Rudi Pecci

Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo Presenting with Torsional Downbeating Nystagmus: An Apogeotropic Variant

The aim of this study is to verify the hypothesis that free-floating particles could sometimes localize into the distal portion of the non ampullary arm of the posterior semicircular canal (PSC) so that assuming the Dix-Hallpikes positions, the clot could move towards the ampulla eliciting a inhibitory torsional-down beating paroxysmal positional nystagmus (PPNy), instead of typical excitatory torsional-up beating PPNy. Among 45 patients with vestibular signs suggesting anterior semicircular canal paroxysmal positional vertigo (PPV), collected from February 2003 to August 2006, we detected a group of 6 subjects whose clinical findings showed a singular behaviour during follow-up. At the first check-up, all patients were submitted to different types of physical manoeuvres for ASC canalolithiasis. Patients were controlled during the same session and after one week. When we found that nystagmus was qualitatively changed we adopted the appropriate physical therapies for that sign. At a next check-up, after having performed some physical therapies, all patients had a typical PSC PPNy of the opposite side, with respect to that of the ASC initially diagnosed. Basing on these observations we conclude that PSC PPV, similarly to lateral semicircular canal PPV, could manifests in a apogeotropic variant.

Can emergency physicians accurately and reliably assess acute vertigo in the emergency department

To validate a clinical diagnostic tool, used by emergency physicians (EPs), to diagnose the central cause of patients presenting with vertigo, and to determine interrater reliability of this tool.

Pathophysiology of lateral semicircular canal paroxysmal positional vertigo

OBJECTIVE To study the pathophysiology of lateral semicircular canal (LSC) paroxysmal positional vertigo (PPV). STUDY DESIGN Retrospective study. METHODS Between June 2004 and June 2005 we observed 471 patients with PPV. In the apogeotropic forms of LSC-PPV, we tried to transform the nystagmus into the geotropic form, either by diagnostic or therapeutic menoeuvres. If we failed, we advised barbecue rotations toward the healthy side and sleeping on the affected side. Patients were evaluated once a week until resolution. RESULTS 91 patients suffered LSC involvement, in 61 cases in the geotropic form and in 30 cases in the apogeotropic form. Out of these, five transformed into the geotropic form during the first examination; in 5 patients we observed geotropic nystagmus at the follow-up visit; the last 20 never showed geotropic nystagmus before resolution. CONCLUSION We hypothesize that in the geotropic form the debris is free floating in the posterior arm of the LSC (canalolithiasis). In the apogeotropic form the debris can be free floating in the anterior arm or attached to the cupula of the ampulla; if we observe transformation from the apogeotropic into the geotropic form this suggested a canalolithiasis, otherwise we have assumed a cupulolithiasis.

About Nystagmus Transformation in a Case of Apogeotropic Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo

There are two forms of lateral semicircular canal benign paroxysmal positional vertigo: geotropic and apogeotropic. When the pathophysiological mechanism of the apogeotropic form is that of canalolithiasis, we can observe a transformation from an apogeotropic nystagmus into a geotropic one. Usually, this phenomenon happens simultaneously on both sides, thus enabling us to observe a right-beating paroxysmal positional nystagmus when the patient lies on the right side and a left-beating paroxysmal positional nystagmus on the left side. We describe a case in which the transformation occurred gradually, so that, after three head rotations from side to side in supine position, there was a right nystagmus beating toward the ground (geotropic) with the patient on the right side and a right nystagmus beating away from the ground (apogeotropic) on the left side. However, after further rotations we observed the nystagmus transformation also on the left side, with a geotropic nystagmus on both sides. The phenomenon of gradual transformation could happen because initially only a part of the debris moved from the anterior to the posterior aspect of the canal during head rotations.

Apogeotropic Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo: Some Clinical and Therapeutic Considerations.

We lately reported the cases of patients complaining positional vertigo whose nystagmic pattern was that of a peripheral torsional vertical positional down beating nystagmus originating from a lithiasis of the non-ampullary arm of the posterior semicircular canal (PSC). We considered this particular pathological picture the apogeotropic variant of PSC benign paroxysmal positional vertigo (BPPV). Since the description of the pilot cases we observed more than 150 patients showing the same clinical sign and course of symptoms. In this paper we describe, in detail, both nystagmus of apogeotropic PSC BPPV (A-PSC BPPV) and symptoms reported by patients trying to give a reasonable explanation for these clinical features. Moreover we developed two specific physical therapies directed to cure A-PSC BPPV. Preliminary results of these techniques are related.

