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In 2016, the Bárány Society defined new diagnostic criteria for the neurovascular compression syndrome of the eighth nerve, called “vestibular paroxysmia” (VP), differentiating between definite (dVP) and probable (pVP) forms. The aim of this study was (1) to describe clinical symptoms and laboratory findings in a well-diagnosed large patient cohort according to those criteria, and (2) to evaluate the long-term course over years in dVP. We identified 146 patients (73 dVP, 73 pVP) from our tertiary dizziness center registry. Data of structured history-taking, clinical neurological, neuro-ophthalmological/-otological examinations as well as MRI imaging were extracted for analyses. Overall, attack frequency ranged between 5 and 30 attacks per day; spinning vertigo was the most frequent type. In two-thirds of patients, attacks occurred spontaneously; in one-quarter, they were triggered by head movements. The majority (approximately 70%) reported no accompanying symptoms; in those with symptoms, mild unilateral cochlear symptoms prevailed. One-third of patients initially showed hyperventilation-induced nystagmus without specific direction, and a deviation of the subjective visual vertical between 3° and 6°. Complete loss of peripheral vestibular function was never evident. dVP and pVP significantly differed concerning the vertigo type, e.g., spinning vertigo was more frequent in dVP. Fortunately, three-quarters of dVP patients remained attack-free during follow-up (mean 4.8 years, standardized questionnaire), more than half of them even without any medication. Patients with ongoing attacks showed significantly higher attack frequency at baseline, but reported persistent frequency reduction. Overall, the long-term prognosis of VP appears favorable, not necessarily requiring ongoing treatment.

BackgroundPersistent postural perceptual dizziness (PPPD) is a common and disabling functional neuro-vestibular disorder. We aimed to determine the feasibility and acceptability of conducting a randomised controlled trial of cognitive-behavioural therapy informed vestibular rehabilitation (INVEST intervention) designed for persistent dizziness.MethodsA two-armed parallel groups randomised feasibility study of INVEST vs. a time-matched gold standard vestibular rehabilitation (VRT) control. Participants with PPPD were recruited from a specialist vestibular clinic in London, UK. Participants were individually randomised using a minimisation procedure with allocation concealment. Measures of feasibility and clinical outcome were collected and assessed at 4 months.ResultsForty adults with PPPD were randomised to six sessions of INVEST (n = 20) or gold standard VRT (n = 20). Overall, 59% of patients screened met the inclusion criteria, of which 80% enrolled. Acceptability of INVEST, as assessed against the theoretical framework of acceptability (TFA), was excellent and 80% adhered to all 6 sessions. There were small to moderate treatment effects in favour of INVEST across all measures, including dizziness handicap, negative illness perceptions, symptom focussing, fear avoidance, and distress (standardised mean difference [SMD]g = 0.45; SMDg = 0.77; SMDg = 0.56; SMDg = 0.50, respectively). No intervention-related serious adverse events were reported.ConclusionsThe study results give strong support for the feasibility of a full-scale trial. Both arms had high rates of recruitment, retention, and acceptability. There was promising support of the benefits of integrated cognitive-behavioural therapy-based vestibular rehabilitation compared to gold standard vestibular rehabilitation. The study fulfilled all the a-priori criteria to advance to a full-scale efficacy trial.Trial registration numberISRCTN10420559.

Background Due to reported barriers in the management of patients with vertigo, dizziness and balance problems (VDB), referral trajectories starting from primary care might be determined by other factors than medical necessity. The objective of this paper was to examine the impact of disease-related and other determinants on referral trajectories of older patients with VDB and to investigate, how these trajectories affect the patients’ functioning and health-related quality of life (HRQoL). Methods Data originate from the longitudinal multicenter study MobilE-TRA, conducted in two German federal states. Referrals to neurologists or ear-nose-throat (ENT) specialists were considered. Referral patterns were visualized using a state sequence analysis. Predictors of referral trajectories were examined using a multinomial logistic regression model. Linear mixed models were calculated to assess the impact of referral patterns on the patients’ HRQoL and functioning. Results We identified three patterns of referral trajectories: primary care physician (PCP) only, PCP and neurologist, and PCP and ENT. Chances of referral to a neurologist were higher for patients with a neurological comorbidity (OR = 3.22, 95%-CI [1.003; 10.327]) and lower for patients from Saxony (OR = 0.08, 95%-CI [0.013; 0.419]). Patients with a PCP and neurologist referral pattern had a lower HRQoL and lower functioning at baseline assessment. Patients with unspecific diagnoses also had lower functioning. Conclusion Referral trajectories were determined by present comorbidities and the regional healthcare characteristics. Referral trajectories affected patients’ HRQoL. Unspecific VDB diagnoses seem to increase the risk of ineffective management and consequently impaired functioning.

Background Vestibular migraine (VM) is considered one of the most common causes of episodic central vestibular disorders, the mechanism of VM is currently still unclear. The development of functional nuclear magnetic resonance (fMRI) in recent years offers the possibility to explore the altered functional connectivity patterns in patients with VM in depth. The study aimed to investigate altered patterns of brain network functional connectivity in patients with VM diagnosed based on the diagnostic criteria of the Bárány Society and the International Headache Society, and hope to provide a scientific theoretical basis for understanding whether VM is a no-structural central vestibular disease, i.e., functional central vestibular disease with altered brain function. Methods Seventeen patients with VM who received treatment in our hospital from December 2018 to December 2020 were enrolled. Eight patients with migraine and 17 health controls (HCs) were also included. Clinical data of all patients were collected. Blood pressure, blood routine tests and electrocardiography were conducted to exclude other diseases associated with chronic dizziness. Videonystagmography, the vestibular caloric test, the video head impulse test and vestibular-evoked myogenic potentials were measured to exclude peripheral vestibular lesions. MRI was utilized to exclude focal lesions and other neurological diseases. All subjects underwent fMRI. The independent component analysis was performed to explore changes in intra- and inter-network functional connectivity in patients with VM. Results Among 17 patients with VM, there were 7 males and 10 females with an average age of 39.47 ± 9.78 years old. All patients had a history of migraine. Twelve (70.6%) patients had recurrent spontaneous vertigo, 2 (11.7%) patients had visually induced vertigo, and 3 (17.6%) patients had head motion-induced vertigo. All 17 patients with VM reported worsening of dizziness vertigo during visual stimulation. The migraine-like symptoms were photophobia or phonophobia (n = 15, 88.2%), migraine-like headache (n = 8, 47.1%), visual aura during VM onset (n = 7, 41.2%). 5 (29.4%) patients with VM had hyperactive response during the caloric test, and 12 (70.6%) patients had caloric test intolerance. Eleven (64.7%) patients had a history of motion sickness. Totally 13 independent components were identified. Patients with VM showed decreased functional connectivity in the bilateral medial cingulate gyrus and paracingulate gyrus within sensorimotor network (SMN) compared with HCs. They also showed weakened functional connectivity between auditory network (AN) and anterior default mode network (aDMN) compared with HCs, and enhanced functional connectivity between AN and the salience network (SN) compared with patients with migraine. Conclusion Patients with vestibular migraine showed obvious altered functional connectivity in the bilateral medial cingulate gyrus and paracingulate gyrus within the SMN. The median cingulate and paracingulate gyri may be impaired, the disinhibition of sensorimotor network and vestibular cortical network may result in a hypersensitivity state (photophobia/phonophobia). Altered functional connectivity between AN and DMN, SN may lead to increased sensitivity to vestibular sensory processing.

Background Dizziness and imbalance are common symptoms that are often inadequately diagnosed or managed, due to a lack of dedicated specialists. Decision Support Systems (DSS) may support first-line physicians to diagnose and manage these patients based on personalised data. Aim To examine the diagnostic accuracy and application of the EMBalance DSS for diagnosis and management of common vestibular disorders in primary care. Methods Patients with persistent dizziness were recruited from primary care in Germany, Greece, Belgium and the UK and randomised to primary care clinicians assessing the patients with (+ DSS) versus assessment without (− DSS) the EMBalance DSS. Subsequently, specialists in neuro-otology/audiovestibular medicine performed clinical evaluation of each patient in a blinded way to provide the “gold standard” against which the + DSS, − DSS and the DSS as a standalone tool (i.e. without the final decision made by the clinician) were validated. Results One hundred ninety-four participants (age range 25–85, mean = 57.7, SD = 16.7 years) were assigned to the + DSS (N = 100) and to the − DSS group (N = 94). The diagnosis suggested by the + DSS primary care physician agreed with the expert diagnosis in 54%, compared to 41.5% of cases in the − DSS group (odds ratio 1.35). Similar positive trends were observed for management and further referral in the + DSS vs. the − DSS group. The standalone DSS had better diagnostic and management accuracy than the + DSS group. Conclusion There were trends for improved vestibular diagnosis and management when using the EMBalance DSS. The tool requires further development to improve its diagnostic accuracy, but holds promise for timely and effective diagnosis and management of dizzy patients in primary care. Trial registration number NCT02704819 (clinicaltrials.gov).

