Assessment of functional and structural brain abnormalities with resting-state functional MRI in patients with vestibular neuronitis.

BACKGROUND: Vestibular neuritis (VN) is a disorder manifesting as acute, isolated, spontaneous vertigo. There are few comprehensive studies on the changes in related functional and structural brain regions. PURPOSE: To evaluate alterations in spontaneous neural activity, functional connectivity (FC), and gray matter volume (GMV) in patients with VN. MATERIAL AND METHODS: A total of 24 patients with VN and 22 age- and sex-matched healthy controls underwent resting-state functional magnetic resonance imaging (rs-fMRI) and three-dimensional T1-weighted anatomical imaging. We calculated the amplitude of low frequency fluctuation (ALFF), regional homogeneity (ReHo), and degree centrality (DC) to discern local brain abnormalities. The most abnormal brain region was selected as the region of interest (ROI) for FC analysis based on ALFF and ReHo values after Bonferroni correction. Voxel-based morphometry (VBM) was used to assess differences in GMV. RESULTS: Patients with VN, compared to healthy controls, showed increased ALFF (P < 0.001), ReHo values (P = 0.002, <0.001), and DC (P = 0.013) in the left lingual gyrus and right postcentral gyrus. FC analysis demonstrated enhanced connectivity between the left lingual gyrus and the left superior frontal gyrus, and decreased connectivity with the right insula gyrus, right and left supramarginal gyrus (P = 0.012, 0.004, <0.001, 0.014). In addition, GMV was reduced in the bilateral caudate (P = 0.022, 0.014). CONCLUSIONS: Patients with VN exhibit abnormal spontaneous neural activity and changes in ALFF, ReHo, DC, GMV, and FC. Understanding these functional and structural brain abnormalities may elucidate the underlying mechanisms of VN.

Stroke mimics: Clinical characteristics and outcome.

OBJECTIVE: To study the prevalence and nature of stroke mimics (SM) among Saudi patients who came to the emergency department with a sudden neurological deficit and suspected stroke. METHODS: The electronic health records from February 2016 to July 2018 of patients who were admitted to the Stroke Unit at King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia (KAMC-RD) with a suspected stroke were all reviewed. A comparison between SM and stroke was established. Our study identified the predictors of SM by using logistic regression analysis. This study was approved by the local institutional review board. RESULTS: Out of 1,063 patients, 131 (12.3%) had SM. The most common causes were a peripheral vestibular disorder (27.4%) followed by psychogenic causes (24.4%). Stroke mimics were more common among younger individuals and women. Arterial hypertension, diabetes, and smoking were less likely to be found in SMs. At discharge, individuals with SM were more likely to be independent, had milder deficits, and shorter hospital stays. Predictors of SM were young age, female gender, mild deficit at presentation, and good functional status before the stroke. CONCLUSION: The incidence of stroke mimics is common among suspected stroke patients. Practicing physicians should consider potential diagnostic errors, particularly in the hyperacute phase of the stroke.

Long-term clinical outcome in vestibular neuritis.

PURPOSE OF REVIEW: To review recent work on clinical and imaging aspects of vestibular neuritis (or acute vestibular syndrome), in particular with a view to identifying factors predicting long-term clinical outcome. RECENT FINDINGS: Evidence for a role of inflammation in the vestibular nerve, and the presence of Gadolinium enhancement acutely in vestibular neuritis, is accruing. Visual dependence, anxiety and somatization traits predict the development of chronic dizziness after acute vestibular neuritis. Adaptation to asymmetric rotation is impaired in vestibular neuritis and this may indicate insufficient central compensation in chronic dizzy patients. Corticosteroids appear ineffective at improving long-term clinical outcome. Functional imaging changes during the central compensation period lead to structural brain changes; both processes correlate with clinical recovery. SUMMARY: Vestibular neuritis appears to be the result of postviral neuroinflammation of the vestibular nerve. However, long-term prognosis is not dependent on the magnitude of the peripheral residual damage (as measured with caloric and video head-impulse test). Instead, a combination of visuovestibular psychophysical factors (visual dependence), psychological traits and dysfunctional vestibular perception are relevant. Several functional and structural neuroimaging changes develop after vestibular neuritis, which reflect and underlie the aforementioned psychophysiological and psychological features.

