Neurovascular Compression Syndrome Research Articles

A case of cerebellopontine angle meningioma presenting as neurovascular compression syndrome of the 8th cranial nerve

A 54-year-old female patient presented with paroxysmal tinnitus and vertigo for 2 years, which have repeatedly occurred while rotating her neck, and lasted about 10 seconds. An anticonvulsant medication was prescribed with a diagnosis of microvascular compression syndrome on the 8th cranial nerve and audiovestibular evaluation and magnetic resonance imaging (MRI) scan were appointed a week later. In her next visit, she reported the disappearance of paroxysmal audiovestibular symptoms after medication. In the left ear, canal paresis and abnormal auditory brainstem response were observed. In MRI, a large meningioma in the cerebellopontine angle in the vicinity of the internal auditory canal orifice was detected, that was surgically resected by a neurosurgeon. After surgical removal of the tumor, she reported continuous dizziness due to vestibular nerve injury, but the paroxysmal attack of tinnitus and vertigo disappeared without anticonvulsant medication. This case suggests that an imaging study is mandatory when diagnosing microvascular compression syndrome on the 8th cranial nerve.

The Anterior Inferior Cerebral Artery Variability in the Context of Neurovascular Compression Syndromes: A Narrative Review.

The anterior inferior cerebellar artery (AICA) is situated within the posterior cranial fossa and typically arises from the basilar artery, usually at the pontomedullary junction. AICA is implicated in various clinical conditions, encompassing the development of aneurysms, thrombus formation, and the manifestation of lateral pontine syndrome. Furthermore, owing to its close proximity to cranial nerves within the middle cerebellopontine angle, AICA's pulsatile compression at the root entry/exit zone of cranial nerves may give rise to specific neurovascular compression syndromes (NVCs), including hemifacial spasm (HFS) and geniculate neuralgia concurrent with HFS. In this narrative review, we undertake an examination of the influence of anatomical variations in AICA on the occurrence of NVCs. Significant methodological disparities between cadaveric and radiological studies (CTA, MRA, and DSA) were found, particularly in diagnosing AICA's absence, which was more common in radiological studies (up to 36.1%) compared to cadaver studies (less than 5%). Other observed variations included atypical origins from the vertebral artery and basilar-vertebral junction, as well as the AICA-and-PICA common trunk. Single cases of arterial triplication or fenestration have also been documented. Specifically, in relation to HFS, AICA variants that compress the facial nerve at its root entry/exit zone include parabola-shaped loops, dominant segments proximal to the REZ, and anchor-shaped bifurcations impacting the nerve's cisternal portion.

Posterior Fossa Anatomy for Microvascular Decompression Surgery

In most microvascular decompression surgeries, surgical maneuvers are performed within normal anatomical structures without any neoplasms. Thus, detailed anatomical knowledge is essential to perform safe and efficient procedures. "Rule of 3" by Rhoton AL Jr. is helpful for understanding not only the anatomy of the posterior fossa but also the three neurovascular compression syndromes. The cerebellar arteries and posterior fossa veins have substantial variability, but a basic understanding of their typical patterns is useful to explore individual cases. To use adequate surgical approaches through the cerebellar tentorial or petrosal surface in individual trigeminal neuralgia surgeries, anatomical knowledge of the bridging veins on the tentorial(the bridging veins into the tentorial sinus)and petrosal surfaces(the superior petrosal vein)is crucial. Fissure openings help to minimize cerebellar retraction, similarly to the sylvian fissure dissection in supratentorial surgeries.

Fully endoscopic microvascular decompression for the treatment of hemifacial spasm, trigeminal neuralgia, and glossopharyngeal neuralgia: a retrospective study

