analyzed.Results: cVEMP was the most affected after CI (36.1%), followed by the caloric test (23.6%), and damped rotation test (7.8%). Cochleostomy was significantly more harmful than a round window (RW) approach or an extended RW approach based on the results of the caloric test (p = 0.035) and damped rotation test (p = 0.029). Perimodiolar electrodes affected the caloric test results greater than straight electrodes (p = 0.041). There were no significant associations among these tests' results.Conclusions: Minimally invasive surgery in children using a round window approach or an extended round window approach with straight electrodes is desirable to preserve vestibular function after CI.

Evaluation of vestibular function following endolymphatic sac surgery.

To evaluate objective vestibular function after endolymphatic sac surgery (ELSS) for Menière's disease (MD), using comparative vestibular function tests: videonystagmography (VNG), vestibular evoked myogenic potentials (VEMP) and video head-impulse test (VHIT) METHODS: Patients with definite MD using the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) of 1995 criteria modified in 2015 and treated with ELSS (sac decompression or sac opening) were included. The primary outcome was the preservation of vestibular function, comparing pre- and postoperative vestibular function tests: VNG, VEMP, VHIT. Secondary outcomes were control of episodes of vertigo, hearing outcome using AAO-HNS criteria, and QoL using the Menière's disease outcome questionnaire. 73 patients were included in the study. We found a significant preservation of vestibular function as measured by VNG and VHIT. There was no statistical difference in the presence or absence of cervical and ocular (P13/N23 and N1/P1) waves on VEMP pre- and postoperatively. 67% of patients had good control of episodes of vertigo post-operatively, with significantly better results in the sac opening group (75%). There was no significant change in hearing postoperatively, and QoL scores were significantly improved after surgery (p < 0.0001). Endolymphatic sac surgery (ELSS) is a conservative surgical treatment, which does not negatively impact vestibular function. It was associated with improved control of episodes of vertigo, preservation of hearing, and a clear improvement in QoL scores. Despite its pathophysiology not being fully understood, it remains a first-line procedure preserving vestibular function, for MD refractory to medical management.

Evaluation of vestibular functions and balance in Edirne Band musicians.

It has been found that intense noise may affect the peripheral vestibular system and consequently causes problems in balance mechanisms. The aim of this study was to investigate the effects of exposure to chronic noise on vestibular functions and balance in Edirne Band musicians. Twenty-two individuals working in the Edirne Band for at least 5 years and a control group of 22 individuals working at Trakya University with similar sociodemographic characteristics were included. The socio-demographic questionnaire was used to inquire about the demographic characteristics of individuals, the ABC Scale to assess how they felt about the balance, and the DHI to determine the quality of life related to dizziness. A 3D ultrasonic system was used to assess the static and dynamic balance of the individuals. There was a statistically significant difference between the band and the control group in terms of longitudinal deviation and self-spin parameters of the Unterberger test, dizziness handicap inventory scores, functional balance according to activity-specific balance confidence scale (p < 0.05). As a result of our study, it has been shown that the balance, quality of life and vestibular system functions are negatively affected in the band exposed to noise for a long time.

Vestibular Function Evaluation in Endemic Diseases Combat Agents

Introduction: Simultaneous exposure to certain chemical agents and noise may cause synergistic, additive or potentiating effects on the auditory and vestibular system. However, there is still a lack of studies investigating simultaneous exposure to pesticides and noise in the vestibular system. Purpose: To analyze the findings of the vestibular evaluation of endemic diseases combat agents when simultaneously exposed to pesticides and noise. Method: Thirty-three male pesticide-exposed and noise-fighting endemic diseases combat agents participated in the study. The age range was 48 to 67 years (mean = 56 years). All participants underwent vestibular examinations, such as positional nystagmus research, spontaneous nystagmus with open and closed eyes, semi-spontaneous nystagmus, optokinetic nystagmus, pendular screening, per rotatory, caloric tests and tonal audiometry. Data were analyzed by descriptive statistics. Results: Altered exams were presented in 36.4% of the cases. There was no statistically significant relationship between pesticide handling time and test results (p = 0.2825). The results of pure tone audiometry correlated significantly (p = 0.0494) with the vestibular exams, as participants who presented with worse hearing thresholds at the frequency of 4000 Hz in the right ear also presented altered results in the vestibular exam. Conclusion: The present study concluded that more than 1/3 of the studied population presented with vestibular dysfunction, which was related to anterior and posterior labyrinth alteration (Cochlear-Vestibular Syndrome). No central vestibular alteration was noted in this population.

Usefulness of the Video Head Impulse Test for the Evaluation of Vestibular Function in Patients With Otitis Media With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis.

