Positive Head Impulse Test Research Articles

EFFICACY OF POSTURAL STABILTY EXERCISES IN CONTROL OF COMMON VERTIGINOUS SYNDROMES

Vestibular system pathology is the most common cause on Vertigo. Such a peripheral vertigo is classically identied by characteristic clinical proles including a positive Head impulse test (HIT). Defective proprioceptive impulses from muscle spindles and Golgi tendon organs contribute the morbidity of vertigo, by increasing the risk of falls in elderly population leading to for example fracture neck of femur. Postural stability exercises aim to alleviate the symptoms of vertigo and improving the balance, by strengthening the postural reexes. Our study aims to investigate the benets of a 6-week regime of home based/ teleconsultation based Vestibular rehabilitation with a focus on practice of Postural stability exercises. The Visual Analogue Scale (VAS) Vertigo and Dynamic Gait Index (DGI) which an index composed of 8 exercises were measured before and after a 6-week exercise regime. We found that Postural stability exercises help improving the quality of life of patients suffering from myriads of vertiginous syndromes like Vestibular neuritis. Patents report benet of the improved balance. Gait and mobility are also improved which is seen by the increased of the modal Dynamic Gait Index (DGI) score. Increase in condence and improvement in attitude of patients was noted on interview, of all cases after completion of the exercise regime.

Vertigo in Systemic Lupus Erythematosus: A Case Report

Introduction: Systemic lupus erythematosus (SLE) is a chronic inflammatory disease with multiorgan involvement based on an autoimmune process. SLE, although rare, is associated with comorbid vertigo. Vertigo in SLE is caused by a disturbance in the balance system in the inner ear. Few journals discuss SLE related to vertigo. We will report a case SLE with complaints of recurrent vertigo. Case: A-37-year-old woman came with complaints of recurrent vertigo since 1 day ago with a duration of about 15 minutes associated with nausea, vomiting and nystagmus. Patient did not complain tinnitus or hearing disorders. The patient has been diagnosed as SLE since two years ago. The physical examination showed normal and Neuro-otological examination revealed nystagmus horizontal unidirectional, negative skew deviation test, positive Head Impulse Test (HIT). Conclusion: Patients with a diagnosis of SLE can find comorbid peripheral vestibular disorders such as vertigo where there is an antibody mechanism that can damage the inner ear. Treatment of audiovestibular symptoms is usually strongly associated with systemic conditions and in patients with vertigo used betahistine to treatment. Keywords: SLE, Inner Ear, Vertigo.

TP1-9 Vestibular dysfunction in acute traumatic brain injury

ObjectivesVestibular dysfunction following traumatic brain injury (TBI) is a major cause of morbidity and unemployment and has impact on the patient’s ability to rehabilitate. Chronically, up to a quarter of TBI cases have cryptogenic dizziness and imbalance, possibly due to chronic brain adaptation that masks the diagnosis. Establishing the spectrum of vestibular diagnoses in acute TBI – when they may be more obvious – may aid diagnosis in chronic TBI cases.DesignProspective audit of referrals to specialist neuro-otology team.SubjectsConsecutive Major Trauma Ward TBI in-patients admitted between June 2014 and May 2015.MethodsAll cases were screened by the therapists for vestibular symptoms and/or signs and referred for specialist neuro-otology review.ResultsOf 111 patients screened, 96 had features of vestibular dysfunction. Of 96 cases, SYMPTOMS (i.e. subjective report) included: – imbalance (58.3%) – headache (50%) -dizziness (40%) Of 96 cases, SIGNS (i.e. examination) included: – gait ataxia (75.5%) – broken smooth pursuit (61.2%) – positive Hallpike (51%) – positive head impulse test (18%). The data indicate that BPPV affects 49% and headache with migraine-like features affect 40.8%. Acute peripheral unilateral vestibular loss affects 18% TBI cases.ConclusionsVestibular dysfunction in TBI is common, typically involving peripheral and central structures, often in the same case, and requires specialist neuro-otological management.