Duplex Sonography of Vertebral Arteries for Evaluation of Patients with Acute Vertigo

We evaluated the role of vertebral artery extracranial color-coded duplex sonography (VAECCS) in predicting vertebrobasilar stroke in consecutive patients presenting to the emergency department with vertigo of suspected ischemic origin. The final diagnosis was established by a panel of experts consisting of an emergency physician, a neurologist, and an otoneurologist. Vertebrobasilar stroke was diagnosed when an acute brain ischemic lesion congruent with symptoms was detected by neuroimaging during the index visit or a stroke was diagnosed within a 3-mo period after emergency department presentation. Among 126 patients, 28 (22%) were diagnosed with vertebrobasilar stroke. Fifteen (75%) of 20 patients with abnormal VAECCS results and 13 (12%) of 106 with normal VAECCS results had a final diagnosis of vertebrobasilar stroke. The sensitivity and specificity of VAECCS were 53.6% and 94.9%, respectively. Detecting an abnormal flow pattern at VAECCS significantly increased the risk of vertebrobasilar stroke (odds ratio = 21.5). The flow patterns most frequently related to vertebrobasilar stroke were absence of flow and high resistance pattern velocity (odds ratio = 9.3 and 22.7, respectively). VAECCS predicts vertebrobasilar stroke and could be a useful bedside screening tool in patients with vertigo.

Differential Diagnosis of Vertigo in the Emergency Department: A Prospective Validation Study of the STANDING Algorithm

Objective We investigated the reliability and accuracy of a bedside diagnostic algorithm for patients presenting with vertigo/unsteadiness to the emergency department. Methods We enrolled consecutive adult patients presenting with vertigo/unsteadiness at a tertiary hospital. STANDING, the acronym for the four-step algorithm we have previously described, based on nystagmus observation and well-known diagnostic maneuvers includes (1) the discrimination between SponTAneous and positional nystagmus, (2) the evaluation of the Nystagmus Direction, (3) the head Impulse test, and (4) the evaluation of equilibrium (staNdinG). Reliability of each step was analyzed by Fleiss’ K calculation. The reference standard (central vertigo) was a composite of brain disease including stroke, demyelinating disease, neoplasm, or other brain disease diagnosed by initial imaging or during 3-month follow-up. Results Three hundred and fifty-two patients were included. The incidence of central vertigo was 11.4% [95% confidence interval (CI) 8.2–15.2%]. The leading cause was ischemic stroke (70%). The STANDING showed a good reliability (overall Fleiss K 0.83), the second step showing the highest (0.95), and the third step the lowest (0.74) agreement. The overall accuracy of the algorithm was 88% (95% CI 85–88%), showing high sensitivity (95%, 95% CI 83–99%) and specificity (87%, 95% CI 85–87%), very high-negative predictive value (99%, 95% CI 97–100%), and a positive predictive value of 48% (95% CI 41–50%) for central vertigo. Conclusion Using the STANDING algorithm, non-sub-specialists achieved good reliability and high accuracy in excluding stroke and other threatening causes of vertigo/unsteadiness.

An unusual case of vertigo: the usefulness of nystagmus examination.

