Diagnostic Contribution of Magnetic Resonance Imaging and Computerized Tomography in Patients with Unidentified Vertigo and Normal Neurologic Examination in Emergency Medicine.

Background: Vertigo and dizziness are common symptoms in patients presenting to emergency medicine (ED) clinics. Vertigo may be caused by peripheral or central origin. Routine imaging is not indicated; however, neuroimaging is increasing, and published studies have revealed a small number of positive findings on imaging modalities. Aims: The aim of this study was to investigate whether neurological imaging was necessary in patients classified as "unidentified vertigo," who were admitted to the emergency department with vertiginous complaints and not revealing typical peripheral vertigo findings and any neurological deficits. Materials and Methods: All patients with "dizzy symptoms" were included in the study. For patients who met the definition of "unidentified vertigo," experimental neurological imaging studies were done. Head computerized tomography (CT), magnetic resonance imaging (MRI) with gradient-echo sequences (GRE), and diffusion weighted images (DWI) were used for imaging. Patients who underwent neuroimaging in the ED were followed up for 6 months in Neurology and ENT clinics. Results: A total of 351 patients were included in the study. Experimental imaging was performed on 100 patients. CT detected a significant pathology associated with the vertigo complaint in only one patient. MRI results were similar to the CT results. MRI-GRE sequences showed some additional pathologies in 14 patients and 4 of them were thought to be related to vertiginous symptoms. None of the patients classified as "non-central causes of vertigo" in the neuroimaging group developed TIA or CVD during 6 months of follow-up. Conclusion: Head CT can be adequate to exclude life-threatening central pathology in "undifferentiated vertigo patients" and the addition of MRI did not add any diagnostic accuracy in ED management. Using the physical examination findings effectively to make a specific diagnosis may reduce misdiagnosis and improve resource utilization.

Nerve ultrasound findings in Sjögren's syndrome-associated neuropathy.

BACKGROUND AND PURPOSE: The phenotype of Sjögren's syndrome-associated neuropathy has been better characterized in recent years. However, Sjögren's syndrome-associated neuropathy remains an underdiagnosed entity with only few insights considering the pathomechanisms of nerve damage. Nerve ultrasound has proven to be a useful and efficient tool in detecting nerve damage of autoimmune origin. We, therefore, aimed to evaluate this method for Sjögren's syndrome-associated neuropathy. METHODS: Patients with Sjögren's syndrome and clinical signs of neuropathy underwent sonographic examination of both median and ulnar nerves. Nerve thickening was classified for cross-sectional areas of >12 mm² at the median nerve and for >10 mm² at the ulnar nerve. Fascicle thickening was documented for cross-sectional areas ≥5 mm² at the median and ≥3 mm² at the ulnar nerve. RESULTS: Forty-three patients were included in the analysis (median age 60 years [interquartile range 53-73 years], female rate 60%). 31/43 patients (72%) showed abnormalities on nerve ultrasound, while nerve thickening was found more frequently than fascicle thickening (90% vs. 52% of patients with sonographic abnormalities, respectively). Abnormal findings were observed more frequently at the median nerve and in proximal localization. Abnormal findings on nerve conduction studies were evident in 36/43 patients (84%). Nerve conduction studies revealed a tendency of demyelinating nerve damage patterns being associated with abnormal findings on nerve ultrasound. CONCLUSIONS: In addition to nerve conduction studies, nerve ultrasound may have a supporting role in the diagnosis of Sjögren's syndrome-associated neuropathy. Also, our data support an immune-mediated inflammatory demyelinating pathogenesis of Sjögren's syndrome-associated neuropathy.

Cerebellar ataxia, neuropathy, vestibular areflexia syndrome due to RFC1 repeat expansion.

