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Lee SU, Tarnutzer AA. Usefulness of Nystagmus Patterns in Distinguishing Peripheral From Central Acute Vestibular Syndromes at the Bedside: A Critical Review. J Clin Neurol 2025; 21:161-172. [PMID: 40308011 PMCID: PMC12056143 DOI: 10.3988/jcn.2025.0105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2025] [Revised: 03/12/2025] [Accepted: 03/13/2025] [Indexed: 05/02/2025] Open
Abstract
Vertigo and dizziness are amongst the most frequent presenting symptoms in the emergency room, accounting for up to 4% of all emergency consultations. The broadness of their differential diagnosis and the often transient nature of these symptoms pose a significant challenge to the treating physician. Combining various subtle oculomotor signs at the bedside has been very successful in distinguishing peripheral from central causes in acutely dizzy patients meeting diagnostic criteria for the acute vestibular syndrome (i.e., acute and prolonged vertigo or dizziness accompanied by nausea or vomiting, gait imbalance, motion intolerance, and [not mandatory] nystagmus). While the diagnostic accuracy of the HINTS (Head-Impulse-Nystagmus-Test-of-Skew) algorithm has been studied extensively, less is known about the value of various nystagmus patterns seen at the bedside in patients with an acute vestibular syndrome. Here we review both spontaneous and triggered presenting nystagmus patterns and discuss their impacts and limitations, including primary-gaze horizontal, vertical, and torsional nystagmus, nystagmus during eccentric gaze, and nystagmus triggered by stimuli such as head-shaking, hyperventilation, positional testing, vibration, and the Valsalva maneuver. We conclude that the usefulness of nystagmus patterns in discriminating peripheral and central causes strongly depends on the pattern seen and the type of testing performed, being highly predictive of a central cause for torsional and vertical spontaneous nystagmus, downbeat, or apogeotropic horizontal and treatment-refractory positional nystagmus. The predictive value for central causes was moderate only for vertical nystagmus after horizontal head-shaking ("perverted" head-shaking nystagmus) since it can also occur in peripheral cases, while the predictive value was low for vibration-induced nystagmus and Valsalva-induced nystagmus.
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Affiliation(s)
- Sun-Uk Lee
- Neurotology and Neuro-Ophthalmology Laboratory, Korea University Medical Center, Seoul, Korea
- Department of Neurology, Korea University Medical Center, Seoul, Korea
| | - Alexander A Tarnutzer
- Neurology Unit, Cantonal Hospital of Baden, Baden, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland.
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Alwood JS, Mulavara AP, Iyer J, Mhatre SD, Rosi S, Shelhamer M, Davis C, Jones CW, Mao XW, Desai RI, Whitmire AM, Williams TJ. Circuits and Biomarkers of the Central Nervous System Relating to Astronaut Performance: Summary Report for a NASA-Sponsored Technical Interchange Meeting. Life (Basel) 2023; 13:1852. [PMID: 37763256 PMCID: PMC10532466 DOI: 10.3390/life13091852] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 08/24/2023] [Accepted: 08/25/2023] [Indexed: 09/29/2023] Open
Abstract
Biomarkers, ranging from molecules to behavior, can be used to identify thresholds beyond which performance of mission tasks may be compromised and could potentially trigger the activation of countermeasures. Identification of homologous brain regions and/or neural circuits related to operational performance may allow for translational studies between species. Three discussion groups were directed to use operationally relevant performance tasks as a driver when identifying biomarkers and brain regions or circuits for selected constructs. Here we summarize small-group discussions in tables of circuits and biomarkers categorized by (a) sensorimotor, (b) behavioral medicine and (c) integrated approaches (e.g., physiological responses). In total, hundreds of biomarkers have been identified and are summarized herein by the respective group leads. We hope the meeting proceedings become a rich resource for NASA's Human Research Program (HRP) and the community of researchers.
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Affiliation(s)
| | | | - Janani Iyer
- Universities Space Research Association (USRA), Moffett Field, CA 94035, USA
| | | | - Susanna Rosi
- Department of Physical Therapy & Rehabilitation Science, University of California, San Francisco, CA 94110, USA
- Department of Neurological Surgery, University of California, San Francisco, CA 94110, USA
| | - Mark Shelhamer
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Catherine Davis
- Department of Pharmacology and Molecular Therapeutics, Uniformed Services University of the Health Sciences (USUHS), Bethesda, MD 20814, USA
| | - Christopher W. Jones
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Xiao Wen Mao
- Department of Basic Sciences, Division of Biomedical Engineering Sciences (BMES), Loma Linda University Health, Loma Linda, CA 92354, USA
| | - Rajeev I. Desai
- Integrative Neurochemistry Laboratory, Behavioral Biology Program, McLean Hospital-Harvard Medical School, Belmont, MA 02478, USA
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Sinno S, Schmerber S, Perrin P, Dumas G. Fifty Years of Development of the Skull Vibration-Induced Nystagmus Test. Audiol Res 2021; 12:10-21. [PMID: 35076447 PMCID: PMC8788279 DOI: 10.3390/audiolres12010002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 12/20/2021] [Accepted: 12/22/2021] [Indexed: 11/24/2022] Open
Abstract
This review enumerates most of the studies on the Skull Vibration-Induced Nystagmus Test (SVINT) in the past 50 years from different research groups around the world. It is an attempt to demonstrate the evolution of this test and its increased interest around the globe. It explores clinical studies and animal studies, both permitting a better understanding of the importance of SVINT and its pathophysiology.
