Vertiginous Patients Research Articles

抑うつ傾向を伴うめまい症例に対するパロキセチンの効果

Patients with vertigo caused by psychological problems have increased in recent years. It has been reported that many outpatients with vertigo also suffer from depression. Selective serotonin reuptake inhibitors are widely used for the treatment of depression because of their efficacy and relatively favorable side-effects profile compared to those of tricyclic antidepressants. We used Paroxetine to treat patients with vertigo who were diagnosed with depression by self-rating questionnaires for depression (SRQ-D). Twenty-six patients experienced relief after taking Paroxetine. Fifteen of them were relieved of their vertigo symptoms, 8 were improved, one was not changed, and two were worse. SRQ-D scores were compared between the day of commencement and the day after 4 weeks. Fifteen patients were normalized. Side effects occurred in seven patients; nausea in five and sleepiness in two. The average duration of taking the medicine was 24.4 weeks. Since Paroxetine showed beneficial clinical effects for patients with vertigo, this medicine might be useful for vertiginous patients with depression.

緊急入院を要しためまい症例の検討

We analyzed 173 emergency patients with acute vertigo who were admitted to the department of otolaryngology, Tokyo Medical University, from January 1999 to December 2003.The hospitalized patients were 4.6% of all vertiginous patients. The most frequent diagnosis was vestibular neuritis, followed by other vestibular lesion, and Meniere's disease. Vertigo with no remarkable finding was 12.1%. We experienced 10 central disorders (5.8%).The 90% of central vertigo was angiopathy. Brain CT was taken in all patients with infarction, but all showed normal images. Brain MRI was mandatory for making diagnosis of brain infarction. High blood pressure was most frequently associated (70.0%) with central vertigo.

Migraine‐Related Vertigo: Diagnostic Criteria and Prophylactic Treatment

The objective of this prospective, observational study was to evaluate the efficacy of migraine pharmacologic prophylaxis on a group of vertiginous patients considered affected by migraine-related vertigo on the basis of precise criteria of inclusion. Fifty-three patients affected by migraine-related vertigo were selected from a cohort of 652 vertiginous patients referred to our Dizziness Unit from March 2001 to June 2005. Inclusion criteria were at least five vertigo attacks occurred in any period of time or dizziness and/or positional vertigo for at least 6 months; migraine, past or present, and/or a family history of migraine and/or motion intolerance; and exclusion of other causes. Patients were submitted to migraine pharmacologic prophylaxis selected on the basis of the characteristics of the patients and of the drug side effects. The efficacy of the treatment was evaluated after 6 months by questionnaire divided into five outcome categories (resolution, substantial control, moderate control, minimal control, no improvement or worsening) and, for the patients with recurrent vertiginous attacks, also reporting the percentage reduction of the attack frequency. Thirty-six patients completed the study and were submitted to analysis of the results: 10 reported complete resolution of symptoms, 15 substantial control, 7 moderate control, one minimum control and 3 no improvement. Thirty-three of them had recurrent vertigo: 19 reported complete disappearance of the attacks, 8 reduction of the frequency >50%, 5 reduction <50%, and one no reduction. Migraine prophylactic treatment shows encouraging results in patients with migraine-related vertigo selected with our criteria of inclusion: 69.3% reported satisfactory control of symptoms (sum of complete resolutions and substantial controls) and 81.8% had at least a 50% reduction of the vertiginous episodes frequency.

めまい患者における東洋医学的気血水の検討

Japanese traditional medical diagnosis using Ki-Ketsu-Sui in vertiginous patients was examined. Among all parameters, the highest positive rate was demonstrated for Suitai. Kiutsu and Kikyo also showed high positive rates, suggesting that psychogenic factors play important roles in the occurrence of vertigo. Multiple parameters were shown to be positive in young and elderly patients, suggesting that multiple factors may contribute to the occurrence of vertigo. A high positive rate was present for Suitai but not for Oketsu with peripheral vestibular disorder. On the other hand, vertebrobasilar insufficiency and idiopathic vertigo demonstrated a high positivity rate for Suitai, Oketsu, and Ketsukyo, suggesting the contribution of vascular disorders to the occurrence of vertigo.

