Visual Vertigo Research Articles

Investigation of the Relationship Between BPPV with Anxiety, Sleep Quality and Falls.

To investigate the effects of dizziness on sleep quality and psychological status in patients with benign paroxysmal positional vertigo (BPPV) and to evaluate its relationship with falls. A Demographic Data Form, a Visual Vertigo Analog Scale, the Falls Efficacy Scale - International (FES-I), the Hospital Anxiety and Depression Scale (HADS), and the Pittsburgh Sleep Quality Index (PSQI) were administered in 102 individuals diagnosed with BPPV by videonystagmography test. The same scales were applied to 75 healthy volunteers as the control group, and the two groups were compared. The BPPV group was divided into two groups as posterior canal and lateral canal BPPV. These two groups were compared among themselves and with the control group. A statistically significant difference was found between the BPPV and control groups, the lateral canal BPPV and posterior canal BPPV groups, the lateral canal BPPV and control groups, and the posterior canal BPPV and control groups in terms of total scores of the PSQI, the FES-I, and the HADS (p<0.001). In the regression model, the FES-I score was fully explained by the PSQI and HADS scores (p<0.001). BPPV significantly affects sleep quality, psychological state, and the risk of fall. The negative effects of BPPV restrict daily living activities, affect the prognosis of the disease, and increase the risk of falling. Considering that psychiatric issues and sleep problems increase the risk of falling in individuals with BPPV, counseling services on this issue would reduce the incidence of falls and related injuries.

Categorizing individuals based on the severity of Visual Vertigo Analogue Scale symptoms.

The Visual Vertigo Analogue Scale (VVAS) assesses visual vertigo. Instead of the original scoring methods (positive VVAS > 1), we propose categorizing patients as having No (0), Mild (0.1-40), Moderate (40.01-70), or Severe (70.01-100) symptoms. Our primary aim was to validate an alternative interpretation of the VVAS by exploring the relationship between categories of visual vertigo symptoms and measures of activity and participation, dizziness handicap, anxiety, and depression. We aimed to describe the severity of visual vertigo reported by patients in different vestibular diagnostic categories. Participants with vestibular disorders (n = 250) completed the VVAS, Vestibular Activities and Participation (VAP) Measure, Dizziness Handicap Inventory (DHI), and the Hospital Anxiety and Depression Scale (HADS). Patients with central disorders were more symptomatic than those with peripheral vestibular disorders. As evaluated by one-way ANOVA, the scores on the VAP, HADS, and DHI significantly differed among mild, moderate, severe, and no visual vertigo categories (p < 0.001). As VVAS severity increased, activity and participation decreased (r = 0.582, p < 0.001); dizziness handicap increased (r = 0.597, p < 0.001, n = 199); anxiety increased (r = 0.405, p < 0.001); and depression increased (r = 0.521, p < 0.001). The findings of this study support the use of an alternative VVAS interpretation method of categorizing symptoms as none, mild, moderate, and severe visual vertigo.

The Portuguese version of the visual vertigo analog scale

ObjectivesVisual vertigo occurs after a vestibular disorder compromising daily living. It can be assessed by “the Visual Vertigo Analogue Scale” (VVAS), a self-administered questionnaire without Portuguese version. To perform the translation, cross cultural adaptation, and validation of VVAS from English to Portuguese. MethodsProspective study involving the translation and cross-cultural adaptation of the VVAS into the Portuguese language, according to recognized guidelines. It was completed by 63 healthy controls and 198 participants with vestibulopathy who also completed the Dizziness Handicap Inventory (DHI) to further explore the link between DHI and VVAS. Groups were compared for severity of visual vertigo and VVAS reliability and internal consistency were tested. ResultsThe VVAS score was significantly higher in vestibular group (p < 0.001). A Cronbach’s α of 0.9 confirmed the valid internally consistent of the applied version. The severity score of VVAS showed a positive strong correlation with DHI (p < 0.0001). ConclusionThe present Portuguese translation of the scale showed satisfactory properties for the assessment of self-perceived and severity of visual vertigo in a significant group of vestibular Portuguese patients. Level of evidence2.

