Subjective and objective responses to caloric stimulation help separate vestibular migraine from other vestibular disorders.

BACKGROUND: Nystagmus generated during bithermal caloric test assesses the horizontal vestibulo-ocular-reflex. Any induced symptoms are considered unwanted side effects rather than diagnostic information. AIM: We hypothesized that nystagmus slow-phase-velocity (SPV) and subjective symptoms during caloric testing would be higher in vestibular migraine (VM) patients compared with peripheral disorders such as Meniere's disease (MD) and non-vestibular dizziness (NVD). METHODS: Consecutive patients (n = 1373, 60% female) referred for caloric testing were recruited. During caloric irrigations, patients scored their subjective sensations. We assessed objective-measures, subjective vertigo (SVS), subjective nausea (SNS), and test completion status. RESULTS: Nystagmus SPV for VM, MD (unaffected side), and NVD were 29 ± 12.8, 30 ± 15.4, and 28 ± 14.2 for warm irrigation and 24 ± 8.9, 22 ± 10.0, and 25 ± 12.8 for cold-irrigation. The mean SVS were 2.5 ± 1.1, 1.5 ± 1.33, and 1.5 ± 1.42 for warm irrigation and 2.2 ± 1.1, 1.1 ± 1.19, and 1.1 ± 1.16 for cold-irrigation. Age was significantly correlated with SVS and SNS, (p < 0.001) for both. The SVS and SNS were significantly higher in VM compared with non-VM groups (p < 0.001), and there was no difference in nystagmus SPV. VM patients SVS was significantly different to the SVS of migraineurs in the other diagnostic groups (p < 0.001). Testing was incomplete for 34.4% of VM and 3.2% of MD patients. To separate VM from MD, we computed a composite value representing the caloric data, with 83% sensitivity and 71% specificity. Application of machine learning to these metrics plus patient demographics yielded better separation (96% sensitivity and 85% specificity). CONCLUSION: Perceptual differences between VM and non-VM patients during caloric stimulation indicate that subjective ratings during caloric testing are meaningful measures. Combining objective and subjective measures could provide optimal separation of VM from MD.

Vestibular-evoked myogenic potentials.

The vestibular-evoked myogenic potential (VEMP) is a short-latency potential evoked through activation of vestibular receptors using sound or vibration. It is generated by modulated electromyographic signals either from the sternocleidomastoid muscle for the cervical VEMP (cVEMP) or the inferior oblique muscle for the ocular VEMP (oVEMP). These reflexes appear to originate from the otolith organs and thus complement existing methods of vestibular assessment, which are mainly based upon canal function. This review considers the basis, methodology, and current applications of the cVEMP and oVEMP in the assessment and diagnosis of vestibular disorders, both peripheral and central.

Ocular vestibular evoked myogenic potentials are abnormal in internuclear ophthalmoplegia.

OBJECTIVE: The cervical vestibular evoked myogenic potential (cVEMP) is sensitive to lower brainstem lesions affecting the vestibulo-collic pathway. We wished to determine whether the ocular VEMP (oVEMP), a recently-described otolith-ocular reflex, is also abnormal in patients with brainstem lesions. We tested patients with internuclear ophthalmoplegia (INO), caused by a brainstem lesion in the medial longitudinal fasciculus (MLF), to investigate whether the oVEMP is abnormal in patients with a lesion of the otolith-ocular pathway. METHODS: We describe a patient who developed a right INO during his first episode of demyelination, and report results from 12 additional patients, most of whom had multiple sclerosis. All subjects were stimulated with air-conducted tone bursts. cVEMPs and oVEMPs were measured using surface electrodes placed over the neck and beneath the eyes. RESULTS: Overall, oVEMPs showed significantly more abnormalities (69%) than cVEMPs (8%). Ocular VEMPs were absent with stimulation of 13/26 ears, significantly delayed in 5/26 cases and normal in only 8/26 cases. CONCLUSION: Ocular VEMPs are often abnormal in patients with multiple sclerosis who have an INO, while cVEMPs are usually normal. SIGNIFICANCE: Ocular VEMPs provide a new, non-invasive method for examining central vestibular pathways in humans and are sensitive to lesions of the MLF.

Vestibular evoked myogenic potentials: past, present and future.