Ataxia, causing imbalance, dizziness and falls, is a leading cause of neurological disability. We have recently identified a biallelic intronic AAGGG repeat expansion in replication factor complex subunit 1 (RFC1) as the cause of cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS) and a major cause of late onset ataxia. Here we describe the full spectrum of the disease phenotype in our first 100 genetically confirmed carriers of biallelic repeat expansions in RFC1 and identify the sensory neuropathy as a common feature in all cases to date. All patients were Caucasian and half were sporadic. Patients typically reported progressive unsteadiness starting in the sixth decade. A dry spasmodic cough was also frequently associated and often preceded by decades the onset of walking difficulty. Sensory symptoms, oscillopsia, dysautonomia and dysarthria were also variably associated. The disease seems to follow a pattern of spatial progression from the early involvement of sensory neurons, to the later appearance of vestibular and cerebellar dysfunction. Half of the patients needed walking aids after 10 years of disease duration and a quarter were wheelchair dependent after 15 years. Overall, two-thirds of cases had full CANVAS. Sensory neuropathy was the only manifestation in 15 patients. Sixteen patients additionally showed cerebellar involvement, and six showed vestibular involvement. The disease is very likely to be underdiagnosed. Repeat expansion in RFC1 should be considered in all cases of sensory ataxic neuropathy, particularly, but not only, if cerebellar dysfunction, vestibular involvement and cough coexist.

Patient preferences for order of the sensory portion of the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) examination.

Objective: The International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) includes testing light touch (LT) and sharp/dull discrimination, also known as pinprick (PP) testing. The order these tests are performed varies by clinician and no true standard exists. The objective of this study was to determine patients' perceptions of discomfort from each modality and their preferences for the order of the sensory exam.Design: A questionnaire was administered following the exam regarding the degree of pain/discomfort experienced from each modality and patients' preferences for testing order.Participants: 91 adults with traumatic SCI, 55% with neurologically complete injuries and 34% first-time examinees/those who did not recall a previous sensory examination.Main Outcome Measures: Level of pain/discomfort from both sensory modalities and preference on order of sensory testing.Results: All subjects reported that LT was not painful. 57% reported the PP testing as not painful, 24% as moderately painful, and 18.7% as very painful. The majority (66%) reported no preference for testing order, however, first-time examinees and those who did not recall previous sensory testing, were more likely to describe PP testing as "very painful" and report more "very painful" experiences when PP testing was completed first.Conclusions: First-time examinees including those who did not recall previous sensory testing, may experience more pain/discomfort from PP testing especially when PP is tested first. Therefore, testing LT first, especially for the first-time examinee and those who do not recall a previous exam, may allow for a more comfortable experience.

Exploring the association between Cerebral small-vessel diseases and motor symptoms in Parkinson's disease.

OBJECTIVES: to explore the association between cerebral small-vessel diseases (CSVDs) and motor symptoms in Parkinson's disease (PD). METHODS: 137 PD patients were recruited into the study. Detailed motor symptoms, including tremor, rigidity, bradykinesia, and axial impairment, were evaluated using Unified Parkinson's disease Rating Scale (UPDRS). Non-motor symptoms, including cognition, anxiety, and depression, were evaluated using Montreal Cognitive Assessment (MoCA), Hamilton anxiety scale (HAMA), and Hamilton depression scale (HAMD). Brain MRI was used to assess the subtypes of CSVDs, including lacunes, enlarged perivascular spaces (EPVS), and white matter hyperintensities (WMH). WMH were furtherly divided into deep WMH (DWMH) and periventricular hyperintensities (PVH). The association between CSVDs and motor symptoms was analyzed. Patients were divided into the postural instability and gait disability (PIGD) group and non-PIGD group. Demographic, clinical and CSVDs variables were compared between the two groups. RESULTS: CSVDs subtypes were all detected in the participants with different prevalence rates and severity degrees. We found a close association between EPVS in basal ganglia and the tremor score (p = 0.032), and between DWMH in the frontal and occipital lobes and the axial motor score (p < 0.05) through the spearman and multivariate liner regression analysis. Compared with the non-PIGD group, the PIGD group demonstrated more serious cognitive impairment and DWMH in the frontal and occipital lobes (p < 0.05). The demographic characteristics and vascular risk factors of the PIGD group were not different from those of the non-PIGD group. Cognitive impairment and DWMH in the frontal lobe were identified to be independent risk factors of PIGD motor phenotype. CONCLUSIONS: We identified a close association between the CSVDs and motor symptoms in PD and DWMH in the frontal lobe was a risk factor of PIGD motor phenotype, which supports the contribution of vascular pathology in PD.

