Relación entre el video head impulse test (vHIT) y la prueba calórica en el estudio evolutivo de pacientes con neuritis vestibular / Relationship between video head impulse test (vHIT) and caloric test in patients with vestibular neuritis

Introducción y objetivos: La prueba calórica es hasta ahora la prueba de referencia para el diagnóstico y el examen de una hipofunción vestibular unilateral. El video head impulse test (vHIT) valora el reflejo vestíbulo-oculomotor, mediante el registro videoasistido de la maniobra impulsiva. Se pretende comparar la variación de los resultados del vHIT y la prueba calórica en pacientes con neuritis vestibular respecto a su estado inicial en diferentes puntos de su evolución, y comprobar su grado de correlación entre sí y con el test Dizziness Handicap Inventory (DHI). Métodos: Exploración en la misma sesión mediante vHIT y prueba calórica de 20 pacientes con neuritis vestibular. Valoración de la correlación de dichas pruebas entre sí y con el test DHI en 2 momentos diferentes de la evolución para cada paciente. Resultados: La asimetría de la ganancia del vHIT y la paresia canalicular de la prueba calórica no evidenciaron una correlación lineal entre ellas. Tampoco se apreció una correlación entre el DHI y la recuperación de los parámetros de estas 2 pruebas. Las sacadas Covert mantienen una velocidad similar mientras están presentes en el vHIT, mientras que las Overt disminuyen su velocidad con el tiempo. Conclusiones: El vHIT y la prueba calórica muestran diferentes respuestas del reflejo vestíbulo-oculomotor, dado que exploran diferentes frecuencias del mismo. No se ha encontrado una correlación entre el vHIT, la prueba calórica y el DHI a lo largo de la evolución de la neuritis vestibular, siendo pruebas complementarias entre sí (AU)

Introduction and objectives: The caloric test is the gold standard for the loss of vestibular function diagnosis. The Video Head Impulse Test (vHIT) assesses the same reflex by using a video- assisted examination of the impulsive maneuver. We intend to compare the variation of results of the vHIT and the caloric test in patients with vestibular neuritis with respect to their initial condition at two different moments of their evolution and to check the level of correlation between them and with that of the DHI test. Methods: We explored 20 patients with neuritis by using both vHIT and the caloric test on the same day. We assessed the correlation between these two tests and with the DHI test for each patient at two different moments of their evolution. Results: We calculated gain asymmetry and compared it with the canal paresis, but we found neither a linear correlation between them, nor a correlation between the DHI test or improvement of these two other tests. We conclude that the covert saccades maintain a similar speed whilst present in the VHIT, but the overts diminish their speed over time. Conclusions: The VHIT and the caloric test show different responses of the vestibulo-ocular reflex, because they stimulate different frequencies of this reflex. No correlation was found between the VHIT, the caloric test and the DHI test. The tests appear to complement one another (AU)

Relationship between video head impulse test (vHIT) and caloric test in patients with vestibular neuritis. / Relación entre el video head impulse test (vHIT) y la prueba calórica en el estudio evolutivo de pacientes con neuritis vestibular.

INTRODUCTION AND OBJECTIVES: The caloric test is the gold standard for the loss of vestibular function diagnosis. The Video Head Impulse Test (vHIT) assesses the same reflex by using a video- assisted examination of the impulsive maneuver. We intend to compare the variation of results of the vHIT and the caloric test in patients with vestibular neuritis with respect to their initial condition at two different moments of their evolution and to check the level of correlation between them and with that of the DHI test METHODS: We explored 20 patients with neuritis by using both vHIT and the caloric test on the same day. We assessed the correlation between these two tests and with the DHI test for each patient at two different moments of their evolution. RESULTS: We calculated gain asymmetry and compared it with the canal paresis, but we found neither a linear correlation between them, nor a correlation between the DHI test or improvement of these two other tests. We conclude that the covert saccades maintain a similar speed whilst present in the VHIT, but the overts diminish their speed over time. CONCLUSIONS: The VHIT and the caloric test show different responses of the vestibulo-ocular reflex, because they stimulate different frequencies of this reflex. No correlation was found between the VHIT, the caloric test and the DHI test. The tests appear to complement one another.

