Superior vestibular neuritis: improved detection using FLAIR sequence with delayed enhancement (1 h).

INTRODUCTION: Vestibular neuritis is the second cause of vertigo and new imaging protocols using delayed FLAIR with double-dose of gadolinium are proposed for its diagnosis. Our aim is to demonstrate that a single dose of gadolinium is sufficient. METHODS: Thirty-three patients with a unilateral vestibular neuritis are compared to a control group. All patients underwent a FLAIR sequence, 1 hour after intravenous injection of a single dose of gadolinium, on a 1.5 Tesla MRI. Two radiologists analyzed the enhancement intensity of the superior (sup VN) and inferior vestibular nerve (inf VN) and ratios to the signal of the cerebellum were calculated (supVN/C). The statistics were performed using Bayesian analysis. RESULTS: A strong enhancement of the sup VN was observed on the pathological side in 85% of patients with vestibular neuritis. The average signal intensity of the pathological sup VN (139 units ± 44) was more than two times the average intensity in the control group (58.5 units ± 5). The average ratios supVN/C were significantly different between the pathological side in vestibular neuritis (2.43 units ± 0.63) and the control group [1.16 ± 0.14 (Pr(diff > 0) = 1)]. A delayed enhancement > 71.5 units had a sensitivity of 96% and a specificity of 100% for the diagnosis of superior vestibular neuritis. CONCLUSION: A delayed FLAIR sequence, acquired 1 hour after a single dose of gadolinium injection, is a useful method for the diagnosis of vestibular neuritis. An enhancement of the sup VN > 71.5 units was in favor of the diagnosis.

Electrophysiological Properties of Rat Vestibular Labyrinth and Their Effect on Parameters of Transmitted Voltage Pulses.

We propose a new approach to optimization of electrical stimulation of the vestibular nerve and improving the transfer function of vestibular implant. A mathematical model of the vestibular organ is developed based on its anatomy, the model premises, 3D-analysis of MRI and CT images, and mathematical description of physical processes underlying propagation of alternating electric current across the tissues of vestibular labyrinth. This approach was tested in vitro on the rat vestibular apparatus and had been examined anatomically prior to the development of its mathematical model and equivalent electrical circuit. The experimental and theoretical values of changes of the gain-phase characteristics of vestibular tissues in relation to location of the reference electrode obtained in this study can be used to optimize the electrical stimulation of vestibular nerve.

[Preoperative determination of nerve of origin in patients with vestibular schwannoma. German version]. / Präoperative Bestimmung des Ursprungsnervs von Vestibularisschwannomen.

BACKGROUND: Vestibular schwannoma (VS) is a benign tumor that develops in the internal auditory canal and the cerebellopontine angle, potentially diminishing hearing or balance. Most VS tumors arise from one of two vestibular branches: the superior or inferior vestibular nerve. Determining the specific nerve of origin could improve patient management in terms of preoperative counseling, treatment selection, and surgical decision-making and planning. The aim of this study was to introduce a novel scoring system that was designed to determine the nerve of origin. METHODS: The nerve of origin was predicted based on video head impulse assessments of all semicircular channels, together with cervical/ocular vestibular-evoked myogenic potential tests. The acquired data were entered into a scoring system developed to allocate the tumor origin. Finally, the nerve of origin was definitively determined intraoperatively. RESULTS: The novel scoring system was applied to 5 consecutive patients undergoing surgical VS treatment. In one case, no determination was possible. In all other cases, the preoperatively predicted tumor origin was the same as the origin determined during surgery. CONCLUSION: The scoring system predicts the nerve of origin and will be evaluated in a larger prospective cohort study of VS patients in the near future.

Vestibular and cochlear nerve enhancement on MRI and its correlation with vestibulocochlear functional deficits in patients with Ramsay Hunt syndrome.