THE EFFECTS OF BETAHISTINE IN ADDITION TO EPLEY MANEUVRE IN THE POSTERIOR CANAL BPPV MANAGEMENT

Benign paroxysmal positional vertigo (BPPV) is a common vestibular disorder that accounts for one fth of all admissions to hospital due to vertigo although it is commonly undiagnosed.5 The most common form is idiopathic, and BPPV tends to occur at a higher rates in women than in men.6 The main mechanism underlying BPPV is accumulation of otoconia (calcium carbonate structures) in the lumen (canalolithiasis) or in the cupula (cupulolithiasis) of the semicircular canal, resulting in impaired uid dynamics of the semicircular canal. This randomized controlled trial and hospital based study was conducted at calcutta national medical college and hospital ENT OPD on July 2020 to June 2021. Total 75cases were taken in our study. Group A (Epley maneuver only) Group B (Epley maneuver only+ Tab Pentoprazol 40) Group C: Epley maneuver with betahistine (16mg TDS) Our study showed that in A Group, 10 patients had previous vertigo attack. In B Group, 13 patients had previous vertigo attack. In C Group, 11 patients had previous vertigo attack. Rest of the patient in our study presented with vertigo attack for 1st time in their life. Association of previous vertigo attack with group was not statistically signicant (p=0.290). In A Group, the mean visual vertigo analog scale Baseline (mean± s.d.) of patients was 6.98 ± 2.133. In B Group, the mean visual vertigo analog scale Baseline (mean± s.d.) of patients was 6.27 ± 2.148. In C Group, the mean visual vertigo analog scale Baseline (mean± s.d.) of patients was 6.21+/- 2.133. Difference of mean visual vertigo analog scale Baseline with Group was not statistically signicant (p=0.100). We concluded that group-C was better result in comparison with group-B and group-A respectively. So in our study it is found that patients treated with Epley's maneuver and Betahistine got better result than the patients treated with only Epley's maneuver.

Comparison of Clinical Balance and Visual Dependence Tests in Patients With Chronic Dizziness With and Without Persistent Postural-Perceptual Dizziness: A Cross-Sectional Study.

BackgroundThe diagnosis of persistent postural-perceptual dizziness (PPPD) is primarily based on medical history taking. Research on the value of clinical balance and visual dependence tests in identifying PPPD is scarce.Objectives(1) to contrast clinical balance and visual dependence tests between PPPD patients, dizzy non-PPPD patients, and healthy persons; and (2) to evaluate whether these clinical tests can help to identify PPPD in patients with chronic dizziness.MethodsConsecutive patients with chronic dizziness (38 PPPD and 21 non-PPPD) and 69 healthy persons underwent Static Balance tests, the Timed Up and Go test, the Tandem Gait test, and the Functional Gait Assessment (FGA). Visual dependence tests included the Visual Vertigo Analog Scale (VVAS), the Rod-and-Disc test (RDT), and postural sway while facing rotating dots. Groups were compared using ANOVA with post-hoc Tukey, or independent samples t-tests. The value of the clinical tests for PPPD identification was evaluated through logistic regression and Partial Least Squares Discriminant (PLS-DA) analyses.ResultsPPPD patients had significantly higher VVAS scores than dizzy non-PPPD patients (p = 0.006). Facing rotating dots, PPPD and dizzy non-PPPD patients had increased postural sway compared to healthy persons (PPPD vs. healthy: center of pressure (COP) velocity p < 0.001, and COP area p < 0.001; but non-PPPD vs. healthy: COP velocity p = 0.116 and COP area p = 0.207). PPPD patients had no significantly increased postural sway compared to dizzy non-PPPD patients. PPPD and dizzy non-PPPD patients also scored significantly worse on balance tests compared to healthy persons (PPPD vs. healthy: for all balance tests p < 0.001; non-PPPD vs. healthy: FGA p < 0.001, for all other tests p < 0.05). Differences were insignificant in balance scores between PPPD and dizzy non-PPPD patients, or in RDT scores between the three study groups. In patients with chronic dizziness, a higher VVAS score was most associated with PPPD [odds ratio 1.04; 95% CI (1.01; 1.07); p = 0.010]. The cross-validated (CV) PLS-DA model with all clinical tests included, had fair discriminative ability (CVerror = 47%).ConclusionPPPD patients were more visually dependent, but did not have worse postural balance compared to dizzy non-PPPD patients. Elevated VVAS scores characterized PPPD most in patients with chronic dizziness.

