Hamish G. MacDougall

The video head impulse test: Diagnostic accuracy in peripheral vestibulopathy

Background: The head impulse test (HIT) is a useful bedside test to identify peripheral vestibular deficits. However, such a deficit of the vestibulo-ocular reflex (VOR) may not be diagnosed because corrective saccades cannot always be detected by simple observation. The scleral search coil technique is the gold standard for HIT measurements, but it is not practical for routine testing or for acute patients, because they are required to wear an uncomfortable contact lens. Objective: To develop an easy-to-use video HIT system (vHIT) as a clinical tool for identifying peripheral vestibular deficits. To validate the diagnostic accuracy of vHIT by simultaneous measures with video and search coil recordings across healthy subjects and patients with a wide range of previously identified peripheral vestibular deficits. Methods: Horizontal HIT was recorded simultaneously with vHIT (250 Hz) and search coils (1,000 Hz) in 8 normal subjects, 6 patients with vestibular neuritis, 1 patient after unilateral intratympanic gentamicin, and 1 patient with bilateral gentamicin vestibulotoxicity. Results: Simultaneous video and search coil recordings of eye movements were closely comparable (average concordance correlation coefficient rc = 0.930). Mean VOR gains measured with search coils and video were not significantly different in normal (p = 0.107) and patients (p = 0.073). With these groups, the sensitivity and specificity of both the reference and index test were 1.0 (95% confidence interval 0.69–1.0). vHIT measures detected both overt and covert saccades as accurately as coils. Conclusions: The video head impulse test is equivalent to search coils in identifying peripheral vestibular deficits but easier to use in clinics, even in patients with acute vestibular neuritis.

Impulsive Testing of Semicircular-Canal Function Using Video-oculography

The head impulse test (HIT) is a safe, quick way of assessing horizontal semicircular‐canal function in patients with peripheral vestibular loss. At the bedside, the clinician identifies “overt” catch‐up saccades back to the target after brisk passive head rotation as an indirect sign of canal paresis. However, saccades during head rotation (“covert” saccades) may not be detectable by the naked eye, and so lead to incorrect diagnosis. Up to now, the scleral search coil technique has been the standard for HIT measurement, but that technique is not practical for routine diagnostic use. A new lightweight, nonslip, high‐speed video‐oculography system (vHIT) that measures eye velocity during horizontal head impulses has been developed. This system is easy to use in a clinical setting, provides an objective measure of the vestibulo‐ocular reflex (VOR), and detects both overt and covert catch‐up saccades in patients with vestibular loss.

Ocular vestibular evoked myogenic potentials to bone conducted vibration of the midline forehead at Fz in healthy subjects

OBJECTIVE To provide the empirical basis for using ocular vestibular evoked myogenic potentials (oVEMPS) in response to Fz bone conducted vibration (BCV) stimulation to indicate vestibular function in human subjects. To show the generality of the response by testing a large number of unselected healthy subjects across a wide age range and the repeatability of the response within subjects. To provide evidence that the response depends on otolithic function. METHODS The early negative component (n10) of the oVEMP to brief BCV of the forehead, in the midline at the hairline (Fz) is recorded by surface EMG electrodes just beneath the eyes. We used a Bruel and Kjaer 4810 Mini-Shaker or a light tap with a tendon hammer to provide adequate BCV stimuli to test a large number (67) of unselected healthy people to quantify the individual differences in n10 magnitude, latency and symmetry to Fz BCV. A Radioear B-71 bone oscillator at Fz is not adequate to elicit a reliable n10 response. RESULTS The n10 oVEMP response showed substantial differences in amplitude between subjects, but is repeatable within subjects. n10 is of equal magnitude in both eyes with an average asymmetry around 11%. The average n10 amplitude for Mini Tone Burst BCV is 8.47microV+/-4.02 (sd), the average latency is 10.35ms+/-0.63 (sd). The amplitude of n10 decreases and its latency increases with age. CONCLUSIONS oVEMPs are a new reliable, repeatable test to indicate vestibular and probably otolithic function. SIGNIFICANCE This study shows the optimum conditions for recording oVEMPs and provides baseline values for individual differences and asymmetry. oVEMPs can be measured in senior subjects without difficulty.