Seventy Meniere’s disease (MD) patients with spontaneous vertigo (100%), unilateral aural fullness (57.1%), tinnitus (78.6%), and subjective hearing loss (75.7%) self-recorded nystagmus during their episodes of vertigo using portable video oculography goggles. All demonstrated ictal spontaneous nystagmus, horizontal in 94.3% (n = 66) and vertical in 5.7% (n = 4), with a mean slow-phase velocity (SPV) of 42.8 ± 31.1°/s (range 5.3–160.1). Direction reversal of spontaneous horizontal nystagmus was captured in 58.6%, within the same episode in 34.3%, and over different days in 24.3%. In 18.6%, we observed ipsiversive then contraversive nystagmus, and in 12.9% contraversive to ipsiversive direction reversal. Ictal nystagmus SPV (42.8 ± 31.1°/s) was significantly faster than interictal (1.4 ± 3.1°/s, p 40%). Using ictal nystagmus findings of SPV > 12°/s, and a caloric canal paresis > 25%, we correctly separated a diagnosis MD from Vestibular Migraine with a sensitivity and specificity of 95.7% and 85.1% (CI 0.89–0.97).

Many patients attending the emergency room (ER) with vertigo, leave without a diagnosis. We assessed whether the three tools could improve ER diagnosis of vertigo. A prospective observational study was undertaken on 539 patients presenting to ER with vertigo. We used three tools: a structured-history and examination, nystagmus video-oculography (VOG) in all patients, additional video head-impulse testing (vHIT) for acute-vestibular-syndrome (AVS). In the intervention-group (n = 424), case-history classified AVS in 34.9%, episodic spontaneous-vertigo (ESV 32.1%), and episodic positional-vertigo (EPV 22.6%). In AVS, we employed “Quantitative-HINTS plus” (Head-Impulse, Nystagmus and Test-of-Skew quantified by vHIT and VOG, audiometry) to identify vestibular-neuritis (VN) and stroke (41.2 and 31.1%). vHIT gain ≤ 0.72, catch-up saccade amplitude > 1.4○, saccade-frequency > 154%, and unidirectional horizontal-nystagmus, separated stroke from VN with 93.1% sensitivity and 88.5% specificity. In ESV, 66.2 and 14% were diagnosed with vestibular migraine and Meniere’s Disease by using history and audiometry. Horizontal-nystagmus velocity was lower in migraine 0.4 ± 1.6○/s than Meniere’s 5.7 ± 5.5○/s (p

Objective Skew deviation results from a dysfunction of the graviceptive pathways in patients with an acute vestibular syndrome (AVS) leading to vertical diplopia due to vertical ocular misalignment. It is considered as a central sign, however, the prevalence of skew and the accuracy of its test is not well known . Methods We performed a prospective study from February 2015 until September 2020 of all patients presenting at our emergency department (ED) with signs of AVS. All patients underwent clinical HINTS and video test of skew (vTS) followed by a delayed MRI, which served as a gold standard for vestibular stroke confirmation. Results We assessed 58 healthy subjects, 53 acute unilateral vestibulopathy patients (AUVP) and 24 stroke patients. Skew deviation prevalence was 24% in AUVP and 29% in strokes. For a positive clinical test of skew, the cut-off of vertical misalignment was 3 deg with a very low sensitivity of 15% and specificity of 98.2%. The sensitivity of vTS was 29.2% with a specificity of 75.5%. Conclusions Contrary to prior knowledge, skew deviation proved to be more prevalent in patients with AVS and occurred in every forth patient with AUVP. Large skew deviations (> 3.3 deg), were pointing toward a central lesion. Clinical and video test of skew offered little additional diagnostic value compared to other diagnostic tests such as the head impulse test and nystagmus test. Video test of skew could aid to quantify skew in the ED setting in which neurotological expertise is not always readily available.

Background Vestibular migraine (VM) is one of the most common causes of vertigo in clinical practice but it is not always easy to make the correct diagnosis. Our aims were to find out how VM patients differ from migraine only (MO) patients, to evaluate co-morbid depression in these two groups and to determine if their disease has an effect on their quality of life. Methods We studied 50 definite VM and 35 MO patients. Each patient was asked about: age of onset, duration of headaches, presence of aura, headache characteristics, triggering factors, associated features, motion sickness history and family history of migraine. VM patients were also asked about their vertigo attacks and accompanying symptoms. Each patient also completed the following questionnaires: (1) Migraine Disability Assessment Scale (MIDAS); (2) headache severity with VAS (Visual Analog Scale); (3) Allodynia Symptom Checklist (ASC-12); (4) Beck Depression Inventory (BDI); (5) World Health Organization Quality of Life Questionnaire Short Form-12 (WHOQL-SF12); (6) Activities Specific Balance Confidence Scale (ABC). VM patients also completed the Dizziness Handicap Inventory (DHI). Results We found that VM patients were more likely than MO patients to be female, post-menopausal, depressed, motion sick, complaining of imbalance and of food-triggered headaches. In contrast, MO patients were more likely than VM patients to have severe headaches and that these can be triggered by certain odors and by noise. Conclusion Our findings showed differences between VM and MO patients and attention to these differences could help clinicians diagnose, characterize and manage their VM patients.

We aimed to characterize the central positional nystagmus (CPN) observed in lesions involving the inferior cerebellar peduncle (ICP). We analyzed the clinical and neurotologic findings in six patients with an isolated unilateral ICP infarction that had been diagnosed at a university hospital in South Korea from 2003 to 2019. Patients usually presented with acute vestibular syndrome in isolation (4/6, 67%). Ipsilesional spontaneous nystagmus was observed in five while supine (5/6, 83%). Four (4/6, 67%) patients showed CPN which included apogeotropic (n = 3) or geotropic (n = 1) during head turning to either side while supine, and vertical nystagmus during straight-head hanging, Dix-Hallpike maneuvers, or up-righting (n = 3). Four patients showed contraversive ocular tilt reaction or tilt of the subjective visual vertical. Bedside and video head-impulse tests were normal in all patients. CPN is a usual finding in ICP lesions, and may be ascribed to damage of the fibers running from the nodulus/uvula onto the vestibular nucleus via the ICP.

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo worldwide. This review considers recent advances in the diagnosis and management of BPPV including the use of web-based technology and artificial intelligence as well as the evidence supporting the use of vitamin D supplements for patients with BPPV and subnormal serum vitamin D.

Early identification of cardiogenic vertigo (CV) is necessary to prevent serious complications of cardiovascular diseases. However, the literature is limited to case reports without detailed clinical features or diagnostic criteria. The aim of this study was to define characteristics of CV and propose diagnostic criteria. This study included patients with CV diagnosed at Pusan National University and Keimyung University Hospitals. Demographic, clinical, laboratory, and treatment data were analyzed. Of 72 patients with clinically suspicious CV, 27 were finally included. The age ranged from 63 to 88 years (75.1 ± 7.2 years). Recurrent vertigo occurred without syncopal attacks in 52% [95% CI, 32–71], while it preceded (37% [19–58]) or followed (11% [2–29]) syncope. The patients with recurrent isolated vertigo had suffered from symptoms from 15 days to 5 years until final diagnosis (median 122 days). The vertigo lasted only for a few seconds (93% [76–99]) or a few minutes (7% [1–24]). Fourteen patients presented with spinning vertigo, and one of them showed spontaneous downbeat nystagmus during the attack. Accompanying symptoms including chest discomfort, palpitation, headache, arm twitching, and lightheadedness were found in 70% [50–86]. Between patients with and without syncope, there was no difference in clinical parameters and results of cardiac function tests. The most common cardiac abnormality during the attacks of vertigo was bradyarrhythmia (89% [71–98]). Cardiovascular diseases can develop recurrent isolated vertigo without or preceding syncope. Onset age, duration of vertigo, accompanying symptoms, and underlying cardiac diseases can aid in differentiation from other vestibular disorders. Early identification of CV would reduce morbidity and mortality associated with cardiac syncope.