Since the first description of sound-evoked short-latency myogenic reflexes recorded from neck muscles, vestibular evoked myogenic potentials (VEMPs) have become an important part of the neuro-otological test battery. VEMPs provide a means of assessing otolith function: stimulation of the vestibular system with air-conducted sound activates predominantly saccular afferents, while bone-conducted vibration activates a combination of saccular and utricular afferents. The conventional method for recording the VEMP involves measuring electromyographic (EMG) activity from surface electrodes placed over the tonically-activated sternocleidomastoid (SCM) muscles. The "cervical VEMP" (cVEMP) is thus a manifestation of the vestibulo-collic reflex. However, recent research has shown that VEMPs can also be recorded from the extraocular muscles using surface electrodes placed near the eyes. These "ocular VEMPs" (oVEMPs) are a manifestation of the vestibulo-ocular reflex. Here we describe the historical development and neurophysiological properties of the cVEMP and oVEMP and provide recommendations for recording both reflexes. While the cVEMP has documented diagnostic utility in many disorders affecting vestibular function, relatively little is known as yet about the clinical value of the oVEMP. We therefore outline the known cVEMP and oVEMP characteristics in common central and peripheral disorders encountered in neuro-otology clinics.

Vestibular hypersensitivity to sound in superior canal dehiscence: large evoked responses in the legs produce little postural sway.

OBJECTIVE: Patients with superior canal dehiscence (SCD) typically have enhanced sound-evoked vestibular reflexes, such as vestibulo-collic and vestibulo-ocular reflexes. We wished to investigate whether sound-evoked lower limb EMG responses and postural sway are also enhanced in this condition. METHODS: Eight patients with CT confirmed SCD (11 affected ears) and 8 age-matched normal controls participated. Three sound-evoked responses were measured; vestibulo-collic reflexes (i.e. vestibular-evoked myogenic potentials, VEMPs), lower limb vestibulo-spinal reflexes and body sway (centre of pressure in mm). Sound stimuli were 500 Hz air-conducted tone bursts of varying lengths (VEMPs: 2 ms; vestibulo-spinal: 20 ms; sway: 1s and 200 ms) set at fixed levels above each subject's VEMP threshold. RESULTS: SCD patients had very large VEMP and vestibulo-spinal responses following high intensity stimulation, but at the matched intensity of 15 dB above threshold amplitudes were similar in both SCD patients and controls. The amplitude of both responses increased linearly with increasing stimulus intensity in both groups. Large ( approximately 20mm), stereotyped sway responses were present in only one (atypical) patient with high intensity stimulation. Small ( approximately 2mm) sway responses were present in the remaining patients, and began immediately following the vestibulo-spinal responses. CONCLUSIONS: Despite the presence of large vestibular reflexes, there is usually very little body sway in response to loud sounds in SCD patients. SIGNIFICANCE: Large short-latency vestibulo-spinal reflexes in SCD do not necessarily evoke large sway responses.

Ocular vestibular evoked myogenic potentials in superior canal dehiscence.

OBJECTIVE: Patients with superior canal dehiscence (SCD) have large sound-evoked vestibular reflexes with pathologically low threshold. We wished to determine whether a recently discovered measure of the vestibulo-ocular reflex-the ocular vestibular evoked myogenic potential (OVEMP)-produced similar high-amplitude, low-threshold responses in SCD, and could differentiate patients with SCD from normal control patients. METHODS: Nine patients with CT-confirmed SCD and 10 normal controls were stimulated with 500 Hz, 2 ms tone bursts and 0.1 ms clicks at intensities up to 142 dB peak SPL. Conventional VEMPs were recorded from the ipsilateral sternocleidomastoid muscle to determine threshold, and OVEMPs were recorded from electrode pairs placed superior and inferior to the eyes. Three-dimensional eye movements were measured with scleral dual-search coils. RESULTS: In patients with SCD, OVEMP amplitudes were significantly larger than normal (p<0.001) and thresholds were pathologically low. The n10 OVEMP in the contralateral inferior electrode became particularly large with increasing stimulus intensity (up to 25 microV) and with up-gaze (up to 40 microV). Sound-evoked (slow-phase) eye movements were present in all patients with SCD (vertical: upward; torsional: upper pole away from the affected side; and horizontal: towards or away from the affected side), but began only as the OVEMP response became maximal, which is consistent with the surface potentials being produced by activation of the extraocular muscles that generated the eye movements. CONCLUSIONS: OVEMP amplitude and threshold (particularly the contralateral inferior n10 response) differentiated patients with SCD from normal controls. Our findings suggest that both the OVEMPs and induced eye movements in SCD are a result of intense saccular activation in addition to superior canal stimulation.

Vestibular-evoked extraocular potentials produced by stimulation with bone-conducted sound.