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.

Acute evaluation of the acute vestibular syndrome: differentiating posterior circulation stroke from acute peripheral vestibulopathies.

This review article aims to provide an evidence-based approach to evaluating the patient who presents with acute prolonged, spontaneous vertigo in the context of the acute vestibular syndrome (AVS). Differentiation of posterior circulation stroke (PCS) presenting as an AVS has been regarded as an important diagnostic challenge for physicians involved in acute care. Current evidence suggests that a targeted approach to history taking and physical examination with emphasis on the oculomotor examination, more specifically the HINTS (Head Impulse/Nystagmus/Test-of-skew) examination battery, yields a higher sensitivity for the diagnosis of PCS than even standard magnetic resonance imaging with diffusion-weighted imaging. However, most studies have only validated the utility of the HINTS examination when performed by experts, who interpret the most powerful component of HINTS, namely the head impulse test (HIT), considerably different to the novice. Several investigations useful in the differentiation of the AVS are becoming more accessible and portable, such as videooculography with Frenzel goggles and video head impulse testing (vHIT), which allows for the quantitative assessment of the HIT. In clinical practice, vHIT has already become accepted as standard of care in the evaluation of AVS.

A video-oculographic study of acute vestibular syndromes.

OBJECTIVES: To quantitate the vestibulo-ocular reflex (VOR) gain in patients with acute vestibular neuritis (VN) and repeat this daily using a portable video head impulse test device to assess vestibular recovery in the acute stage of VN. MATERIALS AND METHODS: We enrolled adults with symptoms and signs of VN presenting to the emergency department within 48 h of symptom onset. We recorded the eye movement response to rapid head impulses using the ICS Impulse(™) video head impulse test device on each day of their hospital admission. RESULTS: There were eight patients (75% men, aged 35-85 years) who had marked variation in their initial vestibulo-ocular reflex gains. Three patients had vestibulo-ocular reflex gains in the normal range initially, despite having physical signs of VN. Two patients had initial contralesional gains below the normal range, associated with markedly reduced ipsilesional gains. Most patients' vestibulo-ocular reflex gains increased during admission, but four patients' ipsilesional gains remained in the abnormal range. Patients with lower vestibulo-ocular reflex gains were less likely to improve into the normal range. No patient with initially abnormal VOR gain recovered normal vestibulo-ocular reflex gain along with resolution of physical signs. CONCLUSION: Early video head impulse testing in the emergency department and each day of admission is feasible and well tolerated. There is marked variation in VOR gain in patients with symptoms and signs of VN, and low initial VOR gains are a predictor for low VOR gains on subsequent days. Improvement in VOR gains was seen in most patients.

Missed Anterior Inferior Cerebellar Artery Aneurysm Mimicking Vestibular Neuritis-Clues to Prevent Misdiagnosis.

We discuss a case with combined vestibulocochlear and facial neuropathy mimicking a less urgent peripheral vestibular pattern of acute vestibular syndrome (AVS). With initial magnetic resonance imaging read as normal, the patient was treated for vestibular neuropathy until headaches worsened and a diagnosis of subarachnoid hemorrhage was made. On conventional angiography, a ruptured distal right-sided aneurysm of the anterior inferior cerebellar artery was diagnosed and coiled. Whereas acute vestibular loss usually points to a benign peripheral cause of AVS, combined neuropathy of the vestibulocochlear and the facial nerve requires immediate neuroimaging focusing on the cerebellopontine angle. Imaging should be assessed jointly by neuroradiologists and the clinicians in charge to take the clinical context into account.

Four-hour-delayed 3D-FLAIR MRIs in patients with acute unilateral peripheral vestibulopathy.