Radiocirugía como tratamiento del neurinoma del acústico. Diez años de experiencia / Radiosurgery as treatment for acoustic neuroma. Ten years’ experience

Introducción y objetivo: El neurinoma del acústico es un tumor benigno que suele afectar a la porción vestibular del VII par craneal. Representan el 8% de todos los tumores intracraneales y el 80% de los que surgen a nivel del ángulo pontocerebeloso. Existen 3 opciones terapéuticas: la microcirugía, que es la técnica de elección, la radiocirugía y la observación. El objetivo del estudio ha sido valorar los resultados obtenidos con la radiocirugía en el tratamiento del neurinoma del acústico, así como los efectos secundarios derivados del mismo. Material y métodos: Hemos realizado en nuestro hospital una revisión de todos los pacientes tratados con radiocirugía (Gamma Knife y LINAC) a dosis de 1.200-1.300 cGy por neurinoma del acústico unilateral, entre enero de 1999 y enero del 2010. En todos los pacientes se valoraron el estado general, la tasa de control de crecimiento tumoral, entendiéndose como tal que no cambia de tamaño o que se reduce, la afectación del V y VII par craneal, así como alteraciones del sistema nervioso central. También el tiempo de seguimiento y las variaciones de los umbrales auditivos tras la radiocirugía. Resultados: De un total de 35 pacientes estudiados, con una edad media de 58,29 años y sin diferencias estadísticamente significativas en cuanto al sexo, la tasa de control de crecimiento tumoral fue superior al 90%. El principal motivo de consulta (65,71%) fue la hipoacusia unilateral y progresiva. Un 34,28% de los pacientes tratados presentaron empeoramiento en su nivel de audición postratamiento. La afectación de los pares craneales (V-VII) en el 100% de los casos fue transitoria. La radiocirugía tipo Gamma Knife fue administrada en la mayoría de los pacientes (82,85%). Conclusión: Aunque la microcirugía sigue siendo el tratamiento de elección para los neurinomas del acústico, consideramos la radiocirugía como una alternativa válida en pacientes seleccionados (edad avanzada, comorbilidad asociada, pequeño tamaño e hipoacusia neurosensorial, entre otros) (AU)

Introduction and objective: The acoustic neuroma is a benign tumour that usually affects the vestibular portion of the vestibulocochlear nerve. It represents 8% of all intracranial tumours and 80% of those arising at the cerebellopontine angle. There are 3 treatment options: microsurgery (the technique of choice), radiosurgery and observation. The objective of the study was to evaluate the results and side effects obtained using radiosurgery as treatment for acoustic neuroma. Material and methods: We performed a review of all patients treated with radiosurgery (Gamma Knife and linear accelerator) at doses of 1200-1300 cGy for unilateral acoustic neuroma in our hospital from January 1999 until January 2010. In all patients we evaluated the overall state, tumour growth control rate (tumour smaller or remaining the same size), the involvement of V and VII cranial nerves and central nervous system disorders. We also assessed follow-up time and changes in hearing thresholds after radiosurgery. Results: From a total of 35 patients studied, with a mean age of 58.29 years and lacking statistically significant differences in gender, the tumour growth control rate was over 90%. The main reason for visit (65.71%) was unilateral and progressive hearing loss. After treatment, 34.28% of patients had hearing loss. The involvement of the cranial nerves (V-VII) was transitory in 100% of cases. Gamma Knife radiosurgery was administered in 82.85% of patients. Conclusion: Although microsurgery is the treatment of choice for acoustic neuroma, we consider radiosurgery as a valid alternative in selected patients (elderly, comorbidity, small tumour size and sensorineural hearing loss, among others) (AU)

Evolución clínica y radiológica de un grupo de neurinomas del acústico no tratados / Clinical and radiological evolution of a group of untreated acoustic neuromas