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Affiliation(s)
- Solara Sinno
- EA 3450 DevAH, Development, Adaptation and Handicap, Faculty of Medicine, University of Lorraine, 54500 Vandoeuvre-lès-Nancy, France; (P.P.); (G.D.)
- Laboratory for the Analysis of Posture, Equilibrium and Motor Function (LAPEM), University Hospital of Nancy, 54500 Vandoeuvre-lès-Nancy, France
| | - Sébastien Schmerber
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Grenoble Alpes University Hospital, 38000 Grenoble, France;
- Brain Tec Lab UMR1205, University Grenoble-Alpes, CHU Michallon, 38000 Grenoble, France
| | - Philippe Perrin
- EA 3450 DevAH, Development, Adaptation and Handicap, Faculty of Medicine, University of Lorraine, 54500 Vandoeuvre-lès-Nancy, France; (P.P.); (G.D.)
- Laboratory for the Analysis of Posture, Equilibrium and Motor Function (LAPEM), University Hospital of Nancy, 54500 Vandoeuvre-lès-Nancy, France
- Department of Pediatric Oto-Rhino-Laryngology, University Hospital of Nancy, 54500 Vandoeuvre-lès-Nancy, France
| | - Georges Dumas
- EA 3450 DevAH, Development, Adaptation and Handicap, Faculty of Medicine, University of Lorraine, 54500 Vandoeuvre-lès-Nancy, France; (P.P.); (G.D.)
- Laboratory for the Analysis of Posture, Equilibrium and Motor Function (LAPEM), University Hospital of Nancy, 54500 Vandoeuvre-lès-Nancy, France
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, Grenoble Alpes University Hospital, 38000 Grenoble, France;
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Waissbluth S, Sepúlveda V. The Skull Vibration-induced Nystagmus Test (SVINT) for Vestibular Disorders: A Systematic Review. Otol Neurotol 2021; 42:646-658. [PMID: 33492062 DOI: 10.1097/mao.0000000000003022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the specificity and sensitivity of the skull vibration-induced nystagmus test (SVINT) for detecting vestibular hypofunction. DATABASES REVIEWED The Cochrane Library, MEDLINE, PubMed, EMBASE, and SciELO. METHODS A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Databases were searched using a comprehensive search strategy including the terms "Vibration-induced nystagmus" or "SVINT" or "skull vibration-induced nystagmus test" or "skull vibration-induced nystagmus" from inception to May 2020. RESULTS A total of 79 articles were identified, and 16 studies met the inclusion criteria. The methodology for performing the SVINT and determining positivity is varied. Most authors refer to reproducibility, sustained response, ending with withdrawal of stimulus, nondirection changing, and response in more than one point of stimulation, as necessary for a positive test. Only seven studies included a slow phase velocity of 2 degrees/s or 2.5 degrees/s as a criterion. Most studies employed 100 Hz stimulus for 10 seconds, while longer duration is suggested for pediatric patients. For partial and total unilateral vestibular loss, positivity varied from 58 to 60%, and 93 to 100%, respectively. Sensitivity ranged from 50 to 100%, and specificity from 62 to 100%. Importantly, the SVINT may decrease with time but does not usually disappear, hence, can provide information of past/compensated vestibular events. CONCLUSIONS The SVINT can be used in pediatric and adult patients. It provides information regarding unilateral vestibular loss, acute, or compensated. It is a quick, safe, and noninvasive test, and is complementary to the dynamic vestibular and positional tests.