BackgroundMicrovascular decompression (MVD) is already the preferred surgical treatment for medically refractory neurovascular compression syndromes (NVC) such as hemifacial spasm (HFS), trigeminal neuralgia (TN), and glossopharyngeal neuralgia (GPN). Endoscopy has significantly advanced surgery and provides enhanced visualization of MVD. The aim of this study is to analyze the efficacy and safety of fully endoscopic microvascular decompression (E-MVD) for the treatment of HFS, TN, and GPN, as well as to present our initial experience.Materials and methodsThis retrospective case series investigated fully E-MVD performed in 248 patients (123 patients with HFS, 115 patients with TN, and 10 patients with GPN ) from December 2008 to October 2021 at a single institution. The operation duration, clinical outcomes, responsible vessels, intra- and postoperative complications, and recurrences were recorded. Preoperative and immediate postoperative magnetic resonance imaging (MRI) and computerized tomography (CT) were performed for imageological evaluation. The Shorr grading and Barrow Neurological Institute (BNI) pain score were used to evaluate clinical outcomes. The efficacy, safety, and risk factors related to the recurrence of the operation were retrospectively analysed, and the surgical techniques of fully E-MVD were summarised.ResultsA total of 248 patients (103 males) met the inclusion criteria and underwent fully E-MVD were retrospectively studied. The effective rate of 123 patients with HFS was 99.1%, of which 113 cases were completely relieved and 9 cases were significantly relieved. The effective rate of 115 patients with TN was 98.9%, of which 105 cases had completely pain relieved after surgery, 5 cases had significant pain relieved, 4 cases had partial pain relieved but still needed to be controlled by medication. The effective rate of 10 patients with GPN was 100%, 10 cases of GPN were completely relieved after surgery. As for complications, temporary facial numbness occurred in 4 cases, temporary hearing loss in 5 cases, dizziness with frequent nausea and vomiting in 8 cases, headache in 12 cases, and no cerebral hemorrhage, intracranial infection, and other complications occurred. Follow-up ranged from 3 to 42 months, with a mean of 18.6 ± 3.3 months. There were 4 cases of recurrence of HFS and 11 cases of recurrence of TN. The other effective patients had no recurrence or worsening of postoperative symptoms. The cerebellopontine angle (CPA) area ratio (healthy/affected side), the length of disease duration, and the type of responsible vessels are the risk factors related to the recurrence of HFS, TN, and GPN treated by fully E-MVD.ConclusionsIn this retrospective study, our results suggest that the fully E-MVD for the treatment of NVC such as HFS, TN, and GPN, is a safe and effective surgical method. Fully E-MVD for the treatment of NVC has advantages and techniques not available with microscopic MVD, which may reduce the incidence of surgical complications while improving the curative effect and reducing the recurrence rate.

Microanatomy of the central myelin portion and transitional zone of the oculomotor and abducens nerves.

The microanatomy of the central myelin portion and transitional zone of several cranial nerves including trigeminal, facial, vestibulocochlear, glossopharyngeal, and vagus nerves have been clearly demonstrated to provide information for neurovascular compression syndrome such as trigeminal neuralgia and hemifacial spasm. However, the study of oculomotor and abducens nerve is limited. Oculomotor and abducens nerves were harvested with a portion of brainstem and embedded in paraffin. Longitudinal and serial sections from ten of each cranial nerve were stained and a photomicrograph was taken to make the following observations and measurements: 1) patterns of central myelin portion, 2) length of central myelin portion, and 3) depth of central myelin- peripheral myelin transitional zone. For oculomotor nerve, the longest central myelin bundle was always seen on the first nerve bundle and that the length of central myelin decreased gradually. For abducens nerve, morphological patterns were classified into four types based on number of nerve rootlets emerging from the brainstem and number of nerve bundles in each rootlet. Length of central myelin portion was between 0.36-6.10 mm (2.75 ± 0.83 mm) and 0.13-5.01 mm (1.66 ± 1.39 mm) for oculomotor and abducens nerves, respectively. The oculomotor nerve transitional zone depth was 0.07-058 mm (0.23 ± 0.07 mm), while for abducens nerve, depth was 0.05-0.40 mm (0.16 ± 0.07 mm). Positive weak correlations between central myelin and depth of TZ were found in oculomotor nerve (r +0.310, p < 0.05) and abducens nerves (r +0.413, p < 0.05). Detailed microanatomy of the central myelin and transitional zone might be beneficial for locating the site of compression in neurovascular conflicts at oculomotor and abducens nerves.

P.099 A novel electrophysiologic reflex in neurovascular compression syndromes serving as a marker of pain resolution

Background: Radiofrequency rhizotomy is a commonly used percutaneous technique for treatment of trigeminal neuralgia especially in cases not eligible for microvascular decompression. This technique is usually performed with the patient under conscious sedation. We devised a method for performance of this technique under general anesthetic with neurophysiology monitoring. Methods: The patient is put under general anaesthetic and EMG monitoring is set up. Needles are placed in temporalis muscle, masseter and mylohyoid or anterior belly of digastric. Resting activityis monitored. Rhizotomy is then performed under fluoroscopic guidance, with monitoring of EMG potentials pre- and post-lesioning, with specific attention paid to presence of an abnormal electrophysiologic reflex. Results: A total of 38 procedures were performed in 23 patients. Of these, 15 were revision procedures. Patients had improvement from BNI pain scale 3.8 ±0.8 to 1.3 ±1.5, and had a reduction in number of medications from 1.9 ±1.0 to 0.8 ±0.9. Survey results indicate greater practitioner satisfaction with this technique. Conclusions: Radiofrequency rhizotomy can be performed under GA with IONM guidance with good results. We present a novel method for EMG-based monitoring. Further study is required to validate this technique.

