Video head impulse test in bilateral vestibulopathy / Teste do impulso efálico com vídeo (vHIT) na vestibulopatia bilateral

Abstract Introduction: Bilateral vestibulopathy is a rare chronic condition with multiple etiologies. Bilateral vestibulopathy is characterized mainly by unsteadiness when walking or standing, which worsens in darkness, as well as oscillopsia. The degree of handicap caused by bilateral vestibulopathy is variable and remains controversial. Objectives: To determine the value of the video Head Impulse Test in quantifying vestibular deficit and to establish its impact on the quality of life. Methods: Twenty patients (mean age, 41.9 years; range 14-80 years) fulfilling the recent Barany criteria of bilateral vestibulopathy, responded to the Situational Vertigo Questionnaire and underwent vestibular examination including fixation, positional tests, oculomotor test battery and video head impulse test. Results: The relation between each of the video head impulse test parameters and the scores from the questionnaire were statistically analyzed. We observed that patients with covert saccades on the video head impulse test were more likely to have a better quality of life than those with both covert and overt saccades, regardless of the vestibulo-ocular reflex gain in each semicircular canal. The presence of covert saccades was found to be associated with an improved quality of life regardless of the severity of vestibule ocular reflex-deficit. Our conclusion was that vestibule ocular reflex gain, measured by video head impulse test, does not quantify the severity of affection of quality of life in patients with bilateral vestibulopathy. Conclusion: Covert saccades are strategies aiming at minimizing the blurring of vision during head movement, that is an adaptive mechanism that improves quality of life. Therefore, we recommend that video head impulse test should be a part of the routine diagnostic workup of bilateral vestibulopathy.

Resumo Introdução: A vestibulopatia bilateral é uma condição crônica rara, com múltiplas etiologias. É caracterizada principalmente por instabilidade ao caminhar ou ficar de pé, que piora na escuridão, e oscilopsia. O grau de deficiência causado pela vestibulopatia bilateral é variável e permanece controverso. Objetivos: Determinar o valor do teste do impulso cefálico na quantificação do déficit vestibular e estabelecer seu impacto na qualidade de vida. Método: Vinte pacientes (média de 41,9 anos; variação de 14 a 80) que atendiam aos critérios recentes da Bárány Society de vestibulopatia bilateral responderam ao Situational Vertigo Questionnaire e foram submetidos a exame vestibular, inclusive fixação, testes posicionais, bateria de testes oculomotores e teste do impulso cefálico com vídeo. Resultados: A relação entre cada um dos parâmetros do teste do impulso cefálico com vídeo e os escores do questionário foram analisados estatisticamente. Observamos que pacientes com sacadas corretivas cobertas do tipo covert no teste de impulso cefálico com vídeo tinham maior probabilidade de ter melhor qualidade de vida do que aqueles com ambas sacadas corretivas cobertas e sacadas corretivas abertas do tipo overt, independentemente do ganho no reflexo vestíbulo-ocular em cada canal semicircular. Verificou-se que a presença de sacadas corretivas do tipo covert está associada a uma melhor qualidade de vida, independentemente da gravidade do déficit no reflexo vestibulo-ocular. Concluímos que o ganho no reflexo vestíbulo-ocular, medido pelo teste do impulso cefálico com vídeo, não quantifica a gravidade do comprometimento da qualidade de vida em pacientes com vestibulopatia bilateral. Conclusão: As sacadas corretivas do tipo covert são estratégias que visam minimizar o embaçamento da visão durante o movimento da cabeça, ou seja, um mecanismo adaptativo que melhora a qualidade de vida. Portanto, recomendamos que o teste do impulso cefálico com vídeo faça parte da rotina de diagnóstico da vestibulopatia bilateral.

Video head impulse test in bilateral vestibulopathy.

INTRODUCTION: Bilateral vestibulopathy is a rare chronic condition with multiple etiologies. Bilateral vestibulopathy is characterized mainly by unsteadiness when walking or standing, which worsens in darkness, as well as oscillopsia. The degree of handicap caused by bilateral vestibulopathy is variable and remains controversial. OBJECTIVES: To determine the value of the video Head Impulse Test in quantifying vestibular deficit and to establish its impact on the quality of life. METHODS: Twenty patients (mean age, 41.9 years; range 14-80 years) fulfilling the recent Barany criteria of bilateral vestibulopathy, responded to the Situational Vertigo Questionnaire and underwent vestibular examination including fixation, positional tests, oculomotor test battery and video head impulse test. RESULTS: The relation between each of the video head impulse test parameters and the scores from the questionnaire were statistically analyzed. We observed that patients with covert saccades on the video head impulse test were more likely to have a better quality of life than those with both covert and overt saccades, regardless of the vestibulo-ocular reflex gain in each semicircular canal. The presence of covert saccades was found to be associated with an improved quality of life regardless of the severity of vestibule ocular reflex-deficit. Our conclusion was that vestibule ocular reflex gain, measured by video head impulse test, does not quantify the severity of affection of quality of life in patients with bilateral vestibulopathy. CONCLUSION: Covert saccades are strategies aiming at minimizing the blurring of vision during head movement, that is an adaptive mechanism that improves quality of life. Therefore, we recommend that video head impulse test should be a part of the routine diagnostic workup of bilateral vestibulopathy.