Unilateral vestibular atelectasis (UVA), an entity first described by Merchant and Schuknecht in 1988, has rarely been reported in vivo as of yet. We specify here the clinical characteristics of 22 patients diagnosed with UVA. Patients with a radiological diagnosis of UVA who underwent delayed inner ear MRI were included between April 2017 and January 2020. Full clinical testing including ocular infrared video-oculography, oVEMPs, cVEMPs, vHIT, bithermal caloric testing and auditory testing was performed. There were 13 men and 9 women, of mean age 58.6 ± 13.7 years. Onset was more frequently sudden (73%) than insidious (27%) though both clinical presentations were reported, and positional vertigo was described in 41% of cases. There were only two (9%) patients reporting Tullio’s phenomenon. Vestibular testing showed that in 90% of cases, there was utricular dysfunction on oVEMP, while in 77% of cases, saccular function was preserved on cVEMP. vHIT showed high-velocity canal function impairment in all 22 patients: 8 patients (36%) had one impaired canal, 5 (23%) had two and 9 (41%) had all three canals affected. Caloric tests found complete unilateral areflexia, in 65% of tested cases, and partial deficiency in 35% of cases. Nine patients (40%) displayed asymmetrical hearing. We described in this study the various clinical presentations of a disease rarely reported in vivo, UVA. Initial clinical presentation can appear similar to an acute vestibular deficit, a recurrent positional vertigo, or fluctuating dizziness.

Objectives Acute diplopia is a diagnostic challenge for clinicians, in particular in the emergency department. The most common cause of acute diplopia are ocular motor nerve palsies (OMP). In this prospective study, we focused on identifying the most crucial signs and symptoms for differentiating between peripheral and central OMP. Methods We prospectively evaluated 56 non-consecutive patients who presented at our emergency department with acute binocular diplopia (≤ 10 days). The patient history was taken using a standardized questionnaire and patients underwent a neurological, neuro-ophthalmological and neuro-otological examination, including measurement of the subjective visual vertical (SVV), Harms tangent screen test, and cranial MRI. Results Forty-six out of 56 patients were diagnosed with an ocular motor cranial nerve palsy (OMP), 21 of peripheral and 23 of central origin; in two patients, the etiology remained unknown. The following features were different in peripheral and central OMP: (1) the presence of vertigo/dizziness was more frequent in central (43.5%) than in peripheral (9.5%) OMP. (2) Central ocular motor signs, such as saccadic smooth pursuit, additional internuclear ophthalmoplegia, skew deviation, and saccade palsies, were also found more frequently in the central than in the peripheral group (86.7% vs. 33.3%). (3) Further, a pathological SVV deviation by monocular testing of the non-affected eye was also more common in central (77.3%) than in peripheral OMP (38.9%). The presence of all three factors has a positive predictive value of 100% (CI 50–100%) for the presence of a central lesion. Conclusions In acute diplopia due to central OMP, the most important accompanying symptom is vertigo/dizziness, and the most important clinical signs are central ocular motor disorders (which require examination of the non-paretic eye) and an SVV deviation in the non-paretic eye.

Intravenous thrombolysis (IVT) is rarely performed in dizzy patients with acute vestibular syndrome (AVS) or acute imbalance (AIS) even if posterior circulation stroke (PCS) is suspected. Decision-making may be affected by uncertainties in discriminating central from peripheral vestibulopathy or concerns of IVT-related harm, particularly intracerebral hemorrhage (ICH), but related studies are missing. Using an in-house register of dizzy patients coming to the emergency room, we identified 29 AVS/AIS patients who presented within 4.5 h after onset, revealed clinical signs indicative of PCS (central oculomotor signs, mild focal abnormalities), and had non-contrast computed tomography (NCCT). Patients treated with IVT (n = 15) were compared to NoIVT patients (n = 14) with regard to clinical and imaging (including perfusion computed tomography, CTP) parameters, occurrence of ICH and short-term clinical outcome (NIHSS improvement; ability to walk independently). IVT and NoIVT patients did not differ in baseline characteristics, central oculomotor signs, or clinical outcome. IVT patients more often exhibited disabling vestibular symptoms (severe dizziness/vertigo, inability to stand unsupported) and focal abnormalities than NoIVT patients. There was no ICH in either group. CTP was performed in 0% of NoIVT versus 80% of IVT patients, seven of twelve revealing posterior circulation hypoperfusion. Comparison of initial hypoperfusion (CTP) and final stroke (NCCT) revealed IVT-related benefit (smaller lesion) in three of seven IVT patients. In AVS/AIS patients with suspected PCS, disabling vestibular symptoms, focal neurological deficits, and hypoperfusion on CTP seem to direct decision-making pro IVT. In our small cohort, there were no significant IVT-related clinical benefits, no IVT-related ICHs, and salvage of brain tissue in some patients.

Unilateral or bilateral vestibular hypofunction presents most commonly with symptoms of dizziness or postural imbalance and affects a large population. However, it is often missed because no quantitative testing of vestibular function is performed, or misdiagnosed due to a lack of standardization of vestibular testing. Therefore, this article reviews the current status of the most frequently used vestibular tests for canal and otolith function. This information can also be used to reach a consensus about the systematic diagnosis of vestibular hypofunction.

In 2017, the term “persistent postural-perceptual dizziness” (PPPD) was coined by the Bárány Society, which provided explicit criteria for diagnosis of functional vertigo and dizziness disorders. PPPD can originate secondarily after an organic disorder (s-PPPD) or primarily on its own, in the absence of somatic triggers (p-PPPD). The aim of this database-driven study in 356 patients from a tertiary vertigo center was to describe typical demographic and clinical features in p-PPPD and s-PPPD patients. Patients underwent detailed vestibular testing with neurological and neuro-orthoptic examinations, video-oculography during water caloric stimulation, video head-impulse test, assessment of the subjective visual vertical, and static posturography. All patients answered standardized questionnaires (Dizziness Handicap Inventory, DHI; Vestibular Activities and Participation, VAP; and Euro-Qol-5D-3L). One hundred and ninety-five patients (55%) were categorized as p-PPPD and 162 (45%) as s-PPPD, with female gender slightly predominating (♀:♂ = 56%:44%), particularly in the s-PPPD subgroup (64%). The most common somatic triggers for s-PPPD were benign paroxysmal positional vertigo (27%), and vestibular migraine (24%). Overall, p-PPPD patients were younger than s-PPPD patients (44 vs. 48 years) and showed a bimodal age distribution with an additional early peak in young adults (about 30 years of age) beside a common peak at the age of 50–55. The most sensitive diagnostic tool was posturography, revealing a phobic sway pattern in 50% of cases. s-PPPD patients showed higher handicap and functional impairment in DHI (47 vs. 42) and VAP (9.7 vs. 8.9). There was no difference between both groups in EQ-5D-3L. In p-PPPD, anxiety (20% vs. 10%) and depressive disorders (25% vs. 9%) were more frequent. This retrospective study in a large cohort showed relevant differences between p- and s-PPPD patients in terms of demographic and clinical features, thereby underlining the need for careful syndrome subdivision for further prospective studies.

Background Positional manoeuvres are an important part of the neurological examination, particularly in patients with vertigo where the presence and characteristics of provoked nystagmus can help differentiate central from peripheral neurological disorders. Methods Case series of functional positional eye and eyelid movements. Results We report four patients with functional eye and eyelid movements provoked during positional manoeuvres. The range of abnormalities observed included positional convergence spasm, brief functional saccadic oscillations, and excessive positional blinking mimicking upbeat nystagmus. The functional movements described were present on a background of pre-existing peripheral or central nystagmus, or positional vertigo. Conclusion Functional positional eye and eyelid movements may co-exist with organic nystagmus that renders an accurate interpretation of the manoeuvre more challenging. A thorough understanding of the clinical features that differentiate these two categories of eye/eyelid movements makes the analysis easier, thus preventing misdiagnosis and avoiding unnecessary investigations.

