Vascular vertigo and dizziness: Diagnostic criteria.

This paper presents diagnostic criteria for vascular vertigo and dizziness as formulated by the Committee for the Classification of Vestibular Disorders of the Bárány Society. The classification includes vertigo/dizziness due to stroke or transient ischemic attack as well as isolated labyrinthine infarction/hemorrhage, and vertebral artery compression syndrome. Vertigo and dizziness are among the most common symptoms of posterior circulation strokes. Vascular vertigo/dizziness may be acute and prolonged (≥24 hours) or transient (minutes to  < 24 hours). Vascular vertigo/dizziness should be considered in patients who present with acute vestibular symptoms and additional central neurological symptoms and signs, including central HINTS signs (normal head-impulse test, direction-changing gaze-evoked nystagmus, or pronounced skew deviation), particularly in the presence of vascular risk factors. Isolated labyrinthine infarction does not have a confirmatory test, but should be considered in individuals at increased risk of stroke and can be presumed in cases of acute unilateral vestibular loss if accompanied or followed within 30 days by an ischemic stroke in the anterior inferior cerebellar artery territory. For diagnosis of vertebral artery compression syndrome, typical symptoms and signs in combination with imaging or sonographic documentation of vascular compromise are required.

Vestibular migraine: Diagnostic criteria1.

This paper presents diagnostic criteria for vestibular migraine, jointly formulated by the Committee for Classification of Vestibular Disorders of the Bárány Society and the Migraine Classification Subcommittee of the International Headache Society (IHS). It contains a literature update while the original criteria from 2012 were left unchanged. The classification defines vestibular migraine and probable vestibular migraine. Vestibular migraine was included in the appendix of the third edition of the International Classification of Headache Disorders (ICHD-3, 2013 and 2018) as a first step for new entities, in accordance with the usual IHS procedures. Probable vestibular migraine may be included in a later version of the ICHD, when further evidence has accumulated. The diagnosis of vestibular migraine is based on recurrent vestibular symptoms, a history of migraine, a temporal association between vestibular symptoms and migraine symptoms and exclusion of other causes of vestibular symptoms. Symptoms that qualify for a diagnosis of vestibular migraine include various types of vertigo as well as head motion-induced dizziness with nausea. Symptoms must be of moderate or severe intensity. Duration of acute episodes is limited to a window of between 5 minutes and 72 hours.

Persistent Postural-Perceptual Dizziness: Precipitating Conditions, Co-morbidities and Treatment With Cognitive Behavioral Therapy.

Persistent postural perceptual dizziness (PPPD) is a common chronic vestibular disorder characterized by persistent vestibular symptoms, including postural instability and non-spinning vertigo, which is aggravated by motion, upright posture and moving or complex visual stimuli. In our review of 198 cases seen over a 5 year period, we have confirmed a number of common precipitating conditions for PPPD, including anxiety disorders and vestibular migraine. Vestibular abnormalities, including a unilateral loss of vestibular hypofunction and isolated otolith abnormalities, were found on investigation in just under half the cases. The use of cognitive behavioral therapy (CBT) as a treatment for PPPD resulted in impressive reductions in anxiety and measures of dizziness over follow up periods of up to 6 months.

HaNDL with bilateral central venous occlusions.

BACKGROUND: The syndrome of Headache and focal Neurological Deficits with cerebrospinal fluid Lymphocytosis (HaNDL) is considered a rare, idiopathic and self-limited condition. METHODS: We present a patient with HaNDL who had unique findings of florid optic disc haemorrhages from bilateral central retinal vein occlusions. RESULTS: Our patient made a full recovery with conservative management. CONCLUSION: It is important for medical attendants to recognise that HaNDL syndrome can be associated with neuro-ophthalmic complications.

Genetic prion disease: D178N with 129MV disease modifying polymorphism-a clinical phenotype.

