Visually enhanced vestibulo-ocular reflex gain in patients with vestibular disease.

Objective: Vestibular migraine (VM) is a diagnostic challenge. Visually enhanced vestibulo-ocular reflex (VVOR) gain, a measure of the visual-vestibular interaction, has been proposed as a tool for diagnosing VM. This study seeks to evaluate VVOR gain's diagnostic capability to predict VM and to compare the phenotypes of vestibular patients with elevated versus normal/low VVOR gain. Methods: A retrospective review of consecutive adult patients at a dizziness clinic from October 2016 and December 2020 was conducted. VVOR gain's diagnostic performance was assessed with the area under the receiver operating characteristic (AUROC) analysis. Demographic factors and clinical presentations were compared between vestibular patients with elevated versus normal/low VVOR gain. Results: One hundred forty patients (70 with VM) were analyzed. VVOR gain was elevated in 68.6% of patients with VM, compared to 52.9% of patients without VM (p = .057). The AUROC of VVOR gain was 0.5902 (95% confidence interval: 0.4958-0.6846). Vestibular patients with elevated VVOR gain were younger than those with normal/low VVOR gain (mean age 50 vs. 62, p < .0001). A higher proportion of subjects with elevated VVOR gain had symptoms triggered by certain foods (17.6% vs. 5.5%, p = .040) and experienced sound sensitivity (34.1% vs. 18.2%, p = .040) and motion sensitivity (23.5% vs. 9.1%, p = .041). A greater proportion of VM patients with elevated VVOR gain were triggered by certain foods (27.1% vs. 0%, p = .006). Conclusion: VVOR gain alone has limited ability to discriminate VM from other vestibular conditions and must be interpreted carefully. VVOR gain elevation may be associated with food triggers and motion and sound sensitivity. Level of Evidence: IV.

A New Method for Gain Calculation in Quantified Visuo-vestibular Interaction Test.

OBJECTIVE: To develop a new method to quantify visually-enhanced vestibulo-ocular reflex (VVOR) gain, in patients with vestibular function loss, that is mathematically suitable given the nature of the test, and determine the reliability of the method by comparing results with those of the gold standard, the video head impulse test (vHIT). MATERIALS AND METHODS: We developed a new method for VVOR gain quantification and conducted a cross-sectional study in patients diagnosed with vestibular function loss and controls, all participants undergoing both a VVOR test and a vHIT. We measured VVOR gain with three different methods: area under the curve (AUC), slope regression, and a Fourier method (VVORAUC , VVORSP , and VVORFR , respectively); and compared these gain values with vHIT gain calculated using the AUC method. RESULTS: Overall, 111 patients were included: 29 healthy subjects and 82 patients with vestibular function loss. Intraclass correlation coefficients (ICC(1,1)) between gain from the gold standard and each of the VVOR gain methods were: 0.68 (CI: 0.61-0.75) for VVORAUC , 0.66 (CI: 0.58-0.73) for VVORSP and 0.71 (CI: 0.64-0.77) for VVORFR . No interference was found between VVOR gain calculation methods and potentially influential variables considered (p ≥ 0.98). CONCLUSION: The new method for quantifying VVOR gain showed good concordance with the vHIT method. LEVEL OF EVIDENCE: 2: Individual cross-sectional studies with consistently applied reference standard and blinding (Diagnosis) Laryngoscope, 133:3554-3563, 2023.

Synchronized refixation saccades in enhanced VVOR test. A new application for PR score.

OBJECTIVE: Main objectives for this study were to develop a quantification method to obtain a Perez-Rey (PR) score adapted to the VVOR test and to evaluate the correlation of the PR score obtained with quantified VVOR with the PR score of the vHIT test. METHODS: A new PR score calculation method for quantified VVOR test was developed using the MATLAB computational software based on saccadic response time latency variability between each head oscillation cycle of the VVOR test. Retrospective correlation between PR scores in VVOR and vHIT tests, performed in the same vHIT testing session for patients with vestibular neuritis and vestibular neurectomy, was performed to correlate new PR (VVOR) score with the classic PR (vHIT) score. RESULTS: Thirty patients were included: 11 post-neurectomy and 19 subacute vestibular neuritis. Pearson's correlation coefficient (R2) for the overall sample was 0.92 (p < 0.001) and 95% confidence interval was 0.85 -0.96. In the linear mixed-effects statistical model developed, only PRVHIT and PRVVOR scores showed statistical association in Wald X2 test (p = 0.008). CONCLUSION: The new developed PR score for synchronization measurement of saccadic responses in VVOR testing is a valid method that outputs synchronization values and highly correlates with PR score in vHIT test.