自律神経失調と起立性調節障害を伴うめまい症例についての臨床的検討

Equilibrium function, psychological tests, and a questionnaire about orthostatic dysregulation were investigated in 103 patients who visited the laboratory of equilibrium function in Kumamoto University hospital from April 2004 to December 2005. The percentage of patients with autonomic nerve dysfunction comprised 42.7% of the total patients. Most (94%) of the patients with autonomic nerve dysfunction presented with orthostatic dysregulation. The patients with autonomic nerve dysfunction and orthostatic dysregulation showed several diagnoses by the equilibrium function test: peripheral vestibular disorders (37%), disease of the central nervous system (28.6%), abnormal blood pressure (75%), psychogenic disorders (100%), and origin unknown (14.3%). Tofisopam was effective in 60% of the patients with autonomic nerve dysfunction and orthostatic dysregulation. In the other patients, only 18.5% were naturally cured without medication. There was a significant difference between the group of patients treated with Tofisopam and a control group without medication. Tofisopam tended to be effective in patients whose blood pressure decreased by the schellong test. We consider that it may be possible to improve the curative effect on vertiginous patients by performing psychological tests and questionnaires about orthostatic dysregulation, adding to the routine equilibrium function tests including the schellong test.

Vertigo with rebound nystagmus as an initial manifestation in a patient with basilar artery occlusion

Basilar artery occlusion (BAO) is generally associated with a high mortality rate and a poor functional outcome in survivors. Recently, we encountered a patient with BAO, initially manifesting as vertigo and rebound nystagmus, subsequently followed by bilateral sudden deafness and dysarthria and terminating in a coma state within an interval of 6 h. A review of his history showed he had had two episodes of transient vertigo 2 weeks before the major stroke, and the neurological decline of BAO was heralded by the vertiginous symptoms. Restated, patients with BAO often have transient vertiginous attacks preceding fatal stroke. Therefore, those with vertigo and nystagmus may be signaling a forthcoming stroke event, something that should be considered for clinicians seeing vertiginous patients.

Impaired visual suppression of manually rotated vestibuloocular reflex indicates the need of further evaluation by MRI and MRA in patients with vertigo

MRI and MRA are accepted as valuable methods for diagnosing vertigo, although they are costly and time-consuming. Thus, some indicator of the necessity of a detailed evaluation by MRI and MRA is desirable. To assess the usefulness of an impairment of the visual suppression (VS) as an indicator, the relation between abnormal findings on MRI and/or MRA and impairment of the VS of manually rotated vestibuloocular reflex (VOR) was retrospectively examined in 40 consecutive patients suffering from vertigo. 12 of 23 patients with a low VS% were found to have a pathologic condition on MRI and/or MRA, however, no abnormality was found in any of the patients with a normal VS%. The rates of abnormality on MRI and/or MRA significantly differed between the 2 groups (chi2, P = 0.0004). The VS% is thought to be a good indicator of the need for further evaluation by MRI and MRA in vertiginous patients.

Vertiges en urgence

One person out of two has experienced (or will experience) dizziness at least once, and one out of seven acute vertigo. 5% of the patients seen by a GP have vertigo and/or disequilibrium. In 37% of the cases, patients are referred to a specialist. In 2%, a serious disorder is diagnosed: an embolic transient ischemic attack due to vertebral artery dissection, or basilar trunk dissection, affecting the posterior fossa. During diving, aero-embolic accidents affect more electively the inner ear, but sometimes severe medullary lesions may be associated. In fact, most of vertiginous patients coming to emergency departments present with benign positional paroxysmal vertigo (35%), first manifestations of a Ménière’s disease (6%), or vestibular neuritis (6%); more rarely temporal bone fracture, or infectious complications such as the rare and severe infectious labyrinthitis. Knowing how to diagnose a transient ischemic attack of the posterior fossa, and being aware of adequate therapeutic strategies for each of the main causes of vertigo, are essential for the emergency doctor.