To investigate usefulness of the video Head Impulse Test (vHIT) as a method for evaluating semicircular canal function in patients with otitis media with antineutrophil cytoplasmic antibody-associated vasculitis (OMAAV). Retrospective case review. Tertiary referral center. Fourteen patients with OMAAV underwent vestibular examination. The gain in vestibulo-ocular reflex (VOR) and the presence of catch-up saccade were examined for each semicircular canal. Seven (50.0%) of the 14 patients felt subjective symptoms of disequilibrium. Dysfunction in at least one semicircular canal was detected in all ears of the OMAAV patients evaluated by vHIT. Dysfunction in posterior semicircular canal was detected more frequently than that in the anterior or horizontal canal. There were no significant correlations between the gain in VOR and hearing loss. vHIT is thought to be the most suitable method for evaluating semicircular canal function in patients with OMAAV as vHIT is not influenced by middle ear pathology and was able to evaluate vertical canal function including the posterior canal.

Functional Loss After Meningitis-Evaluation of Vestibular Function in Patients With Postmeningitic Hearing Loss.

Introduction: The inner ear vestibular system is essential to balance function. Although hearing loss is well-described and quite common following meningitis, the literature evaluating vestibular function following meningitis is very limited. In particular, information on results of contemporary vestibular function tests, e.g., the video head impulse test (VHIT), is scarce. Using contemporary vestibular function tests, this study examines the vestibular function of patients with profound hearing loss (HL) after meningitis.Methods: Review of the literature and retrospective controlled study.Patients: Twenty-one consecutive patients with profound HL after meningitis (cochlear implant candidates) matched with 20 patients with profound HL of unknown etiology and examined during the period 2013–2018.Outcome Measure: Vestibular function loss, as evaluated with VHIT vestibulo-ocular reflex (VOR) gain, eye movement saccades, and cervical vestibular-evoked myogenic potentials (cVEMPs). The results of these tests were correlated to inner ear imaging findings (MRI/CT) and the level of hearing loss.Results: Mean VHIT gain was 0.48 in the meningitis group compared to 0.86 in the control group (p < 0.01). Saccades were present in 21 ears (62%) in the meningitis group compared to six ears (15%) among the controls (p < 0.01). cVEMP responses were present on five ears (18%) in the meningitis group and 25 ears (66%) in the control group (p < 0.01).Discussion: Postmeningitic hearing loss is associated with poor vestibular function, as evaluated by VHIT, saccades, and cVEMP. Loss of vestibular function correlates with the degree of hearing loss and inner ear imaging findings, although not in all cases. Vestibular function should be examined in patients surviving meningitis with hearing loss in order to individualize rehabilitation and improve balance outcome.

Analysis of prognostic factors of low-frequency type of sudden sensorineural hearing loss

Objective: To investigate the prognostic factors of patients with low-frequency type of sudden sensorineural hearing loss. Methods: From February 2017 to February 2019, adult patients with unilateral low-frequency type of sudden sensorineural hearing loss in Department of Otological Medicine, Shandong Provincial ENT Hospital, Shandong University were selected. All patients were examined by audiology, vestibular function evaluation, imaging examination and serum thyroid function test; the same treatment program was given, the curative effect was recorded and followed up for more than 3 months. SPSS 20.0 software was used to analyze concomitant symptoms (tinnitus, ear tightness, echo, rotatory vertigo), degree of deafness, inducement of deafness, basic disease, vestibular function (caloric test), electrocochleogram, inner ear gadolinium enhanced MRI radiography and thyroid function on prognosis of patients. Results: Among the 155 patients, 76 cases were cured (49.0%), 1 case was markedly effective (0.6%), 19 cases were effective (12.3%), and 59 cases were ineffective (38.1%). The total effective rate was 61.9%. Among them, 24 cases (15.5%) had hearing fluctuations during follow-up, and 1 case (0.6%) developed Meniere's disease. Univariate analysis showed that vestibular function, electrocochleogram and inner ear MRI were correlated with prognosis. Multivariate logistic analysis showed that ear tightness, vestibular function, electrocochleogram and inner ear MRI were correlated with the prognosis of the patients. The two analyses showed that tinnitus, echo, rotational vertigo, degree of deafness, predisposing factors and underlying diseases were not significantly correlated with the prognosis of the patients (all P>0.05). Rotational vertigo was closely related to gender, and women had a high incidence. There was a significant correlation between the degree of deafness and prognosis in patients with course of less than 1 week (P<0.05). The abnormal rate of vestibular function in patients with course of disease ≤ 1 week was significantly different from that>1-≤2 and>2-≤4 weeks (P<0.05). The rate of abnormal thyroid function was significantly higher than that of normal people (P<0.05), but there was no significant correlation between thyroid dysfunction and hearing prognosis (χ(2)=0.009, P=0.923) . Conclusions: The prognosis of low-frequency sudden sensorineural hearing loss is not related to clinical symptoms, inducements, underlying diseases and serological abnormalities of thyroid function, but the degree of deafness is positively related to the prognosis within 1 week from onset. Abnormal thyroid function is one of the risk factors of happening with low-frequency descending sudden deafness. Abnormal vestibular caloric test, electrocochleogram and endolymph hydrops are the factors of poor prognosis.