Effects of parameters of video head impulse testing on visually enhanced vestibulo-ocular reflex and vestibulo-ocular reflex suppression.

OBJECTIVE: To investigate the main effects of some testing and analysis variables on clinically quantified visually enhanced vestibulo-ocular reflex (VVOR) and vestibulo-ocular reflex suppression (VORS) results using video head impulse test. METHODS: This prospective observational clinical study included 19 healthy participants who underwent the VVOR and VORS tests. The effect of demographic variables, head oscillation frequency, rotation direction, visual acuity and analysis time window width and location of the recorded tests on the quantified results of both VVOR and VORS were evaluated. And specifically, for the VORS test the effect of cognitive reinforcement of the participant during testing was evaluated. RESULTS: A statistically significant difference was observed among the VVOR, non-reinforced VORS, and reinforced VORS tests for mean gain values of 0.91 ± 0.09, 0.6 ± 0.15, and 0.57 ± 0.16, respectively (p < 0.001). The optimized linear mixed-effect model showed a significant influence of frequency on the gain values for the reinforced and non-reinforced VORS tests (p = 0.01 and p = 0.004, respectively). Regarding the gain analysis method, statistically significant differences were found according to the short time interval sample location of the records for the initial location of the VVOR test (p < 0.006) and final location of the reinforced VORS test (p < 0.023). CONCLUSION: Significant differences were observed in the gain values according to VVOR and VORS testing. Head oscillation frequency is a significant factor that affects the gain values, especially in VORS testing. Moreover, in VORS testing, participant concentration has a significant effect on the test for obtaining suppression gain values. When a short time interval sample is considered for VVOR and VORS testing, intermediate time samples appear the most adequate for both tests. SIGNIFICANCE: The quantified visually enhanced vestibulo-ocular reflex (VVOR) and vestibulo-ocular reflex suppression (VORS) tests have recently been added to the assortment of available clinical vestibular tests. However, despite the clinical validity of these quantified tests that appear to be of increasing clinical interest, the effects of most of the clinical testing methods and mathematical variables are not well defined. In this research we describe what are the main collecting and analysis variables that could influence to the VVOR and VORS tests. Specially for VORS test, participant concentration on test tasks will have positive effect on the measured vestibulo-ocular reflex (VOR) suppression.

Cerebellar ataxia with neuropathy and vestibular areflexia syndrome (CANVAS).

Cerebellar ataxia with neuropathy and bilateral vestibular areflexia syndrome (CANVAS) is a novel ataxic disorder consisting of the triad of cerebellar impairment, bilateral vestibular hypofunction, and a somatosensory deficit. We report the first Japanese case of CANVAS. The patient is a 68-year-old Japanese male. He was referred to our university for further evaluation of progressive gait disturbance and ataxia. He exhibited horizontal gaze-evoked nystagmus and sensory deficit. Nerve conduction studies showed sensory neuronopathy. Magnetic resonance imaging showed the atrophy of vermis but not of the brainstem. The caloric stimulation and video head impulse test (vHIT) showed bilateral vestibulopathy. The visually enhanced vestibulo-ocular reflex (VVOR) was also impaired. In addition to neurological and electrophysiological examinations, simple neuro-otological examinations (i.e., caloric stimulation, vHIT, and VVOR) may reveal more non-Caucasian cases.

Generalization of vestibular learning to earth-fixed targets is possible but limited when the polarity of afferent vestibular information is changed.

To maintain perception of the world around us during body motion, the brain must update the spatial presentation of visual stimuli, known as space updating. Previous studies have demonstrated that vestibular signals contribute to space updating. Nonetheless, when being passively rotated in the dark, the ability to keep track of a memorized earth-fixed target (EFT) involves learning mechanism(s). We tested whether such learning generalizes across different EFT eccentricities. Furthermore, we ascertained whether learning transfers to similar target eccentricities but in the opposite direction. Participants were trained to predict the position of an EFT (located at 45° to their left) while being rotated counterclockwise (i.e., they press a push button when they perceived that their body midline have cross the position of the target). Overall, the results indicated that learning transferred to other target eccentricity (30° and 60°) for identical body rotation direction. In contrast, vestibular learning partly transferred to target location's matching body rotation but in the opposite rotation direction. Generalization of learning implies that participants do not adopt cognitive strategies to improve their performance during training. We argue that the brain learned to use vestibular signals for space updating. Generalization of learning while being rotated in the opposite direction implies that some parts of the neural networks involved in space updating is shared between trained and untrained direction.