A Comparative Study on the Observation of Spontaneous Nystagmus with Frenzel Glasses and an Infrared CCD Camera

To compare the usefulness of a CCD camera with infrared illumination (IR-CCD camera) over Frenzel glasses (F Glasses) for the observation of spontaneous nystagmus, the incidence and direction of nystagmus, and the frequency, amplitude and slow phase of spontaneous nystagmus. One hundred vertiginous patients, fifty-three females and forty-seven males participated in this study. Before undergoing routine neurotological examination, their eye movements were recorded by electronystagmogram (ENG) in conjunction with observations of eye movements under F glasses and through an IR-CCD camera. The data was collected from patients who exhibited spontaneous nystagmus either under F glasses or the IR-CCD camera. Thirty-three patients showed spontaneous nystagmus under F glasses. On the other hand, under the IR-CCD camera, all patients examined exhibited spontaneous nystagmus. The frequency of nystagmus was not significantly different between these two systems. However, the amplitude and slow phase velocity exhibited significantly larger values under the IR-CCD camera in patients with spontaneous nystagmus both under the IR-CCD camera and F glasses. From these observations and evidence, the IR-CCD camera can be recommended as a more useful system and powerful tool for neurotological examination than F glasses.

高齢めまい患者における自律神経機能の検討

We examined the age-related changes in autonomic nerve function affecteding the regulation of blood flow. We used the Schellong test and a questionnaire for orthostatic dysregulation. Two handred seventy-two elderly subjects over 70 years old were examined in this study and 192 healthy volunteers under 70 years old were examined as controls. We classified the former subjects into two groups, one group with dizziness and vertiginous sensation (vertigo group, N=222), and the other with no symptoms (non-vertigo group, N=50). Then, we statistically analyzed the above three groups. More changes in decrease of systolic blood pressure, pulse pressure and/or increase of pulse rate were observed with age increasing, excluding the young subjects in their 20s. In the increase of systolic blood pressure in particular, the vertigo group showed clear changes, and a higher positive rate on the Schellong test and questionnaire. It was suggested that the increase of orthostatic dysregulation with aging might be one factor for the increase of senior vertiginous patients.

Caracterización de la interacción sensorial en posturografía

ObjectiveThe aim of this work is to show the results obtained with a dynamic posturography on a stabilometric platform and to create relative parameters of study Material and MethodsThe study was perfomed on 127 patients with dizzines of a peripheral vestibular origin and the results analized in a dynamic posturography under six conditions of stimulation ResultsThe values obtained under the studied conditions of dynamic posturography are significantly different when the conditions of test increases sensorial conflicts. We could create 15 news relatives parameters which are in normal distribution ConclusionsDynamic posturography over stabilometric platform could be considered as a good test in the evaluation of vertiginous patients. Differents stimulations introduce more sensibility to the test

Monothermal air caloric test in children

We compared the efficacy of bithermal (BAT) and monothermal cold (MCAT) and warm (MWAT) air caloric tests in identifying labyrinthine function anomalies in the child. At first, we established confidence intervals of normality for both monothermal tests in 40 children (22 males, 18 females) aged 6–14 years, clinically healthy and normal as previously shown by BAT. Subsequently, we compared the results of BAT with those of MCAT and MWAT performed in 46 children (22 males, 24 females) aged 6–14 years, affected by multiple labyrinthine diseases. These results confirmed that, as in the adult, MCAT alone should not be used in the evaluation of labyrinthine function in vertiginous patients. As to MWAT, we obtained good sensitivity and specificity with respect to BAT (83% and 90% for 90% probability; 78% and 92.5% for 95% probability). Sensitivity values increased or decreased depending on the disease causing vertiginous symptoms, with decreased or increased number of false negatives. In our opinion, MWAT cannot replace BAT for the study of labyrinthine function in children. MWAT alone can be used when vertigo is ascribable to vestibular neuritis or to endogenous disease (dysmetabolic, dyscrasic, dysendocrine).