BACKGROUND: Human prion diseases are a group of rare neurological diseases with a minority due to genetic mutations in the prion protein (PRNP) gene. The D178N mutation is associated with both Creutzfeldt-Jakob disease and fatal familial insomnia with the phenotype modified by a polymorphism at codon 129 with the methionine/valine (MV) polymorphism associated with atypical presentations leading to diagnostic difficulty. CASE: We present a case of fatal familial insomnia secondary to a PRNP D178N mutation with 129MV disease modifying polymorphism who had no family history, normal MRI, electroencephalography (EEG), cerebrospinal fluid (CSF) and positron emission tomography findings and a negative real-time quaking-induced conversion result. CONCLUSION: Patients with genetic prion disease may have no known family history and normal EEG, MRI brain and CSF findings. PRNP gene testing should be considered for patients with subacute progressive neurological and autonomic dysfunction.

Importance of spontaneous nystagmus detection in the differential diagnosis of acute vertigo.

Vertigo is a common cause of emergency department attendance. Detection of spontaneous nystagmus may be a useful sign in distinguishing vestibular neuritis from other vestibular diagnoses. We aimed to assess the contribution of spontaneous nystagmus in the diagnosis of acute vertigo. We enrolled consecutive consenting patients arriving at a single emergency department with acute vertigo. There was no declared protocol for the emergency department staff. A standardized history and examination was conducted by the investigators. Observation for spontaneous nystagmus, its response to visual fixation, and testing the vestibulo-ocular reflex with the horizontal head impulse test were the chief examination components. MRI was obtained within 24 hours. Clinical criteria and MRI were used to reach the final diagnosis. The investigators' physical findings and final neurological diagnosis were compared with the initial emergency department examination findings and the referral diagnosis. There were 28 patients, 15 with vestibular neuritis, six with benign paroxysmal positional vertigo, one with stroke, suspected clinically, and three with migraine. In three the diagnosis remained uncertain. Spontaneous nystagmus was seen in all 15 patients with vestibular neuritis, fixation-suppressed in eight of 11 tested for this. The head impulse test was positive in 12 of 15 with vestibular neuritis. The emergency department referral diagnosis was correct in six of 23 patients. The ability to detect spontaneous nystagmus is useful in vestibular diagnosis, both in support of a diagnosis of vestibular neuritis and in avoiding false positive diagnoses of benign paroxysmal positional vertigo.

Migraña vestibular: criterios diagnósticos. Documento de consenso de la Bárány Society y la International Headache Society / Vestibular migraine: Diagnostic criteria. Consensus document of the Bárány Society and the International Headache Society

Este trabajo presenta los criterios diagnósticos de migraña vestibular formulados conjuntamente por el Comité de Clasificación de Trastornos Vestibulares de la Bárány Society y el Subcomité de Clasificación de la Migraña de la International Headache Society. La clasificación incluye migraña vestibular y migraña vestibular probable. La migraña vestibular aparecerá en un apéndice de la tercera edición de la Clasificación Internacional de las Cefaleas como un primer paso para nuevas entidades, según los procedimientos habituales de la IHS. La migraña vestibular probable puede ser incluida en una versión posterior de la Clasificación Internacional de las Cefaleas, cuando se acumule más evidencia. El diagnóstico de migraña vestibular está basado en síntomas vestibulares recurrentes, una historia de migraña, una asociación temporal entre síntomas vestibulares y síntomas migrañosos, y la exclusión de otras causas de síntomas vestibulares. Los síntomas requeridos para el diagnóstico de migraña vestibular incluyen varios tipos de vértigo. Así como mareo inducido por movimientos de cabeza con náuseas. Los síntomas deben ser de intensidad moderada o severa. La duración de los episodios se limita a un período entre 5 min y 72 h (AU)