Síndrome de Miller Fisher: relato de caso / Miller Fisher syndrome: case report

A síndrome de Miller Fisher é uma desmielinização dos nervos cranianos e periféricos, gerando graves consequências para o paciente, como, por exemplo, redução ou ausência dos reflexos, paralisia do III, IV e VI nervos cranianos e ataxia. Este relato descreveu o caso de uma mulher de 51 anos, natural e procedente de Penápolis (SP), admitida em um hospital de Araçatuba (SP) com quadro de arreflexia, ataxia e oftalmoplegia. No contexto clínico, foi suspeitada a hipótese de síndrome de Miller Fisher e, assim, começou o processo de investigação, com base nos critérios diagnósticos. O caso foi diagnosticado como síndrome de Miller Fisher, e o tratamento teve início.

Miller Fisher Syndrome is a demyelinating disease affecting cranial and peripheral nerves, leading to severe problems to the patient, such as reduced or absent reflexes, III, IV and VI cranial nerves palsy, and ataxia. This report describes the case of a 51-year-old woman from the city of Penápolis, in the state of São Paulo, who was admitted to the hospital in the city of Araçatuba, in the same state, with ataxia, areflexia and ophthalmoplegia. In the clinical context, the suspicion of Miller Fisher Syndrome was raised, and then investigation ensued for the disease, based on the diagnostic criteria. After evaluation, Miller Fisher Syndrome was confirmed and treatment was started.

Terapia vestibular en vestibulopatía bilateral por gentamicina: reporte de un caso y revisión de la literatura / Vestibular therapy in a case of gentamicin-induced vestibulopathy: case report and literature revision

La vestibulopatía bilateral es poco frecuente, se caracteriza principalmente por inestabilidad al caminar o al estar de pie, visión borrosa inducida por el movimiento u oscilopsia al caminar o al realizar movimientos rápidos de la cabeza o del cuerpo, empeoramiento de la estabilidad en la oscuridad o terrenos irregulares, reducción de los síntomas al estar en condiciones estáticas, ganancia del reflejo vestíbulo-ocular angular reducida de forma bilateral, entre otros. Existen múltiples causas. Dentro de las causas identificables, se describen principalmente medicamentos ototóxicos, meningitis y enfermedad de Ménière. Se presenta el caso de una paciente de 64 años diagnosticada con vestibulopatía bilateral posterior a tratamiento intramuscular con gentamicina por sobreinfección bacteriana cutánea de las manos. La evaluación vestibular complementada con videonistagmografía y prueba de impulso cefálico asistida por video confirman el diagnóstico y se inicia tratamiento con rehabilitación vestibular enfocada en promover la compensación central a través de estrategias de sustitución principalmente; además de habituación y adaptación vestibular, favoreciendo la estabilización de la mirada, mantención del equilibrio, control postural, marcha y reducción de los síntomas.

Bilateral vestibulopathy is infrequent, and it is characterized mostly by unstable walking or when standing, blurred vision induced by movement, or oscillopsia when walking or performing fast movements; worsening of the stability in darkness or uneven ground, but with lack of symptoms in static conditions. Other symptoms may include bilateral reduction of the oculo-vestibular reflex. Among the identifiable causes, there is the use of ototoxic medication, meningitis, Ménière's disease, although it can be idiopathic or have a neurological cause. We hereby describe the case of a 64-year-old woman, diagnosed with bilateral vestibulopathy secondary to intramuscular treatment with gentamicin due to a bacterial hand infection. Vestibular assessment was complemented with video-nystagmography and video head impulse test which confirmed the diagnosis, and therapy was started with vestibular rehabilitation focused on promoting central compensation mainly, through substitution strategies. Also, habituation exercise and vestibular adaptation strategies were used, thus promoting sight stabilization, balance maintenance, postural control, walking, and reduction of the symptoms.