Central and peripheral vestibular signs simultaneously present in a patient with instability: A case report

Introduction. Cerebellar ataxia, neuropathy, vestibular areflexia syndrome is a rare neurodegenerative disease with instability as the main presenting symptom. Patients with this syndrome often present with central and peripheral vestibular signs. This slowly progressive disease usually starts after 60 years of age and it takes 11 years to diagnose it. Case Report. Here I present a 62-year-old woman with instability lasting for 7 years, but deteriorating in the last two years with two episodes of falls, diplopia when looking to the right, paresthesia in the extremities and clumsiness with hands. Clinical examination revealed dysarthria, positive Romberg test, left hand dysmetria, gaze evoked and downbeat nystagmus, positive head impulse test, absent vestibulo-ocular reflex at video head impulse test, no response to caloric stimulation, no smooth pursuit and dysmetric and prolonged saccades at videonystagmography, positive visually enhanced vestibulo ocular reflex test, normal head magnetic resonance imaging, subclinical signs of polyneuropathy at electroneurography and negative autoimmune and paraneoplastic cerebellar antibodies. Conclusion. Instability is the first symptom in patients with cerebellar ataxia, neuropathy, vestibular areflexia syndrome. Easy to perform, positive visually enhanced vestibulo-ocular reflex test points to a concomitant central and peripheral vestibular disorder. Negative autoimmune and paraneoplastic antibodies rule out other cerebellar diseases. However, normal head magnetic resonance imaging findings without expressed signs of peripheral sensory neuropathy are in concordance with a slowly progressive form of this syndrome.

Recent advances in head impulse test findings in central vestibular disorders.

The head impulse test (HIT) is used to evaluate the vestibulo-ocular reflex (VOR) during a high-velocity head rotation. Corrective catch-up saccades that occur during or after the HITs usually indicate peripheral vestibular hypofunction, whereas in acute vestibular syndrome, normal clinical (bedside) HITs should prompt a search for a central lesion. However, recent quantitative studies that evaluated HITs using magnetic search coils or video-based techniques have demonstrated that specific patterns of HIT abnormalities are associated with central vestibular disorders. While normal clinical HITs are typical of central lesions, discrepancies have been observed between clinical and quantitative HITs. The horizontal head impulse VOR gains can be significantly reduced unilaterally or bilaterally (positive HITs) in lesions involving the vestibular nucleus, nucleus prepositus hypoglossi, or flocculus. In diffuse cerebellar lesions, the VOR gain during horizontal head impulses may increase (hyperactive) with corrective saccades directed the opposite way. The presence of cross-coupled vertical corrective saccades during horizontal HITs is also suggestive of diffuse cerebellar lesions. Lesions involving the vestibular nucleus, medial longitudinal fasciculus, and cerebellum may show decreased or increased gains of the VOR during vertical HITs. Defining the differences in patterns observed during abnormal HITs may help practitioners localize the responsible lesions in both central and peripheral vestibulopathy.

Isolated vestibular nuclear infarction: report of two cases and review of the literature

Cerebral infarction presenting with isolated vertigo remains a diagnostic challenge. To define the clinical characteristics of unilateral infarctions restricted to the vestibular nuclei, two patients with isolated unilateral vestibular nuclear infarction had bedside and laboratory evaluation of the ocular motor and vestibular function, including video-oculography, bithermal caloric irrigation, the head impulse test (HIT) using magnetic scleral coils, and cervical and ocular vestibular-evoked myogenic potentials (VEMPs). We also reviewed the literature on isolated vertigo from lesions restricted to the vestibular nuclei, and analyzed the clinical features of seven additional patients. Both patients showed spontaneous torsional-horizontal nystagmus that beat away from the lesion side, and direction-changing gaze-evoked nystagmus. Recording of HIT using a magnetic search coil system documented decreased gains of the vestibular-ocular reflex for the horizontal and posterior semicircular canals on both sides, but more for the ipsilesional canals. Bithermal caloric tests showed ipsilesional canal paresis in both patients. Cervical and ocular VEMPs showed decreased or absent responses during stimulation of the ipsilesional ear. Initial MRIs including diffusion-weighted images were normal or equivocal, but follow-up imaging disclosed a circumscribed acute infarction in the area of the vestibular nuclei. Infarctions restricted to the vestibular nuclei may present with isolated vertigo with features of both peripheral and central vestibulopathies. Central signs should be sought even in patients with spontaneous horizontal-torsional nystagmus and positive HIT. In patients with combined peripheral and central vestibulopathy, a vestibular nuclear lesion should be considered especially when hearing is preserved.

