Epigone migraine vertigo (EMV): a late migraine equivalent.

Migrainous headache is determined by pathogenetic mechanisms that are also able to affect the peripheral and/or central vestibular system, so that vestibular symptoms may substitute and/or present with headache. We are convinced that there can be many different manifestations of vestibular disorders in migrainous patients, representing true different clinical entities due to their different characteristics and temporal relashionship with headache. Based on such considerations, we proposed a classification of vertigo and other vestibular disorders related to migraine, and believe that a particular variant of migraine-related vertigo should be introduced, namely "epigone migraine vertigo" (EMV): this could be a kind of late migraine equivalent, i.e. a kind of vertigo, migrainous in origin, starting late in the lifetime that substitutes, as an equivalent, pre-existing migraine headache. To clarify this particular clinical picture, we report three illustrative clinical cases among 28 patients collected during an observation period of 13 years (November 1991 - November 2004). For all patients, we collected complete personal clinical history. All patients underwent standard neurotological examination, looking for spontaneous-positional, gaze-evoked and caloric induced nystagmus, using an infrared video camera. We also performed a head shaking test (HST) and an head thrust test (HTT). Ocular motility was tested looking at saccades and smooth pursuit. To exclude other significant neurological pathologies, a brain magnetic resonance imaging (MRI) with gadolinium was performed. During the three months after the first visit, patients were invited to keep a diary noting frequency, intensity and duration of vertigo attacks. After that period, we suggested that they use prophylactic treatment with flunarizine (5 mg per day) and/or acetylsalicylic acid (100 mg per day), or propranolol (40 mg twice a day). All patients were again recommended to note in their diary the frequency and intensity of both headache and vertigo while taking prophylactic therapy. Control visits were programmed after 4, 12 and 24 months of therapy. All patients considerably improved symptoms with therapy: 19 subjects (68%) reported complete disappearance of vestibular symptoms, while 9 (32%) considered symptoms very improved. The subjective judgement was corroborated by data from patients diaries. We conclude that EMV is a clinical variant of typical migraine-related vertigo: a migraineassociated vertigo, headache spell independent, following a headache period, during the lifetime of a patient.

Cardiovascular and thrombophilic risk factors for idiopathic sudden sensorineural hearing loss.

BACKGROUND: In recent years there has been a significant increase in the diagnosis of sudden sensorineural hearing loss (SSHL) in western, countries with an incidence of 20 of 100,000 people affected every year. No clear causes for this disease have been found thus far, but cochlear ischemia has been hypothesized in patients in whom an infectious episode or acoustic neurinoma have been excluded. OBJECTIVES: The aim of this case-control study was to investigate a number of acquired and inherited thrombophilic risk factors [antithrombin, protein C and S; factor V (FV) Leiden, FII polymorphism; lupus anticoagulant (LA); anticardiolipin (aCL) antibodies; fasting homocysteine (Hcy); lipoprotein(a) (Lp(a)); plasminogen activator inhibitor-1 (PAI-1)] in addition to cardiovascular risk factors in patients with idiopathic SSHL (ISSHL). PATIENTS AND METHODS: We investigated 155 patients (67 male/88 female; age: 55 (range 19-79 years) with a diagnosis of ISSHL within 30 days from the onset of symptoms, and 155 controls (67 male/88 female; age 54 (range 19-78 years). Fasting Hcy levels were significantly higher in patients than in controls [11.6 (6.7-60) micromol/L vs. 8.7 (5.0-24) micromol/L] as well as PAI-1 levels [19 (2-95) mg/dL vs. 14.5 (4.0-87) mg/dL]. Lupus anticoagulant was present in 13 of 155 (8.4%) patients; 20 patients (12.9%) had positivity of aCL (four IgM and 16 IgG). In no patient was a deficiency of physiological clotting inhibitors antithrombin, protein C and protein S found. No significant differences between patients and controls were observed for Lp(a) plasma levels [111 (1-1146) mg/L vs. 103 (11-695) mg/L] and for the presence of FV Leiden (4.5% vs. 4.5%) and FII variant G20210A (3.8% vs. 3.2%). RESULTS AND CONCLUSIONS: Independent risk factors for ISSHL at the multivariate analysis (adjusted for age, sex and the traditional cardiovascular risk factors) were the positivity of aCL: OR 5.6 (95% CI 2.0-15.3); cholesterol levels within the second and third tertiles (with respect to the first tertile): T2 = OR 4.8 (95% CI 1.9-12.6)/T3 = OR 19 (95% CI 7-50.1); PAI-1 and Hcy levels within the third tertile (with respect to the first tertile): OR 20 (95% CI 7.8-78) and OR 4.0 (95% CI 2.0-8.1), respectively. These preliminary data suggest that hypercholesterolemia, hyperhomocysteinemia, elevated PAI-1 levels and anticardiolipin antibodies are associated with ISSHL, so indirectly supporting the hypothesis of a vascular occlusion in the pathogenesis of the disease.