Deafness associated with vertebrobasilar insufficiency

The incidence of auditory disturbances in vertebrobasilar insufficiency (VBI) is considered much rarer than vestibular disturbances, but no routine audiometric test results for VBI patients have been published. To determine the incidence of deafness associated with VBI and the sites predominantly involved in deafness, we studied 70 vertiginous patients with VBI using a routine audiological examination and magnetic resonance imaging (MRI). MRI detected a lacunar infarct involving the cochlear nuclei in one patient, but lacunae did not involve central auditory structures in the other patients. Twenty-five patients experienced tinnitus, deafness, or both, during vertigo episodes. Audiological examinations confirmed the development of unilateral deafness in 15 (21%) patients, involving the cochlea in 14 and cochlear nuclei in one. These findings indicate that hearing loss occurs in approximately one-fifth of VBI patients, much less frequently than vestibular disturbances, and that deafness associated with VBI mainly involves the cochlea.

Experiences of otoneurological expert system for vertigo.

We have developed an OtoNeurological Expert system (ONE) to aid the diagnostics of vertigo, to assist teaching and to implement the database for research. The database contains detailed information on the patient history, signs and test results necessary for the diagnostic work with vertiginous patients. The pattern recognition method was used in the reasoning process. Questions regarding symptoms, signs and test results are weighted and scored for each disease, and the most likely disease is recognized from the defined disease profiles. Uncertainties in reasoning, caused by missing information, were solved with a method resembling fuzzy logic. We have also applied adaptive computer applications, such as genetic algorithms and decision trees, in the reasoning process. In the validation the expert system ONE proved to be a sound decision maker, by solving 65% of the cases correctly, while the physicians' mean was 69%. To improve the expert system ONE further, a follow-up should be implemented for the patients, to ease the diagnostic work of some difficult diseases. The six diseases were detected with high accuracy also with adaptive learning methods and discriminant analysis. An expert system is a practical tool in otoneurology. We aim to construct a hybrid program for the reasoning, where the best reasoning method for each disease is used.

Head Tilt Suppression Test as a Differential Diagnostic Tool in Vertiginous Patients

The head tilt suppression test has been known to be a diagnostic tool to distinguish between centrally originating dizziness and peripheral vertigo, as the latter enhances the natural spontaneous firing rate of the velocity storage system and decreases the time constant; however, the otolith organ is now considered to be a cause of head tilting effect. Therefore we questioned whether the head tilt suppression test is still worth differential diagnostic tool. We measured the time constant and initial eye velocity of pre- and post-rotatory nystagmus in a velocity step test in nine healthy adults. The time constant was significantly affected by head tilting ( p = 0.001), pre- and post-rotatory nystagmus ( p = 0.020) and the compounding interaction between them ( p < 0.000). The initial eye velocity was also significantly affected by pre- and post-rotatory nystagmus ( p = 0.016) and the compounding interaction ( p < 0.000), but not by head tilting (Wilks' Lambda=0.054). The head tilt suppression test is a useful method for the differential diagnosis of vertiginous patients. It is affected by pre- and post-rotatory nystagmus and their interaction, however, other central parameters in vestibular function testing should also be considered in order to obtain an exact differential diagnosis.

神経血管圧迫によると思われるめまい症例と脳底動脈偏位 画像診断に役立つ情報か

On the basis of the fact that 92% of the cases with hemifacial spasm caused by neurovascular compression (NVC) at the root entry zone of the facial nerve have dolichoectatic ipsilateral convexity of the basilar artery (BA) on a MR image (MRI), 37 of 40 vertiginous patients suspected as due to NVC were evaluated with T2-weighted MRI.MRI of 18 patients with sudden deafness or vestibular neuronitis were used as controls. The displacement and distance of the cross section of BA from the midline were assessed at the level of the internal auditory meatus in the axial view. The displacement was ipsilateral to the affected side in 32 (86.5%), contralateral in 4 (10.8%) and not recognized in one (2.5%) of 37 patients, whereas it was ipsilateral to the lesion in 4 (22.2%), contralateral in 7 (38.9%) and not recognized in 7 (38.9%) of 18 controls. The mean distance in 33 of 37 patients and 17 of 18 controls was 5.7 mm (0-11.8 mm) and 2.9 mm (0-8.9), respectively.These results showed that the ipsliateral convexity of BA in vertiginous patients suspected as due to NVC was significantly more severe and seen at a significantly high incidence. The ipsilateral displacement of BA on the axial view of MRI has been suggested to serve as a diagnosis of vertigo due to NVC.