OBJECTIVE: Conventionally, MRI aids in differentiating acute unilateral peripheral vestibulopathy/vestibular neuritis (AUPV/VN) from mimickers. Meanwhile, the diagnostic utility of MRIs dedicated to the inner ear remains to be elucidated for diagnosing AUPV/VN. METHODS: We prospectively recruited 53 patients with AUPV/VN (mean age ± SD = 60 ± 15 years, 29 men). Initial MRIs were performed with a standard protocol, and an additional axial 3D-fluid-attenuated inversion recovery (3D-FLAIR) sequence was obtained 4 h after intravenous injection of gadoterate meglumine. Abnormal enhancement was defined as a signal intensity that exceeded the mean + 2SD value on the healthy side. The findings of neurotologic evaluation and MRIs were compared. RESULTS: Overall, the inter-rater agreement for gadolinium enhancement was 0.886 (Cohen's kappa coefficient). Enhancement was observed in 26 patients (49%), most frequently in the vestibule (n = 20), followed by the anterior (n = 12), horizontal (HC, n = 8), posterior canal (n = 5), and superior (n = 3) and inferior (n = 1) vestibular nerves. In multivariable logistic regression analysis, the enhancement was associated with decreased HC gain in video head-impulse tests (p = 0.036), increased interaural difference in ocular vestibular-evoked myogenic potentials (p = 0.001), and a longer onset-to-MRI time span (p = 0.024). The sensitivity and specificity were 92.3% and 81.5%, respectively, with an area under the curve of 0.90 for predicting gadolinium enhancement. INTERPRETATION: Robust gadolinium enhancement was observed on 4-hour-delayed 3D-FLAIR images in nearly half of the patients with AUPV/VN, with a good correlation with the results of neurotologic evaluation. The positivity may be determined by the extent of vestibular deficit, timing of imaging acquisition, and possibly by the underlying etiology causing AUPV/VN. MRIs may aid in delineating the involved structures in AUPV/VN.

Vestibular Nucleus Involvement in Patients With Acute Vertigo Due to Herpes Zoster Oticus or Vestibular Neuritis.

OBJECTIVES: Herpes zoster oticus (HZO) typically provokes vestibular symptoms and is traditionally viewed as a cranial nerve equivalent of shingles, but in contrast to vestibular neuritis (VN), it is unclear whether the pathology of HZO is limited to the vestibular nerve (neuritis) or can also involve the brainstem (nucleitis). METHODS: We retrospectively compared brain MRIs of patients with HZO with those of patients with VN to study radiologic changes in the brainstem. RESULTS: Five of 10 patients with HZO showed signal abnormalities in the vestibular nuclei, which lie in multiple vascular territories, whereas no patients with VN exhibited such findings. DISCUSSION: HZO may at least in part reflect vestibular nucleitis, as opposed to a pure neuritis.

The "Vestibular Eye Sign"-"VES": a new radiological sign of vestibular neuronitis can help to determine the affected vestibule and support the diagnosis.

INTRODUCTION: Nystagmus is a valuable clinical finding. Although nystagmus is often described by the direction of its quick phases, it is the slow phase that reflects the underlying disorder. The aim of our study was to describe a new radiological diagnostic sign called "Vestibular Eye Sign"-VES. This sign is defined as an eye deviation that correlates with the slow phase of nystagmus (vestibule pathological side), which is seen in acute vestibular neuronitis and can be assessed on a CT head scan. MATERIALS AND METHODS: A total of 1250 patients were diagnosed with vertigo in the Emergency Department at Ziv Medical Center (ED) in Safed, Israel. The data of 315 patients who arrived at the ED between January 2010 and January 2022 were collected, with criteria eligible for the study. Patients were divided into 4 groups: Group A, "pure VN", Group B, "non-VN aetiology", Group C, BPPV patients, and Group D, patients who had a diagnosis of vertigo with unknown aetiology. All groups underwent head CT examination while in the ED. RESULTS: In Group 1, pure vestibular neuritis was diagnosed in 70 (22.2%) patients. Regarding accuracy, VES (Vestibular Eye Sign) was found in 65 patients in group 1 and 8 patients in group 2 and had a sensitivity of 89%, specificity of 75% and a negative predictive value of 99.4% in group 1-pure vestibular neuronitis. CONCLUSION: VN is still a clinical diagnosis, but if the patient undergoes head CT, we suggest using the "Vestibular Eye Sign" as a complementary sign. As per our findings, this is a valuable sign on CT imaging for diagnosing the pathological side of isolated pure VN. It is sensitive to support a diagnosis with a high negative predictive value.