Bedside Evaluation of Dizzy Patients

In recent decades there has been marked progress in the imaging and laboratory evaluation of dizzy patients. However, detailed history taking and comprehensive bedside neurotological evaluation remain crucial for a diagnosis of dizziness. Bedside neurotological evaluation should include examinations for ocular alignment, spontaneous and gaze-evoked nystagmus, the vestibulo-ocular reflex, saccades, smooth pursuit, and balance. In patients with acute spontaneous vertigo, negative head impulse test, direction-changing nystagmus, and skew deviation mostly indicate central vestibular disorders. In contrast, patients with unilateral peripheral deafferentation invariably have a positive head impulse test and mixed horizontal-torsional nystagmus beating away from the lesion side. Since suppression by visual fixation is the rule in peripheral nystagmus and is frequent even in central nystagmus, removal of visual fixation using Frenzel glasses is required for the proper evaluation of central as well as peripheral nystagmus. Head-shaking, cranial vibration, hyperventilation, pressure to the external auditory canal, and loud sounds may disclose underlying vestibular dysfunction by inducing nystagmus or modulating the spontaneous nystagmus. In patients with positional vertigo, the diagnosis can be made by determining patterns of the nystagmus induced during various positional maneuvers that include straight head hanging, the Dix-Hallpike maneuver, supine head roll, and head turning and bending while sitting. Abnormal smooth pursuit and saccades, and severe imbalance also indicate central pathologies. Physicians should be familiar with bedside neurotological examinations and be aware of the clinical implications of the findings when evaluating dizzy patients.

Clinical diagnosis of bilateral vestibular loss: three simple bedside tests

Bilateral vestibular loss (BVL) may present with or without vertigo and hearing loss. Amongst the causes of BVL are vestibulotoxic antibiotics, autoimmune ear diseases, Menière's disease and meningitis. Clinical diagnosis of BVL is based on the result of three simple bedside tests: a positive head impulse test, reduced dynamic visual acuity and a positive Romberg test on foam rubber. With these signs, diagnosis of severe BVL is usually straightforward to establish.

Isolated Vestibular Nucleus Infarction Mimicking Acute Peripheral Vestibulopathy

Although several articles have been published on central vestibular syndrome mimicking acute peripheral vestibulopathy (ie, pseudo-acute peripheral vestibulopathy), there are no reports of a brainstem infarct that selectively involves the vestibular nucleus and causes isolated vertigo. We report a patient with an isolated vestibular nucleus infarction who presented with isolated prolonged vertigo, spontaneous horizontal nystagmus with a torsional component, a positive head impulse test result, and unilateral canal paresis to caloric stimulation. This is the first report of pseudo-acute peripheral vestibulopathy associated with isolated vestibular nucleus infarction. Isolated vestibular nucleus infarction should be considered in the differential diagnosis of central vascular vertigo syndrome, especially when the patient has unilateral canal paresis but without other neurologic symptoms or signs.