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Affiliation(s)
- Sofia Waissbluth
- Department of Otolaryngology, Pontificia Universidad Católica de Chile, Santiago, Chile
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Zhang Y, Soper J, Lohse CM, Eggers SDZ, Kaufman KR, McCaslin DL. Agreement between the Skull Vibration-Induced Nystagmus Test and Semicircular Canal and Otolith Asymmetry. J Am Acad Audiol 2021; 32:283-289. [PMID: 33873220 DOI: 10.1055/s-0041-1723039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND How significant asymmetries in otolith organ function in the presence of symmetrical and asymmetrical semicircular canal function influence skull vibration-induced nystagmus testing (SVINT) has not been well described. PURPOSE The aim of the study is to examine the agreement between SVINT and caloric testing, ocular vestibular-evoked myogenic potentials (oVEMP), and cervical vestibular-evoked myogenic potentials (cVEMP) for detecting asymmetric vestibular function. RESEARCH DESIGN This is a retrospective study of patients presenting with the chief complaint of vertigo, dizziness, or imbalance. STUDY SAMPLE A total of 812 patients were studied with a median age at testing of 59 years (interquartile range 46-70; range 18-93) and included 475 (59%) women. INTERVENTION Either the monothermal warm caloric test or alternate binaural bithermal caloric test, oVEMP, and cVEMP tests were administered to all patients. All patients underwent the SVINT prior to vestibular laboratory testing. DATA COLLECTION AND ANALYSIS Agreement between tests categorized as normal versus abnormal was summarized using percent concordance (PC). Sensitivity and specificity values were calculated for SVINT compared with other tests of vestibular function. RESULTS There was higher agreement between ipsilateral and contralateral SVINT with the caloric test (PC = 80% and 81%, respectively) compared with oVEMP (PC = 63% and 64%, respectively) and cVEMP (PC = 76% and 78%, respectively). Ipsilateral and contralateral SVINT showed higher sensitivity for the caloric test (sensitivity = 47% and 36%, respectively) compared with oVEMP (sensitivity = 26% and 21%, respectively), or cVEMP (sensitivity = 33% vs. 27%, respectively). Specificity of SVINT was high (>80%) for all assessments of vestibular function. CONCLUSION The presence of SVIN is a useful indicator of the asymmetry of vestibular function between the two ears when making judgments about semicircular canal asymmetry but is less sensitive to asymmetries in otolith organ function.
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Affiliation(s)
- Yue Zhang
- Vestibular and Balance Program, Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota.,Department of Rehabilitation Medicine, Tianjin Huanhu Hospital, Tianjin, China
| | - Jamie Soper
- MercyOne Waterloo Medical Center, ENT/Allergy Care, Waterloo, Iowa
| | - Christine M Lohse
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota
| | - Scott D Z Eggers
- Vestibular and Balance Program, Department of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Kenton R Kaufman
- Motion Analysis Laboratory, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Devin L McCaslin
- Vestibular and Balance Program, Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota
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Martin-Sanz E, Esteban-Sánchez J, González-Márquez R, Larrán-Jiménez A, Cuesta Á, Batuecas-Caletrio Á. Vibration-induced nystagmus and head impulse test screening for vestibular schwannoma. Acta Otolaryngol 2021; 141:340-347. [PMID: 33583327 DOI: 10.1080/00016489.2021.1872797] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
LEVEL OF EVIDENCE II-2. BACKGROUND Vestibular schwannomas are benign tumors of the eight cranial nerve that may cause asymmetric sensorineural hearing loss (ASHL) and vestibular dysfunction. OBJECTIVE The aim of this study was to assess the role of the video head impulse test (vHIT) and vibration-induced nystagmus (VIN) test in diagnosing vestibular schwannoma in a population of patients with Asymmetric sensorineural hearing loss. MATERIAL AND METHODS For this prospective case-control study, 23 consecutive patients with ASHL and normal magnetic resonance were enrolled in the control group, and 33 consecutive patients with ASHL and vestibular schwannoma were enrolled in the case group. Gold standard was magnetic resonance imaging. Audiometry, vHIT, and VIN tests were performed for each patient. Significance of VIN and vHIT testing was determined by evaluation of their sensitivity, specificity, and correlation with vestibular function tests. RESULTS Regarding the vHIT, sensitivity and specificity were 45.5% and 82.6%, respectively, for horizontal canal gain, 60.6% and 87.6%, respectively, for posterior canal gain, and 45.5% and 78.3%, respectively, when analyzing superior canal gains. Regarding the VIN test, the sensitivity and specificity were 81.8% and 73.9%, respectively, when based on the presence of a VIN with any mastoid stimulation. CONCLUSIONS Our results suggest that using the VIN test may be an efficient approach to screen for vestibular schwannoma in patients with asymmetric sensorineural hearing loss. SIGNIFICANCE Our results suggest that using the VIN test may be an efficient approach to screen for vestibular schwannoma in patients with ASHL.