[The role of clinical history in the evaluation of balance and spatial orientation disorders in the elderly]. / Il ruolo della storia clinica nella valutazione dei disturbi vertiginoso-posturali dell'anziano.

Balance and spatial orientation complaints are very frequent in the elderly. The aetiology of these complaints may be related to specific peripheral or central vestibular disorders or to an extravestibular dizziness resulting from impairment or disease in multiple systems. A preliminary diagnostic orientation, permitting the patient to be referred to the most appropriate specialist (otologist, neurologist, consultant in internal medicine, psychiatrist, physical therapist) would be very useful. We examined 163 patients, referred for balance and spatial orientation complaints to the otoneurological outpatient services of 6 university hospital centres in the northern and central Italy, by a detailed questionnaire about characteristics, frequency, duration of any dizziness symptom and by a bedside vestibular examination. The questions were designed to determine whether the patients suffered from true vertigo, considered to be an expression of a vestibular disorder, or of an aspecific dizziness of multifactorial origin. Comparison of the conclusions of the vestibular examination and the diagnostic hypotheses deduced from the clinical history showed a high degree of concordance (Cohen Index 70.5%). To the patient, vertigo and dizziness are synonymous. By asking appropriate questions, a clearer picture should begin to emerge from the patient complaints so that distinction between psychogenic, nonvestibular and vestibular causes can be made. The importance of obtaining a good history cannot be overemphasized. A correct and rigorous approach by the general practitioner could be of great utility both for the health of the patient and for the efficiency of the national health service. The vestibular examination proved that about half the patients (80/163) suffered from vestibular disorders, mainly of peripheral origin (BPV, Menière's disease, vestibular neuritis).

[The relationship between cognitive impairment, anxiety-depression symptoms and balance and spatial orientation complaints in the elderly]. / Relazione tra decadimento cognitivo, stato ansioso-depressivo e disturbi vertiginoso-posturali nell'anziano.

Balance and spatial orientation complaints, generically defined as "dizziness", are frequent in the elderly. They can cause a greater or lesser degree of handicap, and be associated with a greater or lesser degree of cognitive impairment and anxiety-depression symptoms. We examined 163 patients, referred for these complaints to the otoneurological outpatient services of 6 university hospital centres of the northern and central Italy, performing a bedside vestibular examination. The test allowed to distinguish between subjects with specific vestibular disorders (mainly BVP, Menière's disease and vestibular neuritis) and subjects in who the vestibular examination was not significant, and whose dizziness probably resulted from impairment or disease in multiple systems. The evaluation of the degree of handicap, using the Dizziness Handicap Inventory, showed that in the former group the physical parameters were significantly impaired with respect of a group of 81 age matched healthy controls, whereas the functional and emotional parameters were not. The evaluation of the degree of anxiety-depression, using the Hospital Anxiety Depression Scale, showed that all elderly people with balance and spatial orientation complaints present a degree of anxiety, but not of depression, greater than the controls, irrespective of the vestibular or extravestibular origin of the symptoms. The evaluation of the cognitive level, using the Mini Mental Test, showed that it is similar to the cognitive level in the controls when, according to the results of the otoneurological examination, the balance and spatial orientation complaints are due to vestibular disorders, but it is impaired when these symptoms are related to a dizziness of multifactorial aetiology. The presence of comorbidities is also higher in these patients. It is likely that in the elderly balance and spatial orientation complaints not caused by specific vestibular disorders are due to a dizziness of multifactorial origin, both organic and psychic, that can be classified as a geriatric syndrome.

Betahistine dihydrochloride in the treatment of peripheral vestibular vertigo.