Vertigo and dizziness are amongst the most common symptoms in medicine and often have a major impact on activities of daily life. Although many causes of vertigo and dizziness can easily be recognized, patients often receive inappropriate and ineffective treatment. The reasons for this are various. Because vertigo/dizziness is an interdisciplinary symptom and there is a lack of standardised diagnostic tools, it is easy to lose the overview of the possible differential diagnoses. There is evidence though, that the management of patients with vertigo/dizziness can be optimized using standardized care pathways with digital support. The present study (within the framework of “PoiSe—prevention, online feedback, and interdisciplinary therapy of acute vestibular syndromes by e-health”) aims to evaluate the implementation of a program with several interlocking components. The three main components are a computerized clinical decision system, a mobile application, a counselling and interdisciplinary educational program developed by the German Center for Vertigo and Balance Disorders (DSGZ). The study is a cluster-randomized controlled trial with a parallel-group design, as well as a detailed process evaluation. Clusters comprise of primary care physician practices in Bavaria, Germany. In the scope of the study the effectiveness, acceptability and efficiency of the intervention will be evaluated. It is anticipated that the intervention will improve the quality and efficiency of the management of dizzy patients. A higher diagnostic accuracy, optimized treatment, and disease progression monitoring is expected to improve patient-relevant outcomes and reduce health-care costs.

Distinguishing between serious (e.g., stroke) and benign (e.g., benign paroxysmal positional vertigo, BPPV) disorders remains challenging in emergency consultations for vertigo and dizziness (VD). A number of clues from patient history and clinical examination, including several diagnostic index tests have been reported recently. The objective of the present study was to analyze frequency and distribution patterns of specific vestibular and non-vestibular diagnoses in an interdisciplinary university emergency room (ER), including data on daytime and season of presentation. A retrospective chart analysis of all patients seen in a one-year period was performed. In the ER 4.23% of all patients presented with VD (818 out of 19,345). The most frequent-specific diagnoses were BPPV (19.9%), stroke/transient ischemic attack (12.5%), acute unilateral vestibulopathy/vestibular neuritis (UVH; 8.3%), and functional VD (8.3%). Irrespective of the diagnosis, the majority of patients presented to the ER between 8 a.m. and 4 p.m. There are, however, seasonal differences. BPPV was most prevalent in December/January and rare in September. UVH was most often seen in October/November; absolute and relative numbers were lowest in August. Finally, functional/psychogenic VD was common in summer and autumn with highest numbers in September/October and lowest numbers in March. In summary, daytime of presentation did not distinguish between diagnoses as most patients presented during normal working hours. Seasonal presentation revealed interesting fluctuations. The UVH peak in autumn supports the viral origin of the condition (vestibular neuritis). The BPPV peak in winter might be related to reduced physical activity and low vitamin D. However, it is likely that multiple factors contribute to the fluctuations that have to be disentangled in further studies.

Background Most questionnaires currently used for assessing symptomatology of vestibular disorders are retrospective, inducing recall bias and lowering ecological validity. An app-based diary, administered multiple times in daily life, could increase the accuracy and ecological validity of symptom measurement. The objective of this study was to introduce a new experience sampling method (ESM) based vestibular diary app (DizzyQuest), evaluate response rates, and to provide examples of DizzyQuest outcome measures which can be used in future research. Methods Sixty-three patients diagnosed with a vestibular disorder were included. The DizzyQuest consisted of four questionnaires. The morning- and evening-questionnaires were administered once each day, the within-day-questionnaire 10 times a day using a semi-random time schedule, and the attack questionnaire could be completed after the occurrence of a vertigo or dizziness attack. Data were collected for 4 weeks. Response rates and loss-to-follow-up were determined. Reported symptoms in the within-day-questionnaire were compared within and between patients and subgroups of patients with different vestibular disorders. Results Fifty-one patients completed the study period. Average response rates were significantly higher than the desired response rate of > 50% (p Conclusion The DizzyQuest is able to capture vestibular symptoms within their psychosocial context in daily life, with little recall bias and high ecological validity. The DizzyQuest reached the desired response rates and showed different disease profiles between subgroups of patients with different vestibular disorders. This is the first time ESM was used to assess daily symptoms and quality of life in vestibular disorders, showing that it might be a useful tool in this population.

To compare the efficacy of gentamicin and steroids in patients with Meniere's disease (MD). The study protocol was structured in accordance with the Population, Intervention, Comparison and Outcome (PICO) framework. We used “Endnote” (Thomson ResearchSoft; Stanford, Connecticut, the United States) to retrieve database documents. A systematic literature search of Web of Science and PubMed Database through May 2020 was conducted using specific search terms. Inclusion criteria, exclusion criteria, vertigo improvement, and exact hearing changes were defined. Review Manager 5.3 (Cochrane) was used for data analysis. A total of 80 articles were searched from Web of Science and 23 articles were searched from PubMed database. After further reviewing the specific points of the inclusion criteria and exclusion criteria, 9 papers were finally selected. Intratympanic gentamicin (ITG) was superior to intratympanic steroid (ITS) in reducing the number of vertigo attacks (odds ratio (OR) 3.08, 95% confidence intervals (CI) [2.05–3.65]), probability (P)

The usefulness of brain imaging studies in dizzy patients presenting to the emergency department (ED) is controversial. We aimed to assess the ‘real-world’ probability of ischemic stroke and other acute brain lesions (ABLs) in these patients to create an algorithm that helps decision-making on whether which and when brain imaging is needed. By reviewing medical records, we identified 610 patients presenting with dizziness, vertigo or imbalance to our university hospital’s ED and receiving neurological workup. We collected timing/triggers of symptoms, ABCD2 score, focal neurological abnormalities, HINTS (head impulse, nystagmus, test-of-skew) and other central oculomotor signs. ABLs were extracted from CT/MRI reports. Uni-/multivariate logistic regression analyses investigated associations between clinical parameters and ABLs. Finally, the likelihood of ABLs was assessed for different clinically defined subgroups (‘dizziness syndromes’). Early CT (day 1) was performed in 539 (88%) and delayed MR imaging (median: day 4) in 299 (49%) patients. ABLs (89% ischemic stroke) were revealed in 75 (24%) of 318 patients with adequate imaging (MRI or lesion-positive CT). The risk for ABLs increased with the presence of central oculomotor signs (odds ratio 2.8, 95% confidence interval 1.5–5.2) or focal abnormalities (OR 3.3, 95% CI 1.8–6.2). The likelihood of ABLs differed between dizziness syndromes, e.g., HINTS-negative acute vestibular syndrome: 0%, acute imbalance syndrome with ABCD2-score ≥ 4: 50%. We propose a clinical pathway, according to which patients with HINTS-negative acute vestibular syndrome should not receive brain imaging, whereas imaging is suggested in dizzy patients with acute imbalance, central oculomotor signs or focal abnormalities.

Historical descriptions of fear at heights date back to Chinese and Roman antiquity. Current definitions distinguish between three different states of responses to height exposure: a physiological height imbalance that results from an impaired visual control of balance, a more or less distressing visual height intolerance, and acrophobia at the severest end of the spectrum. Epidemiological studies revealed a lifetime prevalence of visual height intolerance including acrophobia in 28% of adults (32% in women; 25% in men) and 34% among prepubertal children aged 8–10 years without gender preponderance. Visual height intolerance first occurring in adulthood usually persists throughout life, whereas an early manifestation in childhood usually shows a benign course with spontaneous relief within years. A high comorbidity was found with psychiatric disorders (e.g. anxiety and depressive syndromes) and other vertigo syndromes (e.g. vestibular migraine, Menière’s disease), but not with bilateral vestibulopathy. Neurophysiological analyses of stance, gait, and eye movements revealed an anxious control of postural stability, which entails a co-contraction of anti-gravity muscles that causes a general stiffening of the whole body including the oculomotor apparatus. Visual exploration is preferably reduced to fixation of the horizon. Gait alterations are characterized by a cautious slow walking mode with reduced stride length and increased double support phases. Anxiety is the critical factor in visual height intolerance and acrophobia leading to a motor behavior that resembles an atavistic primitive reflex of feigning death. The magnitude of anxiety and neurophysiological parameters of musculoskeletal stiffening increase with increasing height. They saturate, however, at about 20 m of absolute height above ground for postural symptoms and about 40 m for anxiety (70 m in acrophobic participants). With respect to management, a differentiation should be made between behavioral recommendations for prevention and therapy of the condition. Recommendations for coping strategies target behavioral advices on visual exploration, control of posture and locomotion as well as the role of cognition. Treatment of severely afflicted persons with distressing avoidance behavior mainly relies on behavioral therapy.