A systematic review of suggestive seizure induction for the diagnosis of psychogenic nonepileptic seizures.

Suggestive seizure induction is a widely used method for diagnosing psychogenic nonepileptic seizures (PNES). Despite seven decades of multidisciplinary research, however, there is still no unified protocol, no definitive agreement on the ethical framework and no consensus on diagnostic utility. This systematic review surveys the evidence at hand and addresses clinically relevant aspects of suggestive seizure induction. In addition to its use for facilitating the diagnostic process, its mechanism of action and utility in elucidating the psychopathology of PNES will be discussed.

Factors influencing aversion to specific electrodiagnostic studies.

OBJECTIVE: To compare the degree of discomfort caused by nerve conduction studies (NCS) versus needle electromyography (EMG), and to determine what factors predict aversion to one test or the other. METHODS: Two hundred patients underwent both EMG and NCS, and were asked to indicate which test was more uncomfortable. Responses were then correlated with demographic information, testing characteristics, and medical histories to identify any notable associations. RESULTS: Of the 200 patients, 58.5% (117) of the patients found the NCS more uncomfortable than EMG. Sixty-one percent (11/18) of the younger patients (18-29 years old) found EMG more uncomfortable (P = 0.08), whereas 68% (40/59) of the older patients (age greater than 60 years old) found NCS more uncomfortable (P = 0.05). Sixty-seven percent (14/21) of the patients whose BMI was less than 22 kg/m(2) rated EMG as more uncomfortable (P = 0.01). Sixty-nine percent (27/39) of the patients whose BMI was greater than or equal to 38 found the NCS more uncomfortable (P = 0.02). A positive correlation existed between NCS discomfort and number of nerves tested. 67% (35/52) of the patients with polyneuropathy found NCS more uncomfortable. CONCLUSION: Nerve conduction studies are more uncomfortable than needle EMG in the majority of patients, and predictions regarding which test will be more uncomfortable for a given patient are possible.

The effect of optotype size and velocity parameters on the performance of healthy young adult subjects on the gaze stabilization test.

HYPOTHESIS: The purpose of the current study was to examine the influence of the optotype (the letter E) size, presentation time, and head velocity on gaze stabilization test (GST) performance. BACKGROUND: The gaze stabilization test is a functional measure of the vestibulo-ocular reflex. METHODS: Twenty-one healthy young subjects (mean age, 26 ± 4; range, 21-34, 10 male subjects) performed the computerized GST. Testing was repeated several times using different combinations of the optotype size and presentation time over a wide range of head velocities (<60 to >220 degrees per second). The sizes examined were 0.20, 0.25, and 0.30 logMAR above the subject's static visual acuity (SVA). The presentation times examined were 20, 30, and 40 ms above the subject's minimum perception time (mPT). RESULTS: Performance varied considerably based on the optotype parameters used in the GST. The optotype combination of SVA + 0.20 logMAR and mPT + 20 ms was the most difficult combination with the average of all subjects' performance less than 64% at all velocities. The optotype combination SVA + 0.30 logMAR and mPT + 40 ms was the easiest combination with subjects being able to correctly identify the optotype at any head velocity with greater than 70% average accuracy. Increasing the head velocity in any size/time combination caused deterioration in subjects' performance. CONCLUSION: Our study findings show that optotype parameters have significant influence on subjects' performance on the GST.

The neurological wake-up test increases stress hormone levels in patients with severe traumatic brain injury.