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Affiliation(s)
- Eduardo Martin-Sanz
- Otoneurology Unit, ENT Department, University Hospital of Getafe, Madrid, Spain
| | | | | | - Alba Larrán-Jiménez
- Otoneurology Unit, ENT Department, University Hospital of Getafe, Madrid, Spain
| | - Ángela Cuesta
- Otoneurology Unit, ENT Department, University Hospital of Getafe, Madrid, Spain
| | - Ángel Batuecas-Caletrio
- Otoneurology Unit, ENT Department, University Hospital of Salamanca, IBSAL, Salamanca, Spain
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Matos R, Navarro M, Pérez-Guillén V, Pérez-Garrigues H. The role of vertical semicircular canal function in the vertical component of skull vibration-induced nystagmus. Acta Otolaryngol 2020; 140:639-645. [PMID: 32329666 DOI: 10.1080/00016489.2020.1751877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: Generally, vertical component of the skull vibratory nystagmus (VCN) is ignored in the clinical practise. Thus, the relative contribution of the vestibular organs in the presence of VCN remains unknown.Objectives: To determine the association between vertical semicircular canal (vSCC) function and the presence of VCN.Material and methods: Comparisons were made between Video Head Impulse Test and SVINT (100 Hz) results at the time of the acute peripheral vestibular lesion (PVL) and at the post-acute phase in patients diagnosed PVL. Later on, a paired analysis was performed restricting the assessments to patients with vestibular explorations in both the acute and post-acute phases.Results: In an univariable analysis, larger mean total gain differences (TGD) between vSCC VOR gains, significantly related with the appearance of VCN in nystagmography in the acute phase (p = .001), unlike the post-acute phase (p = .46). After a multivariate analysis, mean TGD was the only predictive factor of the VCN (p = .013). In the paired analysis, we found an increase in the post-acute phase mean TGD, approaching zero value.Conclusions and significance: Global relation between all vertical canals has at least a contributory role in the presence of the vertical component of nystagmus in SVINT.
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Affiliation(s)
- Ricardo Matos
- Department of Otorhinolaryngology, Centro Hospitalar Universitário São João EPE, Porto, Portugal University of Porto Medical School, Porto, Portugal.,University of Porto Medical School, Porto, Portugal
| | - Marta Navarro
- Otoneurology Unit, ENT Department, Hospital "La Fe", Valencia, Spain
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Aghababaei Ziarati M, Taziki MH, Hosseini SM. Autonomic laterality in caloric vestibular stimulation. World J Cardiol 2020; 12:144-154. [PMID: 32431785 PMCID: PMC7215963 DOI: 10.4330/wjc.v12.i4.144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/12/2020] [Accepted: 03/26/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Caloric stimulation of the vestibular system is associated with autonomic response. The lateralization in the nervous system activities also involves the autonomic nervous system.
AIM To compare the effect of the right and left ear caloric test on the cardiac sympathovagal tone in healthy persons.
METHODS This self-control study was conducted on 12 healthy male volunteers. The minimal ice water caloric test was applied for vestibular stimulation. This was done by irrigating 1 milliliter of 4 ± 2 °C ice water into the external ear canal in 1 s. In each experiment, only one ear was stimulated. For each ear, the pessimum position was considered as sham control and the optimum position was set as caloric vestibular stimulation of horizontal semicircular channel. The order of right or left caloric vestibular stimulation and the sequence of optimum or pessimum head position in each set were random. The recovery time between each calorie test was 5 min. The short-term heart rate variability (HRV) was used for cardiac sympathovagal tone metrics. All variables were compared using the analysis of variance.
RESULTS After caloric vestibular stimulation, the short-term time-domain and frequency-domain HRV indices as well as, the systolic and the diastolic arterial blood pressure, the respiratory rate and the respiratory amplitude, had no significant changes. These negative results were similar in the right and the left sides. Nystagmus duration of left caloric vestibular stimulations in the optimum and the pessimum positions had significant differences (e.g., 72.14 ± 39.06 vs 45.35 ± 35.65, P < 0.01). Nystagmus duration of right caloric vestibular stimulations in the optimum and the pessimum positions had also significant differences (e.g., 86.42 ± 67.20 vs 50.71 ± 29.73, P < 0.01). The time of the start of the nystagmus following caloric vestibular stimulation had no differences in both sides and both positions.
CONCLUSION Minimal ice water caloric stimulation of the right and left vestibular system did not affect the cardiac sympathovagal balance according to HRV indices.
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Affiliation(s)
- Mohammadreza Aghababaei Ziarati
- Department of Internal Medicine, Medical Faculty, Golestan University of Medical Sciences, Gorgan 4934174515, Golestan, Iran
| | - Mohammad Hosein Taziki
- Department of Otolaryngology, Medical Faculty, Golestan University of Medical Sciences, Gorgan 4934174515, Golestan, Iran
| | - Seyed Mehran Hosseini
- Department of Physiology, Medical Faculty, Golestan University of Medical Sciences, Gorgan 4934174515, Golestan, Iran
- Neuroscience Research Center, Faculty of Medicine, Golestan University of Medical Sciences, Gorgan 4934174515, Golestan, Iran
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