Validated argentine version of the visual vertigo analogue scale.

Visual vertigo (VV), triggered by environmental or dynamic visual stimuli and repetitive visual patterns, can affect daily life activities. The Visual Vertigo Analogue Scale (VVAS) is a valid and reliable self-administered questionnaire to assess VV, which has been culturally adapted to the Argentine population but has not been validated. To validate the Argentine version of VVAS (VVAS-A) by confirming its psychometric properties in patients with vestibular disorders. Vestibular patients (n = 82) completed the VVAS-A and the Dizziness Handicap Inventory Argentine version (DHI-A) during their initial visit and one week later. The VVAS-A's internal consistency, test retest reliability, ceiling and floor effects, and construct validity were determined. Test-retest data (n = 71) was used to calculate reliability using the intraclass correlation coefficient (ICC 2.1). A ceiling effect was observed in 12 patients (14.6%). Internal consistency was acceptable (Cronbach's alpha: 0.91). The reliability was r = 0.764 [CI 95%: 0.7 -0.86]). Correlations were observed between the VVAS-A and the total DHI-A score (rho = 0.571), the DHI-A physical subscale (rho: 0.578), and DHI-A functional and emotional subscales of the DHI-A (rho: 0.537 and 0.387, respectively). The VVA-A is a valid, reliable tool to evaluate VV in patients with vestibular disorders.

The Association Between Precuneus Function and Residual Dizziness in Patients With Benign Paroxysmal Positional Vertigo.

ObjectivesThe purpose of this study was to apply the amplitude of the low-frequency fluctuation (ALFF) method to investigate the spontaneous brain activity alterations in patients with residual dizziness (RD) after successful canalith repositioning manoeuvre for benign paroxysmal positional vertigo (BPPV).MethodsAll BPPV patients underwent visual vertigo analog scale (VVAS) evaluations and functional magnetic resonance imaging (fMRI). The ALFF method was used to assess the spontaneous brain activity. Screening of brain regions with significant changes in ALFF values was based on analysis of the whole brain. We further analyze the relationship between ALFF values of the altered regions and VVAS scores in BPPV patients with RD.ResultsFifteen BPPV patients with RD and fifteen without RD were recruited in this study. In contrast to without RD, RD patients exhibited increased scores in VVAS tests (p < 0.001) and RD patients also showed significant ALFF decrease in the bilateral precuneus (left: 251 voxels; x = −10, y = −69, z = 51; peak t-value = −3.25; right: 170 voxels; x = 4, y = −59, z = 42; peak t-value = −3.43). Correlation analysis revealed that the mean ALFF z-values in the left precuneus displayed significant negative correlations with the VVAS scores(r = −0.44, p = 0.01).ConclusionsThis study shows that RD is associated with left precuneus function as revealed by fMRI. It might provide useful information for explaining neural mechanisms in BPPV patients with RD.

Postural Control in Relapsing-Remitting Multiple Sclerosis.