This work presents the diagnostic criteria for vestibular migraine, jointly formulated by the Committee for Classification of Vestibular Disorders of the Bárány Society and the Migraine Classification Subcommittee of the International Headache Society. The classification includes vestibular migraine and probable vestibular migraine. Vestibular migraine will feature in an appendix of the third edition of the International Classification of Headache Disorders as a first step for new entities, in accordance with the usual procedures of the International Headache Society. Probable vestibular migraine may be included in a later version of the International Classification of Headache Disorders, when further evidence has been gathered. The diagnosis of vestibular migraine is based on recurrent vestibular symptoms, a history of migraine, a temporal association between vestibular symptoms and migraine symptoms and on the exclusion of other causes of vestibular symptoms. The symptoms required for a diagnosis of vestibular migraine include various types of vertigo, as well as head motion-induced dizziness with nausea. Symptoms must be of moderate or severe intensity. The duration of acute episodes is limited to a window of between 5 min and 72 h (AU)

Vestibular migraine: diagnostic criteria.

This paper presents diagnostic criteria for vestibular migraine, jointly formulated by the Committee for Classification of Vestibular Disorders of the Bárány Society and the Migraine Classification Subcommittee of the International Headache Society (IHS). The classification includes vestibular migraine and probable vestibular migraine. Vestibular migraine will appear in an appendix of the third edition of the International Classification of Headache Disorders (ICHD) as a first step for new entities, in accordance with the usual IHS procedures. Probable vestibular migraine may be included in a later version of the ICHD, when further evidence has been accumulated. The diagnosis of vestibular migraine is based on recurrent vestibular symptoms, a history of migraine, a temporal association between vestibular symptoms and migraine symptoms and exclusion of other causes of vestibular symptoms. Symptoms that qualify for a diagnosis of vestibular migraine include various types of vertigo as well as head motion-induced dizziness with nausea. Symptoms must be of moderate or severe intensity. Duration of acute episodes is limited to a window of between 5 minutes and 72 hours.

Two patients with audiovestibular sarcoidosis.

We report two patients with biopsy-proven audiovestibular sarcoidosis who presented with hearing loss, vertigo and gait ataxia. Oto-neurological investigations confirmed the presence of sensorineural hearing loss, vestibular hypofunction and abnormal auditory brainstem responses. MRI scans of the brain revealed enhancement of the vestibulo-cochlear nerves. Both patients responded to high dose oral corticosteroid treatment, although one patient has required multiple trials of immunosuppressant drug therapy because of relapsing disease.

Cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS): a review of the clinical features and video-oculographic diagnosis.

The association of bilateral vestibulopathy with cerebellar ataxia was first reported in 1991 and delineated as a distinct syndrome with a characteristic and measurable clinical sign--an absent visually enhanced vestibulo-ocular reflex--in 2004. We reviewed 27 patients with this syndrome and show that a non-length-dependent sensory deficit with absent sensory nerve action potentials is an integral component of this syndrome, which we now call "cerebellar ataxia with neuropathy and bilateral vestibular areflexia syndrome" (CANVAS). All patients had brain MRI and 22/27 had evidence of cerebellar atrophy involving anterior and dorsal vermis, as well as the hemispheric crus I. Brain and temporal bone pathology in one patient showed marked loss of Purkinje cells and of vestibular, trigeminal, and facial ganglion cells, but not of spiral ganglion cells. There are two sets of sibling pairs, suggesting CANVAS is a late-onset recessive disorder. The characteristic clinical sign-the visual vestibulo-ocular reflex deficit-can be demonstrated and measured clinically using video-oculography.

Vertebrobasilar ischaemia presenting as recurrent isolated vertigo.

Chronic recurrent isolated vertigo is an uncommon manifestation of vertebrobasilar ischaemia. We report a 43-year-old female with 12-month history of recurrent attacks of isolated vertigo who presented with acute pontine infarctions. Clinical examination and vestibular function testing showed bilateral vestibular hypofunction affecting the horizontal and posterior semicircular canals and right saccule. Diffusion-weighted magnetic resonance imaging (MRI) demonstrated acute bilateral pontine infarcts and significant vertebrobasilar stenoses. The findings of recurrent isolated vertigo and bilateral vestibular hypofunction should not prevent a search for vertebrobasilar ischaemia, particularly in the presence of vascular risk factors.

Does otolith organ dysfunction influence outcomes after a customized program of vestibular rehabilitation?