The present study compares the efficacy and safety of betahistine dihydrochloride to that of a placebo in recurrent vertigo resulting from Meniere's disease (MD) or in paroxysmal positional vertigo (PPV) of probable vascular origin. The design was double-blind, multicentre and parallel-group randomised. Eleven Italian centres enrolled 144 patients: 75 of the patients were treated with betahistine (41 MD/34 PPV) and 69 with placebos (40 MD/29 PPV). The betahistine dosage was 16 mg twice per day for 3 months. Compared to the placebo, betahistine had a significant effect on the frequency, intensity and duration of vertigo attacks. Associated symptoms and the quality of life also were significantly improved by betahistine. Both the physician's judgement and the patient's opinion on the efficacy and acceptability of the treatment were in agreement as to the superiority of betahistine. The effective and safe profile of betahistine in the treatment of vertigo due to peripheral vestibular disorders was confirmed.

Effects of the major Pasteurella multocida porin on bovine neutrophils.

OBJECTIVE: To evaluate in vitro effect of the major fraction of outer membrane proteins of Pasteurella multocida with porin-like activities on some biological functions of bovine neutrophils. ANIMALS: Neutrophils from 5 adult cattle. PROCEDURE: Variations in such biological processes as actin polymerization and chemotaxis and evaluation of hydrogen peroxide attributable to variable concentrations of P multocida were recorded and compared. Data were obtained, using the porin and lipopolysaccharide (LPS) isolated from a strain of P multocida cultivated in brain-heart infusion (BHI) broth. Various concentrations of porin and LPS were analyzed to evaluate changes in functional activation and microbicidal activity of bovine neutrophils. RESULTS: The 37.5-kd major polypeptide of the outer membrane of P multocida was isolated. Presence of this porin was significantly correlated with variations of some biological functions of bovine neutrophils. These immunocompetent cells had a concentration-dependent increase in actin polymerization and chemotactic activity. A concentration-dependent variation in the oxidative burst also was observed. CONCLUSIONS: The porins of gram-negative bacteria affect several biological functions of cells involved in the immune response as well as in inflammation. Significant correlation of results of in vitro experiments also was identified between porin and LPS effect. Pretreatment of bovine neutrophils with various concentrations of porin always caused a concentration-dependent increase in examined biological activities.

Role of Pasteurella multocida porin on cytokine expression and release by murine splenocytes.

The aim of this study was to verify whether Pasteurella multocida porin can affect the expression and release of IL-1alpha, IL-6, TNF-alpha, IL-4, IFN-gamma, IL-10 and IL-12 by murine splenocytes in vitro. P. multocida porin and lipopolysaccharide (LPS) were able to induce the release of IL-1alpha, IL-6, TNF-alpha, IFN-gamma and IL-12 in a dose-dependent fashion. The greatest release of these cytokines was obtained using P. multocida porin at a concentration of 5 microg ml(-1) and LPS at a concentration of 1 microg ml(-1). The time-courses of release showed that P. multocida LPS was able to stimulate the production of IL-1alpha, IL-6, TNF-alpha, IFN-gamma and IL-12 earlier than porin and at a greater rate. No effect was observed on IL-4 and IL-10 release under the same experimental conditions. P. multocida porin and LPS were also able to up-regulate the mRNA expression of IL-1alpha, IL-6, TNF-alpha, IFN-gamma and IL-12 p40. Our findings suggest that P. multocida porin is able to modulate inflammatory and immunological responses by affecting the release of several cytokines and the expression of their genes.

[Delayed endolymphatic hydrops]. / Idrope endolinfatico ritardato.