Introduction Postural instability is considered one of the most disabling symptoms of relapsing-remitting multiple sclerosis (RRMS). Objective To evaluate postural control in patients with RRMS. Method A total of 79 individuals between 18 and 65 years old, of both genders, were distributed into an experimental group composed of patients with RRMS ( n = 51) and in a control group composed by healthy individuals ( n = 28). The evaluation consisted of anamnesis, Dizziness Handicap Inventory (DHI), visual vertigo analog scale (VVAS), and static posturography (Tetrax IBS). Results Patients with RRMS presented mild degree in the DHI and in the VVAS; in Tetrax IBS, they presented higher or lower values of the indices of general stability, weight distribution, synchronization of postural oscillation, fall risk, and frequency bands of postural oscillation in two, five or all eight sensory conditions, in relation to the control group. Vestibular, visual and/or somatosensory dysfunction of peripheral type (51.0%) prevailed over the central type. The RRMS group, with an expanded scale of disability status > 3 points, presented a higher fall risk than with a score ≤ 3 points ( p = 0.003). There was a positive correlation of the Fall Risk Index with the total DHI Score (s = 0.380; p = 0.006) and with the VVAS score (s = 0.348; p = 0.012). Conclusion Patients with RRMS may present with inability to maintain postural control due to general instability, desynchronization and increased postural oscillation at frequencies that suggest deficiencies in the vestibular, visual, and somatosensory systems; as well as fall risk related to the state and intensity of functional disability and self-perception of the influence of dizziness on quality of life.

Visual stress responses to static images are associated with symptoms of Persistent Postural Perceptual Dizziness (PPPD).

Images that deviate from natural scene statistics in terms of spatial frequency and orientation content can produce visual stress (also known as visual discomfort), especially for migraine sufferers. These images appear to over-activate the visual cortex. To connect the literature on visual discomfort with a common chronic condition presenting in neuro-otology clinics known as persistent postural perceptual dizziness (PPPD). Patients experience dizziness when walking through highly cluttered environments or when watching moving stimuli. This is thought to arise from maladaptive interaction between vestibular and visual signals for balance. We measured visual discomfort to stationary images in patients with PPPD (N = 30) and symptoms of PPPD in a large general population cohort (N = 1858) using the Visual Vertigo Analogue Scale (VVAS) and the Situational Characteristics Questionnaire (SCQ). We found that patients with PPPD, and individuals in the general population with more PPPD symptoms, report heightened visual discomfort to stationary images that deviate from natural spectra (patient comparison, F (1, 1865) = 29, p < 0.001; general population correlations, VVAS, rs (1387) = 0.46, p < 0.001; SCQ, rs (1387) = 0.39, p < 0.001). These findings were not explained by co-morbid migraine. Indeed, PPPD symptoms showed a significantly stronger relationship with visual discomfort than did migraine (VVAS, zH = 8.81, p < 0.001; SCQ, zH = 6.29, p < 0.001). We speculate that atypical visual processing -perhaps due to a visual cortex more prone to over-activation -may predispose individuals to PPPD, possibly helping to explain why some patients with vestibular conditions develop PPPD and some do not.

Are secondary descriptors of headache useful in neuroimaging examinations? Results of a multicenter retrospective study of 1041 brain MRI studies

Headache is a common health problem in the general population. In clinical practice it is common to request neuroimaging examinations to rule out secondary headache, especially brain magnetic resonance imaging (MRI). The aim of this study is to analyze the secondary descriptors of headache-associated symptoms in brain MRI studies to assess their usefulness as predictors of potential intracranial structural abnormalities. Retrospective observational study of brain MRI studies performed due to headache in 6 centers in Andalusia between January 1 and May 30, 2019. The studies were performed on MRI machines with similar technical characteristics and imaging protocols, and were subjected to double reading by two neuroradiologists. Uni- and bivariate analyses were performed on the variables of interest: age, sex, headache-associated symptoms, and imaging findings. A total of 1041 patients who underwent brain MRI were included -mean age: 38.6 years (range: 3-86); 69.9% women-. In 737 (70.80%) cases there were no headache-associated symptoms and in the remaining patients (304 cases, 29.20%) there were headache-associated symptoms, the most frequent being: visual alterations, paresthesia, and vertigo and dizziness. Bivariate analyses showed no significant differences between groups. The findings of this study suggest that symptoms accompanying headache are not associated with a greater or lesser detection of intracranial structural abnormalities in MRI. Prospective studies that overcome the limitations of the present work are needed to verify this hypothesis.