OBJECTIVE: The correlation between enhancement of the vestibulocochlear nerves on gadolinium-enhanced magnetic resonance imaging (MRI) and vestibulocochlear functional deficits was examined in patients with Ramsay Hunt syndrome (RHS). METHODS: Nineteen patients with RHS who showed herpes zoster oticus, peripheral facial palsy, and vertigo were enrolled. Canal paresis (CP) in the caloric test, abnormal response to ocular and cervical vestibular myogenic potentials (oVEMP and cVEMP), and refractory sensorineural hearing loss were evaluated. MRI images perpendicular to the internal auditory canal were reconstructed to identify the superior (SVN) and inferior vestibular nerves (IVN) and the cochlear nerve (CV). The signal intensity increase (SIinc) of the four-nerve enhancement was calculated as an index. RESULTS: Among RHS patients, 79%, 53%, 17% and 26% showed CP in the caloric test, abnormal responses to oVEMP and cVEMP, and refractory sensorineural hearing loss, respectively. SIinc rates of the SVN were significantly increased in RHS patients with CP in the caloric test, and with abnormal responses to oVEMP and cVEMP. SIinc rates of the SVN tended to increase in RHS patients with refractory sensorineural hearing loss (p = 0.052). SIinc rates of the IVN were significantly increased in RHS patients with abnormal responses to oVEMP and cVEMP, and refractory sensorineural hearing loss, but not in those with CP in the caloric test. SIinc rates of the CN were significantly increased in RHS patients with CP in the caloric test, abnormal response to oVEMP and refractory sensorineural hearing loss, but not in those with abnormal response to cVEMP. CONCLUSION: In patients with RHS, the origin of vertigo may be superior vestibular neuritis, which is affected by reactive varicella-zoster virus from the geniculate ganglion of the facial nerve through the faciovestibular anastomosis. The results also suggested that in some RHS patients, inferior vestibular neuritis contributes to the development of vertigo and that the origin of refractory sensorineural hearing loss is cochlear neuritis.

Vestibular nerve deficiency and vestibular function in children with unilateral hearing loss caused by cochlear nerve deficiency.

BACKGROUND: High-resolution MR imaging enables the visualization of individual nerves in the internal auditory canal (IAC). Cochlear nerve deficiency (CND) is recognized as one of the major causes of sensory neural hearing loss (SNHL), especially in cases of unilateral hearing loss in childhood. Some patients with CND are thought to have accompanying vestibular nerve deficiency (VND). However, there have been few reports focusing on VND and vestibular function in these children. AIMS: The aim of this study was to evaluate the frequency of VND and vestibular dysfunction in children with unilateral SNHL caused by CND. MATERIAL AND METHODS: Thirty-eight children with unilateral SNHL, who were diagnosed with CND by 3 T-MRI, were evaluated for VND and underwent caloric testing and cervical vestibular evoked potential (cVEMP). RESULTS: Fourteen of 38 patients (37%) had VND, and eleven (29%) of the patients [ten of the patients (71%) with VND] had at least one vestibular dysfunction. The patients with VND had significantly worse hearing and an IAC of smaller diameter than did patients without VND. CONCLUSIONS AND SIGNIFICANCE: We should pay attention to VND as well as vestibular dysfunction in hearing loss patients with CND.

Arachnoid Cysts of the Internal Auditory Canal: Multiplanar Magnetic Resonance Imaging With Audio-Vestibular Correlates.

OBJECTIVES/HYPOTHESIS: To investigate prevalence, radiological characteristics, and functional correlates of arachnoid cysts (AC) of the internal auditory canal (IAC) region, including associations of nerve compression with auditory/vestibular symptoms and asymmetrical audiogram or vestibular testing. STUDY DESIGN: Retrospective study. METHODS: T2-weighted magnetic resonance imaging (MRI) studies of IACs were retrospectively analyzed from 1247 patients with asymmetric auditory or vestibular symptoms. Patients with radiological findings of AC of the IAC were identified. Multiplanar analysis was used to analyze cyst position in the IAC and assess nerve displacement or compression. Size, position, and presence of nerve compression were correlated with symptoms. RESULTS: Twenty-four patients had a cyst in the middle or fundus in the IAC. Diameter (P = .04) and position (P = .002) of AC were associated with symptoms. Sagittal analyses identified displacement versus compression (P = .003) more reliably than axial imaging. Symptom laterality was associated with the site of radiological abnormality. Vestibular nerve compression was associated with vertigo (P = .0001), and cochlear nerve compression was associated with auditory symptoms (P < .0001). CONCLUSIONS: In a retrospective series of patients undergoing MRI of IACs for asymmetric auditory or vestibular impairment, clinical symptom profile correlated with blinded assessment of IAC lesions. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2323-2331, 2021.