Preoperative Frailty Predicts Worse Outcomes after Microvascular Decompression for Trigeminal Neuralgia, Hemifacial Spasm, and Glossopharyngeal Neuralgia: A Multicenter Analysis of 1,473 Patients from a Prospective Surgical Registry

Introduction: Microvascular decompression (MVD) is an efficacious neurosurgical intervention for patients with medically intractable neurovascular compression syndromes. However, MVD may occasionally cause life-threatening or altering complications, particularly in patients unfit for surgical operations. Recent literature suggests a lack of association between chronological age and surgical outcomes for MVD. The Risk Analysis Index (RAI) is a validated frailty tool for surgical populations (both clinical and large database). The present study sought to evaluate the prognostic ability of frailty, as measured by RAI, to predict outcomes for patients undergoing MVD from a large multicenter surgical registry. Methods: The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database (2011–2020) was queried using diagnosis/procedure codes for patients undergoing MVD procedures for trigeminal neuralgia (n = 1,211), hemifacial spasm (n = 236), or glossopharyngeal neuralgia (n = 26). The relationship between preoperative frailty (measured by RAI and 5-factor modified frailty index [mFI-5]) for primary endpoint of adverse discharge outcome (AD) was analyzed. AD was defined as discharge to a facility which was not home, hospice, or death within 30 days. Discriminatory accuracy for prediction of AD was assessed by computation of C-statistics (with 95% confidence interval) from receiver operating characteristic (ROC) curve analysis. Results: Patients undergoing MVD (N = 1,473) were stratified by RAI frailty bins: 71% with RAI 0–20, 28% with RAI 21–30, and 1.2% with RAI 31+. Compared to RAI score 19 and below, RAI 20 and above had significantly higher rates of postoperative major complications (2.8% vs. 1.1%, p = 0.01), Clavien-Dindo grade IV complications (2.8% vs. 0.7%, p = 0.001), and AD (6.1% vs. 1.0%, p < 0.001). The rate of primary endpoint was 2.4% (N = 36) and was positively associated with increasing frailty tier: 1.5% in 0–20, 5.8% in 21–30, and 11.8% in 31+. RAI score demonstrated excellent discriminatory accuracy for primary endpoint in ROC analysis (C-statistic: 0.77, 95% CI: 0.74–0.79) and demonstrated superior discrimination compared to mFI-5 (C-statistic: 0.64, 95% CI: 0.61–0.66) (DeLong pairwise test, p = 0.003). Conclusions: This was the first study to link preoperative frailty to worse surgical outcomes after MVD surgery. RAI frailty score predicts AD after MVD with excellent discrimination and holds promise for preoperative counseling and risk stratification of surgical candidates. A risk assessment tool was developed and deployed with a user-friendly calculator: <ext-link ext-link-type="uri" xlink:href="https://nsgyfrailtyoutcomeslab.shinyapps.io/microvascularDecompression" xmlns:xlink="http://www.w3.org/1999/xlink">https://nsgyfrailtyoutcomeslab.shinyapps.io/microvascularDecompression</ext-link>.

Correlation of Preoperative High-Resolution Neurovascular Imaging and Surgical Success in Neurovascular Compression Syndromes.

