Complex benign horizontal canal positional vertigo: new perceptual management.

OBJECTIVE: Horizontal semicircular canal site pathology of benign paroxysmal positional vertigo demonstrating three types of nystagmi on positional test were studied. We have attempted to design a protocol for its diagnosis and treatment. METHODS: 320 patients of HSC-BPPV were subjected to two types of positional tests. Of these, patients with bilateral steady apogeotropic nysatgmus were treated with VAV modification of Semont's maneuver. Patients with unsteady or changing apo/geotropic signs were converted into steady geotropic ones by repetitive positional tests; followed by barbecue maneuver with forced prolong positioning. RESULTS: Overall 88% of patients had a total recovery. 92% of patients with geotropic nystagmus showed no symptoms after second maneuveral sitting. 85% of patients with apogeotropic nystagmus recovered fully after third maneuveral sitting. CONCLUSIONS: Correct identification of subtypes of HSC-BPPV is based on provoked nystagmus by positional tests. After locating the site and side on the basis of nystagmic pattern, physician can apply the appropriate PRM. LEVEL OF EVIDENCE: II a.

Central positional vertigo: A clinical-imaging study.

The diagnosis of central positional vertigo (CPV) is challenging, mainly because symptoms overlap with the common variants of benign paroxysmal positional vertigo (BPPV). Recent correlations of imaging with neurotologic exams have improved our understanding of CPV and ability differentiate it from BPPV. Yet, there is still a need to develop better diagnostic algorithms to improve timely diagnosis and early intervention. Here we present a retrospective review of the clinical characteristics, neurotologic evaluation and imaging of CPV in a cohort of 27 patients and propose a diagnostic algorithm to be tested in future prospective fashion. Most patients had positional nystagmus (downbeat and apogeotropic horizontal), cerebellar ocular motor abnormalities and truncal ataxia indicative of a central lesion. 61.5% of our cohort had paroxysmal CPV, 30.5% had a non-paroxysmal CPV and 8% paroxysmal-evolving-to-non-paroxysmal CPV. The most common pattern of positional nystagmus evoked with maneuvers was positional downbeat nystagmus (pDBN, 69.2%), apogeotropic horizontal nystagmus (42.3%), geotropic (7.69%) and multiplanar (23.0%). Notably, 13 (50%) of patients had cerebral imaging prior to CPV being on the differential diagnosis, whereas another 50% of patients had CPV diagnosis preceding their work-up. Unilateral lesions on imaging were 4× less likely to exhibit nausea and vomiting, nearly 2× less likely to exhibit paroxysmal nystagmus, and 2× less likely to exhibit nystagmus with habituality. Findings of pDBN or apogeotropic nystagmus alone were enough to diagnose CPV in 50% of our patient cohort, underscoring the importance of clinical evaluation in a time when an "imaging-first" philosophy is gaining popularity in Neurology.

25 (OH) D3 levels, incidence and recurrence of different clinical forms of benig paroxysmal positional vertigo / Níveis de 25 (OH) D3, incidência e recorrência de diferentes formas clínicas de vertigem posicional paroxística benigna

Abstract Introduction Benign paroxysmal positional vertigo is the most common cause of dizziness in the general population. It is a condition with potential impact of reduced levels of vitamin D on its recurrent attacks. Objectives The aim of this study was to measure the serum levels of 25-hydroxyvitamin D3 (25-OH D3) in patients with benign paroxysmal positional vertigo and determine whether there is a difference in the serum levels of vitamin D3 between patients with and without recurrence, as well as between the different clinical forms of benign paroxysmal positional vertigo. Methods The study included 40 patients who came to the regular medical examination, diagnosed with posterior canal-benign paroxysmal positional vertigo based on the positive Dix-Hallpike's test. All patients underwent Epley manoeuvre after the diagnosis. Patients were classified according to current guidelines for levels of vitamin D3 in the serum in three groups: the deficiency, insufficiency and adequate level. Results The average serum level of 25-OH D3 among respondents was 20.78 ng/mL, indicating a lack or insufficiency of the aforementioned 25-OH D3. According to the levels of 25-OH D3, most patients suffer from deficiency (47.5%). 7 (17.5%) respondents had adequate blood level of 25-OH D3, and 14 (35%) respondents suffer from insufficiency. A significant difference was not found in the serum level of 25-OH D3 between patients with and without benign paroxysmal positional vertigo recurrence. There was a significant difference in the serum levels of 25-OH D3 in comparison to the clinical form of the disease. Lower 25-OH D3 values were found in patients with canalithiasis compared to those with cupulolithiasis. Conclusions There were no significant differences in the vitamin D3 serum level in patients with and without recurrence. The study showed a low level of serum vitamin D3 in most patients, indicating the need for supplemental therapy.