Delayed Endolymphatic Hydrops (DEH) is a disease entity that must be distinguished from idiopathic endolymphatic hydrops (Ménière's disease). Idiopathic hydrops is characterized by the following symptoms: 1) vertigo often accompanied by nausea and vomiting; 2) tinnitus; 3) hearing loss, usually fluctuating; and 4) sensation of pressure or fullness in the affected ear. Idiopathic hydrops most commonly occurs in middle-aged patients, usually between 30 and 50 years. It may involve one or both ears and usually exibits fluctuating hearing loss and episodic vertigo, although one symptom may precede the other by months or years. It is rare for Ménière's disease to present with a severe sensorineural hearing loss. Delayed Endolymphatic Hydrops was first described, under the name of "unilateral deafness with subsequent vertigo", by Wolfson and Lieberman and Nadol et al.; this was later confirmed by other authors. The disease is characterized by a profound sensorineural hearing loss in one ear, found to have been present in most cases from early childhood, due to an unknown cause, trauma or viral infections. After a prolonged period (usually many years) patients with DEH experience the onset of episodic vertigo from the deaf ear (Ipsilateral Delayed Endolymphatic Hydrops) or develop a fluctuating hearing loss and/or episodic vertigo in the opposite ear, previously with normal hearing (Controlateral Delayed Endolymphatic Hydrops). Vestibular symptoms are identical to those of Ménière's disease: in fact there is evidence that endolymphatic hydrops in the previously damaged ear or in the previously normal ear represents at least part of the labyrinthine pathology. Histopathology studies recently conducted on temporal bones of subjects affected with controlateral DEH show pathologic changes in the deaf ears similar to those found in viral labyrinthitis, whereas pathologic changes in the hearing ears resemble those known to occur in Ménière's disease. Medical treatment has not been found to be effective in patients with DEH, but it must be the first choice of treatment especially in controlateral forms of the disease. So far, surgical intervention has been demonstrated to give the best results; either conservative or more radical, depending on the type of DEH. Pharmacological labyrinthectomy with ototoxic drugs could be the therapy of choice in the future. In this paper we review the literature in order to summarize the clinical features and criteria for diagnosing DEH, we also report histopathologic findings and pathogenetic hypotheses formulated for this syndrome. Moreover, we discuss the best therapeutic approach for the ipsilateral and controlateral variants of DEH.

Treatment of horizontal semicircular canal benign paroxysmal positional vertigo.

We evaluated a new therapeutic maneuver-Prolonged Position on the healthy side, for Benign Paroxysmal Positional Vertigo (BPPV) of the horizontal semicircular canal. We devised this type of physical treatment in accordance with the "canalolithiasis" theory of BPPV, in order to try to free the horizontal semicircular canal of otoconial debris. We compared the results obtained by Prolonged Position with two other physical therapies by dividing our horizontal canal BPPV patients into three therapeutic groups: 1) 35 patients treated with Prolonged Position; 2) 24 patients treated with head shaking in a supine position; 3) 15 patients for whom therapy was omitted. More than 90% of the patients treated with Prolonged Position recovered within 3 days, although 6 patients out of 35 subsequently developed BPPV of the posterior semicircular canal, which then responded well to a particular repositioning maneuver. The results of Prolonged Position were significantly better than those obtained by performing head shaking or by omitting treatment. Prolonged Position can be applied to patients of all ages and general conditions and does not require hospitalization.

Benign paroxysmal positional vertigo of the horizontal canal: a form of canalolithiasis with variable clinical features.

Benign paroxysmal positional vertigo of the horizontal semicircular canal (HC-BPPV) is a well-defined syndrome characterized by direction-changing horizontal positional nystagmus. We report the clinical features of 5 patients who illustrate the possible variables of the syndrome. In most cases, nystagmus is geotropic and more intense when the pathological ear is lowermost; less often the syndrome presents with apogeotropic nystagmus that is more intense when the affected ear is uppermost. The nystagmus pattern may vary in time in the same patient, changing from apogeotropic to geotropic even in observations at short intervals. In some patients, the features indicate involvement of more than one canal, either simultaneously or in succession. It is sustained that the clinical findings can be explained by movement of endolymph caused by displacement of otoconia in the semicircular canals and that variants are due to different positions of the otoconia within the canals.

[A comparison between the "bithermal caloric test" and the "hot monothermal with simultaneous cold test"]. / Confronto fra "test calorico bitermico" E "test monotermico caldo con simultanea fredda".

Hot (44) and cold (30) caloric test are the most common tool to investigate canal activity. Many authors, otherwise, have pointed out that this method is very long needing about five minutes of interval among the irrigations and that it is often troublesome for the patient that is exposed four times to a vertigo. To investigate vestibular function some of these authors tried to use the hot monothermal test alone but results were poor. The aim of this study was to propose a shorter and a less troublesome method of investigation and to introduce a new diagnostic possibility not pointed out with traditional caloric test. We have tried to determine some new reliable diagnostic criteria modifying confidential value of the hot monothermal test and considering the eventual presence of the nystagmus and its direction during the cold simultaneous test; on the basis of this results we are able to distinguish a normal vestibular function from a labyrinthine preponderance or a directional preponderance or an aspecific disfunction. When the vestibular function is normal or when there is a labyrinthine preponderance our results are in total accord with those achieved with the traditional bithermal test. Therefore we suggest to use always the hot monothermal test associated with the cold simultaneous test, performing the two cold irrigations in additions, only in the case of a directional preponderance or an aspecific disfunction.