Artificial intelligence in detection and segmentation of internal auditory canal and its nerves using deep learning techniques.

PURPOSE: Artificial intelligence (AI) in medical imaging is a burgeoning topic that involves the interpretation of complex image structures. The recent advancements in deep learning techniques increase the computational powers to extract vital features without human intervention. The automatic detection and segmentation of subtle tissue such as the internal auditory canal (IAC) and its nerves is a challenging task, and it can be improved using deep learning techniques. METHODS: The main scope of this research is to present an automatic method to detect and segment the IAC and its nerves like the facial nerve, cochlear nerve, inferior vestibular nerve, and superior vestibular nerve. To address this issue, we propose a Mask R-CNN approach driven with U-net to detect and segment the IAC and its nerves. The Mask R-CNN with its backbone network of the RESNET50 model learns a background-based localization policy to produce an actual bounding box of the IAC. Furthermore, the U-net segments the structure related information of IAC and its nerves by learning its features. RESULTS: The proposed method was experimented on clinical datasets of 50 different patients including adults and children. The localization of IAC using Mask R-CNN was evaluated using Intersection of Union (IoU), and segmentation of IAC and its nerves was evaluated using Dice similarity coefficient. CONCLUSIONS: The localization result shows that mean IoU of RESNET50, RESNET101 are 0.79 and 0.74, respectively. The Dice similarity coefficient of IAC and its nerves using region growing, PSO and U-net method scored 92%, 94%, and 96%, respectively. The result shows that the proposed method outperform better in localization and segmentation of IAC and its nerves. Thus, AI aids the radiologists in making the right decisions as the localization and segmentation of IAC is accurate.

Vestibular Nerve Atrophy After Vestibular Neuritis - Results from a Prospective High-Resolution MRI Study.

PURPOSE: Sudden unilateral peripheral vestibular deficit is mostly termed vestibular neuritis (VN), even if its cause or the exact location of the lesion remains unclear. Thus, therapy is mostly symptomatic. We aimed to prove if there is peripheral atrophy after VN with persistent canal paresis. METHODS: After approval by the ethics committee and according to the declaration of Helsinki and with informed consent, ten patients with persistent canal paresis after VN and ten age-matched healthy controls were included. High-resolution measurement (in-plane resolution 0.2 mm) of the internal auditory canal (IAC) using a 3 D CISS sequence at 3 Tesla was performed. The course of the pertaining nerves was reconstructed in the 3 D dataset and the measurement was performed at 60 % of the length of the IAC. The cross-sectional areas of the superior (SVN) and inferior vestibular nerve (IVN) were taken independently by two blinded readers. RESULTS: The interrater difference regarding the area was 22 %. We found significant atrophy of the SVN with a 24 % smaller area (p = 0.026) and found a smaller ratio of SVN/IVN on the symptomatic side (p = 0.017). Concerning single subject data, only 5 patients showed extensive atrophy of the NVS, while 5 patients did not. The time since symptom onset did not significantly influence the atrophy. CONCLUSION: MRI measuring of the area of the NVS after VN could detect atrophy after VN. However, only 5 patients exhibited marked atrophy, while the other 5 patients did not. With the background of stringent inclusion criteria (more than 6 months of symptom duration and proven persistent canal paresis), one has to wonder if there might be different etiologies behind the apparently identical symptoms. KEY POINTS: · MRI measuring of the area of the NVS after VN could detect atrophy after VN. · Only half of the 10 researched patients showed atrophy, while the other patients did not. · There are different etiologies to be suspected for VN. CITATION FORMAT: · Freund W, Weber F, Schneider D et al. Vestibular Nerve Atrophy After Vestibular Neuritis - Results from a Prospective High-Resolution MRI Study. Fortschr Röntgenstr 2020; 192: 854 - 861.

Functional brain imaging of peripheral and central vestibular disorders.

