Recent advances in central acute vestibular syndrome of a vascular cause

Kim, Hyun-Ah; Lee, Hyung

doi:10.1016/j.jns.2012.07.055

Cited by 57 publications

(36 citation statements)

References 53 publications

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“…38 While not yet extensively studied, 43 there is mounting evidence that new hearing loss in patients with AVS favors a stroke syndrome. 8,19,44 HINTS outperforms initial MRI-DWI for ischemic stroke detection when patients are assessed in the first 48 hours. One in seven ischemic strokes had initially false-negative MRI-DWI scans.…”

Section: Discussionmentioning

confidence: 99%

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Newman‐Toker

Kerber

Hsieh

et al. 2013

Academic Emergency Medicine

314

351

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ObjectivesDizziness and vertigo account for about 4 million emergency department (ED) visits annually in the United States, and some 160,000 to 240,000 (4% to 6%) have cerebrovascular causes. Stroke diagnosis in ED patients with vertigo/dizziness is challenging because the majority have no obvious focal neurologic signs at initial presentation. The authors sought to compare the accuracy of two previously published approaches purported to be useful in bedside screening for possible stroke in dizziness: a clinical decision rule (head impulse, nystagmus type, test of skew [HINTS]) and a risk stratification rule (age, blood pressure, clinical features, duration of symptoms, diabetes [ABCD2]).MethodsThis was a cross‐sectional study of high‐risk patients (more than one stroke risk factor) with acute vestibular syndrome (AVS; acute, persistent vertigo or dizziness with nystagmus, plus nausea or vomiting, head motion intolerance, and new gait unsteadiness) at a single academic center. All underwent neurootologic examination, neuroimaging (97.4% by magnetic resonance imaging [MRI]), and follow‐up. ABCD2 risk scores (0–7 points), using the recommended cutoff of ≥4 for stroke, were compared to a three‐component eye movement battery (HINTS). Sensitivity, specificity, and positive and negative likelihood ratios (LR+, LR–) were assessed for stroke and other central causes, and the results were stratified by age. False‐negative initial neuroimaging was also assessed.ResultsA total of 190 adult AVS patients were assessed (1999–2012). Median age was 60.5 years (range = 18 to 92 years; interquartile range [IQR] = 52.0 to 70.0 years); 60.5% were men. Final diagnoses were vestibular neuritis (34.7%), posterior fossa stroke (59.5% [105 infarctions, eight hemorrhages]), and other central causes (5.8%). Median ABCD2 was 4.0 (range = 2 to 7; IQR = 3.0 to 4.0). ABCD2 ≥ 4 for stroke had sensitivity of 61.1%, specificity of 62.3%, LR+ of 1.62, and LR– of 0.62; sensitivity was lower for those younger than 60 years old (28.9%). HINTS stroke sensitivity was 96.5%, specificity was 84.4%, LR+ was 6.19, and LR– was 0.04 and did not vary by age. For any central lesion, sensitivity was 96.8%, specificity was 98.5%, LR+ was 63.9, and LR– was 0.03 for HINTS, and sensitivity was 99.2%, specificity was 97.0%, LR+ was 32.7, and LR– was 0.01 for HINTS “plus” (any new hearing loss added to HINTS). Initial MRIs were falsely negative in 15 of 105 (14.3%) infarctions; all but one was obtained before 48 hours after onset, and all were confirmed by delayed MRI.ConclusionsHINTS substantially outperforms ABCD2 for stroke diagnosis in ED patients with AVS. It also outperforms MRI obtained within the first 2 days after symptom onset. While HINTS testing has traditionally been performed by specialists, methods for empowering emergency physicians (EPs) to leverage this approach for stroke screening in dizziness should be investigated.

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Section: Discussionmentioning

confidence: 99%

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Newman‐Toker

Kerber

Hsieh

et al. 2013

Academic Emergency Medicine

314

351

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“…This diversity likely stems from the AICA blood supply to vestibular structures in the brainstem and labyrinth. Ipsilesional abnormal VOR responses in AICA strokes can be caused by infarction of the pontine vestibular nucleus, vestibular nerve root entry zone (fascicle), or labyrinth (10). Contralesional abnormal VOR responses may be caused by flocculus infarction, which can cause an asymmetric bilateral vestibular loss by HIT, worse opposite the affected flocculus (13).…”

Section: Figmentioning

confidence: 99%

“…The horizontal HIT consists of a rapid (100Y300 degrees per second), passive, lowamplitude (10Y20 degrees), unpredictable head movement in the plane of the horizontal canal while the subject fixates on a central target (9). Clinically, a unilaterally abnormal HIT is found in approximately 95% of patients with vestibular neuritis (1), whereas it is found in less than 10% of patients with stroke (generally those causing ischemia directly to the labyrinth, vestibular nerve, or vestibular nucleus) (10).…”

mentioning

confidence: 99%

VOR Gain by Head Impulse Video-Oculography Differentiates Acute Vestibular Neuritis from Stroke