White Matter Hyperintensities (WMH) and clinical outcome after vestibular neuritis.

OBJECTIVES: Identification of patients at high risk for chronic dizziness after Vestibular Neuritis (VN) would allow these patients to be the target of focused therapies. However, there is a discrepancy between studies with regard to which factors best predict symptom recovery. The present study provides a comprehensive evaluation of Vestibular Neuritis and the major predictors for the development of chronic vestibular insufficiency. METHODS: All subjects (n = 54) with acute vestibular neuritis admitted to the Department of Neurology of Beijing Luhe Hospital affiliated to Capital Medical University from 2018 to 2020 were retrospectively identified . Forty-three subjects who received a 4-test battery as well as 3.0T brain MRI, were included in the study. Patients were divided into two groups: Group 1 with complete recovery and Group 2 without recovery, as determined by symptoms 3 months after the VN episode. In addition, we recruited 21 healthy subjects to characterize the profiles of acute VN . RESULTS: The total WMH score negatively correlated with a clinical recovery (Phi coefficient = -0.808, p value = 0.000). Statistical regression for predicting the outcome of clinical recovery using cerebral white matter changes as an independent variable was significant (p = 0.004). However, clinical recovery was not associated with the nerve divisions (Phi coefficient = 0.108, p = 0.492), age (p = 0.247) and the grade of nystagmus (p = 0.797)   . CONCLUSIONS: A 4-test battery provides essential information to identify vestibular nerve dysfunction. Cerebral white matter change on MRI was predictive of chronic vestibular insufficiency after vestibular neuritis.

Isolated cerebellar nodulus infarction: Two case reports and literature review.

BACKGROUND: Isolated cerebellar nodulus infarction (ICNI) is rare and has great clinical similarity with acute peripheral vestibulopathy (APV), from which it is difficult to distinguish. We report two cases of ICNI followed by a literature review to identify the discriminant clinical elements that differentiate ICNI from APV. METHODS: We describe in detail our 2 cases. Besides, a literature search in Medline via PubMed and Scopus was performed up to May 17, 2020. Clinical characteristics, mainly of well-described cases, were extracted and analyzed. RESULTS: Our search yielded 43 total publications, among which 13 were selected, including 23 patients. Spontaneous or positional rotatory vertigo with unidirectional spontaneous horizontal nystagmus, associated with the postural imbalance and unilateral lateropulsion or fall on Romberg's test, was the most common clinical picture. According to our literature review, the discriminant clinical elements which differentiate ICNI from APV were direction-changing gaze-evoked nystagmus, bilateral lateropulsion or fall on Romberg's test, and normal horizontal head impulse test. Our two patients reported a positional fleeting abnormal visual perception of spatial orientation of objects. We proposed this symptom as a discriminant clinical element. CONCLUSION: The ICNI constitutes a difficult differential diagnosis of APV. Through our two patients reported here, we proposed a supplementary discriminant symptom helpful for the clinical diagnosis.

Usefulness of vertebrobasilar artery radiological finding as a predictive and prognostic factor for sudden sensorineural hearing loss.