This review summarizes our current knowledge of multisensory vestibular structures and their functions in humans. Most of it derives from brain activation studies with PET and fMRI conducted over the last decade. The patterns of activations and deactivations during caloric and galvanic vestibular stimulations in healthy subjects have been compared with those in patients with acute and chronic peripheral and central vestibular disorders. Major findings are the following: (1) In patients with vestibular neuritis the central vestibular system exhibits a spontaneous visual-vestibular activation-deactivation pattern similar to that described in healthy volunteers during unilateral vestibular stimulation. In the acute stage of the disease regional cerebral glucose metabolism (rCGM) increases in the multisensory vestibular cortical and subcortical areas, but simultaneously it significantly decreases in the visual and somatosensory cortex areas. (2) In patients with bilateral vestibular failure the activation-deactivation pattern during vestibular caloric stimulation shows a decrease of activations and deactivations. (3) Patients with lesions of the vestibular nuclei due to Wallenberg's syndrome show no activation or significantly reduced activation in the contralateral hemisphere during caloric irrigation of the ear ipsilateral to the lesioned side, but the activation pattern in the ipsilateral hemisphere appears 'normal'. These findings indicate that there are bilateral ascending vestibular pathways from the vestibular nuclei to the vestibular cortex areas, and the contralateral tract crossing them is predominantly affected. (4) Patients with posterolateral thalamic infarctions exhibit significantly reduced activation of the multisensory vestibular cortex in the ipsilateral hemisphere, if the ear ipsilateral to the thalamic lesion is stimulated. Activation of similar areas in the contralateral hemisphere is also diminished but to a lesser extent. These data demonstrate the functional importance of the posterolateral thalamus as a vestibular gatekeeper. (5) In patients with vestibulocerebellar lesions due to a bilateral floccular deficiency, which causes downbeat nystagmus (DBN), PET scans reveal that rCGM is reduced in the region of the cerebellar tonsil and flocculus/paraflocculus bilaterally. Treatment with 4-aminopyridine lessens this hypometabolism and significantly improves DBN. These findings support the hypothesis that the (para-) flocculus and tonsil play a crucial role in DBN. Although we can now for the first time attribute particular activations and deactivations to functional deficits in distinct vestibular disorders, the complex puzzle of the various multisensory and sensorimotor functions of the phylogenetically ancient vestibular system is only slowly being unraveled.

Air CT cisternography in the diagnosis of vascular loop causing vestibular nerve dysfunction.

Considerable interest has developed in otology concerning the relationship between the vascular loop and compression of the eighth nerve, producing vertigo. Several authors have described the radiographic findings relative to the anatomy of these vascular loops. Few previous articles have dealt with cases that have had surgical confirmation or repair of the defect. Our presentation concerns 27 patients who were studied by air CT cisternography of the cerebellopontine angle cistern and internal auditory canal followed by surgical repair. We postulate dampened pulsation as the reason for being able to visualize the vessels on the air study. The diversity of vessel-eighth nerve defects is illustrated. Compression of the vestibular nerve by a vascular loop should be considered one of the causes of intractable vertigo and motion intolerance and is a differential diagnosis in Meniere disease. Air CT cisternography is useful in diagnosing this condition in patients who do not respond to medical treatment.

CT in the evaluation of the vestibulocochlear nerves and their central pathways. Evaluation of neurotologic disorders.

CT has evolved to become an important technique for the diagnosis of neurotologic disorders. By obtaining thin sections, the central pathway of the vestibulocochlear nerve can be rather properly evaluated with satisfactory clinical correlation when pathology exists. The validity of central vestibular and audiometric signs can be best substantiated with CT. The functional neuroanatomy of the vestibulocochlear and vestibulo-oculomotor systems is discussed. Results of the assessment of endocranial lesions involving the vestibulocochlear system are presented.

Acoustic neuroma. Assessment and management.

Acoustic neuroma results from abnormal proliferation of Schwann cells. These tumors originate in the region of Scarpa's ganglion at the junction of peripheral and central myelin of the vestibular nerve located in the internal auditory canal (IAC). The bony confine of the IAC houses the VII and the VIII cranial nerves. The presence of tumor mass compresses these structures. The growing tumor mass may also prolapses into the cerebellopontine angle (CPA). With continued growth, the tumor eventually compresses on the brain stem and cerebellum. Despite the benign nature of these tumors, the clinical course of this disease may be fraught with complications.

Thallium chloride 201Tl combined with single photon emission computed tomography (SPECT) in the evaluation of vestibular schwannoma growth.