Introducción: El neurinoma del acústico es un tumor benigno que se origina en la rama vestibular del viii par craneal. Su tratamiento de elección es quirúrgico, pero muchos autores defienden que en pacientes de edad avanzada o en neurinomas de pequeño tamaño se puede optar por simple vigilancia. Métodos: Estudio retrospectivo, del 2007 al 2013, que incluye a 27 pacientes diagnosticados de neurinoma del acústico que no fueron tratados, bien por el tamaño del tumor, por la edad y las comorbilidades asociadas, o por decisión del paciente. Se evaluaron el estado general, los umbrales auditivos, el grado de paresia canalicular y las posibles alteraciones a nivel central. Resultados: A los 6 años de seguimiento, la clínica - hipoacusia (70%), acúfeno (15%) y vértigo (4%) - de 18 pacientes se mantuvo sin variaciones; 5 casos experimentaron caída del umbral auditivo y desarrollaron acúfeno, 2 casos intensificaron su acúfeno y 2 casos presentaron vértigo. Los controles radiológicos por resonancia magnética demostraron que los diámetros máximos iniciales (5-16 mm) se incrementaron en 1,7 mm como media, con tasas de crecimiento anual inferiores a 0,5 mm. Conclusión: En casos seleccionados, neurinomas de pequeño tamaño y pacientes de edad avanzada, la opción conservadora mediante vigilancia estrecha con resonancia magnética es una alternativa importante, puesto que, según nuestra muestra, ni la clínica ni la imagen radiológica sufren cambios significativos y, en caso de que lo hagan, siempre estamos a tiempo de una actuación terapéutica (AU)

Introduction: The acoustic neuroma is a benign tumour that originates in the vestibular branch of the eighth cranial nerve. The main treatment is surgery, but many authors suggest that with elderly patients or in small neuromas we can opt for watchful waiting. Methods: This was a retrospective study from 2007 to 2013 that included 27 patients diagnosed of acoustic neuroma that had not been treated due to the size of the tumour, age and comorbidities, or by patient choice. We evaluated overall condition, hearing thresholds, degree of canal paresis and central disorders. Results: After 6 years of follow up, clinical manifestations of 18 patients remained unchanged, 5 patients underwent hearing loss and developed tinnitus, 2 cases had more intense tinnitus and 2 cases had dizziness. The radiological controls by magnetic resonance imaging showed that the initial maximum diameters (5-16 mm) increased by 1.7 mm on average, with annual growth rates below 0.5 mm. Conclusion: In selected cases, such as for small neuromas and in elderly patients, the conservative option of close monitoring with magnetic resonance imaging is an important alternative given that, in our cases, clinical features and radiological image did not suffer major changes. If there were any such changes, therapeutic options could be proposed (AU)

Radiosurgery as treatment for acoustic neuroma. Ten years' experience.

INTRODUCTION AND OBJECTIVE: The acoustic neuroma is a benign tumour that usually affects the vestibular portion of the vestibulocochlear nerve. It represents 8% of all intracranial tumours and 80% of those arising at the cerebellopontine angle. There are 3 treatment options: microsurgery (the technique of choice), radiosurgery and observation. The objective of the study was to evaluate the results and side effects obtained using radiosurgery as treatment for acoustic neuroma. MATERIAL AND METHODS: We performed a review of all patients treated with radiosurgery (Gamma Knife and linear accelerator) at doses of 1200-1300 cGy for unilateral acoustic neuroma in our hospital from January 1999 until January 2010. In all patients we evaluated the overall state, tumour growth control rate (tumour smaller or remaining the same size), the involvement of v and vii cranial nerves and central nervous system disorders. We also assessed follow-up time and changes in hearing thresholds after radiosurgery. RESULTS: From a total of 35 patients studied, with a mean age of 58.29 years and lacking statistically significant differences in gender, the tumour growth control rate was over 90%. The main reason for visit (65.71%) was unilateral and progressive hearing loss. After treatment, 34.28% of patients had hearing loss. The involvement of the cranial nerves (v-vii) was transitory in 100% of cases. Gamma Knife radiosurgery was administered in 82.85% of patients. CONCLUSION: Although microsurgery is the treatment of choice for acoustic neuroma, we consider radiosurgery as a valid alternative in selected patients (elderly, comorbidity, small tumour size and sensorineural hearing loss, among others).

[Clinical and radiological evolution of a group of untreated acoustic neuromas]. / Evolución clínica y radiológica de un grupo de neurinomas del acústico no tratados.