[Sandwich-graft myringoplasty: the authors' personal technic and results]. / Miringoplastica a sandwich: tecnica personale e risultati.

The authors describe the anatomic and functional results obtained with a sandwich myringoplasty technique (MPL) employing an endaural approach. The suggested technique is a modified sandwich MPL by endaural approach with a reduced Shambaugh incision, a systematic profiling of the canal wall bulge and separation of the meatal and tympano-meatal flaps that are maintained pedunculated. The temporal fascia is inserted between the fibrous layer of the tympanic remnant and a single pedunculated tympano-meatal cutaneous flap replaced in the original location. The authors present 72 cases operated between January 1987 and December 1989 for perforations involving up to three quadrants. In 93.1% of the cases a complete and lasting resolution of the perforation was obtained. Of the 5 failures, 4 presented a perforation smaller than the original one. An average (250, 500, 1000 Hz) functional recovery of 14.1 dB was observed compared to an average pre-operatory gap of 21.6 dB. In 25% of the cases, average recovery was greater than 25 dB and in 5 patients a slight worsening with an average difference of -3.3 dB was observed. On the whole, in 41 patients a residual post-operatory gap of only 10 dB was achieved. The anatomical results obtained with the MPL presented are similar to those found in the literature describing the classical overlay technique. However, the cases reported do not present those inconveniences associated to the latter technique (lateralization of the graft and blunting). The anatomic and functional results obtained with the technique discussed are on the whole superior to those described with the underlay and the classical overlay techniques. The Authors believe that this is mainly due to the absence of the gelfoam in the middle ear and to the double contention and vascularization of the temporal fascia graft. By means of the profiling of the canal wall the endaural approach permits a good view of the operating field. Furthermore, it is less traumatic and more acceptable to the patient than the postauricular one that has to be limited to the MPL where there are clinical indications for the exploration of antrum. The personal technique here presented implies, however, a certain presence of epithelial pearls. Their localization is nevertheless facilitated by the absence of blunting, thickening and lateralization of the graft. This allows for an early and easy removal on an out-patient basis. Other inconveniences of the technique are the length of the procedure and a more difficult control of the ossicular chain.(ABSTRACT TRUNCATED AT 400 WORDS)

[Bidirectional horizontal and tridimensional apogeotropic nystagmus: 2 semeiological realities]. / Il nistagmo orizzontale bidirezionale e apogeotropo tridirezionale: due realtà semeiologiche.

The authors take into account two different types of stationary, persistent and direction-changing nystagmus (ny): 1) the horizontal bidirectional ny (nyOB), apogeotropic (nyOBA) and geotropic (nyOBG); 2) the tridirectional apogeotropic ny (nyAT). The nyOBA was identified in experimental studies in 1973 but no other studies on the subject have been published since then. In existing literature the nyOBG has been reported in only one paper, whereas the nyAT has not yet been studied at all. The nyOBA is the combination of a 2nd degree left ny with the head turned right and a 2nd degree right ny with the head turned left. The nyOBG is the combination of a 2nd degree right ny with the head turned right and a 2nd degree left ny with the head turned left. The nyAT is a 2nd degree apogeotropic ny noticeable with the head turned left, right and in the position of Rose (head hanging down). From among a total of 5,960 consecutive vestibular examinations performed from 1986 to 1990, the authors chose those presenting nyOBA, nyOBG and nyAT and discuss them in the light of other vestibular findings and clinical diagnosis. A routine vestibular examination aims at verifying an eventual, spontaneous/evoked ny with the head turned right and left, in the position of Rose and in the two rapid Hallpike positionings. Frenzel glasses are used for detecting the gaze and rebound ny and these, in turn, are checked for visual fixation. During the caloric stimulation, according to the Fitzgerald-Hallpike method, the ny visual suppression test is performed at the culmination period. When electronystagmography is performed, visual oculomotor reflexes are often tested as well. The nyOB and/or nyAT were observed in 3.9% of the patients (234 subjects). The nyOB was present in 177 patients as follows: apogeotropic ny in 128 and geotropic in 49. This was the only vestibular finding in 46.9% of the nyOB cases (83 out of 177 patients). The nyAT was observed in 57 patients and in 17.6% of them was the only pathological finding of the otoneurological examination. When nyOB or nyAT were observed, clinical diagnosis evidenced their central origin in 138 of the 234 patients, most frequently present in cranial trauma, vertebral-basilar vasculopathy and multiple sclerosis. In a limited number of cases some sign of peripheral vestibulopathy were also observed.(ABSTRACT TRUNCATED AT 400 WORDS)

Electronystagmography in the diagnosis of multiple sclerosis.