Thallium chloride 201Tl combined with SPECT was performed in a series of 29 patients with neuroradiological evidence of vestibular schwannoma (VS). The relative tumor uptake (U) and relative tumor concentration (C) of the radiotracer 201Tl was determined, and the cerebellum served as a reference. The relative tracer concentration and uptake were correlated to tumor volume determined by gadolinium DTPA enhanced MR, to prediagnostic duration of symptoms, to tumor vascularity expressed by the average number of intratumoral vessels using the endothelial marker CD31, and to the proliferative activity in the tumors expressed by positive staining with the monoclonal antibody MIB-1 for Ki-67. A positive 201TI enhancement was detected in 17 tumors (n = 17). Tumors U and C were statistically unrelated to tumor volume (p = 0.236 and p = 0.439). SPECT demonstrated all tumors > 0.8 cm3, but it had its limitation as a diagnostic modality of small intracanalicular tumors, when compared with gadolinium DTPA enhanced MR. Relating U and C in all tumors (n = 29) and the prospectively registered data on the prediagnostic duration of symptoms, a statistical significance was found (p = 0.012 and p = 0.015). No statistically significant correlation was observed between U and C and the proliferative activity of the tumors expressed by positive staining with the monoclonal antibody MIB-1 for Ki-67 (p = 0.063 and p = 0.086). A statistically significant correlation was noted between C and U in the operated group (n = 12) and tumor vascularity expressed by the average number of the intratumoral vessels (p = 0.003 and p = 0.014). SPECT was found to be superior to MR in determining VS growth potentials as it expresses tumor vascularity, which is essential for tumor growth. It seems that we now have an in vivo functional radiological modality capable of providing data on VS vascularity and determination of growth potential in the individual tumor. A high radioactive tracer uptake in the tumor corresponded to high tumor vascularity, indicating a high growth rate and vice versa.

Vestibular schwannoma in an only hearing ear.

A vestibular schwannoma in an only hearing ear is a difficult management problem. A case is presented of a patient who had a Nucleus-22 channel device implanted into a nonfunctioning ear and auditory rehabilitation prior to resection of a large vestibular schwannoma in the contralateral ear.

Cystic vestibular schwannomas: neuroimaging and growth rate.

In a series of 571 vestibular schwannomas (VS) operated on in the period 1976-1992, via the translabyrinthine approach, 23 tumours (4 per cent) from 23 patients were radiologically, peroperatively and histologically identified as cystic VS. Neuroimaging examinations (CT and MRI) revealed 15 tumours (2.6 per cent) with extracystic formations and in eight cases (1.4 per cent) intratumoural cysts. In 15 cases (65 per cent), tumours were located extracanalicularly with no involvement of the internal auditory canal (IAC). The extracanalicular tumour extension including the cystic elements ranged between 10 and 60 mm with a mean of 45 mm. In eight cases out of 23 (35 per cent) other diagnostic possibilities such as trigeminal schwannoma, epidermoid cyst and meningioma were proposed at the primary evaluation. Deformation, displacement and/or impression of the fourth ventricle was demonstrated in 17 cases (74 per cent). Three patients (13 per cent) had obstructive hydrocephalus which demanded shunt insertion. Residual tumour was detected in two patients (9 per cent). Growth rate in four cases was more than 10 times higher when compared to the annual growth rate of noncystic VS. The results of this study provide data on cystic VS attenuation demonstrated by CT or MRI which may be valuable in neuroradiological diagnosis of these cystic lesions and emphasizes that the wait-and-see policy should not be applied to the cystic variant of VS.

[Transcranial duplex scanning in estimation of cerebral hemodynamics in patients with secondary cochleovestibular neuritis]. / Transkranial'noe dupleksnoe skanirovanie v otsenke tserebra'noi gemodinamiki u bol'nykh s vtorichnym kokhleovestibuliarnym nevritom.

The authors present pilot experience with transcranial duplex scanning (TCDS) of the cerebral vessels in 17 patients with secondary cochleovestibular neuritis combined with chronic leptomeningitis (primarily of the posterior cranial fossa). This method has determined extra- and intracranial hemodynamics, characterized arterial and venous blood flow qualitatively and quantitatively, outlined possible genetically determined factors in development of dyscirculatory disorders. Finally, hemodynamic defects of two types were revealed in 12 patients. Type 1 (3 patients) was characterized by asymmetric circulation in the territory of the middle, anterior and posterior cerebral arteries, by the absence of venous congestion. Type 2 (9 patients) was characterized by impaired venous outflow manifesting as higher speed of the blood flow and its phase response along the intracranial veins and sinuses. In 7 patients these defects combined with asymmetric circulation along brain stem arteries. These patients were diagnosed to have perilymphatic labyrinthine hydrops.