A 50-year-old gardener presented to our Emergency Department (ED) after the onset of a sudden objective vertigo while standing up during work, accompanied by imbalance, nausea, and vomiting. Neither tinnitus nor other aural symptoms were present, but, if asked, he also complained of a mild headache. He had no medical background of interest except for a known hypertension, left untreated, and a possible history of migraine for which he was admitted to the ED 1 year before. He denied recent viral infections or trauma. He was an active smoker (35 pack years), but denied alcohol or sympathomimetic intake; he was not taking any medication and had no allergies. Clinical examination revealed no neurological deficit, in particular neither dysmetria nor motor or sensitive deficit, and the patient’s physical examination was normal except for a right beating horizontal nystagmus in primary position. Due to vomiting and overt vagal signs, upright position was impossible to evaluate. The blood pressure was found high and symmetric in both arms (160/100 mmHg), but the other vital signs were normal (HR 80 beats/min, SpO2 99 % in FiO2 21 %, temperature 36.5 C). The National Institutes of Health Stroke Scale (NIHSS) was 0 [1]. The absence of otological and aural symptoms, as well as the absence of a recurrent vertigo in the history of the patient, was not compatible with Menière disease. A vestibular migraine could be excluded too because of the lack of diagnostic criteria of migraine [2]. The patient was free from neurological signs except for nystagmus and referred imbalance. These features could be typical of an acute vestibular syndrome of peripheral origin; however, a more detailed nystagmus evaluation was needed. The STANDING, a recently developed diagnostic algorithm for the evaluation of patients with acute vertigo, was used to evaluate the patient [3] (Fig. 1). Frenzel goggles confirmed the presence of a spontaneous, i.e., not triggered by head movements, horizontal, right beating, and unidirectional nystagmus, thus excluding a Benign Paroxysmal Positional vertigo (BPPV). As indicated by the diagnostic algorithm, to differentiate a peripheral from a central disease, a head impulse test (HIT) was performed [4]. The HIT test was negative, strongly suggesting a central origin. Therefore, a first-level bedside eco-color Doppler of the neck vessels was obtained that showed the absence of blood flow in the right vertebral artery. These findings prompted the execution of a CT angiography of cervical and intracranial vessels that showed a sub occlusive stenosis of the right vertebral artery at the onset, probably caused by a spontaneous dissection (Fig. 2). To confirm the diagnosis, the patient underwent a DWI sequences MRI that clearly revealed a cerebellar stroke (Fig. 3a, b). Systemic thrombolysis was not initiated, because of the delay of presentation to the ED (more than 6 h from the onset of symptoms to ED presentation), and ASA was started. The patient was admitted to the neurologic ward. The next day the patient’s neurologic state worsened, and a new onset dysmetria of the left arm, left hemi-anaesthesia of the face, left VI and VII cranial nerves palsy, and left hearing loss were detected. The patient underwent new MRI, and acute lesions in the left cerebellar peduncle were found. An & Carlotta Casati carlotta.casati86@gmail.com

Audio Vestibular Involvement in Behçet’s Disease

The audio-vestibular system is often involved in many autoimmune syndromes as Cogan’s syndrome and Granulomatosis with polyangiitis (Wegener’s granulomatosis) but an involvement in Behcet’s disease is reported more frequently only in the last years. Behcet’s disease was first defined by Hulusi Behcet in 1937. It is a refractory multisystem disorder mainly presenting with recurrent oral aphthae and genital ulcerations, skin lesions, and uveitis. The disease is a chronic inflammatory disorder involving the small vessels, which is of unknown etiology. It has a worldwide distribution with a prevalence ranging from 1:1000 to 1:10,000 in Japan and Turkey to 1:500,000 in North America and Europe. The aetiopathogenesis is obscure but Behcet’s disease is considered to be immune-mediated.

Clinical features of headache in patients with diagnosis of definite Vestibular Migraine: The VM-phenotypes projects

Migraine is a common neurological disorder characterized by episodic headaches with specific features, presenting familial aggregation. Migraine is associated with episodic vertigo, named Vestibular Migraine (VM) whose diagnosis mainly rely on clinical history showing a temporary association of symptoms. Some patient refers symptoms occurring in pediatric age, defined “episodic symptoms which may be associated with migraine.” The aim of this cross sectional observational study was to assess migraine-related clinical features in VM subjects. For the purpose, 279 patients were recruited in different centers in Europe; data were collected by a senior neurologist or ENT specialist through a structured questionnaire. The age of onset of migraine was 21.8 ± 9. The duration of headaches was lower than 24 h in 79.1% of cases. Symptoms accompanying migrainous headaches were, in order of frequency, nausea (79.9%), phonophobia (54.5%), photophobia (53.8%), vomiting (29%), lightheadedness (21.1%). Visual or other auras were reported by 25.4% of subjects. A familial aggregation was referred by 67.4%, while migraine precursors were reported by 52.3% of subjects. Patients reporting nausea and vomiting during headaches more frequently experienced the same symptoms during vertigo. Comparing our results in VM subjects with previously published papers in migraine sufferers, our patients presented a lower duration of headaches and a higher rate of familial aggregation; moreover some common characters were observed in headache and vertigo attacks for accompanying symptoms like nausea and vomiting and clustering of attacks.