Usefulness of imputation for the analysis of incomplete otoneurologic data

The usefulness of imputation in the treatment of missing values of an otoneurologic database for the discriminant analysis was evaluated on the basis of the agreement of imputed values and the analysis results. The data consisted of six patient groups with vertigo ( N=564). There were 38 variables and 11% of the data was missing. Missing values were filled in with the means, regression and Expectation-Maximisation (EM) imputation methods and a random imputation method provided the baseline results. Means, regression and EM methods agreed on 41–42% of the imputed missing values. The level of agreement between these and the random method was 20–22%. Despite the moderate agreement between the means, regression and EM methods, the discriminant functions were similar and accurate (prediction accuracy 83–99%). The discriminant functions obtained from the randomly imputed data were also accurate having prediction accuracy 88–97%. Imputation seems to be a useful method for treating the missing data in this database. However, a lot of data was missing in otoneurologic tests, which are likely to be of less importance in the diagnosis of vertiginous patients. Consequently, the disagreement of the methods did not affect clearly the discriminant analysis, and, therefore, future research requires more complete data and advanced imputation methods.

前庭誘発筋電位

Intense clicks evoke short-latency myogenic potentials on the sternocleidomastoid (SCM) muscle ipsilaterally. These potentials are namedvestibular evoked myogenic potentials (VEMP) because they are lost after vestibular deafferentation, but independent of the cochlear function. To induce VEMP, the subjects need to contract their SCM muscle during the test. The characteristics of the tuning curve of VEMP are a high threshold and low best frequency. They are similar in animal studies, suggesting that the saccule is the most promising candidate for the origin. Some diagnostic merit has been reported in previous papers. First, there is a discrepancy between VEMP and caloric response in patients with both inner ear and retrolabyrinthine disorders. Therefore, the test battery of these two tests is very useful for diagnosing vertiginous patients. Second, the Tullio phenomenon, the phenomenon of vertigo or loss of balance due to intense sound, is also evaluated by using VEMP. The Tullio phenomenon has been found in patients with various disorders, including congenital syphilis, Meniere's disease and perilymphatic fistula. VEMP are expected to be used in a new vestibular function test to evaluate the neural pathway from the saccule to the SCM muscle.

The effect of severity of unilateral vestibular dysfunction on symptoms, disabilities alphanudelta handicap in vertiginous patients

This study compares the symptoms, disabilities and handicap, as assessed by means of a questionnaire, in two groups of patients with a unilateral peripheral vestibular disorder: those with a total canal paresis and those with a partial canal paresis, as judged by the duration parameter using the Fitzgerald Hallpike caloric test in the absence of optic fixation. The results of the study indicate that the severity of dizziness, the Dizziness Index (severity x frequency) and the overall level of disabilities related to visual vertigo are less severe in unilateral profound or total loss of vestibular function than in unilateral mild vestibular loss.

Otoneurological Expert System for Vertigo

We have developed an otoneurological expert system (ONE) to aid the diagnostics of vertigo, to assist teaching and to implement a database for research. The ONE database is set to harvest data on patient history, signs and test results necessary for diagnostic work with vertiginous patients. A method based on pattern recognition was used in the reasoning process. Questions about symptoms, signs and test results are weighted and scored for each disease and the most likely disease is recognized from defined disease profiles. Missing information and uncertainties are solved with a method resembling fuzzy logic. ONE was validated by comparing diagnoses assessed by physicians with those provided by the system. It proved to be a valid decision-maker by solving 65% of the cases correctly, while the physicians' mean was 69%. To improve ONE further, a follow-up should be implemented for the patients, since diagnosing sudden deafness and Meniere's disease during the first visit is often impossible. We aim to obtain new information on diseases involving vertigo by applying adaptive computer applications, such as genetic algorithms, to the reasoning process.