INTRODUCTION: The acoustic neuroma is a benign tumour that originates in the vestibular branch of the eighth cranial nerve. The main treatment is surgery, but many authors suggest that with elderly patients or in small neuromas we can opt for watchful waiting. METHODS: This was a retrospective study from 2007 to 2013 that included 27 patients diagnosed of acoustic neuroma that had not been treated due to the size of the tumour, age and comorbidities, or by patient choice. We evaluated overall condition, hearing thresholds, degree of canal paresis and central disorders. RESULTS: After 6 years of follow up, clinical manifestations of 18 patients remained unchanged, 5 patients underwent hearing loss and developed tinnitus, 2 cases had more intense tinnitus and 2 cases had dizziness. The radiological controls by magnetic resonance imaging showed that the initial maximum diameters (5-16mm) increased by 1.7mm on average, with annual growth rates below 0.5mm. CONCLUSION: In selected cases, such as for small neuromas and in elderly patients, the conservative option of close monitoring with magnetic resonance imaging is an important alternative given that, in our cases, clinical features and radiological image did not suffer major changes. If there were any such changes, therapeutic options could be proposed.

Hallazgos de potenciales vestibulares miogénicos evocados en la esclerosis múltiple / Vestibular evoked myogenic potential findings in multiple sclerosis

Introducción: La esclerosis múltiple es una enfermedad consistente en la aparición de lesiones desmielinizantes, neurodegenerativas y crónicas del sistema nervioso central. Se propone en esta enfermedad, estudiar los potenciales vestibulares miogénicos evocados, que nos van a permitir evaluar de forma no invasiva el sáculo, el nervio vestibular inferior y la vía vestíbulo-espinal. Métodos: Presentamos 23 pacientes diagnosticados de esclerosis múltiple a los que se les realizaron los potenciales vestibulares miogénicos evocados, comparando resultados con nuestro grupo control, integrado por 35 sujetos sanos. Se registró la latencia de las ondas p13 y n23, la diferencia interaural de amplitud y el índice de asimetría entre ambos oídos. También se llevó a cabo una exploración de otoscopia y audiometría. Resultados: La prolongación de las latencias de las ondas p13 y n23 es la característica a destacar, con una media en la onda p13 de 19,53 ms y 30,06 ms para la n23. El índice de asimetría, por el contrario, no mostraba diferencias estadísticamente significativas con nuestro grupo control. Conclusiones: En el caso de la esclerosis múltiple, la prolongación de la latencia de las ondas p13 y n23 de los potenciales vestibulares miogénicos evocados es una característica que se ha atribuido a un enlentecimiento de la conducción por la desmielinización de la vía vestíbulo-espinal. En este sentido, la alteración de la respuesta o ausencia de la misma en estos potenciales tiene un carácter localizador de la lesión a nivel de troncoencéfalo inferior (AU)

Introduction: Multiple sclerosis is an inflammatory disease involving the occurrence of demyelinating, chronic neurodegenerative lesions in the central nervous system. We studied vestibular evoked myogenic potentials (VEMPs) in this pathology, to allow us to evaluate the saccule, inferior vestibular nerve and vestibular-spinal pathway non-invasively. Methods: There were 23 patients diagnosed with multiple sclerosis who underwent VEMP recordings, comparing our results with a control group consisting of 35 healthy subjects. We registered p13 and n23 wave latencies, interaural amplitude difference and asymmetry ratio between both ears. Subjects also underwent an otoscopy and audiometric examination. Results: The prolongation of p13 and n23 wave latencies was the most notable characteristic, with a mean p13 wave latency of 19.53 ms and a mean latency of 30.06 ms for n23. In contrast, the asymmetry index showed no significant differences with our control group. Conclusions: In case of multiple sclerosis, the prolongation of the p13 and n23 VEMP wave latencies is a feature that has been attributed to slowing of conduction by demyelination of the vestibular-spinal pathway. In this regard, alteration of the response or lack thereof in these potentials has a locator value of injury to the lower brainstem (AU)

Vestibular evoked myogenic potential findings in multiple sclerosis.