Neurovascular compression syndromes (NVCSs) are a group of neurological disorders characterized by compression of a cranial nerve and include trigeminal neuralgia (TN), hemifacial spasm, geniculate neuralgia, glossopharyngeal neuralgia, vestibular paroxysmia, and trochlear palsy. The European Academy of Neurology recommends constructive interference in steady-state/fast imaging employing steady-state (CISS/FIESTA) magnetic resonance imaging (MRI) in the evaluation of medically intractable TN, but similar recommendations do not exist for the remaining NVCSs. We conducted a retrospective chart review of 300 patients with an NVCS who underwent microvascular decompression (MVD) by a single neurosurgeon from 2004 to 2021. Data were collected on preoperative diagnosis, pre- and postoperative symptoms, presence/absence of preoperative high-spatial-resolution CISS/FIESTA MRI, and intraoperative findings. Rates of symptomatic improvement were used as a correlate of surgical success. The rate of symptomatic improvement in the patients with a preoperative CISS/FIESTA MRI was 5.8% greater than those without preoperative high-spatial-resolution neuroimaging (98.8% vs. 93%, respectively; P= 0.008). Stratified by diagnosis, patients with TN had the greatest difference in surgical success between the 2 groups (99.3% vs. 92.9%, n= 268; P= 0.006). No statistically significant differences were observed in the other NVCSs, although positive trends were noted. Preoperative CISS/FIESTA MRI correlated with greater rates of surgical success in cases of medically intractable TN; however, definitive conclusions could not be made regarding the remaining NVCSs. We support the recommendation that this imaging modality be included as part of the standard of practice for the evaluation and management of TN and encourage future studies to further elucidate this relationship for the less common NVCSs using a larger cohort.

Suprafloccular transhorizontal fissure approach to the cerebellopontine angle: an anatomical study with case series.

The suprafloccular transhorizontal fissure approach is a modified variant of the classical retrosigmoid approach option to be chosen for cerebellopontine angle lesions. In this study, we aimed to demonstrate a previously described but not widely used method, the suprafloccular transhorizontal fissure approach with anatomical dissection on the cadaver, accompanied by a case presentation with the largest clinical series in the literature. Klingler's protocol was used to prepare 8 silicone injected and 8 non-silicone injected human hemispheres. A total of 210 patients who underwent surgery in the cerebellopontine angle between 2019 and 2022 were evaluated in our clinic. Of these, the suprafloccular transhorizontal fissure approach was applied in 33 patient, and it was successful in 26 patient, but this approach could not be achieved in 7 patients. The transhorizontal fissure is a fissure in the cerebellum located between the superior semilunar lobule and the inferior semilunar lobule. In the 26 patients we operated with the suprafloccular transhorizontal fissure approach, there was no need for retraction and no complications developed. However, in 7 patients, this fissure could not be dissected due to adhesions. Suprafloccular approach is an alternative to the classical retrosigmoid approach in tumours smaller than 2 cm, medially localised with little cerebellar oedema and neurovascular compression syndrome. Because in this approach, no cerebellum retraction is required, vascular structures are better preserved and the surgical time is shortened. This approach can be applied in smaller tumours than 2 cm when the sulcal anatomy is appropriate.

Combined four neurovascular compression syndromes: the first case report and literature review

BackgroundNeurovascular compression syndromes (NVCs) are cranial nerve syndromes caused by direct contact or compression of vascular structures on the cranial nerves at the root exit/entry zone. Cases of combined NVCs are extremely rare.CaseWe reported the first case of a 41-year-old woman with combined four NVCs presenting with left hemifacial spasm followed by simultaneous left glossopharyngeal neuralgia, left type-writer tinnitus and vestibular paroxysmia due to the left posterior inferior cerebellar artery compression at the root exit/entry of the left facial, vestibulocochlear and glossopharyngeal nerves. All the symptoms resolved immediately after microvascular decompression without recurrence in a period of follow-up for one year. In addition, we presented a literature review of combined three or more NVCs.ConclusionWe discussed the hypothesis of combined three or more NVCs development, especially the central hyperactivity of the cranial nerve nuclei mechanism.

PICA ischemic stroke

The posterior inferior cerebellar artery (PICA) has a unique anatomical complexity, which is of great clinical importance and is involved in many pathologies, such as aneurysm, ischemic stroke, neurovascular compression syndrome (NVCS), arteriovenous malformation (AVM) and brain tumour (1).&#x0D; PICA has a sinuous and variable trajectory, divided into 5 segments. PICA infarction usually manifests lateral bulbar syndrome and is more likely to cause mass effects. PICA frequently compresses the bulb and cranial nerves, resulting in various neurovascular compression syndromes (NVCS) (2).&#x0D; The ischemic stroke caused by thromboembolism in the PICA segment is accounted for more than 2% of all cases of ischemic stroke (3). Moreover, it tends to be underdiagnosed due to the symptomatology, represented usually by vertigo which mimics a possible peripheral vestibulopathy (4).

Neurovascular Compression Syndromes: A Pictorial Essay

Neurovascular compression syndromes are typically brought on by arteries that come into contact with a cranial nerve’s (CN) cisternal section. Neurovascular contact does not always present with clinical symptoms. The most susceptible area for symptomatic neurovascular compression syndromes is the transitional zone between the peripheral and central myelin. Individual CN functional abnormalities are the clinical hallmark of neurovascular compression disorders. We present a series of four cases of patients presenting to a tertiary care center in Central India with symptoms and signs of neurovascular compression syndrome.