Potential risk factors of persistent postural-perceptual dizziness: a pilot study.

Persistent postural-perceptual dizziness (PPPD) unifies the main characteristics of chronic subjective dizziness, visual vertigo and related diseases, which is a common chronic disease in neurology. At present, the pathology of PPPD is not fully understood. In this single-center retrospective case series review, we aim to investigate the potential risk factors of PPPD. Eighty inpatients diagnosed with PPPD were recruited with 81 apparently healthy controls. Patient-specific clinico-radiological data were collected from both groups. Conditions of hypertension, diabetes, smoking, and drinking were derived from medical history. Blood test results were recorded including total cholesterol, triglyceride, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, fibrinogen, vitamin B12, folic acid, total cholesterol, triglyceride, and folate level. The subjects were examined by carotid artery CTA and cranial MRI, and the imaging findings of carotid atherosclerosis (CAS), white matter hyperintensities (WMHs) and lacunar infarction (LI) were recorded. Binary logistic regression analysis was used to investigate the difference between the case and control groups. Significance was defined as p value less than 0.05. The prevalence rate of hypertension in the case group was significantly higher than that in the control group, and the detection rates of CAS, WMHs, and LI in the case group were significantly higher than those in the control group (p < 0.05 for all). Hypertension, CAS, WMHs, and LI are associated with PPPD, which may be potential risk factors for its development.

Virtual reality versus optokinetic stimulation in visual vertigo rehabilitation.

Visual vertigo (VV) is a condition at which there is worsening or triggering of vestibular symptoms in certain visual environments with large size (full field) repetitive or moving visual patterns as shopping malls. This work was designed to study effect of virtual reality and optokinetic stimulation on rehabilitation of VV. A total of 60 subjects divided into 2 groups that were simply randomized by the concealed envelope method: Group I consisted of 30 VV patients underwent vestibular rehabilitation using virtual reality. Group II consisted of 30 VV patients underwent vestibular rehabilitation using optokinetic stimulation. Significant improvement in performance in the two groups after rehabilitation with no statistically significant difference when comparing both groups. A combined intense rehabilitation program including OPK stimulation or VR rehabilitation combined with home-based exercises appeared to be equally effective for management of patients with VV and improving their quality of life.

The efficacy of topiramate and flunarizine hydrochloride for prophylactic treatment of vestibular migraine

Objective:To evaluate the efficacy and safety of topiramate and flunarizine hydrochloride in the prophylactic treatment of vestibular migraine prophylaxis. Methods:47 patients with confirmed or probable vestibular migraine（VM） treated at the vertigo clinic of our neurology department from August 2020 to April 2021 were reviewed, and 42 patients were finally included. They were divided into topiramate group （n=22） and flunarizine hydrochloride group （n=20）. The two groups were treated with topiramate 50 mg daily and flunarizine hydrochloride 10 mg daily, respectively. The visual analogue scale, vertigo duration, vertigo frequency, and Dizziness Handicap Inventory （DHI） scores of patients with VM before and 3 months after treatment were compared. The anxiety screening scale （GAD-7） and depression screening scale （PHQ-9） were recorded to assess the improvement of patients' anxiety and depression, and the occurrence of adverse events. Results:Topiramate and flunarizine hydrochloride effectively reduced vertigo intensity, vertigo duration, and vertigo frequency in VM patients （P<0.05）. Meanwhile, total DHI score, DHI physical （DHI-P）, DHI emotional （DHI-E）, DHI functional （DHI-F）, PHQ-9 and GAD-7 were significantly decreased（P<0.05）. Furthermore, topiramate was superior to flunarizine hydrochloride in reducing vertigo intensity, vertigo duration, vertigo frequency, DHI-P, and DHI-F, while there was no significant difference between two drugs in improving patients' mood（P>0.05）. No serious adverse events were reported in either group. Conclusion:This study suggests that topiramate and flunarizine hydrochloride are safe and effective in the prevention of VM, and the daily dose of topiramate 50 mg is superior to the daily dose of flunarizine hydrochloride 10 mg. However, there was no significant difference between the two drugs in terms of mood improvement.

