The Bucket Test Differentiates Patients with MRI Confirmed Brainstem/Cerebellar Lesions from Patients Having Migraine and Dizziness Alone

Abstract

Background: Among the most challenging diagnostic dilemmas managing patients with vestibular symptoms (i.e. vertigo, nausea, imbalance) is differentiating dangerous central vestibular disorders from benign causes. Migraine has long been recognized as one of the most common causes of vestibular symptoms, but the clinical hallmarks of vestibular migraine are notoriously inconsistent and thus the diagnosis is difficult to confirm. Here we conducted a prospective study investigating the sensitivity and specificity of combining standard vestibular and neurological examinations to determine how well central vestibular disorders (CVD) were distinguishable from vestibular migraine (VM). Method: Twenty-seven symptomatic patients diagnosed with CVD and 36 symptomatic patients with VM underwent brain imaging and clinical assessments including; 1) SVV bucket test, 2) ABCD2, 3) headache/vertigo history, 4) presence of focal neurological signs, 5) nystagmus, and 6) clinical head impulse testing. Results: Mean absolute SVV deviations measured by bucket testing in CVD and VM were 4.8±4.1° and 0.7±1.0°, respectively. The abnormal rate of SVV deviations (>2.3°) in CVD was significantly higher than VM (p<0.001). Using the bucket test alone to differentiate CVD from VM, sensitivity was 74.1%, specificity 91.7%, positive likelihood ratio (LR+) 8.9, and negative likelihood ratio (LR-) 0.3. However, when we combined the SVV results with the clinical exam assessing gaze stability (nystagmus) with an abnormal focal neurological exam, the sensitivity (92.6%) and specificity (88.9%) were optimized (LR+ (8.3), LR- (0.08)). Conclusion: The SVV bucket test is a useful clinical test to distinguish CVD from VM, particularly when interpreted along with the results of a focal neurological exam and clinical exam for nystagmus.

Misperception of Visual Verticality in Patients with Primary Headache Disorders: A Systematic Review with Meta-Analysis

“…Figure 2 shows the number of records removed and the reasons for exclusion. Finally, seven studies [ 52 , 53 , 54 , 55 , 56 , 57 , 58 ] were included in the present review.…”

“…The seven studies included in this review comprised 10 samples with 10 independent comparisons providing data from 816 participants (34% males and 66% females). The seven studies [ 52 , 53 , 54 , 55 , 56 , 57 , 58 ] had eight independent comparisons, including 669 patients with migraine (mean age of 36.72 ± 4.9 years old); two of the studies [ 52 , 56 ] had two independent comparisons with reported data for 147 subjects with TTH (mean age of 39.52 ± 6.81 years old). The exposed group incorporated patients with migraine and TTH, and 364 healthy subjects formed the non-exposed group (mean age 35.87 ± 5.81 years old).…”

“…All subjects included in this meta-analysis were in the chronic phase of the disease. The criteria of diagnosis of PHD in the included studies were the The International Classification of Headache Disorders [ 52 , 55 , 56 , 58 ], the International Classification of Vestibular Disorders [ 54 , 57 ], and the Neuhauster’s Classification [ 53 ]. The chosen measure to assess the perception of VV was the SVV test in the sitting position.…”

“…The chosen measure to assess the perception of VV was the SVV test in the sitting position. Two studies assessed the SVV with the bucket test [ 54 , 56 ] and the rest of the studies analyzed the SVV with techniques based on the projection of a fluorescent rod on a screen that was oriented to the earth vertical with a manual controller (joystick potentiometer) [ 52 , 53 , 55 , 57 , 58 ]. More characteristics about the SVV measurement in each study are shown in Table 3 .…”

“…The methodological quality of the studies included in this review, as evaluated with the Newcastle–Ottawa Scale (NOS), was moderate (NOS mean score of 6.4). Four studies [ 52 , 54 , 55 , 58 ] (57% of included studies) showed a medium quality, and three studies showed a high quality [ 53 , 56 , 57 ] (47% of the total). Table 4 summarizes the NOS rating for selection, comparability, and exposure/outcome of the selected studies.…”