A Case of Neurovascular Compression Syndrome Confirmed by the Finding of Nystagmus During a Vertigo Attack

A Case of Neurovascular Compression Syndrome Confirmed by the Finding of Nystagmus During a Vertigo Attack

Increased cerebrospinal fluid S100B protein levels in patients with trigeminal neuralgia and hemifacial spasm.

The pathophysiology of neurovascular compression syndrome has not been fully elucidated, and cerebrospinal fluid levels of nerve tissue-related markers involved in this disorder have not yet been reported. We measured cerebrospinal fluid levels of S100B protein, neuron-specific enolase, and myelin basic protein in 21 patients with trigeminal neuralgia, 9 patients with hemifacial spasms, and 10 patients with non-ruptured intracranial aneurysms (control). Cerebrospinal fluid levels of these markers were determined using commercially available assay kits. Both trigeminal neuralgia and hemifacial spasm groups showed significantly increased cerebrospinal fluid levels of S100B compared with the control group (1120 [IQR 391-1420], 766 [IQR 583-1500], and 255 [IQR 190-285] pg/mL, respectively; p = 0.001). There were no statistically significant differences in cerebrospinal fluid levels of neuron-specific enolase or myelin basic protein among the groups. Cerebrospinal fluid S100B levels were significantly higher in patients with trigeminal neuralgia and hemifacial spasm than in controls, which suggests the involvement of S100B in the underlying pathophysiology of neurovascular compression syndrome.

Oculomotor nerve segment between proximal posterior and superior cerebellar arteries: an MRI study.

No study has documented the oculomotor nerve (OMN) segment lying between the posterior cerebral (PCA) and superior cerebellar (SCA) arteries adjacent to the brainstem. The present study aimed to characterize it. A total of 71 patients underwent thin-sliced, sagittal T2-weighted magnetic resonance imaging for analysis. The OMN segments lying between the PCA and SCA were identified in all patients. The OMN segment in relation to the PCA and SCA was classified into five types. Of them, the PCA-OMN contact type was the most frequent and found in 35.2% of 71 sides on the right and 39.4% on the left. Also, the PCA-OMN compression type was identified in 12.7% on the right and 15.5% on the left. In these types, the mean distance between the brainstem and contact/compression sites were measured 4.4 ± 2.3mm on the right and 4.4 ± 1.6mm on the left. In more than forty percent, the sites were located at the level of the pontomesencephalic junction. The OMN may be frequently in contact with the PCA near the brainstem. The site located more distal than the central-peripheral myelin junction of the OMN can attribute to a low frequency of neurovascular compression syndrome of the nerve.

Microvascular triple decompression for combined simultaneous trigeminal neuralgia, hemifacial spasm, and pulsatile tinnitus due to separate offending vessels

Neurovascular compression syndrome is generally caused by vascular compression at the root entry or exit zone of the corresponding cranial nerve. Trigeminal neuralgia is the most frequent syndrome, followed by hemifacial spasm. Despite ongoing debate in the literature, pulsatile tinnitus is also known to be a neurovascular compression syndrome resulting from vascular compression of the vestibulocochlear nerve. Combined manifestations of neurovascular compression symptoms are very rare. We report a case with a simultaneous manifestation of trigeminal neuralgia, hemifacial spasm, and pulsatile tinnitus as neurovascular compression syndrome with separate offending vessels. A 53-year-old female presented with lancinating pain in the left face, left hemifacial spasm, and ipsilateral pulsatile tinnitus for 2 years. Trigeminal neuralgia and hemifacial spasm were diagnosed after a neurological examination, imaging study, and electromyography. Microvascular decompression via a retrosigmoid approach for separate offenders, including the superior cerebellar artery, anterior inferior cerebellar artery, and posterior inferior cerebellar artery was performed using Teflon sponges. The patient’s hemifacial spasm, pulsatile tinnitus, and hemifacial pain improved immediately after microvascular decompression.