Effect of vestibular exercise and optokinetic stimulation using virtual reality in persistent postural-perceptual dizziness

To determine the effect of customized vestibular exercise (VE) and optokinetic stimulation (OS) using a virtual reality system in patients with persistent postural-perceptual dizziness (PPPD). Patients diagnosed with PPPD were randomly assigned to the VE group or VE with OS group. All participants received VE for 20 min using a virtual reality system with a head mount display once a week for 4 weeks. The patients in the VE with OS group additionally received OS for 9 min. We analysed the questionnaires, timed up-to-go (TUG) test, and posturography scores at baseline and after 4 weeks. A total of 28 patients (median age = 74.5, IQR 66–78, men = 12) completed the intervention. From baseline to 4 weeks, the dizziness handicap inventory, activities of daily living (ADL), visual vertigo analogue scale, and TUG improved in the VE group, but only ADL and TUG improved in the VE with OS group. Patients with severe visual vertigo improved more on their symptoms than patients with lesser visual vertigo (Pearson’s p = 0.716, p < 0.001). Our VE program can improve dizziness, quality of life, and gait function in PPPD; however, additional optokinetic stimuli should be applied for individuals with visual vertigo symptoms.

Seizure semiology in temporal lobe vs. temporal plus epilepsy using intracranial EEG monitoring.

Objectives:To utilize our tertiary center’s experience with Temporal lobe epilepsy (TLE) and Temporal plus epilepsy (TPE) cases and determine whether a correlation exists between ictal semiology signs, their localization/lateralization value after intracranial electroencephalography (EEG) monitoring, and surgical outcomes.Methods:A retrospective study was conducted among epilepsy patients who underwent resective surgery for TLE or TPE after intracranial EEG monitoring between January 2008 and December 2018 at King Faisal Specialist Hospital in Riyadh, Saudi Arabia. Data were retrieved for 464 patients; 181 had intracranial electrode monitoring.Results:Forty-eight patients with a mean age of 27 years (SD=8.4) were included; 15 patients had TPE. Auras were frequently reported, emotional auras, in the form of fear (35%). The localization/lateralization value of aura was statistically significant for TPE patients, including visual hallucinations and vertigo, lateralized to the left and right temporo-occipital, respectively (p=0.009 and <0.001). Early-onset ictal manual automatism, oral automatism, late-onset dystonic posture, and late head-turning were significant for TLE without significant lateralization value. The ictal onset zone’s localization was significant between the scalp and intracranial EEG findings in mesial TLE patients. The probability of seizure freedom (Engel class I) was 74%, 60%, and 67% at 2-year follow-up for mesial, lateral TLE, and TPE, respectively.Conclusion:Our results are consistent with previous studies and confirm the importance of ictal semiology signs in TLE and TPE. The addition of intracranial EEG monitoring in these cases helped improve the surgical outcomes.

Subtypes of Persistent Postural-Perceptual Dizziness.