INTRODUCTION: Multiple sclerosis is an inflammatory disease involving the occurrence of demyelinating, chronic neurodegenerative lesions in the central nervous system. We studied vestibular evoked myogenic potentials (VEMPs) in this pathology, to allow us to evaluate the saccule, inferior vestibular nerve and vestibular-spinal pathway non-invasively. METHODS: There were 23 patients diagnosed with multiple sclerosis who underwent VEMP recordings, comparing our results with a control group consisting of 35 healthy subjects. We registered p13 and n23 wave latencies, interaural amplitude difference and asymmetry ratio between both ears. Subjects also underwent an otoscopy and audiometric examination. RESULTS: The prolongation of p13 and n23 wave latencies was the most notable characteristic, with a mean p13 wave latency of 19.53 milliseconds and a mean latency of 30.06 milliseconds for n23. In contrast, the asymmetry index showed no significant differences with our control group. CONCLUSIONS: In case of multiple sclerosis, the prolongation of the p13 and n23 VEMP wave latencies is a feature that has been attributed to slowing of conduction by demyelination of the vestibular-spinal pathway. In this regard, alteration of the response or lack thereof in these potentials has a locator value of injury to the lower brainstem.

[Radiosurgery treatment of acoustic neuromas. Our experience]. / Tratamiento del neurinoma del acústico con radiocirugía. Nuestra experiencia.

OBJECTIVE: To evaluate the results and side effects obtained using radiosurgery to treat acoustic neuromas. MATERIAL AND METHOD: Between 1999 and 2004 we treated 30 patients with unilateral acoustic neuromas with a mean age of 54 years old (31-76), a mean follow-up of 34 months (12-54), and tumour size between 4 and 38 millimetres (mean, 16.5). All of them were treated with radiosurgery (24 Gamma Knife and 6 LINAC) with doses of 1200-1300 cGy. RESULTS: Tumour growth control rate (smaller or same size) was 93 % (28/30). In 11 patients there was a post-treatment hearing loss (36.6 %). Trigeminal (3/30) and facial (2/30) neuropathy was transient. CONCLUSIONS: Although microsurgery is the treatment of choice for acoustic neuromas, we consider radiosurgical treatment a valid alternative for selected patients (the elderly, co-morbid conditions, small size, contralateral hearing loss...).

Tratamiento del neurinoma del acústico con radiocirugía. Nuestra experiencia / Radiosurgery treatment of acoustic neuromas. Our experience

Objetivo: Valorar los resultados obtenidos, así como los efectos secundarios derivados del tratamiento con radiocirugía del neurinoma del acústico. Material y método: Entre los años 1999 y 2004, hemos tratado a 30 pacientes afectos de neurinoma del acústico (NA) unilateral, con una media de edad de 54 (31-76) años, un tiempo medio de seguimiento de 34 (12-54) meses y un tamaño que osciló en 4-38 (media, 16,5) mm. Se practicó radiocirugía a todos ellos (24 Gamma Knife y 6 LINAC) a dosis de 1.200-1.300 cGy. Resultados: La tasa de control del crecimiento tumoral fue del 93 % (28/30). Un 36,6 % (11/30) presentó empeoramiento de su nivel de audición postratamiento. La afección del V par (3/30), así como la del VII (2/30), fue transitoria. Conclusiones: Aunque la microcirugía sigue siendo el tratamiento de elección para los NA, consideramos la radiocirugía como una alternativa válida en pacientes seleccionados (edad avanzada, comorbilidad asociada, pequeño tamaño, hipoacusia contralateral, entre otros)

Objective: To evaluate the results and side effects obtained using radiosurgery to treat acoustic neuromas. Material and method: Between 1999 and 2004 we treated 30 patients with unilateral acoustic neuromas with a mean age of 54 years old (31-76), a mean follow-up of 34 months (12-54), and tumour size between 4 and 38 millimetres (mean, 16.5). All of them were treated with radiosurgery (24 Gamma Knife and 6 LINAC) with doses of 1200-1300 cGy. Results: Tumour growth control rate (smaller or same size) was 93 % (28/30). In 11 patients there was a post-treatment hearing loss (36.6 %). Trigeminal (3/30) and facial (2/30) neuropathy was transient. Conclusions: Although microsurgery is the treatment of choice for acoustic neuromas, we consider radiosurgical treatment a valid alternative for selected patients (the elderly, co-morbid conditions, small size, contralateral hearing loss...)