The Video Head Impulse Test (vHIT) Detects Vertical Semicircular Canal Dysfunction

Background The video head impulse test (vHIT) is a useful clinical tool to detect semicircular canal dysfunction. However vHIT has hitherto been limited to measurement of horizontal canals, while scleral search coils have been the only accepted method to measure head impulses in vertical canals. The goal of this study was to determine whether vHIT can detect vertical semicircular canal dysfunction as identified by scleral search coil recordings. Methods Small unpredictable head rotations were delivered by hand diagonally in the plane of the vertical semicircular canals while gaze was directed along the same plane. The planes were oriented along the left-anterior-right-posterior (LARP) canals and right-anterior-left-posterior (RALP) canals. Eye movements were recorded simultaneously in 2D with vHIT (250 Hz) and in 3D with search coils (1000 Hz). Twelve patients with unilateral, bilateral and individual semicircular canal dysfunction were tested and compared to seven normal subjects. Results Simultaneous video and search coil recordings were closely comparable. Mean VOR gain difference measured with vHIT and search coils was 0.05 (SD = 0.14) for the LARP plane and −0.04 (SD = 0.14) for the RALP plane. The coefficient of determination R2 was 0.98 for the LARP plane and 0.98 for the RALP plane and the results of the two methods were not significantly different. vHIT and search coil measures displayed comparable patterns of covert and overt catch-up saccades. Conclusions vHIT detects dysfunction of individual vertical semicircular canals in vestibular patients as accurately as scleral search coils. Unlike search coils, vHIT is non-invasive, easy to use and hence practical in clinics.

Ocular Vestibular Evoked Myogenic Potentials in Response to Bone-Conducted Vibration of the Midline Forehead at Fz

If a patient, who is lying supine and looking upward, is given bone-conducted vibration (BCV) of the forehead at the hairline in the midline (Fz) with a clinical reflex hammer or a powerful bone conduction vibrator, short-latency surface potentials called ocular vestibular evoked myogenic potentials (oVEMP) can be recorded from just beneath the eyes. The early negative (excitatory) component (n10) is approximately equal in amplitude for both eyes in healthy subjects, but in patients with unilateral vestibular loss, the n10 component is significantly asymmetrical under the 2 eyes – the n10 component is small or absent under the eye on the side contralateral to the prior unilateral vestibular nerve removal, but of normal amplitude under the eye on the side contralateral to the healthy ear. The n10 component of the oVEMP response to BCV at Fz stimuli reflects vestibular and probably mainly otolithic function via crossed otolithic-ocular pathways, and so n10 asymmetry is a new way of identifying the affected side in patients with unilateral otolithic loss.

The video head impulse test (vHIT) of semicircular canal function – age dependent normative values of VOR gain in healthy subjects

Background/hypothesis The video Head Impulse Test (vHIT) is now widely used to test the function of each of the six semicircular canals individually by measuring the eye rotation response to an abrupt head rotation in the plane of the canal. The main measure of canal adequacy is the ratio of the eye movement response to the head movement stimulus, i.e., the gain of the vestibulo-ocular reflex (VOR). However, there is a need for normative data about how VOR gain is affected by age and also by head velocity, to allow the response of any particular patient to be compared to the responses of healthy subjects in their age range. In this study, we determined for all six semicircular canals, normative values of VOR gain, for each canal across a range of head velocities, for healthy subjects in each decade of life. Study design The VOR gain was measured for all canals across a range of head velocities for at least 10 healthy subjects in decade age bands: 10–19, 20–29, 30–39, 40–49, 50–59, 60–69, 70–79, 80–89. Methods The compensatory eye movement response to a small, unpredictable, abrupt head rotation (head impulse) was measured by the ICS impulse prototype system. The same operator delivered every impulse to every subject. Results Vestibulo-ocular reflex gain decreased at high head velocities, but was largely unaffected by age into the 80- to 89-year age group. There were some small but systematic differences between the two directions of head rotation, which appear to be largely due to the fact that in this study only the right eye was measured. The results are considered in relation to recent evidence about the effect of age on VOR performance. Conclusion These normative values allow the results of any particular patient to be compared to the values of healthy people in their age range and so allow, for example, detection of whether a patient has a bilateral vestibular loss. VOR gain, as measured directly by the eye movement response to head rotation, seems largely unaffected by aging.