Background: Persistent postural-perceptual dizziness (PPPD) is a persistent chronic vestibular syndrome exacerbated by upright posture/walking, active or passive motion, and exposure to moving or complex visual stimuli. PPPD has four precursors: phobic postural vertigo, space-motion discomfort, visual vertigo, and chronic subjective dizziness. These four diseases share clinical features that form the basis of the diagnostic criteria for PPPD. Semiological similarities do not necessarily mean that PPPD is a single entity. However, if PPPD is not a single disorder but just a composite of four precursors, it may be subdivided according to the characteristics of each precursor.Objective: To test whether PPPD is a single disorder, we attempted a subtyping of PPPD.Methods: One-hundred-eight untreated patients with PPPD were enrolled in the study, who filled out the Niigata PPPD Questionnaire (NPQ) that consists of 12 questions on exacerbating factors for PPPD. A factor analysis of the patients' answers to the NPQ and a subsequent cluster analysis of the patients with PPPD using factors revealed by the factor analysis were performed. To validate our cluster classification, cluster differences were assessed using analysis of variance. Multiple comparison analyses were performed on demographical data, precipitating diseases, the Dizziness Handicap Inventory, the Hospital Anxiety and Depression Scale, and several vestibular tests to characterize each cluster.Results: Factor analysis revealed three underlying factors among the exacerbating factors in the NPQ. Exacerbation by visual stimuli (visual factor) accounted for 47.4% of total variance in the questionnaire. Exacerbation by walking/active motion (active-motion factor) and by passive motion/standing (passive-motion/standing factor) accounted for 12.0 and 7.67% of variance, respectively. Cluster analysis revealed three clusters: the visual-dominant subtype (n = 49); the active motion-dominant subtype (n = 20); and the mixed subtype (n = 39). The patients in the active motion-dominant subtype were significantly older than those in the visual-dominant subtype. There were no significant differences among the subtypes in other demographical data or conventional vestibular tests.Conclusions: The most common main exacerbating factor of PPPD was the visual factor. PPPD may be categorized into three subtypes. Conventional vestibular tests failed to point the characteristics of each subtype.

Swiss guidelines for the prehospital phase in suspected acute stroke

Acute stroke treatment has advanced substantially over the last years. Important milestones constitute intravenous thrombolysis, endovascular therapy (EVT), and treatment of stroke patients in dedicated units (stroke units). At present in Switzerland there are 13 certified stroke units and 10 certified EVT-capable stroke centers. Emerging challenges for the prehospital pathways are that (i) acute stroke treatment remains very time sensitive, (ii) the time window for acute stroke treatment has opened up to 24 h in selected cases, and (iii) EVT is only available in stroke centers. The goal of the current guideline is to standardize the prehospital phase of patients with acute stroke for them to receive the optimal treatment without unnecessary delays. Different prehospital models exist. For patients with large vessel occlusion (LVO), the Drip and Ship model is the most commonly used in Switzerland. This model is challenged by the Mothership model where stroke patients with suspected LVO are directly transferred to the stroke center. This latter model is only effective if there is an accurate triage by paramedics, hence the patient may benefit from the right treatment in the right place, without loss of time. Although the Cincinnati Prehospital Stroke Scale is a well-established scale to detect acute stroke in the prehospital setting, it neglects nonmotor symptoms like visual impairment or severe vertigo. Therefore we suggest “acute occurrence of a focal neurological deficit” as the trigger to enter the acute stroke pathway. For the triage whether a patient has a LVO (yes/no), there are a number of scores published. Accuracy of these scores is borderline. Nevertheless, applying the Rapid Arterial Occlusion Evaluation score or a comparable score to recognize patients with LVO may help to speed up and triage prehospital pathways. Ultimately, the decision of which model to use in which stroke network will depend on local (e.g. geographical) characteristics.

Spontaneous Intracranial Hypotension - A Dilemma.