Background Persistent postural perceptual dizziness (PPPD) is a common chronic condition presenting in neurology and neuro-otology clinics. Symptoms lie on a spectrum in the general population. The cause is unknown and thought to involve interactions between visual and vestibular systems, but symptoms also correlate with anxiety and migraine. Objective To test whether PDDD symptoms are associated with reported differences in other senses (touch, hearing, smell and taste); to investigate possible mediation via anxiety or migraine; to discover the proportion of variance accountable to these non-vestibular factors. Methods We measured self-report multisensory sensitivity, anxiety, visual difficulties, visual discomfort and migraine in patients with PPPD (N = 29) and a large general population cohort (N > 1100). We used structural equation modelling to examine relationships between the factors using a step-wise approach. Results We found increased self-reported over-sensitivity in sensory domains beyond vision and balance in both patients with PPPD and non-clinical participants with more PPPD symptoms. SEM analysis revealed that anxiety partly, but not wholly, mediated this relationship. Adding visual difficulties and visual discomfort to the model allowed it to explain 50% of PPPD symptom variance. Most of the path coefficients and mediation effects in our model were unchanged between participants with and without migraine. Conclusions Our findings support the idea that PPPD is a complex neurological condition that includes broad perceptual factors, and may suggest that some brains are predisposed to generalised cross-modal sensory-overload. This may give rise to vulnerability to severe PPPD should a vestibular insult occur.

This study aimed to define the factors affecting accuracy of bedside determination of the involved side in HC-BPPV. We developed 44 video clips including the nystagmus induced during supine head-roll test from patients with apogeotropic (n = 23) or geotropic (n = 21) HC-BPPV. The intensity of nystagmus was also quantified using video-oculography. Each video clip was presented twice to 25 participants, 14 medical students, and 11 medical personnel trained in neurology or neurotology, and the participants reported the lesion side using an evaluation sheet after each presentation. From the quantified video-oculographic data, absolute difference and asymmetry (absolute difference divided by the sum) of nystagmus intensity were calculated. The accuracy of bedside lateralization of HC-BPPV was 83.5% after the first presentation, and 86.0% after the second presentation, and was not different between the medical students and trained personnel after the second presentation. The accuracy was more closely correlated with the asymmetry than the absolute difference (Spearman’s ρ = 0.627, p

Evolution of vestibular function requires further elucidation in spinocerebellar ataxia (SCA). This study aimed to determine temporal evolution in the findings of head impulse tests (HITs) in SCA type 6 (SCA6). We serially evaluated HITs in 12 patients with SCA6 using video-oculography for 3 months to 5 years [median = 12 months, interquartile range (IQR) = 9-50] at two university hospitals in South Korea. Patients (8/12, 67%) usually showed abnormal responses at least for one semicircular canal during video-HITs. The gains of the vestibulo-ocular reflex (VOR) for the anterior canals (ACs) were larger than those for the posterior canals (PCs, p = 0.005) at initial presentation. During the follow-up, the VOR gains decreased for the horizontal canals (HCs, p = 0.008) and ACs (p = 0.021), but those for the PCs remained unchanged (p = 0.212). Perverted HITs were observed in seven patients (7/12, 58%). The differences in the head impulse VOR gains were larger between the ACs and PCs (ΔACs - PCs) in those with perverted HITs than in those without (p = 0.003). The gains for each semicircular canal showed a negative correlation with the Scale for the Assessment and Rating of Ataxia (HCs, Spearman's coefficient = - 0.675, p = 0.003; ACs, - 0.637, p = 0.006; PCs, - 0.605, p = 0.010). The head impulse gain of the VOR may serve a marker for clinical decline in SCA6. The dissociation in the temporal evolution of the VOR gain indicates dissimilar cerebellar modulation of the vestibular signals from each semicircular canal.

This study aimed to determine the incidence, pattern, and etiology of dissociated vestibulo-ocular reflex (VOR) function according to the stimulus frequency in dizzy patients. We retrospectively evaluated the results of bithermal caloric tests and video-head impulse tests (vHITs) in 1022 patients with dizziness or vertigo between July 2016 and April 2021. Patients were classified into concordant group (normal or abnormal results on both tests) and discordant group (dissociated results between two tests). Of 1022 patients, discordant group had 159 (16%), comprising abnormal horizontal vHITs with normal caloric responses (n = 36, 23%) and abnormal caloric tests with normal horizontal vHITs (n = 123, 77%). The former group showed similar frequency of peripheral (44%) and central (42%) causes, and more common involvement of bilateral horizontal semicircular canals in central than peripheral causes (86.7 vs 37.5%, p = 0.005). The most common peripheral causes were Meniere's disease and chronic vestibular neuritis, while central causes were variable, but mainly affecting the cerebellum. In the latter group, peripheral causes were common (67%), with the main etiologies being Meniere's disease and vestibular neuritis, whereas central causes were found in only 5%. The degree of canal paresis did not differ significantly between patients with central and peripheral causes. Discordant VOR function according to the stimulus frequency was not uncommon in dizzy patients. Specific patterns of VOR dissociation according to the disease etiologies may offer insight into underlying pathophysiology.

Clinically, central positional nystagmus (CPN) is often suspected when atypical forms of its peripheral counterpart, i.e., benign paroxysmal positional vertigo (BPPV), are observed, namely a linear horizontal nystagmus as in horizontal canal BPPV or a downwardly and torsionally beating nystagmus as in anterior canal BPPV. Pathophysiologically, CPN is caused by cerebellar and/or brainstem dysfunction. Recent work has provided further insights into the different clinical phenotypes and the underlying pathomechanisms. We performed a PubMed review focused on the findings on CPN using the key words “Central Positional Nystagmus”, “Central Positional Vertigo”, “Positional Nystagmus” OR “Positioning Nystagmus” OR “Positional Vertigo” OR “Positioning Vertigo” AND “Central” from January 2015 to August 2021. CPN may account for up to 12% of patients with positional nystagmus. Clinical data on CPN are mostly based on case reports or small retrospective case series. CPN is frequently associated with cerebellar and/or brainstem structural lesions, namely stroke, tumours or demyelination, or diffuse involvement of these structures due to degenerative or autoimmune/paraneoplastic diseases; it is also found in patients with vestibular migraine. CPN can be paroxysmal or persistent. The direction of the nystagmus is often downward in head-hanging or apogeotropic in lateral supine positions; combinations of both forms also occur. Clinically it is important to note that CPN is often associated with other central, often cerebellar ocular motor or other neurological signs; typically, it is not improved by the therapeutic liberatory manoeuvres for BPPV. These additional features are also important for the diagnosis, in particular if no structural lesions are found. Pathophysiologically, CPN is believed to reflect an abnormal integration of semicircular canal-related signals by the cerebellar nodulus, uvula and/or tonsil, ultimately providing an erroneous estimation of the head tilt and/or eye position coordinates. The natural course of CPN remains, so far, largely unknown. Symptomatic treatment of CPN consists of pharmacotherapy, e.g., with 4-aminopyridine, and causative treatment of the underlying disease if known. CPN is an important differential diagnosis to BPPV and a clinically relevant entity with heterogenous clinical presentations and various pathomechanisms and etiologies. In particular, studies on the natural course and treatment of CPN are needed.

Persistent postural-perceptual dizziness (PPPD) unifies the main characteristics of chronic subjective dizziness, visual vertigo and related diseases, which is a common chronic disease in neurology. At present, the pathology of PPPD is not fully understood. In this single-center retrospective case series review, we aim to investigate the potential risk factors of PPPD. Eighty inpatients diagnosed with PPPD were recruited with 81 apparently healthy controls. Patient-specific clinico-radiological data were collected from both groups. Conditions of hypertension, diabetes, smoking, and drinking were derived from medical history. Blood test results were recorded including total cholesterol, triglyceride, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, fibrinogen, vitamin B12, folic acid, total cholesterol, triglyceride, and folate level. The subjects were examined by carotid artery CTA and cranial MRI, and the imaging findings of carotid atherosclerosis (CAS), white matter hyperintensities (WMHs) and lacunar infarction (LI) were recorded. Binary logistic regression analysis was used to investigate the difference between the case and control groups. Significance was defined as p value less than 0.05. The prevalence rate of hypertension in the case group was significantly higher than that in the control group, and the detection rates of CAS, WMHs, and LI in the case group were significantly higher than those in the control group (p