BACKGROUND AND PURPOSE: Vestibular rehabilitation (VR) is a successful approach to the treatment of vestibular dysfunction. The purpose of this study was to investigate the influence of otolith dysfunction on the response to VR in individuals with a peripheral vestibular disorder. PARTICIPANTS AND METHODS: Eighteen participants with loss of semicircular canal function only, and 29 participants with combined loss of semicircular canal and otolith organ function were recruited. All participants received a comprehensive clinical assessment before and after an 8-week customized program of VR. RESULTS: Both groups achieved significant improvements on most measures at the end of the 8-week VR program. However, no significant differences were identified between participants with versus without otolith dysfunction with respect to change in symptom severity (P = .81), self-perceived handicap (P = .92), functional limitations (P = .93), or balance performance after VR. DISCUSSION AND CONCLUSIONS: Otolith dysfunction does not significantly influence the response to rehabilitation of individuals with a peripheral vestibular disorder. Vestibular rehabilitation is associated improvements in symptom severity, self-perceived handicap, and balance function in individuals with otolith dysfunction.

The influence of otolith dysfunction on the clinical presentation of people with a peripheral vestibular disorder.

BACKGROUND AND PURPOSE: Traditional vestibular function testing has measured horizontal semicircular canal function only. Otolith function tests have recently been developed, but their clinical significance has not been determined. The purpose of this study was to investigate the influence of otolith dysfunction on the clinical presentation of individuals with a peripheral vestibular disorder. SUBJECTS AND METHODS: Twenty-one subjects with loss of horizontal semicircular canal function only and 37 subjects with combined loss of horizontal semicircular canal and otolith organ function were recruited. All subjects received a comprehensive clinical assessment, including self-report questionnaires and measures of balance performance. RESULTS: No significant differences were identified between subjects with or without otolith dysfunction with respect to symptom severity, self-perceived handicap, functional limitations, or balance performance. DISCUSSION AND CONCLUSION: Otolith dysfunction does not significantly influence the clinical presentation of individuals with a peripheral vestibular disorder. Other factors, including symptom severity, may be more influential.

A pilot study of falls risk and vestibular dysfunction in older fallers presenting to hospital emergency departments.

PURPOSE: To compare falls risk in older fallers and non-fallers, with an emphasis on dizziness and signs of vestibular dysfunction. METHOD: The fallers had presented to the Emergency Department of the Royal Melbourne Hospital, Australia following a fall and were discharged directly home (n = 20) (75% female, mean age 78 years). The non-fallers were an age and gender matched group, who had not fallen in the past 12 months (n = 20). All clients received a home-based assessment, which involved a comprehensive assessment of falls risk. RESULTS: Over three-quarters of the fallers took four or more medications, had balance impairments, and used a gait aid in the community. The fallers had a significantly higher falls risk score (P < 0.001), demonstrated significantly poorer balance (P < 0.001) and walked significantly more slowly (P < 0.001) than the non-fallers. There was no significant difference between the groups in their reports of dizziness (P = 0.68), although static balance testing (CTSIB condition 5) suggested a greater degree of underlying vestibular dysfunction in the group of fallers (P < 0.001). CONCLUSION: Older people discharged home from the ED following a fall are at high risk of falling in the future and have a greater level of vestibular dysfunction based on simple clinical testing. Additional clinically applicable tests of vestibular function are required to further investigate the relationship between vestibular dysfunction and falling in older people.

Chronic migrainous vertigo.

A series of 16 subjects is described who presented with chronic vertigo that was thought to be migrainous in nature. The vertigo occurred on a daily basis and had been present for six months or more. Common symptoms included motion-induced dizziness, positional vertigo and motion sensitivity. Investigations were frequently normal apart from the finding of atypical positional nystagmus in four subjects and unilateral vestibular hypofunction in two subjects. It was frequently not possible to make a diagnosis of migraine on the basis of International Headache Society criteria, however the dramatic beneficial response to anti-migraine therapy supported the hypothesis that the vertigo was migrainous in nature.