Benign paroxysmal positioning vertigo in multiple sclerosis: diagnosis,pathophysiology and therapeutic techniques

OBJECTIVE: To report on the most common causes of vertigo in patients with multiple sclerosis (MS) and emphasize appropriate diagnostic techniques and treatment interventions. BACKGROUND: True vertigo is estimated to occur in about 20% of MS patients. Lesions within the vestibular nuclei and in the root entry zone of cranial nerve VIII represent the most common locations where demyelinating activity can provoke vertigo in patients with MS. However, other causes of vertigo should be explored in MS patients in order to avoid unnecessary treatment with corticosteroids and vestibular suppressants. Recently, we reviewed our four-year experience with new onset vertigo in our university-based MS population and found that benign paroxysmal positioning vertigo (BPPV) to be the most common cause. All patients diagnosed with BPPV were treated successfully with particle repositioning maneuvers. The remaining patients were treated with conventional therapies appropriate for the specific diagnosis. CONCLUSIONS: Empiric treatments with corticosteroids and/or vestibular suppressants should not be employed until all MS patients undergo a careful bedside examination, which includes diagnostic positional and, if indicated, particle repositioning maneuvers. Here we emphasize the pathophysiology of BPPV and illustrate the proper techniques for the diagnostic and therapeutic maneuvers.     

Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo has been recognized as the most common vestibular disorder. The evolution of its pathophysiological concepts has led to current therapeutic strategies that have made it the most successfully treatable cause of vertigo.     

Migraine and isolated recurrent vertigo of unknown cause

Chronic recurrent attacks of vertigo, not associated with any auditory or neurological symptoms, are a common reason for referral to our neurotology clinic. Even after an extensive neurotological evaluation, some cases remain undiagnosed. We prospectively evaluated 72 consecutive patients who presented to the clinic with isolated recurrent vertigo of unknown cause. All patients underwent diagnostic evaluation to exclude identifiable causes of isolated recurrent vertigo. We compared the prevalence of migraine, according to the International Headache Society (IHS) criteria, in the isolated recurrent vertigo group, with a sex- and age-matched control group of orthopedic patients. The prevalence of migraine according to IHS criteria was higher in the isolated recurrent vertigo group (61.1%) than in the control group (10%; p < 0.01). Only 16.7% of patients had an abnormal vestibular function test. The most common abnormal finding was a unilateral vestibular weakness to caloric stimulation. Our results suggest that migraine should be considered in the differential diagnosis of isolated recurrent vertigo of unknown cause.     

Differential diagnosis of tinnitus and vertigo. A review

Tinnitus and vertigo, two common neurological complaints, often challenge the physician's ability with respect to possible etiology. Objective tinnitus can result from an abnormally patent eustachian tube, from tetanic contractions of the muscles of the soft palate, or from vascular abnormalities within the head or neck. Subjective tinnitus refers to lesions involving the external ear canal, tympanic membrane, ossicles, cochlea, auditory nerve, brainstem, and cortex. As many as 50% of patients with tinnitus do not exhibit associated hearing loss; in these patients, the cause of the tinnitus is rarely identified. An illusion of movement is specific for vestibular system disease--a peripheral or central location depending upon associated audiologic and neurologic symptoms, respectively. However, a presyncopal, light-headed sensation is most commonly associated with diffuse cerebral ischemia: in the young patient, this may be caused by a hyperventilation syndrome; in the aged individual, this can result from diffuse atherosclerotic cerebrovascular disease and decreased cardiac output. Postural and gait imbalance associated with acute vertigo indicates a unilateral peripheral vestibular or a central vestibular lesion; if vertigo is absent, either a cerebellar, proprioceptive, or bilateral peripheral vestibular lesion is likely. Transient oscillopsia suggests unilateral peripheral vestibular lesions. Permanent oscillopsia indicates a bilateral peripheral vestibular lesion or--in the absence of severe vertigo--brainstem or cerebellar damage.     