OBJECTIVE: The association between sudden sensorineural hearing loss (SSNHL) and radiological findings of the vertebrobasilar artery is not well-known and little research has been done. We hypothesized that the radiological features of the vertebrobasilar artery contribute to the incidence and prognosis of SSNHL. METHODS: We retrospectively enrolled patients diagnosed with unilateral SSNHL (SSNHL group) and those with acute vestibular neuritis (AVN; control group) in our hospital. All patients underwent magnetic resonance imaging and computed tomography. We measured the following parameters on the radiological images: basilar artery diameter, direction and distance of basilar artery deviation, direction and distance of vertebral artery deviation, and incidence of vertebral artery obstruction. Pure tone audiometry (PTA) was performed in all patients. Follow up PTA between 1 week and 1 month after treatment was performed in the SSNHL group. RESULTS: A total of 244 SSNHL patients and 62 AVN patients were included in the analysis. Age, body mass index, and basilar artery diameter were found to be significantly associated with SSNHL. In the SSNHL group, patients were divided into three subgroups based on the consistency between the basilar artery deviation site and disease site. No significant difference was noted in initial PTA, final PTA, PTA recovery, and symptom improvement among the three groups. In case of the basilar artery, when the deviation and disease sites were in the opposite direction and the basilar artery diameter was >3.5 mm, diameter of basilar artery was positively correlated with PTA recovery. CONCLUSIONS: The strength of this study is that radiological evaluation of the vertebrobasilar artery was performed. Further research on the association between SSNHL and radiological features of the vertebrobasilar artery should be conducted to emphasize the importance of vascular assessment in SSNHL.

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.

Results in caloric test, video head impulse test and inner ear MRI in patients with Ménière's disease.

OBJECTIVE: Our aim was to elucidate relationships between results from the caloric test (c-test), video Head Impulse Test (vHIT) and inner ear gadolinium-enhanced MRI (ieMRI) in patients with endolymphatic hydrops (EH), especially patients with Ménière's disease (MD). METHODS: We managed 1789 successive patients at the Vertigo/Dizziness Center in Nara Medical University from May 2014 to December 2018. After providing informed consent for vertigo/dizziness examinations, 281 patients were hospitalized to check their inner ear function for proper diagnosis and treatment. Then 76 participants underwent the c-test, vHIT and ieMRI. Among these 76 cases, 20 were diagnosed with MD (20/76; 26.3%) and 56 were non-MD (56/76; 73.7%) according to the 2015 diagnostic guideline of the International Classification of Vestibular Disorders. The MD group included 15 unilateral and 5 bilateral cases. The non-MD group included 22 benign paroxysmal positional vertigo, 10 vestibular neuritis, 8 sudden deafness with vertigo, 6 orthostatic dysregulation, 4 vestibular neuropathy and 6 others. Results in these examinations in the side of an active lesioned inner ear were representative in each peripheral case. RESULTS: Twenty-nine of the 76 patients (38.1%) showed discrepant results between the c-test (outside of normal range) and vHIT (within normal range). Twenty-two of 76 patients (28.9%) had a positive EH sign on ieMRI. The c-test/vHIT discrepancy percentage in MD (14/20; 70.0%) was significantly higher than that in non-MD (15/56; 26.8%) (p=0.00179). The positive EH sign in ieMRI percentage in MD (15/20; 75.0%) was significantly higher than that in non-MD (7/56; 12.5%) (p=0.0015). There was a significant positive relationship between the c-test/vHIT discrepancy and the positive EH sign (p=0.00058) in all 76 cases combined. However, there was no significant relationship between c-test/vHIT discrepancy and positive EH sign (p=0.13) in the 20 MD cases. Considering the 15 unilateral and 5 bilateral MD cases, the c-test/vHIT discrepancy was observed in 14 of the 25 affected ears. Positive signs of vestibular EH herniation into the cupula in the lateral semicircular canal was seen in 14 of the 25 MD ears. There was significant relationship between the c-test/vHIT discrepancy and EH herniation (p=0.0012) in MD ears. CONCLUSION: The present results suggest that patients with MD could have inner ear EH significantly more often than those with non-MD. In cases with MD, a positive EH sign on ieMRI did not always indicate a c-test/vHIT discrepancy; both findings may occur due to herniation of vestibular EH adjacent to the lateral semicircular canal.