Vestibular migraine (VM) is considered one of the most common causes of episodic central vestibular disorders, the mechanism of VM is currently still unclear. The development of functional nuclear magnetic resonance (fMRI) in recent years offers the possibility to explore the altered functional connectivity patterns in patients with VM in depth. The study aimed to investigate altered patterns of brain network functional connectivity in patients with VM diagnosed based on the diagnostic criteria of the Bárány Society and the International Headache Society, and hope to provide a scientific theoretical basis for understanding whether VM is a no-structural central vestibular disease, i.e., functional central vestibular disease with altered brain function.Seventeen patients with VM who received treatment in our hospital from December 2018 to December 2020 were enrolled. Eight patients with migraine and 17 health controls (HCs) were also included. Clinical data of all patients were collected. Blood pressure, blood routine tests and electrocardiography were conducted to exclude other diseases associated with chronic dizziness. Videonystagmography, the vestibular caloric test, the video head impulse test and vestibular-evoked myogenic potentials were measured to exclude peripheral vestibular lesions. MRI was utilized to exclude focal lesions and other neurological diseases. All subjects underwent fMRI. The independent component analysis was performed to explore changes in intra- and inter-network functional connectivity in patients with VM.Among 17 patients with VM, there were 7 males and 10 females with an average age of 39.47 ± 9.78 years old. All patients had a history of migraine. Twelve (70.6%) patients had recurrent spontaneous vertigo, 2 (11.7%) patients had visually induced vertigo, and 3 (17.6%) patients had head motion-induced vertigo. All 17 patients with VM reported worsening of dizziness vertigo during visual stimulation. The migraine-like symptoms were photophobia or phonophobia (n = 15, 88.2%), migraine-like headache (n = 8, 47.1%), visual aura during VM onset (n = 7, 41.2%). 5 (29.4%) patients with VM had hyperactive response during the caloric test, and 12 (70.6%) patients had caloric test intolerance. Eleven (64.7%) patients had a history of motion sickness. Totally 13 independent components were identified. Patients with VM showed decreased functional connectivity in the bilateral medial cingulate gyrus and paracingulate gyrus within sensorimotor network (SMN) compared with HCs. They also showed weakened functional connectivity between auditory network (AN) and anterior default mode network (aDMN) compared with HCs, and enhanced functional connectivity between AN and the salience network (SN) compared with patients with migraine.Patients with vestibular migraine showed obvious altered functional connectivity in the bilateral medial cingulate gyrus and paracingulate gyrus within the SMN. The median cingulate and paracingulate gyri may be impaired, the disinhibition of sensorimotor network and vestibular cortical network may result in a hypersensitivity state (photophobia/phonophobia). Altered functional connectivity between AN and DMN, SN may lead to increased sensitivity to vestibular sensory processing.

We aimed to determine the incidence of all vestibular symptoms in a large interdisciplinary tertiary emergency department (ED) and to assess stroke prevalence, and frequency of other life-threatening aetiologies. In this 1-year retrospective study, we manually screened all medical records of 23,608 ED visits for descriptions of vestibular symptoms. Symptoms were classified according to the International Classification of Vestibular Disorders of the Barany Society. We evaluated all patients older than 16 years in whom vestibular symptoms were the main or accompanying complaint. We extracted clinical, radiological, and laboratory findings as well as aetiologies from medical records. We identified a total of 2596 visits by 2464 patients (11% of ED visits) who reported at least one vestibular symptom. In 1677/2596 visits (64.6%), vestibular symptoms were the main reason for the ED consultation. Vestibular symptoms were classified as dizziness (43.8%), vertigo (33.9%), postural symptoms (6.5%), or more than one symptom (15.8%). In 324/2596 visits (12.5%), cerebrovascular events were the aetiology of vestibular symptoms, and in 355/2596 visits (13.7%), no diagnosis could be established. In 23.8% of visits with vestibular symptoms as the main complaint, the underlying condition was life-threatening. Frequency and impact of vestibular symptoms in patients visiting the ED were higher than previously reported, and life-threatening aetiologies such as strokes are common. Therefore, awareness among physicians regarding the importance of vestibular symptoms has to be improved.

There is a recognized association of Meniere's disease (MD) and benign paroxysmal positional vertigo (BPPV). However, the frequency and clinical characteristics of BPPV in MD are unclear. The aim of this review was to determine the mean frequency and clinical features of BPPV in MD. Three databases were searched: MEDLINE, PubMed and Google Academia. Studies reporting the frequency of BPPV in MD were pooled. A total of 4198 references were identified, of which 20 studies were considered eligible. The pooled frequency of BPPV in MD was 14% (95% CI 9-18%). It was 38% (95% CI 26-49%) in longitudinal studies and 8% (95% CI 6-11%) in cross-sectional ones. BPPV comorbid with MD was mostly observed in the ear affected by hydrops, in females, in patients with more advanced disease. Canalolithiasis of the horizontal semicircular canal was more common in patients with BPPV associated with MD than in idiopathic BPPV. BPPV in MD was more prone to recurrence and required more canal repositioning maneuvers.

Gaze stabilisation exercises are a mainstay of vestibular rehabilitation (VR). They are frequently prescribed to patients with vestibular hypofunction with the aim of improving the gain of the vestibular ocular reflex, improving visual acuity during head movement, and reducing the symptoms of dizziness and vertigo. This review will examine current evidence that has evaluated the efficacy of gaze stabilisation exercises on VOR gain, dynamic visual acuity and oscillopsia. In addition, recent experimental studies that have employed digital technologies and newer forms of gaze stabilisation exercises will be reviewed. The implications for future clinical practice and research in the area of VR will be discussed.

A retrospective analysis of the horizontal video head impulse test (vHIT) results and caloric testing results was undertaken on 644 patients who attended a neuro-otology outpatient facility. Presenting symptoms included spontaneous vertigo, positional vertigo, imbalance or chronic subjective dizziness. For 570 patients, the results of vHIT and caloric testing were concordant. Both tests were normal in 500 subjects with an average vHIT gain = 0.92 ± 0.09 (L); 0.98 ± 0.10 (R) and canal paresis (CP) = 7.88 ± 6.12; (range 0–28%). 54 had concordant asymmetries, average ipsilesional vHIT gain = 0.56 ± 0.15, average contralesional vHIT gain = 0.88 ± 0.12. CP = 68.02 ± 24.38 (range 31–100%). 16 subjects had bilateral vestibular hypofunction with average vHIT gains of 0.42 ± 0.20 (L); 0.41 ± 0.19 (R), peak slow phase velocity (SPV) on warm caloric testing = 2.68 ± 2.08, range 0–6°/s (L) and 3.75 ± 3.43 range, 0–10°/s (R). 36 patients showed a dissociation of results between the two tests. In these subjects, the vHIT gain was normal (0.93 ± 0.06 left and 0.98 ± 0.07 right) and the caloric test showed a CP > 30% (48 ± 13.8%). Their final diagnoses included clinically definite Meniere’s disease (MD) (n = 27), vestibular schwannoma (VS) (n = 2) vestibular migraine (VM) (n = 1), vestibular neuritis (VN) (n = 5) and unknown (n = 1). No patient with abnormal HSCC gain on vHIT had a normal caloric result. The caloric test complements the vHIT in the assessment of vestibular disorders and is most useful in suspected endolymphatic hydrops. Asymmetric caloric function in the presence of normal horizontal head impulse tests is most commonly associated with Meniere’s disease and may function as a diagnostic marker.

A prospective study focused on whether vestibular symptoms are seen in acute hemispheric strokes, and if so, the frequency and lateralization of causative lesions on MRI. Among 668 patients with hemispheric infarction, we prospectively included those with chief complaints of acute vestibular symptoms, such as vertigo/dizziness, nausea/vomiting and gait instability, in the "VS" group. We also retrospectively reviewed MRI of all stroke patients, and included cases with the findings of parieto-insular vestibular cortex (PIVC) or temporo-periSylvian vestibular cortex (TPSVC) lesion by diffusion-weighted MRI, in the "PIVC" group. Eight patients were found to belong to the VS group, and six other patients to the PIVC group. In the VS group, six patients had the responsible lesion on the right hemisphere, in the middle cerebral artery (MCA) territory except one case and two on the left MCA territory, particularly in the insula, retro-insular region, superior/middle temporal gyrus, angular gyrus, supra-marginal gyrus, putamen and hippocampus/para-hippocampal gyrus. In contrast, none of the six other patients of the PIVC group had vestibular symptoms. One of them had a lesion in the right hemisphere and five in the left hemisphere. Four lesions were located in the insular area and two within the temporal lobe. In conclusion, cerebral hemispheric infarction limited to the PIVC or TPSVC does not necessarily cause vertigo. However, unilateral hemispheric infarctions, restricted to the areas belonging to the vestibular cortical network may cause vestibular symptoms. The lesions responsible for vestibular symptoms are located more often in the right hemisphere.