OBJECTIVE: To investigate the origin, whether ocular or extraocular, of the short latency frontal potential (N15) reported by following vestibular stimulation. METHODS: Fourteen subjects with low VEMP thresholds (V(T)) and 9 patients with vestibular or ocular disorders were stimulated at the mastoid with bone-conducted tone bursts (500 Hz, 8 ms) above vestibular threshold, using a B71 bone vibrator. Surface potentials were recorded from Fpz and around the eyes and referred to linked earlobes. RESULTS: The N15 was present at Fpz, but was largest around the eyes (mean amplitude 2.6 microV, peak latency 13.4 ms, with stimulation at +18 dB above threshold) and was generally in phase above and below the eyes. The response was vestibular-dependent and modulated by alteration of gaze direction. The potentials were delayed in a patient with Miller Fisher syndrome and were larger in patients with superior canal dehiscence than in controls. CONCLUSIONS: We report a new vestibular-evoked extraocular potential. Its properties are not consistent with an eye movement. It is likely to be produced, mainly or exclusively, by synchronous activity in extraocular muscles (i.e. a myogenic potential). SIGNIFICANCE: Vestibular-evoked extraocular potentials extend the range of vestibular pathways that can be assessed electrophysiologically, and may be a useful additional test of vestibular function.

Vestibular activation by bone conducted sound.

OBJECTIVE: To examine the properties and potential clinical uses of myogenic potentials to bone conducted sound. METHODS: Myogenic potentials were recorded from normal volunteers, using bone conducted tone bursts of 7 ms duration and 250-2000 Hz frequencies delivered over the mastoid processes by a B 71 clinical bone vibrator. Biphasic positive-negative (p1n1) responses were recorded from both sternocleidomastoid (SCM) muscles using averaged unrectified EMG. The best location for stimulus delivery, optimum stimulus frequency, stimulus thresholds, and the effect of aging on evoked response amplitudes and thresholds were systematically examined. Subjects with specific lesions were studied. Vestibular evoked myogenic potentials (VEMP) to air conducted 0.1 ms clicks, 7 ms/250-2000 Hz tones, and forehead taps were measured for comparison. RESULTS: Bone conducted sound evoked short latency p1n1 responses in both SCM muscles. Ipsilateral responses occurred earlier and were usually larger. Mean (SD) p1 and n1 latencies were 13.6 (1.8) and 22.3 (1.2) ms ipsilaterally and 14.9 (2.1) and 23.7 (2.7) ms contralaterally. Stimuli of 250 Hz delivered over the mastoid process, posterosuperior to the external acoustic meatus, yielded the largest amplitude responses. Like VEMP in response to air conducted clicks and tones, p1n1 responses were absent ipsilaterally in subjects with selective vestibular neurectomy and preserved in those with severe sensorineural hearing loss. However, p1n1 responses were preserved in conductive hearing loss, whereas VEMP to air conducted sound were abolished or attenuated. Bone conducted response thresholds were 97.5 (3.9) dB SPL/30.5 dB HL, significantly lower than thresholds to air conducted clicks (131.7 (4.9) dB SPL/86.7 dB HL) and tones (114.0 (5.3) dB SPL/106 dB HL). CONCLUSIONS: Bone conducted sound evokes p1n1 responses (bone conducted VEMP) which are a useful measure of vestibular function, especially in the presence of conductive hearing loss. For a given perceptual intensity, bone conducted sound activates the vestibular apparatus more effectively than air conducted sound.

Differential effect of current rise time on short and medium latency vestibulospinal reflexes.

OBJECTIVES: To investigate the effect of varying current rise time on galvanic-evoked short (SL) and medium (ML) latency vestibulospinal reflexes. METHODS: We recorded the soleus EMG of standing subjects in response to 3 mA direct current transmastoid stimulation with a series of current ramps with rise times of 0-300 ms. RESULTS: Longer current rise times significantly delayed the onset of both SL (P<<0.001) and ML (P<<0.001) vestibulospinal responses, by approximately 20 and 39 ms, respectively. The SL response amplitude was reduced with increasing rise time (P<<0.001), whereas the ML response amplitude was relatively unaffected by stimulus rise time. With very slow rise times a prolonged ML response alone was evoked. CONCLUSIONS: Both SL and ML reflexes can be evoked by changes in vestibular activity produced by transmastoid galvanic stimulation with a ramp onset. We found a differential effect of current rise time on SL and ML vestibulospinal reflexes, suggesting different potential functional roles for the two reflexes. SL reflexes can participate in the response to abrupt disturbances only. ML reflexes are evoked by both fast and slow changes in vestibular discharge and may be particularly effective for slowly-changing disturbances.