Cerebral plasticity in acute vestibular deficit.

The aim of this study was to analyze the effect of acute vestibular deficit on the cerebral cortex and its correlation with clinical signs and symptoms. Eight right-handed patients affected by vestibular neuritis, a purely peripheral vestibular lesion, underwent two brain single photon emission computed tomography (SPECT) in 1 month. The first SPECT analysis revealed reduced blood flow in the temporal frontal area of the right hemisphere in seven of eight patients, independent of the right/left location of the lesion. The alteration was present always in the right, non-dominant hemisphere and was reversible in some patients 1 month after the onset, together with attenuation of signs and symptoms. It may be hypothesized that the transient reduction of cortical blood flow and subsequently of cortical activity in the non-dominant hemisphere, also the expression of cerebral plasticity, may serve as a defense mechanism aimed to attenuate the vertigo symptom.

Measurement of horizontal ocular deviation on magnetic resonance imaging in various disease with acute vertigo.

In our previous study, we found that horizontal ocular deviation (OD) was significantly increased in patients with unilateral vestibular neuritis (VN). This study is aimed to compare the measurements of horizontal OD in various diseases which can present as acute vertigo in the emergency department. We retrospectively reviewed patients who visited the emergency department and underwent brain MRI due to acute vertigo. We compared them to healthy controls who underwent brain MRI for a regular health examination. Among the study participants, 149 patients who were diagnosed with benign paroxysmal positional vertigo (BPPV), unilateral Ménière's disease (MD), vestibular migraine (VM), unilateral vestibular neuritis (VN), or posterior inferior cerebellar artery (PICA) infarction were enrolled. Absolute angles of horizontal OD were larger in the definite MD (19.1 ± 12.7°), possible and probable MD (15.5 ± 11.7°), and VN (22.2 ± 11.7°) groups compared to the control group (4.3 ± 3.7°). Most VN patients (83.3%) had horizontal OD toward the direction of the lesion. About half of the MD patients (46.2%) and half of the patients with PICA infarction (50.0%) had horizontal OD toward the opposite direction of the lesion. Regarding PICA infarction, horizontal OD was observed only in patients who immediately underwent an MRI after developing the PICA territory vestibulocerebellar infarction. Although the exact mechanism of horizontal OD is unclear, this study suggests that horizontal OD reflects a static vestibular imbalance, and that the eyeball is deviated to the weaker of the two vestibular nuclei during neural resting activity. Therefore, horizontal OD could be helpful in assessing for a prior vestibular imbalance.

Enlarged vestibular aqueduct (EVA) related with recurrent benign paroxysmal positional vertigo (BPPV).

The vestibular aqueduct is a bony canal related to the bony labyrinth of the inner ear and represents the non-sensory components of the endolymph-filled, closed, membranous labyrinth. The association of congenital sensorineural hearing loss with a large or enlarged vestibular aqueduct is well known as the large vestibular aqueduct syndrome (LVAS). The enlarged VA (EVA) comprises abnormalities not only in the structure of the inner ear, but also in the physiology of the auditory and vestibular systems. The clinical picture of this clinical entity is variable [Yetiser S, Kertment M, Ozkaptan Y. Vestibular disturbance in patients with Large Vestibular Aqueduct Syndrome (LVAS). Acta Otolaryngol (StochK) 1999;119: 641-646]. Signs and symptoms of the auditory impairment are more commonly described in the literature: hearing loss ranges from mild to profound, arising from fluctuating to stepwise progressive or sudden. Vestibular disturbances, ranging from mild imbalance to episodic vertigo, are rarely described in the literature. Benign paroxysmal positional vertigo (BPPV) is a labyrinthine disorder with a typical behavior: intense crises of rotational vertigo induced by postural changes of the head, with short duration and usually good responsiveness to rehabilitative maneuvers. These maneuvers are effective in about 80% of patients with BPPV. BPPV often recurs. About 1/3 of patients have a recurrence in the first year after treatment, and by five years, about half of all patients have a recurrence. Vestibular aqueduct has been demonstrated by conventional tomography and computed tomography (CT), however, CT scans cannot show the membranous labyrinth itself. On MR images it is not the vestibular aqueduct that is visualized but its contents, the endolymphatic duct and sac, and can show the abnormalities of the fluid spaces related to the membranous labyrinth. It is proposed that recurrent benign paroxysmal positional vertigo (BPPV) is related with volumetric abnormalities of vestibular aqueduct. This verifiable hypothesis tries to define this rapport and explore new diagnostic and therapeutic possibilities.