Caloric tests are useful for disease surveillance of Meniere’s disease (MD), although the interpretation of caloric tests remains controversial during the attacks of MD. Therefore, we aimed to characterize the findings of caloric tests during the attacks of MD. We analyzed the results of bithermal caloric tests during and between the attacks in 43 patients with unilateral definite MD. Evaluation was performed during the irritative/recovery phase in 22 and during the paretic phase in 26 patients. During the irritative/recovery phase, less than half of patients (10/22, 45%) showed a caloric asymmetry of more than 25%, lesser responses in the affected ear in six and in the healthy ear in the other four. In contrast, patients usually showed a caloric asymmetry of more than 25% during the paretic phase (19/26, 73%) with a decreased response almost always in the affected ear (18/19, 95%). Between the attacks, caloric asymmetry was found in less than half of the patients (20/43, 47%) with a decreased response almost always in the affected ear (19/20, 95%) when observed. The caloric asymmetry was less during the irritative/recovery phases than between the attacks (p = 0.007). In contrast, the caloric asymmetry was larger during the paretic phase than between the attacks (p = 0.041). The caloric asymmetry decreased during the irritative/recovery phases with an estimated mean difference of 34% (adjusted 95% CI 16–53%, p

The study aimed to identify the predictors of response to selective serotonin reuptake inhibitors (SSRIs) for 12 weeks in patients with persistent postural–perceptual dizziness (PPPD). Short-term treatment responses were studied in 197 outpatients [127 (64.5%) women, mean age ± SD = 51.7 ± 15.9] diagnosed with PPPD. Clinical and self-rated assessments were analyzed at the baseline and at the end of pharmacotherapy for 12 weeks. Multivariable logistic regression analysis was used to determine the following variables as the potential predictors of treatment response as measured by scoring in clinical global impression-improvement scale (CGI-I) scores: age, sex, comorbidity, baseline CGI-S score, Beck Depression Inventory–II score, State-Trait Anxiety Inventory score, Dizziness Handicap Inventory score at the baseline, and prescribed doses of antidepressants or benzodiazepines. The overall response rate to pharmacotherapy was 65.0% (128/197). Female sex and greater disease severity at the baseline (higher CGI-S score) were associated with a better response to the pharmacotherapy. Subgroup analyses by sex identified younger age and lower anxiety as the indicators for better outcomes in men, and absence of comorbidities in women. During the initial assessment, the severity of PPPD was associated with depressive symptoms and subjective functional handicap due to dizziness. The response to pharmacotherapy is favorable in PPPD. Sex, age and initial disease severity are the predictors of the response to SSRIs in patients with PPPD.

The evaluation of central vestibular syndromes, especially in the acute setting, can pose a challenge even for the most experienced clinician. Of particular importance is the evaluation of ocular torsion and nystagmus, which can be sensitive for central vestibular pathology, but easily missed by the untrained eye. We present two cases of acute vestibular syndrome of central origin in which the use of magnified fundoscopy at the bedside aided the precise anatomical diagnosis to inform appropriate further management. We also review aspects of the pathophysiology and anatomy of vestibular roll plane disorders. In case 1, the finding of position-dependent ocular torsion facilitated a rapid distinction between central skew deviation and a trochlear nerve palsy. In case 2, the fundoscopic magnification identified a pure rotatory nystagmus indicative of a central vestibular disorder. Ophthalmoscopy remains a useful bedside technique in acute vertigo, but the use of inexpensive magnification with a smartphone can provide objective and recordable evidence of central vestibular pathology, aiding therapeutic decisions.

We aimed to characterize the central positional nystagmus (CPN) observed in lesions involving the inferior cerebellar peduncle (ICP). We analyzed the clinical and neurotologic findings in six patients with an isolated unilateral ICP infarction that had been diagnosed at a university hospital in South Korea from 2003 to 2019. Patients usually presented with acute vestibular syndrome in isolation (4/6, 67%). Ipsilesional spontaneous nystagmus was observed in five while supine (5/6, 83%). Four (4/6, 67%) patients showed CPN which included apogeotropic (n = 3) or geotropic (n = 1) during head turning to either side while supine, and vertical nystagmus during straight-head hanging, Dix-Hallpike maneuvers, or up-righting (n = 3). Four patients showed contraversive ocular tilt reaction or tilt of the subjective visual vertical. Bedside and video head-impulse tests were normal in all patients. CPN is a usual finding in ICP lesions, and may be ascribed to damage of the fibers running from the nodulus/uvula onto the vestibular nucleus via the ICP.

Intratympanic therapies, usually including glucocorticoid and gentamicin, are becoming worldwide used in clinical practice of Meniere’s disease today. However, clinical efficacy and safety of these two therapies are still in controversial. Electronic searches in PubMed, CENTRAL, Web of Science, EMBASE, CINAHL, ClinicalTrials.gov and the European Union Clinical Trials Register were conducted from inception until September 2020. The pre-specified protocol of this systematic review and meta-analysis has been registered and published in November 2018 (PROSPERO Identifier: CRD42018114389). All randomized controlled trials of intratympanic gentamicin or glucocorticoids for Meniere’s disease, compared with each other or placebo, were considered for this review. Ten studies with 455 patients met the inclusion criteria. Pooled results indicated significant advantage of intratympanic gentamicin and glucocorticoids over placebo treatments in vertigo control (gentamicin vs placebo: risk rate, RR, 2.56; 95% CI 1.18–5.54; glucocorticoids vs placebo: RR, 3.02; 95% CI 1.36–6.73). There was no significant difference between gentamicin and glucocorticoids in vertigo control (gentamicin vs placebo: RR, 1.18; 95% CI 0.97–1.45). Intratympanic glucocorticoids showed better hearing protective results than gentamicin (change of pure tone audiometric, PTA, mean difference, MD, − 6.48 dB; 95% CI − 11.84 to − 1.13 dB; change of speech discrimination scale, SDS, MD 7.69%; 95% CI 0.83–14.55%). Intratympanic gentamicin and glucocorticoids are two effective approaches to control vertigo symptoms for Meniere’s disease. Glucocorticoids showed a potentially better hearing protective role over gentamicin.

Early identification of cardiogenic vertigo (CV) is necessary to prevent serious complications of cardiovascular diseases. However, the literature is limited to case reports without detailed clinical features or diagnostic criteria. The aim of this study was to define characteristics of CV and propose diagnostic criteria. This study included patients with CV diagnosed at Pusan National University and Keimyung University Hospitals. Demographic, clinical, laboratory, and treatment data were analyzed. Of 72 patients with clinically suspicious CV, 27 were finally included. The age ranged from 63 to 88 years (75.1 ± 7.2 years). Recurrent vertigo occurred without syncopal attacks in 52% [95% CI, 32-71], while it preceded (37% [19-58]) or followed (11% [2-29]) syncope. The patients with recurrent isolated vertigo had suffered from symptoms from 15 days to 5 years until final diagnosis (median 122 days). The vertigo lasted only for a few seconds (93% [76-99]) or a few minutes (7% [1-24]). Fourteen patients presented with spinning vertigo, and one of them showed spontaneous downbeat nystagmus during the attack. Accompanying symptoms including chest discomfort, palpitation, headache, arm twitching, and lightheadedness were found in 70% [50-86]. Between patients with and without syncope, there was no difference in clinical parameters and results of cardiac function tests. The most common cardiac abnormality during the attacks of vertigo was bradyarrhythmia (89% [71-98]). Cardiovascular diseases can develop recurrent isolated vertigo without or preceding syncope. Onset age, duration of vertigo, accompanying symptoms, and underlying cardiac diseases can aid in differentiation from other vestibular disorders. Early identification of CV would reduce morbidity and mortality associated with cardiac syncope.