Migraine and isolated recurrent vertigo of unknown cause

Abstract

Chronic recurrent attacks of vertigo, not associated with any auditory or neurological symptoms, are a common reason for referral to our neurotology clinic. Even after an extensive neurotological evaluation, some cases remain undiagnosed. We prospectively evaluated 72 consecutive patients who presented to the clinic with isolated recurrent vertigo of unknown cause. All patients underwent diagnostic evaluation to exclude identifiable causes of isolated recurrent vertigo. We compared the prevalence of migraine, according to the International Headache Society (IHS) criteria, in the isolated recurrent vertigo group, with a sex- and age-matched control group of orthopedic patients. The prevalence of migraine according to IHS criteria was higher in the isolated recurrent vertigo group (61.1%) than in the control group (10%; p< 0.01). Only 16.7% of patients had an abnormal vestibular function test. The most common abnormal finding was a unilateral vestibular weakness to caloric stimulation. Our results suggest that migraine should be considered in the differential diagnosis of isolated recurrent vertigo of unknown cause.     

Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo is the most common vestibular disorder, accounting for about 20% of referrals in specialized dizziness clinics. Nowadays, canalolithiasis of the posterior semicircular canal has been widely accepted as the biological basis for typical benign paroxysmal positional vertigo as it is compatible with all clinical features of the disorder. Better understanding of its pathophysiological concepts has led to specific therapeutic strategies, which aim to clear the affected semicircular canal from mobile particles. After a single maneuver both Epley's and Semont's procedures lead to complete recovery in about 60% of patients and in nearly 100% when performed repeatedly. These positioning maneuvers have made benign paroxysmal positional vertigo the most successfully treatable cause of vertigo.     

Update on benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo worldwide. This review considers recent advances in the diagnosis and management of BPPV including the use of web-based technology and artificial intelligence as well as the evidence supporting the use of vitamin D supplements for patients with BPPV and subnormal serum vitamin D.

     

Migraine-related vertigo: Diagnosis and treatment

A comprehensive review of the neurotologic manifestations of migraine is presented, focusing on the most recent publications regarding the epidemiology, clinical presentation, pathophysiology, diagnosis, and management of migraine-related vertigo (MV). A strong association exists between vertigo and migraine, with MV being the most common cause of spontaneous (nonpositional) episodic vertigo. Symptoms can be quite variable among patients and within individual patients over time, creating a diagnostic challenge. MV generally presents with attacks of spontaneous or positional vertigo lasting seconds to days with associated migrainous symptoms. Operational diagnostic criteria have been proposed but are not included in the most recent International Headache Society classification of migraine. Better elucidation of the neurologic linkages between the central vestibular pathways and migraine-related pathways and the discovery of ion channel defects underlying some causes of familial migraine, ataxia, and vertigo have furthered the understanding of MV pathophysiology. Treatment of MV currently parallels that of migraine headache, as proper studies of optimal MV management are just beginning.     

Migraine-related vertigo: Diagnosis and treatment

A comprehensive review of the neurotologic manifestations of migraine is presented, focusing on the most recent publications regarding the epidemiology, clinical presentation, pathophysiology, diagnosis, and management of migraine-related vertigo (MV). A strong association exists between vertigo and migraine, with MV being the most common cause of spontaneous (nonpositional) episodic vertigo. Symptoms can be quite variable among patients and within individual patients over time, creating a diagnostic challenge. MV generally presents with attacks of spontaneous or positional vertigo lasting seconds to days with associated migrainous symptoms. Operational diagnostic criteria have been proposed but are not included in the most recent International Headache Society classification of migraine. Better elucidation of the neurologic linkages between the central vestibular pathways and migraine-related pathways and the discovery of ion channel defects underlying some causes of familial migraine, ataxia, and vertigo have furthered the understanding of MV pathophysiology. Treatment of MV currently parallels that of migraine headache, as proper studies of optimal MV management are just beginning.     

Final diagnosis of patients with clinically suspected vestibular neuritis showing normal caloric response

Vestibular neuritis is one of the most common peripheral causes of acute vestibular syndrome, of which the diagnosis is generally based on a comprehensive interpretation of clinical and laboratory findings following reasonable exclusion of other disorders. This study aimed to investigate the final diagnosis of patients admitted to hospital under the clinical impression of vestibular neuritis who showed no unilateral caloric paresis.Forty-five patients who visited the emergency department with isolated acute spontaneous vertigo were included. Among them, six patients (13%) developed definitive spontaneous vertigo lasting longer than 20 min again after discharge from hospital, accompanied by hearing loss, which was audiometrically documented, leading to a final diagnosis of definite Ménière’s disease. Nine patients (20%) revisited our clinic with recurrent episodic vertigo without any documented hearing loss or auditory symptoms such as hearing loss, tinnitus or ear fullness, which led to a final diagnosis of possible Ménière’s disease. In four patients (9%), initial spontaneous vertigo and nystagmus changed to positional vertigo and nystagmus on the second hospital day. In 26 patients (58%), neither another episode of vertigo nor auditory symptoms developed during follow-up period (7–92 months), a condition to which the authors gave an arbitrary diagnosis of “mild unilateral vestibular deficit”. In conclusion, patients admitted to hospital under clinical impression of vestibular neuritis may have various final diagnoses, and “mild unilateral vestibular deficit” was the most common final diagnosis among patients who did not meet the diagnostic criteria of vestibular neuritis.     