The aim of our study was to define the diagnostic importance of a complete electronystagmographic (ENG) examination (visual-vestibular, vestibular and visual suppression tests on caloric nystagmus) in patients affected by MS. Of 144 patients examined, 116 were definite and 28 possible. Descriptive data of the instrumental findings showed very frequent alterations of one or more subtests: pursuit movements and visual suppression test were especially pathological, in respectively 56% and 58% of the cases; spontaneous and/or evoked nystagmus was present in 45%. A comparison between clinical and instrumental evidence of brainstem/cerebellar involvement indicated that 18% of the definite and 32% of the possible MS cases presented a negative clinical examination with positive instrumental findings. The usefulness of including a comprehensive ENG examination to obtain paraclinical evidence of a second lesion in the CNS in early MS is discussed.

Benign paroxysmal vertigo of the horizontal canal.

Over a period of 4 years we observed 15 cases of benign positional vertigo (BPV) probably caused by deposition of otoliths in the horizontal semicircular canal. Rapid rolling onto one side in recumbent position provokes a paroxysmal, purely horizontal and geotropic nystagmus which nearly always spontaneously inverts direction. Rolling the patient onto the other side provokes a left intense geotropic nystagmus. BPV is more violent but resolves more rapidly than that of the better known posterior canal positional vertigo. Sometimes both syndromes are present together.

In vitro cytotoxicity of recombinant ricin A chain-antitransferrin receptor immunotoxin against human adenocarcinomas of the colon and pancreas.

The sensitivity of three human colon adenocarcinoma cell lines (LoVo, LS174T, and SW1116) and a human pancreatic adenocarcinoma cell line (Hs766T) to a recombinant ricin A chain-antitransferrin receptor immunotoxin was studied. In addition, the carboxylic ionophore monensin was used in conjunction with the immunotoxin to determine the possibility of increased cytotoxicity without loss of specificity. The immunotoxin, 454A12-rRTA, is composed of the monoclonal antibody 454A12 directed against transferrin receptor and of ricin A chain, which was produced by recombinant DNA techniques. In 18 h dose-response cytotoxicity assays, the median inhibitory dose (ID50) against LoVo, LS174T, and SW1116 was found to be 3 X 10(-10), 3.6 X 10(-11), and 3.6 X 10(-10) M, respectively; in the same assay, the ID50 for Hs766T was found to be 4 X 10(-10) M. In the presence of monensin, the ID50 for the adenocarcinoma cell lines was reduced 9-fold, 28-fold, and 5-fold, respectively. In cytotoxic kinetic assays, 50% of control protein inhibition was reached in immunotoxin-treated LS174T cells 12-fold faster in the presence of monensin than in its absence. Immunotoxin-treated LoVo cells reached 50% inhibition of control protein synthesis fivefold faster in the presence of monensin than in its absence. Furthermore, no toxicity of immunotoxin or potentiation by monensin was observed in either a control cell line (Swiss albino mouse 3T6) treated with specific immunotoxin or with a control immunotoxin assay. These results show the in vitro specificity and selectivity of 454A12-rRTA immunotoxin for human gastrointestinal and pancreatic cancer cell lines.

Electro-oculographic routine examination in Parkinson's disease.

The authors studied a group of 36 patients with idiopathic Parkinson's disease by electro-oculographic examination in order to evaluate the most frequent vestibular and oculomotor findings. Vestibular alterations were detected mainly in caloric nystagmus (82.9%). Hyperreflectivity was the most frequent evidence, but it does not necessarily represent the sign of a lesion. The occurrence of spontaneous and evoked nystagmus was not significant. Oculomotor findings were more interesting, as they were altered in two-thirds of the cases. Particularly, saccadic eye movements presented a "multiple step" morphology in 58.3% of the series. This saccadic disarrangement was scarcely found in neurological patients with brainstem and/or cerebellum pathology (7.7%). Moreover, in Parkinson's disease patients no other saccadic alterations typical of brainstem or cerebellum involvement were found. Such observations suggest a possible non-cerebellar origin of "multiple step". Vestibular and oculomotor findings were not significantly correlated with the clinical features of the patients.