Background Earlier studies on stance and gait with posturographic and EMG-recordings and automatic gait analysis in patients with phobic postural vertigo (PPV) or visual height intolerance (vHI) revealed similar patterns of body stiffening with muscle co-contraction and a slow, cautious gait. Visual exploration in vHI patients was characterized by a freezing of gaze-in-space when standing and reduced horizontal eye and head movements during locomotion. Objective Based on the findings in vHI patients, the current study was performed with a focus on visual control of locomotion in patients with PPV while walking along a crowded hospital hallway. Methods Twelve patients with PPV and eleven controls were recruited. Participants wore a mobile infrared video eye-tracking system that continuously measured eye-in-head movements in the horizontal and vertical planes and head orientation and motion in the yaw, pitch, and roll planes. Visual exploration behavior of participants was recorded at the individually preferred speed for a total walking distance of 200 m. Gaze-in-space directions were determined by combining eye-in-head and head-in-space orientation. Walking speeds were calculated based on the trial duration and the total distance traversed. Participants were asked to rate their feelings of discomfort during the walk on a 4-point numeric rating scale. The examiners rated the crowdedness of the hospital hallway on a 4-point numeric rating scale. Results The major results of visual exploration behavior in patients with PPV in comparison to healthy controls were: eye and head positions were directed more downward in the vertical plane towards the ground ahead with increased frequency of large amplitude vertical orientation movements towards the destination, the end of the ground straight ahead. The self-adjusted speed of locomotion was significantly lower in PPV. Particularly those patients that reported high levels of discomfort exhibited a specific visual exploration of their horizontal surroundings. The durations of fixating targets in the visual surroundings were significantly shorter as compared to controls. Conclusion Gaze control of locomotion in patients with PPV is characterized by a preferred deviation of gaze more downward and by horizontal explorations for suitable auxiliary means for potential postural support in order to prevent impending falls. These eye movements have shorter durations of fixation as compared to healthy controls and patients with vHI. Finally, the pathological alterations in eye–head coordination during locomotion correlate with a higher level of discomfort and anxiety about falling.

Background Diagnostic classification of central vs. peripheral etiologies in acute vestibular disorders remains a challenge in the emergency setting. Novel machine-learning methods may help to support diagnostic decisions. In the current study, we tested the performance of standard and machine-learning approaches in the classification of consecutive patients with acute central or peripheral vestibular disorders. Methods 40 Patients with vestibular stroke (19 with and 21 without acute vestibular syndrome (AVS), defined by the presence of spontaneous nystagmus) and 68 patients with peripheral AVS due to vestibular neuritis were recruited in the emergency department, in the context of the prospective EMVERT trial (EMergency VERTigo). All patients received a standardized neuro-otological examination including videooculography and posturography in the acute symptomatic stage and an MRI within 7 days after symptom onset. Diagnostic performance of state-of-the-art scores, such as HINTS (Head Impulse, gaze-evoked Nystagmus, Test of Skew) and ABCD2 (Age, Blood, Clinical features, Duration, Diabetes), for the differentiation of vestibular stroke vs. peripheral AVS was compared to various machine-learning approaches: (i) linear logistic regression (LR), (ii) non-linear random forest (RF), (iii) artificial neural network, and (iv) geometric deep learning (Single/MultiGMC). A prospective classification was simulated by ten-fold cross-validation. We analyzed whether machine-estimated feature importances correlate with clinical experience. Results Machine-learning methods (e.g., MultiGMC) outperform univariate scores, such as HINTS or ABCD2, for differentiation of all vestibular strokes vs. peripheral AVS (MultiGMC area-under-the-curve (AUC): 0.96 vs. HINTS/ABCD2 AUC: 0.71/0.58). HINTS performed similarly to MultiGMC for vestibular stroke with AVS (AUC: 0.86), but more poorly for vestibular stroke without AVS (AUC: 0.54). Machine-learning models learn to put different weights on particular features, each of which is relevant from a clinical viewpoint. Established non-linear machine-learning methods like RF and linear methods like LR are less powerful classification models (AUC: 0.89 vs. 0.62). Conclusions Established clinical scores (such as HINTS) provide a valuable baseline assessment for stroke detection in acute vestibular syndromes. In addition, machine-learning methods may have the potential to increase sensitivity and selectivity in the establishment of a correct diagnosis.

Background The DizzyQuest, an app-based vestibular diary, provides the opportunity to capture the number and nature of vertigo attacks in daily life. To accomplish this, the DizzyQuest provides different strategies: event sampling using an attack questionnaire, and time sampling using an evening questionnaire. Objective of this study was to investigate whether the number and nature of reported vertigo attacks was comparable between the two questionnaires. Methods Fifty-seven patients, who reported vertigo attacks, used the DizzyQuest for on average 24 days. The number and nature (including symptoms, triggers and duration) of vertigo attacks were compared between the attack and the evening questionnaire. Results The attack questionnaire was used 192 times. In contrast, at least 749 new vertigo attacks were reported in 446 evening questionnaires. A vertigo attack was not always reported in both questionnaires during the same day. Vertigo attacks that were most likely captured by both questionnaires were not always reported the same in both questionnaires regarding triggers and duration. Conclusion Event sampling using an attack questionnaire has low recall bias and, therefore, reliably captures the nature of the attack, but induces a risk of under-sampling. Time sampling using an evening questionnaire suffers from recall bias, but seems more likely to capture less discrete vertigo attacks and it facilitates registration of the absence of vertigo attacks. Depending on the clinical or research question, the right strategy should be applied and participants should be clearly instructed about the definition of a vertigo attack.

Since oral betahistine has a very high first-pass effect (ca. 99%), metabolized by monoamine oxidases (MAO), the benefits of a high-dosage betahistine monotherapy were compared with those of a lower dosage of betahistine in combination with the MAO-B inhibitor (MAO-B) selegiline on the frequency of acute attacks of vertigo in patients with Meniere’s disease (MD). Thirteen adults aged 40–75 years (mean 58.9 years; six females) had initially been treated with a high dosage of betahistine dihydrochloride for at least 1 year. Under this therapy, all of them had ≤ 1 attack for ≥ 3 months prior to the combination pharmacotherapy. Subsequently, they received 5 mg/day selegiline and the dosage of betahistine was reduced to about one tenth and then individually adjusted to the dosage needed to achieve the same treatment response (≤ 1 per 3 months, observational period of at least 6 months). The initial dosage for the long-term “titration” of the attacks of vertigo was 9–80 24-mg tablets/day (mean 37.3), i.e. 216–1920 mg/day (mean 895.4 mg/day). After the combination with selegiline, the dosage needed to achieve the same benefit for ≥ 3 months was 3–36 24-mg tablets (mean 8.5), i.e., 72–864 mg/day [mean 204.9 mg/day, p 9 months), one patient had to increase the selegiline dosage to 5 mg bd, one patient stopped the treatment with selegiline. The achievement of the same clinical effect with a significantly lower (about 1/5) dosage of betahistine can be explained by the inhibition of the MAO-B by selegiline leading to higher serum concentrations of betahistine. This approach is in line with recent developments to bypass the first-pass effect of betahistine by transbuccal or intranasal application. Despite the substantial methodological limitations of such an observational study, this combined pharmacotherapy could be an alternative to a high-dosage monotherapy with betahistine of MD.

Abnormal vestibular function has been reported in patients with vestibular migraine (VM). However, it is unclear whether the proportion of patients with vestibular dysfunction differs between the diagnoses of VM and probable VM (PVM).We reviewed the medical records of 1736 patients who underwent cervical vestibular-evoked myogenic potential testing to air-conducted sound (ACS cVEMP), ocular VEMP testing to bone-conducted vibration (BCV oVEMP), and caloric testing. We used the diagnostic criteria for VM provided in the appendix of the International Classification of Headache Disorders 3 Beta, and the diagnostic criteria consensus published by the Barany Society and the International Headache Society for PVM. Twenty-two VM patients and a further 22 PVM patients were included. Binomial logistic regression analyses were performed to see whether the subjects' age, sex, or the diagnostic certainty of VM (i.e., VM vs. PVM) have an association with the presence of vestibular dysfunction.There was no significant association between the diagnostic certainty of VM and abnormality in caloric or ACS cVEMP testing. On the other hand, VM had a significant positive association with abnormality in BCV oVEMPs compared with PVM.VM is associated with dysfunction of the utriculo-ocular pathway more frequently than PVM, suggesting that the pathophysiology of VM involves the utriculo-ocular pathway.

This study aimed to determine the etiologic distribution of dizziness and vertigo in a referral-based dizziness clinic in South Korea. We analyzed the diagnoses of 21,166 consecutive dizzy patients (12,691 women, mean age = 57.9 ± 15.7, age range = 3–97) seen from 2003 to 2019 using a registry and medical records. Overall, dizziness and vertigo were more common in women (60.0%, CI 0.59–0.61) than in men without a difference in age (57.7 ± 15.5 vs. 58.1 ± 16.1, p = 0.094). Benign paroxysmal positional vertigo (BPPV, 24.1%) was the most common cause of dizziness/vertigo, followed by psychiatric or persistent postural perceptual dizziness (20.8%), vascular disorders (12.9%), vestibular migraine (10.2%), Meniere’s disease (7.2%), and vestibular neuritis (5.4%). These six disorders comprised more than 80% of all disorders. The etiology could not be determined in 5.0%, and more than one etiology was found in 14.1%. Vestibular migraine was the most common disorder in children and adolescents (