The clinical application of head-shaking test combined with head-shaking tilt suppression test in distinguishing between peripheral and central vertigo at bedside vs. examination room

Abstract Objectives: To investigate the clinical value of using Head-Shaking Test (HST) + Head-Shaking Tilt Suppression Test (HSTST) to distinguish between peripheral and central vertigo as well as to analyze the consistency of findings between tests at the bedside vs. in the examination room. Methods: We retrospectively analyzed patients who presented for central or peripheral vertigo from July 2019 to July 2021. The results were compared between HST and HST+HSTST. The concordance between bedside and examination room outcomes was analyzed. Results: Forty-seven (58.8%) patients in the peripheral vertigo group and 33 (41.2%) patients in the central vertigo group were included. In the peripheral group, 44 (both examination room and bedside: 93.6%) patients had horizontal Head-Shaking Nystagmus (hHSN), most of which were suppressed in HSTST. However, in the central group, most cases had perverted HSN (pHSN; examination room: 72.7%; bedside: 66.7%), which was seldomly suppressed in HSTST. The HST+HSTST showed a >20% higher specificity in identifying peripheral vertigo than HST alone. The bedside results were consistent with the examination room results using the kappa test (p< 0.001). Conclusions: Suppressed hHSN was a strong indicator of peripheral vertigo. Conversely, pHSN was more often seen in central vertigo, which was not readily suppressed in HSTST. The bedside results of HST+ HSTST yielded qualitative agreement with the tests in the examination room. HST+ HSTST could be used as reliable methods in the clinic to distinguish between peripheral and central vestibular disorders. Level of evidence: Level 3.

Nistagmo vertical hacia abajo / Downbeat nystagmus

RESUMEN El downbeat nystagmus o nistagmo vertical hacia abajo es el nistagmo de fijación adquirido más frecuente, que en la mayoría de los casos es causado por patología a nivel del sistema nervioso central que genera disrupción del control inhibitorio del flóculo y paraflóculo cerebeloso sobre los núcleos vestibulares. Entre sus causas se encuentran enfermedades neurodegenerativas y vasculares de cerebelo o tronco cerebral, tumores y traumas, pero cerca del 40% de los casos son idiopáticos y hasta la mitad de los pacientes presentan estudio imagenológico negativo. En este artículo presentamos dos casos que consultaron en el Servicio de Otorrinolaringología del Hospital Clínico de la Universidad de Chile.

ABSTRACT Downbeat nystagmus is the most frequent acquired fixation nystagmus and it is generally caused by central pathology disrupting the inhibitory control of the cerebellar flocculus and paraflocculus over the vestibular nuclei. Among its causes are neurodegenerative and vascular diseases of cerebellum or brainstem, tumors and trauma, but nearly 40% of the cases are idiopathic and up to half the patients have negative imaging study. In this article we present two cases that were evaluated in the Otolaryngology Department of the Clinical Hospital of the University of Chile.

Comparison of electrophysiological features in peripheral vertigo and central vertigo / 临床神经病学杂志

Objective To compared the electrophysiological features in peripheral vertigo and central vertigo. Methods The electronystagmograph ( ENG ) and brainstem auditory evoked potentials ( BAEP ) were applied in peripheral vertigo group(85 cases) and central vertigo group(61 cases).Result ENG abnomal was in 67 cases (78.8%) in peripheral vertigo group.Overshoot or undershoot of dysmetria test was in 6 cases ( 7.1%);spontaneous nystagmus was in 5 cases(5.9%);abnormal of gaze test was in 16 cases(18.8%); eye tracking test typeⅠwas in 42 case(49.4%), typeⅡwas in 17 cases(20.0%), and typeⅢwas in 8 cases(9.4%); bilateral asymmetry of optokinetic nystagmus test was in 19 cases(22.4%);positioning nystagmus was in 51 cases(60.0%);abnormal of cold and hot test was in 31 cases(36.5%).ENG abnomal was 42 cases(49.4%) in central vertigo group.Overshoot or undershoot of dysmetria test was in 19 case(31.1%);spontaneous nystagmus was in 13 cases (21.3%);abnormal of gaze test was in 23 cases(37.7%);eye tracking test typeⅠwas in 35 cases(57.4%), typeⅡwas in 13 cases(21.3%), and typeⅢwas in 8 cases(13.1%);bilateral asymmetry of optokinetic nystagmus test was in 33 cases(54.1%); positioning nystagmus was in 2 cases(3.3%); abnormal of cold and hot test was in 6 cases(9.8%).Compared with peripheral vertigo group, the abnormal rates of optokinetic nystagmus test, gaze test, eye tracking test, optokinetic nystagmus test in central vertigo group were significantly increased, and the abnormal rates of positioning nystagmus, cold and hot test in central vertigo group were significantly decreased (all P<0.05). There were 32 cases(37.6%) in peripheral vertigo group with BAEP abnormal, and 31 cases(50.8%) were in central vertigo group with BAED abnormal.Compared with central vertigo group, the latency ofⅠwave andⅠ-Ⅲwave latency delayed in peripheral vertigo group were significantly increased, the latency ofⅤwave andⅠ-Ⅴwave latency delayed were significantly decreased ( all P<0.05 ) .Conclusions There are high sensitivity of optokinetic nystagmus test, gaze test, eye tracking test, optokinetic nystagmus test of ENG to the diagnosis of central vertigo. There are high sensitivity of positioning nystagmus, cold and hot test to the diagnosis of peripheral vertigo.The positive rate of BAEP is relatively lower, but it can provide objective foundation for location of vertigo patients.

Acute Central Vertigo / 대한이비인후과학회지

Acute vertigo is a common symptom at the otolaryngology clinics or the Emergency Department. Also, many otolaryngologists see these patients first or they are referred from the Emergency Department. Although the stroke incidence in all dizzy patients is relatively low, the misdiagnosis of central vertigo may lead to serious morbidity and even mortality. Nevertheless, it is difficult to diagnose in vertigo patients whether the origin is central or not, especially at the initial visit. The purpose of this clinical review was to investigate clinical findings of acute central vertigo and to suggest the recent advance of differential diagnosis in these patients from peripheral vestibulopathy. We also suggest an appropriate practice for the radiologic investigation in these patients.

Digital subtraction angiography of global cerebral blood flow of patients with central vertigo / 第二军医大学学报

Objective: To investigate the morphological changes of cerebral blood vessels by digital subtraction angiography (DSA) in patients with central vertigo, so as to provide references for diagnosis and treatment of patients with central vertigo. Methods: Ninety-two patients suffering from central vertigo were subjected to cerebral angiography through femoral artery. The types, proportion, and distribution (site predilection and number of involved vessels) of the cerebrovascular abnormalities were observed and analyzed. Results: Of the 92 patients with central vertigo, cerebrovascular lesions were found in 137 sides, including 15 (10. 95%) anterior circulation lesions and 122 (89.05%) posterior circulation lesions. Thirty-one (33.7%) patients had 2 or more lesions. The most common lesion was vertibroarterial lesion accompanied with other cerebrovascular stenosis. The lesions included 39 (28.47%) sides with vertibro-basilar stenosis or occlusion, 13 (9.49%) sides with posterior cerebral artery stenosis or occlusion, and 59 (43.06%) sides with posterior circulation abnormalities. Conclusion: The posterior circulation stenoses or abnormalities might be the major reasons for central vertigo in middle- and old-age patients.