Mantokoudis¹,

Tehrani²,

Wozniak³

et al. 2015

Otology &Amp; Neurotology

118

126

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Objective: Vestibular neuritis is often mimicked by stroke (pseudoneuritis). Vestibular eye movements help discriminate the two conditions. We report vestibulo-ocular reflex (VOR) gain measures in neuritis and stroke presenting acute vestibular syndrome (AVS). Methods: Prospective cross-sectional study of AVS (acute continuous vertigo/dizziness lasting 924 h) at two academic centers. We measured horizontal head impulse test (HIT) VOR gains in 26 AVS patients using a video HIT device (ICS Impulse). All patients were assessed within 1 week of symptom onset. Diagnoses were confirmed by clinical examinations, brain magnetic resonance imaging with diffusion-weighted images, and follow-up. Brainstem and cerebellar strokes were classified by vascular territoryVposterior inferior cerebellar artery (PICA) or anterior inferior cerebellar artery (AICA). Results: Diagnoses were vestibular neuritis (n = 16) and posterior fossa stroke (PICA, n = 7; AICA, n = 3). . VOR gains were asymmetric in neuritis (unilateral vestibulopathy) and symmetric in PICA stroke (bilaterally normal VOR), whereas gains in AICA stroke were heterogeneous (asymmetric, bilaterally low, or normal). In vestibular neuritis, borderline gains ranged from 0.62 to 0.73. Twenty patients (12 neuritis, six PICA strokes, two AICA strokes) had at least five interpretable HIT trials (for both ears), allowing an appropriate classification based on mean VOR gains per ear. Classifying AVS patients with bilateral VOR mean gains of 0.70 or more as suspected strokes yielded a total diagnostic accuracy of 90%, with stroke sensitivity of 88% and specificity of 92%. Conclusion: Video HIT VOR gains differ between peripheral and central causes of AVS. PICA strokes were readily separated from neuritis using gain measures, but AICA strokes were at risk of being misclassified based on VOR gain alone.

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“…Thus, it is essential to differentiate peripheral vestibular neuritis from central vestibular “pseudoneuritis” already at the bedside in order to manage patients who present with signs and symptoms similar to those of acute prolonged vertigo. Whereas acute vestibular vertigo with spontaneous nystagmus and a pathological head-impulse test are typical for an acute peripheral failure, a normal head-impulse test, especially when combined with skew deviation of the eyes, indicates a central origin (Cnyrim et al, 2008; Newman-Toker et al, 2008; Kattah et al, 2009; Kim and Lee, 2012). However, it is important to note that a pathological head-impulse test can also be found in central lesions affecting the vestibular nuclei and even the cerebellum, thus mimicking a peripheral vestibular lesion (Cnyrim et al, 2008).…”

Section: A Central Lesion May Mimick a Peripheral Disordermentioning

confidence: 99%

Towards a concept of disorders of â€œhigher vestibular functionâ€

Brandt

Strupp

Dieterich

2014

Front. Integr. Neurosci.

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Background: Vestibular disorders are commonly characterized by a combination of perceptual, ocular motor, postural, and vegetative manifestations, which cause the symptoms of vertigo, nystagmus, ataxia, and nausea. Multisensory convergence and numerous polysynaptic pathways link the bilaterally organized central vestibular network with limbic, hippocampal, cerebellar, and non-vestibular cortex structures to mediate “higher” cognitive functions.Anatomical classification of vestibular disorders: The traditional classification of vestibular disorders is based on the anatomical site of the lesion. While it distinguishes between the peripheral and the central vestibular systems, certain weaknesses become apparent when applied clinically. There are two reasons for this: first, peripheral and central vestibular disorders cannot always be separated by the clinical syndrome; second, a third category, namely disorders of “higher vestibular function”, is missing. These disorders may be caused by peripheral as well as central vestibular lesions.Functional classification: Here we discuss a new concept of disorders of higher vestibular function which involve cognition and more than one sensory modality. Three conditions are described that exemplify such higher disorders: room tilt illusion, spatial hemineglect, and bilateral vestibulopathy all of which present with deficits of orientation and spatial memory.Conclusions: Further elaboration of such disorders of higher multisensory functions with respect to lesion site and symptomatology is desirable. The room tilt illusion and spatial hemineglect involve vestibular and visual function to the extent that both conditions can be classified as either disorders of higher vestibular or of higher visual functions. A possible way of separating these disorders in a first step is to determine whether the causative lesion site affects the vestibular or the visual system. For the vestibular system this lesion site may be peripheral or central. The criterion of “higher function” is fulfilled if cognition or senses other than the primarily affected one come into play.

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Recent advances in central acute vestibular syndrome of a vascular cause

Cited by 57 publications

References 53 publications

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

VOR Gain by Head Impulse Video-Oculography Differentiates Acute Vestibular Neuritis from Stroke

Towards a concept of disorders of â€œhigher vestibular functionâ€

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Recent advances in central acute vestibular syndrome of a vascular cause

Cited by 57 publications

References 53 publications

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

VOR Gain by Head Impulse Video-Oculography Differentiates Acute Vestibular Neuritis from Stroke

Towards a concept of disorders of â€œhigher vestibular functionâ€

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Towards a concept of disorders of â€œhigher vestibular functionâ€