Correlation between vestibular function and hip fracture following falls in the elderly: a case-controlled study

Objective To examine vestibular function following falls in the elderly. Design A case-controlled study to compare vestibular function in elderly people with hip fractures and elderly people with no prior hip fractures. Participants One hundred and sixty-nine people aged 65 years or older took part in the study. Study Group A consisted of 84 hospitalised volunteers who had received hip surgery due to a fall and who were undergoing rehabilitation. Control Group B consisted of 85 volunteers from retirement homes with no prior history of hip fracture. Intervention All participants underwent four clinical tests to determine their level of vestibular functioning in order to allow comparison between the groups. Three methods were used to test the vestibulo-ocular reflex (VOR), and one method was used to test benign paroxysmal positional vertigo. Results Thirty-eight percent of the participants in Study Group A and 11% of the participants in Control Group B demonstrated a positive visual acuity test ( P < 0.001). The odds ratio suggests that the participants of Study Group A were 4.83 [95% confidence interval (CI) 2.1 to 11.0] times more likely to present a positive static and dynamic visual acuity test than the participants of Control Group B, and 3.12 (95% CI 1.62 to 6.02) times more likely to have a positive head impulse test. There were no differences in the head shaking nystagmus test or the Dix-Hallpike test between groups, and no association between the side of the fracture and the side of the vestibular impairment. Conclusions Study Group A exhibited greater VOR impairment than Control Group B. Therefore, impairment of this reflex may be considered as a risk factor for falls.

VESTIBULAR EVALUATION IN INDIVIDUALS WITH MILD BRAIN INJURY.

Purpose/Hypothesis: Clients with mild brain injuries (MBI) are susceptible to vestibular dysfunction. The Dizziness Handicap Inventory (DHI), Sensory Organization Testing (SOT), Dynamic Gait Index (DGI), Dix-Hallpike Maneuver (DHM), and Head-Impulse Test (HIT) are objective vestibular examination measures that have been validated in subjects with vestibular pathologies. Research utilizing these tests to examine the prevalence of vestibular dysfunction post-MBI and assessing the validity of these measures in clients with MBI is lacking. The primary purpose of this descriptive study was to investigate the application of objective measures to examine the incidence of vestibular dysfunction in clients with MBI and secondly, to examine the concurrent validity of the DGI with SOT and DHI scores in clients with MBI. Number of Subjects: Fifteen subjects with diagnosis of MBI with onset < 6 months were recruited from MBI outpatient clinic. Mean age was 40 years (range 19–78) and mean time post-injury was 69 days (range 12–167). Subjects were excluded if they had spinal or extremity injuries that contraindicated test administration or previous neurologic diagnoses. Materials/Methods: The DHI, SOT, DGI, DHM, and HIT were administered in controlled order to subjects over two sessions. The DHI was used to quantify subjects' self report of dizziness. SOT was used to assess the use of sensory inputs for balance, specifically vestibular input. The DGI was used to evaluate subjects' functional balance during gait tasks. The DHM and HIT were administered to detect BPPV and vestibulo-ocular function, respectively. Descriptive statistics were used to examine the sample's score distribution for each test and Pearson correlation was used to examine the relationship between tests. Results: The mean score on the DHI was 50 (IQR 35–72), with 60% of scores being 50 or higher. The mean SOT composite balance score was 61.1 (IQR 54.5–71.0), with 73.3% of subjects falling below their normative age group scores. Forty-six percent of subjects were determined to have difficulty using vestibular input to maintain balance. The mean score on the DGI was 19 (IQR 16.5–22.0), with 53.3% of subjects in a fall risk category. Two subjects had positive DHM results and 3 subjects had positive HIT results. A significant good correlation (r = −0.795) was found between DHI and DGI scores, indicating that subjective vestibular symptoms were related to subjects' functional balance deficits. Conclusions: These findings demonstrate that vestibular dysfunction is prevalent in clients with MBI. The DHI, DGI, and SOT findings detected a large percentage of subjects with vestibular impairment, demonstrating the validity of vestibular testing in MBI. Clinical Relevance: Individuals who experience MBI should be screened for vestibular dysfunction. In this study the DHI demonstrated sensitivity in measuring self-reported vestibular symptoms, which correlated with subjects' functional balance scores. The DGI and SOT were valid measures for detecting balance dysfunction in MBI.