Resumo Introdução Vertigem posicional paroxística benigna é a causa mais comum de tonturas na população em geral. É uma condição no qual níveis reduzidos de vitamina D podem ter um potencial impacto para o desenvolvimento de crises recorrentes. Objetivos O objetivo desse estudo foi medir os níveis séricos de 25-hidroxivitamina D3 (25-OH D3) em pacientes com vertigem posicional paroxística benigna e determinar se há diferença nos níveis séricos de vitamina D3 entre pacientes com e sem recorrência, bem como entre as diferentes formas clínicas de vertigem posicional paroxística benigna. Método O estudo incluiu 40 pacientes submetidos a exame médico regular, diagnosticados com vertigem posicional paroxística benigna de canal posterior baseado no resultado positivo do teste de Dix-Hallpike. Todos os pacientes foram submetidos à manobra de Epley após o diagnóstico. Os pacientes foram classificados de acordo com as diretrizes atuais para os níveis de vitamina D3 sérica em três grupos: deficiência, insuficiência e nível adequado. Resultados O nível sérico médio de 25-OH D3 entre os indivíduos avaliados foi de 20,78 ng/mL, indicando falta ou insuficiência desta vitamina. De acordo com os níveis de 25-OH D3, a maioria dos pacientes apresentou deficiência (47,5%). Sete indivíduos (17,5%) entrevistados tinham nível sanguíneo adequado de 25-OH D3 e 14 (35%) apresentavam insuficiência. Não foi encontrada diferença significativa no nível sérico de 25-OH D3 entre pacientes com e sem recidiva de vertigem posicional paroxística benigna. Houve uma diferença significativa nos níveis séricos de 25-OH D3 de acordo com a forma clínica da doença. Baixos níveis de 25-OH D3 foram mais encontrados em pacientes com canalitíase em comparação com aqueles com cupulolitíase. Conclusões Não houve diferenças significativas no nível sérico de vitamina D3 em pacientes com e sem recorrência. O estudo mostrou um baixo nível de vitamina D3 sérica na maioria dos pacientes, indicando a necessidade de terapia suplementar.

25 (OH) D3 levels, incidence and recurrence of different clinical forms of benig paroxysmal positional vertigo.

INTRODUCTION: Benign paroxysmal positional vertigo is the most common cause of dizziness in the general population. It is a condition with potential impact of reduced levels of vitamin D on its recurrent attacks. OBJECTIVES: The aim of this study was to measure the serum levels of 25-hydroxyvitamin D3 (25-OH D3) in patients with benign paroxysmal positional vertigo and determine whether there is a difference in the serum levels of vitamin D3 between patients with and without recurrence, as well as between the different clinical forms of benign paroxysmal positional vertigo. METHODS: The study included 40 patients who came to the regular medical examination, diagnosed with posterior canal-benign paroxysmal positional vertigo based on the positive Dix-Hallpike's test. All patients underwent Epley manoeuvre after the diagnosis. Patients were classified according to current guidelines for levels of vitamin D3 in the serum in three groups: the deficiency, insufficiency and adequate level. RESULTS: The average serum level of 25-OH D3 among respondents was 20.78ng/mL, indicating a lack or insufficiency of the aforementioned 25-OH D3. According to the levels of 25-OH D3, most patients suffer from deficiency (47.5%). 7 (17.5%) respondents had adequate blood level of 25-OH D3, and 14 (35%) respondents suffer from insufficiency. A significant difference was not found in the serum level of 25-OH D3 between patients with and without benign paroxysmal positional vertigo recurrence. There was a significant difference in the serum levels of 25-OH D3 in comparison to the clinical form of the disease. Lower 25-OH D3 values were found in patients with canalithiasis compared to those with cupulolithiasis. CONCLUSIONS: There were no significant differences in the vitamin D3 serum level in patients with and without recurrence. The study showed a low level of serum vitamin D3 in most patients, indicating the need for supplemental therapy.