Exercise therapy for positional vertigo.

We present a common cause of vertigo, benign positional paroxysmal vertigo (BPPV), and its history, diagnosis, and therapy. BPPV is suggested by history, readily diagnosed by office examination, and cured by appropriate exercise therapy. Since the condition is so common and often unrecognized, physicians are encouraged to consider BPPV as a possible cause of treatable dizziness.     

Recent Advances in Cerebellar Ischemic Stroke Syndromes Causing Vertigo and Hearing Loss

Cerebellar ischemic stroke is one of the common causes of vascular vertigo. It usually accompanies other neurological symptoms or signs, but a small infarct in the cerebellum can present with vertigo without other localizing symptoms. Approximately 11 % of the patients with isolated cerebellar infarction simulated acute peripheral vestibulopathy, and most patients had an infarct in the territory of the medial branch of the posterior inferior cerebellar artery (PICA). A head impulse test can differentiate acute isolated vertigo associated with PICA territory cerebellar infarction from more benign disorders involving the inner ear. Acute hearing loss (AHL) of a vascular cause is mostly associated with cerebellar infarction in the territory of the anterior inferior cerebellar artery (AICA), but PICA territory cerebellar infarction rarely causes AHL. To date, at least eight subgroups of AICA territory infarction have been identified according to the pattern of neurotological presentations, among which the most common pattern of audiovestibular dysfunction is the combined loss of auditory and vestibular functions. Sometimes acute isolated audiovestibular loss can be the initial symptom of impending posterior circulation ischemic stroke (particularly within the territory of the AICA). Audiovestibular loss from cerebellar infarction has a good long-term outcome than previously thought. Approximately half of patients with superior cerebellar artery territory (SCA) cerebellar infarction experienced true vertigo, suggesting that the vertigo and nystagmus in the SCA territory cerebellar infarctions are more common than previously thought. In this article, recent findings on clinical features of vertigo and hearing loss from cerebellar ischemic stroke syndrome are summarized.     

Vision and vertigo

This review deals with two syndromes, oscillopsia and visual vertigo. Oscillopsia is the illusion of oscillation of the visual surroundings. For diagnosis purposes one should ask, when does the oscillopsia occur? If oscillopsia is only present during head (or whole body) movements, the likely underlying cause is a bilateral defect in the vestibulo-ocular reflex (VOR). The more common causes are post meningitic vestibular damage, gentamicin ototoxicity or bilateral idiopathic vestibular failure. When oscillopsia develops after specific head positions, it is usually due to a positional nystagmus, usually the result of brainstem-cerebellar disease. When the oscillopsia is largely unrelated to head movements, one should ask, is it fairly constant or is it in attacks (paroxysmal)? If the oscillopsia is constant it is usually due to the presence of a clinically observable nystagmus; the most common is downbeat nystagmus but the most visually disabling is pendular nystagmus. If the oscillopsia comes in brief attacks it is usually due to a paroxysmal nystagmus as observed in irritative VIII nerve and brainstem lesions. However, the most common cause of paroxysmal oscillopsia is a non organic condition called voluntary nystagmus. Treatment of oscillopsia is often pharmacological but disappointing; the best chance of success is carbamazepine for paroxysmal disorders secondary to structural vestibular nerve/nuclear lesions.Visual vertigo should not be confused with oscillopsia. It can be defined as dizziness provoked by visual environments with large size (full field) repetitive or moving visual patterns. Patients with visual vertigo report discomfort in supermarkets and when viewing movement of large visual objects, eg crowds, traffic, clouds or foliage. Visual vertigo is present in many patients with a history of a peripheral vestibular disorder, particularly those who are visually dependent (ie subjects who use vision preferentially for postural and space orientation control). Patients with visual vertigo benefit from the addition to their standard vestibular rehabilitation of optic flow (optokinetic) stimuli and exercises involving visuo-vestibular conflict.     

Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common and most treatable cause of vertigo. In most cases, a simple maneuver that takes less than a few minutes to do resolves the problem. BPPV is caused by misplaced calcium carbonate crystals (otoconia) in the semicircular canal of the inner ear that have broken free from the utricle. When these crystals break free, they either remain loose in one of three different semicircular canals or attach to the hair cells within a canal. Several different types of treatment maneuvers have been described. The maneuver to use varies according to the semicircular canal involved and whether the crystals are loose or attached to the hair cells.     

The genetics of vertigo

Vertigo is a common principal complaint among patients seen by primary care physicians, neurologists, and otolaryngologists. The most common causes of recurrent episodes of vertigo are benign inner ear disorders, but central nervous system disorders must be excluded. Several common vertigo syndromes are now known to be familial, a feature distinguishing them from other common causes of vertigo. Familial vertigo has been recognized in patients with isolated recurrent attacks of vertigo, genetic deafness syndromes, and in patients with neurological disorders. Although susceptibility loci and mutations have been identified, genetic heterogeneity is common in all familial vertigo syndromes. Research in these disorders has advanced the understanding of vertigo pathophysiology but much remains to be known. This article provides an overview of the clinical features, genetic analyses, and treatment strategies for these disorders.     

Begutachtung des posttraumatischen Schwindels

Post-traumatic vertigo refers to a group of different disorders which occur following trauma, mainly closed head injury and whiplash injury of the cervical spine. Aside from headaches, vertigo is the most common symptom in this group of patients. In general, there are two main groups of patients with post-traumatic vertigo: those with documented vestibular dysfunctions and those without. The most common post-traumatic vestibular disorders are benign paroxysmal positioning vertigo, labyrinthine concussion, canal dehiscence and otolithic lesions. Some of these disorders are characterized by spontaneous improvement or recovery over weeks or months and some may also be treated effectively. A number of patients, however, develop phobic postural vertigo requiring psychiatric or psychosomatic exploration.     

A minute demyelinating lesion causing acute positional vertigo

Clinico-anatomical correlations in multiple sclerosis patients presenting with central positional vertigo are lacking. We report on a patient with acute onset positional vertigo mimicking benign paroxysmal positional vertigo with a single enhancing lesion in the inner part of the superior cerebellar peduncle, disclosed only after thin slice MR-imaging. This location appears to be a common cause of central positional vertigo and should be regarded as characteristic for demyelinating rather than vascular pathology. In cases presenting with positional nystagmus and vertigo without other cerebellar deficits one should look explicitly for signal abnormalities in the inner part of the superior cerebellar peduncle. High spatial resolution-MRI seems to be mandatory for lesion detection.     

Schwannoma of the vestibulocochlear nerve presenting as isolated paroxysmal vertigo

We report a patient with a schwannoma of the eighth cranial (vestibulocochlear) nerve who presented with isolated episodes of paroxysmal vertigo and positive Dix-Hallpike maneuver, and without the common features of hearing loss, disequilibrium and tinnitus. There are no previous reports of paroxysmal episodes of vertigo as the sole manifestation of schwannoma of the vestibulocochlear nerve. Hence, recurrent paroxysmal vertigo should therefore prompt the physician to rule out schwannoma of the vestibulocochlear nerve as a potential cause even in the presence of normal hearing tests.     

Benign paroxysmal positional vertigo following diagnostic transcranial magnetic stimulation

Neurological Sciences - Benign paroxysmal positional vertigo is the most frequent cause of recurrent vertigo and according to the canalo- and cupulolithiasis theory it is caused by detached...     

良性阵发性位置性眩晕发病与复发相关危险因素分析

良性阵发性位置性眩晕（benign paroxysmal positional vertigo,BPPV）是所有眩晕疾病中最 常见的类型,主要表现为短暂的旋转样感觉,由头位改变（相对于重力作用方向）诱发。其病因尚不 明确,可能与头部外伤、各种内耳疾病等有关,耳石复位是有效的治疗方法,尽管BPPV患者无论治疗 与否疾病缓解率较高,但是仍有复发情况存在。本文结合近年国内外发表的文献对良性阵发性位置 性眩晕发病与复发相关的危险因素进行探讨。