Prognostic factors of hearing preservation after gamma knife radiosurgery for vestibular schwannoma.

We conducted a prospective study to identify prognostic factors of hearing preservation after gamma knife radiosurgery (GKRS) for vestibular schwannoma (VS). Twenty-seven patients with unilateral VS and serviceable hearing underwent GKRS. The mean lesion diameter was 17.3mm (range 6.1-30.0mm), the median marginal dose was 12 Gy (11-15 Gy), and the mean follow-up duration was 35.7 months (9-81 months). The probabilities of hearing preservation after GKRS were calculated using the Kaplan-Meier method. Tumor growth was controlled in 26 of the 27 patients (96.3%), and rates of hearing preservation were 85.1% and 68.1% at 2 and 3 years, respectively. A normal auditory brainstem response (ABR) (p = 0.008) and Gardner-Robertson class I hearing (p = 0.012) before GKRS were found to be significant prognostic factors of a favorable outcome. Our findings suggest that a normal pre GKRS ABR strongly predicts hearing preservation after GKRS. Accordingly, we advise that ABR should be considered with other prognostic factors when GKRS is considered in patients with VS.

Imaging case study: enlarged superior vestibular nerve canal with sensorineural hearing loss.

OBJECTIVE: We report a new temporal bone anomaly - an enlarged superior vestibular nerve canal - associated with sensorineural hearing loss. CASE REPORT: A 10-month-old male infant presented with sensorineural hearing loss together with bilaterally enlarged superior vestibular nerve canals. Compared with published temporal bone computed tomography measurements, our patient's canals were normal in length but approximately double the normal width. In addition, careful review of the imaging did not clearly identify a bony wedge between the superior and inferior vestibular nerve canals. CONCLUSION: Enlarged superior vestibular nerve canal malformation may be a marker for sensorineural hearing loss. Increased vigilance amongst otologists may establish the prevalence of this anomaly and its possible effects on hearing.

Gamma knife radiosurgery in younger patients with vestibular schwannomas.

OBJECTIVE: Management options for patients with vestibular schwannoma include observation, surgical resection, stereotactic radiosurgery (SRS), and stereotactic radiation therapy. In younger patients, resection is often advocated because of concern regarding the long-term effects of radiation. We studied tumor response and clinical outcomes after SRS in such patients. METHODS: We reviewed long-term outcomes in 55 patients with vestibular schwannomas. Patients were 40 years of age or younger, underwent gamma knife (GK) SRS between 1987 and 2003, and were followed up for a minimum of 4 years. The median patient age was 35 years (range, 13-40 years). Forty-one patients had Gardner-Robertson class 1 to 4 hearing. Thirteen patients (24%) had undergone surgical removal. The median tumor volume was 1.7 mm. The median tumor margin dose was 13.0 Gy (range, 11-20 Gy). RESULTS: At a median of 5.3 years, (range, 4-20 years), 2 of 55 patients underwent GK SRS for a second time; 1 of these patients had had a recurrence after initial resection. The 5-year rate of freedom from additional management was 96%. Hearing preservation rates (i.e., remaining within the same Gardner-Robertson hearing class) were 93%, 87%, and 87% at 3, 5, and 10 years, respectively. In patients with serviceable hearing before SRS, it was maintained in 100%, 93%, and 93% of patients at 3, 5, and 10 years, respectively. Hearing preservation was related to a margin dose lower than 13 Gy (P = 0.017). At the last assessment, facial and trigeminal nerve function was preserved in 98.2% and 96.4% of patients, respectively; the only facial deficit (House-Brackmann grade III) occurred in a patient who received a tumor dose of 20 Gy early in our experience (1988). None of the patients treated with doses lower than 13 Gy experienced facial or trigeminal neuropathy. All patients continued their previous level of activity or employment after GK SRS. No patient developed a secondary radiation-related tumor. CONCLUSION: Our experience indicates that GK SRS is an effective management strategy for younger patients with vestibular schwannoma, most of whom have no additional cranial nerve dysfunction.