Impaired fixation suppression of horizontal vestibular nystagmus during smooth pursuit: pathophysiology and clinical implications

Korda, Athanasia; Zee, David S.; Wyss, Thomas R.; Zamaro, Ewa; Caversaccio, Marco; Wagner, Franca; Kalla, Roger; Mantokoudis, Georgios

doi:10.1111/ene.14909

Cited by 9 publications

(9 citation statements)

References 23 publications

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“…Nystagmus on Dix–Hallpike testing can also be negative in patients with hc‐BPPV and in patients with so‐called “subjective” BPPV (i.e., positional vestibular symptoms without nystagmus). Experimental evidence suggests that since visual fixation can partially suppress nystagmus, apparently “subjective” BPPV will be more common if special goggles (Frenzel lenses or VOG) are not used to block visual fixation 226,227 …”

Section: Methodsmentioning

confidence: 99%

“…Experimental evidence suggests that since visual fixation can partially suppress nystagmus, apparently "subjective" BPPV will be more common if special goggles (Frenzel lenses or VOG) are not used to block visual fixation. 226,227 Indirect evidence shows that emergency clinicians can successfully use the Dix-Hallpike test to diagnose pc-BPPV, 2,3,71,149,[228][229][230] resulting in decreased imaging, hospitalization and total costs of care, 230 excellent diagnostic accuracy, 2,3,149 and increased physician satisfaction with the process of care. 231 Given the frequency of BPPV, the minimal time required to perform the Dix-Hallpike test, and the resultant improved efficiency of care, the writing committee members, including the patient representatives, felt that emergency clinician adoption of the Dix-Hallpike test was important to improve patient-centered outcomes (Figure 7).…”

Section: Direct and Indirect Evidencementioning

confidence: 99%

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Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

Edlow,

Carpenter,

Akhter

et al. 2023

Academic Emergency Medicine

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This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").

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Section: Methodsmentioning

confidence: 99%

Section: Direct and Indirect Evidencementioning

confidence: 99%

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

Edlow,

Carpenter,

Akhter

et al. 2023

Academic Emergency Medicine

View full text Add to dashboard Cite

show abstract

“…We did not test pursuit systematically in our patients. Smooth pursuit, however, might appear abnormal because of a superimposed spontaneous nystagmus e.g., in patients with vestibular neuritis [11].…”

Section: Discussionmentioning

confidence: 99%

“…Gaze-evoked nystagmus (GEN) assessed by an expert and videooculography (VOG) superimposed spontaneous nystagmus e.g., in patients with vestibular neuritis[11].Holmes et al[12] examined patients with cerebellar lesions after gunshot injury during the first world war, and described a "null point" or rest point (10° to 30°). This null point was usually shifted towards gaze to the unaffected side and thus nystagmus beat towards the side of the lesion in straight-ahead gaze.…”

mentioning

confidence: 99%

Bruns' nystagmus revisited: A sign of stroke in patients with the acute vestibular syndrome

Mantokoudis

Korda

Zee

et al. 2021

Euro J of Neurology

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Pathologic gaze-evoked nystagmus (GEN) is a central sign in patients with acute dizziness, however, the discrimination between a pathologic and physiologic GEN is challenging. Neurology textbooks [1] suggest that physiologic GEN is not sustained and beats at a lower frequency. The direction and intensity of GEN is more difficult to discern in patients with an acute vestibular syndrome (AVS), since they have spontaneous nystagmus (SN).We have not found a study quantifying GEN in the acute phase of patients with the AVS either from peripheral or central causes. The slow-phase velocity (SPV), frequency (beats per second), and direction of eye drift of GEN can be quantified using mobile eye tracking

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“…A subset of VOR gain data presented here have been published elsewhere (6,(18)(19)(20)(21). A neurootologist with 2 years' experience in the field, performed physical examination, Caloric Testing, and vHIT testing in all enrolled patients.…”

Section: Vhit Measurementsmentioning

confidence: 99%

Artificial intelligence for early stroke diagnosis in acute vestibular syndrome

et al. 2022

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ObjectiveMeasuring the Vestibular-Ocular-Reflex (VOR) gains with the video head impulse test (vHIT) allows for accurate discrimination between peripheral and central causes of acute vestibular syndrome (AVS). In this study, we sought to investigate whether the accuracy of artificial intelligence (AI) based vestibular stroke classification applied in unprocessed vHIT data is comparable to VOR gain classification.MethodsWe performed a prospective study from July 2015 until April 2020 on all patients presenting at the emergency department (ED) with signs of an AVS. The patients underwent vHIT followed by a delayed MRI, which served as a gold standard for stroke confirmation. The MRI ground truth labels were then applied to train a recurrent neural network (long short-term memory architecture) that used eye- and head velocity time series extracted from the vHIT examinations.ResultsWe assessed 57 AVS patients, 39 acute unilateral vestibulopathy patients (AUVP) and 18 stroke patients. The overall sensitivity, specificity and accuracy for detecting stroke with a VOR gain cut-off of 0.57 was 88.8, 92.3, and 91.2%, respectively. The trained neural network was able to classify strokes with a sensitivity of 87.7%, a specificity of 88.4%, and an accuracy of 87.9% based on the unprocessed vHIT data. The accuracy of these two methods was not significantly different (p = 0.09).ConclusionAI can accurately diagnose a vestibular stroke by using unprocessed vHIT time series. The quantification of eye- and head movements with the use of machine learning and AI can serve in the future for an automated diagnosis in ED patients with acute dizziness. The application of different neural network architectures can potentially further improve performance and enable direct inference from raw video recordings.

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Impaired fixation suppression of horizontal vestibular nystagmus during smooth pursuit: pathophysiology and clinical implications

Cited by 9 publications

References 23 publications

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

Bruns' nystagmus revisited: A sign of stroke in patients with the acute vestibular syndrome

Artificial intelligence for early stroke diagnosis in acute vestibular syndrome

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