Spontaneous intracranial hypotension (SIH) is a highly misdiagnosed and underdiagnosed disorder. Update evaluation and treatment of spontaneous intracranial hypotension. Narrative review. Traditionally, SIH is diagnosed when a headache has developed spontaneously and in temporal relation to a CSF leak (evident on imaging) and/or CSF hypotension (lumbar puncture opening pressure <60 mm CSF). However, lumbar puncture is not mandatorily required to diagnose SIH. Besides headache, other symptoms such as nausea/vomiting in 50.6%, neck pain/stiffness in 33%, tinnitus in 19%, dizziness in 14%, hearing disturbances in 10.7%, followed by visual disturbances, vertigo, back pain, and cognitive symptoms may be present. In suspected cases of SIH, brain and spine should be evaluated with MRI. Dynamic computerized tomographic myelography is required to demonstrate the site of spinal CSF leak. Epidural blood patch (EBP) is a minimally invasive treatment for spontaneous intracranial hypotension (SIH) refractory to medical management and provides symptomatic relief in up to 90% of patients even in patients with bilateral subdural hematomas. The CSF-venous fistulas do not respond well to EBP, and the most definitive curative treatment is the surgical closure of the fistula. The SIH is a distinct entity and requires a high index of suspicion for diagnosis. A post-contrast MRI should be included for evaluation of headaches. Spinal MRI should be done to demonstrate the site of leak. Epidural blood patch therapy is the most effective treatment of SIH. Most SDHs associated with SIH do not require treatment.

Posterior reversible encephalopathy syndrome– our experience

Introduction: Posterior Reversible Encephalopathy syndrome (PRES) is an emergency medical condition with varied etiology, presentation and outcome reported in literature. The objective of this study was to determine the clinical and radiological presentations, and clinical outcomes in cases of PRES admitted over the last one year at a tertiary care hospital.Materials and Methods: We retrospectively analysed all cases diagnosed with PRES from May 2019 to May 2020. We reviewed clinical presentations, etiological history, imaging characteristics, management and clinical outcomes.Results: Five patients diagnosed with PRES were identified. All patients were females, with age range between 16 to 32 years. Etiological factors were eclampsia (2/5), drug (tacrolimus), massive blood transfusion and chronic kidney disease with hypertension. Headache was the most common clinical presentation. Other clinical presentations were visual symptoms, seizures, altered sensorium, vertigo and vomiting. The most common imaging characteristic was supratentorial T2/FLAIR white matter hyperintensity on MRI, predominantly in parieto-occipital region. Other areas of white matter involvement were cerebellum and brainstem. One patient had hemorrhage complicating PRES. All patients were primarily managed by elimination and treatment of the precipitating factors, along with standard anti-oedema measures and anti-epileptic drugs. There was complete recovery in all patients within one week.Conclusion: PRES has variable clinical and radiological presentation. Early diagnosis and elimination of precipitating factors are vital for complete recovery.

Neurological and endocrinological manifestations of 49 children with intracranial pure germinoma at initial diagnosis in Taiwan

Intracranial pure germinoma is a rare extragonadal neoplasm. Affected patients may have motor impairment, visual disturbance, neurological signs, and endocrine disorder, depending on the size and location of the tumor. This study investigated and analyzed patients' demographic data and neuroimaging, clinical, laboratory, and endocrinological findings. We performed a retrospective chart review of 49 children diagnosed with pure germinoma in Taiwan from 1990 to 2018. The initial clinical presentation, tumor markers (beta-hCG, alpha fetoprotein, and carcinoembryonic antigen), pituitary function, and brain images were reviewed and analyzed. This study included 49 patients (37 boys and 12 girls). Their ages ranged from 7.5 to 17.9 years, and the mean age at diagnosis was 13.6 years. Initial symptoms included visual disturbance (n=23, 47.9%), motor impairment (n=20, 40.8%), polyuria (n=20, 40.8%), headache (n=17, 34.7%), dizziness or vertigo (n=14, 28.6%), nausea/vomiting (n=13, 26.5%), and short stature (n=8, 18.2%). Laboratory data indicated growth hormone deficiency or low IGF-1 levels (n=18, 85.7%), adrenal insufficiency (n=21, 77.8%), central diabetes insipidus (n=27, 55.1%), central hypothyroidism (n=15, 48.4%), and hypogonadotropic hypogonadism (n=4, 44.4%). Intracranial pure germinomas may initially manifest as neurological symptoms or endocrinological findings at diagnosis. As endocrinologic presentation is related to delayed diagnosis, clinicians should be aware of patients with such complaints. Laboratory data should be surveyed carefully, and neuroimaging must be considered if the result is abnormal.