Coexistence of neurovascular compression syndrome and unruptured cerebral aneurysm

Unruptured cerebral aneurysms (UCAs) are usually asymptomatic and detected incidentally by intracranial examinations. The coexistence of neurovascular compression syndrome (NVCS) and UCAs has not been well described. The aim of this study was to clarify the characteristics of UCAs with the NVCS. A total of 103 cases that underwent microvascular decompression (MVD) for trigeminal neuralgia (TN) or hemifacial spasm (HFS) were assigned to the NVCS group. The prevalence of UCAs in the NVCS group was compared retrospectively to that in 110 control cases (a control group) by neuro-imaging. Overall treatment courses for NVCS and UCAs were investigated in the NVCS group. Sixteen (15.3%; TN 11 cases, HFS 5 cases) of 103 MVD cases had 19 UCAs, a significantly higher prevalence than the 3.6% in the control group. Binomial logistic regression showed that NVCS is a significant factor for predicting the presence of UCAs, with an odds ratio of 4.80. In the NVCS group, 18 UCAs (94.7%) were supratentorial aneurysms, and 17 UCAs (89.5%) were less than 5 mm in size. Nine UCAs were surgically treated with clipping or coiling. Of the surgical cases, 2 UCAs were treated before MVD for NVCS, whereas the other 7 UCAs were treated after MVD. No aneurysms ruptured during the treatment course. The NVCS occurred with UCAs at a significantly higher rate than in the control group. Most UCAs with the NVCS were supratentorial, small aneurysms that did not affect the surgical treatment of NVCS.

A Case Series on Morphological Variations of Biceps Brachii in Adult Human Cadavers and its Clinical Implications

Biceps brachii, a powerful forearm supinator, is a muscle in which many anatomical variations have been reported. Biceps brachii anomalies may play an important role in neurovascular compression syndromes in the arm and also affect shoulder joint movements. Three significant morphological variations in Biceps brachii were noted during routine dissection of upper limbs used for undergraduate teaching purposes. An extra articular origin of tendon of long head of Biceps brachii which was passing through the subpectoral tunnel formed by Pectoralis major was observed in one right upper limb. Nonfusion of two bellies of Biceps brachii with an accessory bicipital tendon was observed in one right upper limb. Presence of one supernumerary head of Biceps Brachii with a communicating branch between Median and Musculocutaneous nerves was observed in one right upper limb. Knowledge of these variations is essential for Surgeons and Orthopaedicians during surgery involving shoulder, arm and elbow regions. Key words: Biceps brachii, Supernumerary heads, Extra articular.

Neurovascular Compression in the Anterior Visual Pathway: A Case Series.

A retrospective review of 29 patients with neurovascular compression syndrome (NVCS) involving the anterior visual pathway was conducted. Various patterns of NVCS and visual defects were identified, most commonly involving the optic nerve and internal carotid artery. Most patients were stable, except one with progressive visual field defects. Although mostly asymptomatic, NVCS can rarely cause compressive optic neuropathy. NVCS should be kept in the differential diagnosis of normal tension glaucoma, especially with progressive visual loss despite treatment. Patients with progressive visual loss may require decompression surgery. Non-contrast computed tomography scan may miss NVCS, and magnetic resonance imaging is diagnostic.

Vestibular paroxysmia: clinical characteristics and long-term course

In 2016, the Bárány Society defined new diagnostic criteria for the neurovascular compression syndrome of the eighth nerve, called “vestibular paroxysmia” (VP), differentiating between definite (dVP) and probable (pVP) forms. The aim of this study was (1) to describe clinical symptoms and laboratory findings in a well-diagnosed large patient cohort according to those criteria, and (2) to evaluate the long-term course over years in dVP. We identified 146 patients (73 dVP, 73 pVP) from our tertiary dizziness center registry. Data of structured history-taking, clinical neurological, neuro-ophthalmological/-otological examinations as well as MRI imaging were extracted for analyses. Overall, attack frequency ranged between 5 and 30 attacks per day; spinning vertigo was the most frequent type. In two-thirds of patients, attacks occurred spontaneously; in one-quarter, they were triggered by head movements. The majority (approximately 70%) reported no accompanying symptoms; in those with symptoms, mild unilateral cochlear symptoms prevailed. One-third of patients initially showed hyperventilation-induced nystagmus without specific direction, and a deviation of the subjective visual vertical between 3° and 6°. Complete loss of peripheral vestibular function was never evident. dVP and pVP significantly differed concerning the vertigo type, e.g., spinning vertigo was more frequent in dVP. Fortunately, three-quarters of dVP patients remained attack-free during follow-up (mean 4.8 years, standardized questionnaire), more than half of them even without any medication. Patients with ongoing attacks showed significantly higher attack frequency at baseline, but reported persistent frequency reduction. Overall, the long-term prognosis of VP appears favorable, not necessarily requiring ongoing treatment.