OBJECTIVES: The "neurological wake-up test" is needed to evaluate the level of consciousness in patients with severe traumatic brain injury. However, the neurological wake-up test requires interruption of continuous sedation and may induce a stress response and its use in neurocritical care is controversial. We hypothesized that the neurological wake-up test induces an additional biochemical stress response in patients with severe traumatic brain injury. PATIENTS: Twenty-four patients who received continuous propofol sedation and mechanical ventilation after moderate to severe traumatic brain injury (Glasgow Coma Scale score ≤ 8; patient age 18-71 yrs old) were analyzed. Exclusion criteria were age <18 yrs old, ongoing pentobarbital infusion, or markedly increased intracranial pressure on interruption of continuous sedation. DESIGN: Single-center prospective study. During postinjury days 1-8, 65 neurological wake-up tests were evaluated. Adrenocorticotrophic hormone, epinephrine, and norepinephrine levels in plasma and cortisol levels in saliva were analyzed at baseline (during continuous intravenous propofol sedation) and during neurological wake-up test. Data are presented using medians and 25th and 75th percentiles. SETTING: The study was performed in a university hospital neurocritical care unit. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: At baseline, adrenocorticotrophic hormone and cortisol levels were 10.6 (6.0-19.4) ng/L and 16.0 (10.7-31.8) nmol/L, respectively. Immediately after the neurological wake-up test, adrenocorticotrophic hormone levels increased to 20.5 (11.1-48.4) ng/L (p < .05) and cortisol levels in saliva increased to 24.0 (12.3-42.5) nmol/L (p < .05). The plasma epinephrine and norepinephrine levels increased from a baseline of 0.3 (0.3-0.6) and 1.6 (0.9-2.3) nmol/L, respectively, to 0.75 (0.3-1.4) and 2.8 (1.28-3.58) nmol/L, respectively (both p < .05). CONCLUSIONS: The neurological wake-up test induces a biochemical stress response in patients with severe traumatic brain injury. The clinical importance of this stress response remains to be established but should be considered when deciding the frequency and use of the neurological wake-up test during neurocritical care.

Selective propofol injection into the M1 segment of the middle cerebral artery (MCA Wada test) reduces adverse effects and enhances the reliability of the Wada test for determining speech dominance.

OBJECT: The Wada test is had been the most reliable for determining speech dominance. Drugs injected into the internal carotid artery, however, may be heterogeneously distributed as the result of asymmetry of the anterior cerebral arteries and the presence of a fetal-type posterior cerebral artery. Variations in drug distribution could occasionally alter consciousness and complicate the evaluation of the test results. We examined selective propofol injection into the M1 segment of the middle cerebral artery (MCA Wada test). METHODS: For the MCA Wada test (17 patients), 7 or 8 mg of propofol was injected via a microcatheter navigated into the M1 segment, and language function was evaluated by patient performing several tasks. The conventional Wada test (internal carotid artery [ICA] Wada test) was performed in four patients (both the ICA and MCA Wada tests were performed in one patient). The efficacy and adverse effects of both procedures were evaluated; all tests were performed by well-trained interventional neuroradiologists. RESULTS: Immediately after propofol injection during the MCA Wada test, patients developed transient contralateral hemiplegia and transient aphasia (in the case of injection on the dominant side). Confusion and other severe adverse effects did not occur during the MCA Wada test, but two of four patients who underwent the ICA Wada test showed altered consciousness that affected the performance of the test. CONCLUSIONS: The MCA Wada test is a feasible and reliable preoperative evaluation, if performed by a trained team of interventional neuroradiologists.

Benign focal epilepsy of childhood: epileptic seizure during somatosensory evoked potential: a case report.

A 6-year-old girl with a history of partial seizures had parietal spontaneous spikes, and high-voltage paroxysms, evoked by tapping of the hands and feet, in the parietal contralateral region during the electroencephalogram. The girl underwent a somatosensory evoked potential study, when she had a seizure, with tonic contraction rising of the right leg then followed by clonic jerks of the right leg, version of the head to the right, followed by a tonic contraction of the ipsilateral arm with flexion at the elbow. The seizure lasted 20-30 seconds. We believe this is the first description of a seizure during a somatosensory evoked potential procedure.