Maintained ocular torsion produced by bilateral and unilateral galvanic (DC) vestibular stimulation in humans

Abstract This study was designed to measure ocular movements evoked by galvanic (DC) stimulation using computerised video-oculography. Long duration (>30 s) galvanic vestibular stimulation at currents of up to 5 mA through large-area surface electrodes over the mastoid processes causes maintained changes in the ocular torsional position of both eyes in healthy human subjects. With the subject seated and the head held firmly, torsion was measured by a computer-based image-processing system (VTM). Torsion was recorded in darkness, with or without a single fixation point. With bilateral stimulation, the upper poles of both eyes always torted away from the side of cathode placement and toward the anode. For unilateral stimulation, torsion was directed away from the cathode or toward the anode. The magnitude of ocular torsion was dependent on current strength: with bilateral stimulation the peak torsion was on average 2.88° for 5-mA current intensity compared with 1.58° for 3 mA. A smaller amplitude of torsion was obtained for unilateral stimulation. The average peak torsion was the same for both eyes for all forms of stimulation. Our findings indicate that low-intensity galvanic stimulation evokes ocular torsion in normal subjects, an effect which is consistent with an action on otolith afferents.

Electrophysiological evidence for vestibular activation of the guinea pig hippocampus

&NA; Vestibular information modulates hippocampal activity for spatial processing and place cell firing. However, evidence of a purely vestibular stimulus modulating hippocampal activity is confounded as most studies use stimuli containing somatosensory and visual components. In the present study, high‐frequency electrical stimulation of specific vestibular sensory regions of the right labyrinth in anaesthetized guinea pigs induced an evoked field potential in the hippocampal formation bilaterally with a latency of about 40 ms following stimulation onset. Field potentials localized in the hippocampal formation occurred with stimulus current parameters that were too small to produce eye movements. This provides direct electrophysiological evidence of vestibular input to the hippocampus.

Cerebellar ataxia, neuropathy, vestibular areflexia syndrome (CANVAS): a review of the clinical features and video-oculographic diagnosis

The association of bilateral vestibulopathy with cerebellar ataxia was first reported in 1991 and delineated as a distinct syndrome with a characteristic and measurable clinical sign—an absent visually enhanced vestibulo‐ocular reflex—in 2004. We reviewed 27 patients with this syndrome and show that a non‐length‐dependent sensory deficit with absent sensory nerve action potentials is an integral component of this syndrome, which we now call “cerebellar ataxia with neuropathy and bilateral vestibular areflexia syndrome” (CANVAS). All patients had brain MRI and 22/27 had evidence of cerebellar atrophy involving anterior and dorsal vermis, as well as the hemispheric crus I. Brain and temporal bone pathology in one patient showed marked loss of Purkinje cells and of vestibular, trigeminal, and facial ganglion cells, but not of spiral ganglion cells. There are two sets of sibling pairs, suggesting CANVAS is a late‐onset recessive disorder. The characteristic clinical sign—the visual vestibulo‐ocular reflex deficit—can be demonstrated and measured clinically using video‐oculography.

Gentamicin ototoxicity: a 23-year selected case series of 103 patients

Objective: To review patients with severe bilateral vestibular loss associated with gentamicin treatment in hospital.