[Diagnostic value of color-coded Doppler sonography in neuro-otologic disorders]. / Wertigkeit der farbkodierten Duplexsonografie bei neuro-otologischen Krankheitsbildern.

PURPOSE: The successful introduction of Doppler and Color-Coded Doppler Sonography (CCDS) in the field of Otorhinolaryngology has improved the diagnostic sonographic value for several diseases of the head and neck region, e. g. in hemangiomas and vascular malformations. The diagnostic value of CCDS for examination of the extracranial brain supplying vessels in combination with neuro-otologic disorders is still under controversial discussion. MATERIALS AND METHODS: We investigated the diagnostic CCDS findings for 215 patients suffering from different neuro-otologic disorders. All patients were classified into 4 groups according to the different disorder entity (sudden deafness, tinnitus, vestibular neuropathy, combined diagnosis). The frequency of pathologic CCDS findings was correlated with the different groups using sonographic parameters such as atherosclerosis, stenosis and intima-media thickness. RESULTS: Classification of the disorder entities led to the following distribution: Sudden deafness group (85 patients; 40 %), Tinnitus group (44 patients; 20 %), Vestibular neuropathy group (41 patients; 19 %), Combined diagnosis group (45 patients; 21 %). Sonographic evaluation of atherosclerosis was possible in 76 cases (35 %), changes of the intima-media thickness were observed in 43 cases (20 %) while proof of stenoses was identified in 15 cases (7 %). The evaluation of plaque formation (atherosclerosis) in the sudden deafness group was significantly higher (p < 0.01) than in all other groups although the combined diagnosis group demonstrated certain tendencies (p < 0.08) without significant correlation. CONCLUSION: Our results reinforce the hypothesis of a vascular genesis of sudden deafness and seem to offer the possibility of sonographic differentiation between neuro-otologic disorder entities by use of CCDS. In contrast, it seems that the role of CCDS is negligible for individual diagnostic purposes.

Arteriosclerotic changes as background factors in patients with peripheral vestibular disorders.

Symptoms such as vertigo and unsteady gait occur in various diseases and are among the relatively common chief complaints. Even at present, the mechanisms underlying these disorders are unclear. We considered the possibility of peripheral vestibular disorders correlating with lifestyle-related illnesses. Under these circumstances, we assessed correlations of lifestyle-related illness as background factors for peripheral vestibular disorders and associated arteriosclerotic changes. Using carotid ultrasonography, we assessed maximum intima-media thickness (max IMT) and maximum common carotid artery IMT and evaluated biochemical examinations in 85 patients with peripheral vertigo. The patients were divided into two groups: those with benign paroxysmal positional vertigo (BPPV) and those with peripheral vestibular disorders. The frequency of abnormal IMT was significantly higher in those in the BPPV group. Calculating for average age, max IMT was significantly higher in the BPPV group. The correlation coefficient between age and max IMT was 0.343 (p < .001). All other correlation coefficients also reached statistical significance. Our results indicate that cervical ultrasonography is useful for noninvasive examination of arteriosclerotic changes in patients with peripheral vestibular disorders. Our results also indicated that peripheral vestibular disorder patients show progression of arteriosclerotic changes.