Temporal Relationship between Nystagmus and Perception during Bithermal Alternate Caloric Test

Objectives: During caloric irritation, the spinning/rotating sensation is predominant. However, there is no report on the temporal relationship between caloric nystagmus and perception.Methods: Consecutive 57 participants underwent bithermal caloric test in the dizziness clinic of Chungnam National University Hospital from February 2018 to September 2018. For vestibular perception, we asked the subject to report feelings of rotation and/or linear sensation during each warm and cold water irrigation period. Besides routine caloric parameters, the duration of nystagmus and vestibular sensation were analyzed.Results: In most participants, the caloric nystagmus preceded the vestibular sensation (79.6% in right warm, 83.3% in left warm, 88.5% in right cool, and 84.6% in left cool stimuli). The precedence of perception was observed in 5 normal persons and 15 patients with vestibular migraine (n=4), unilateral vestibulopathy (n=3), and Menière’s disease (n=2), multiple systemic atrophy (n=2), cerebellar ataxia (n=2), vertebrobasilar insufficiency (n=1), and post-earthquake dizziness (n=1). The mean latency between nystagmus and perception was 11.7 seconds. And the duration of nystagmus was longer than that of perception in all conditions. Non-spinning sensations during the caloric test were also observed in some participants (26.8% in right warm, 30.3% in left warm, 29.1% in right cool, and 24.1% in left cool stimuli).Conclusions: During the bithemal alternate caloric test, various vestibular perception and temporal relationship between perception and nystagmus suggest the bithermal caloric stimulation does not reflect only the signal originating from the horizontal canal pathway. A further validation study is needed.

Subclavian Steal Syndrome Secondary to Atherosclerosis: A Case Report and Review of Literature

Subclavian Steal Syndrome (SSS) is a rare vascular syndrome caused due to proximal occlusion or stenosis of subclavian or innominate artery. It is usually asymptomatic but occasionally may present with vertebrobasilar insufficiency and/or upper limb ischemia. Atherosclerosis is the most common cause.

Cerebral Blood Flow Volume in Posterior Circulation Ischemic Disorders

Objective: The aim of this study was to determine blood flow volume (BFV) in the normal state and its features in patients with acute posterior circulation ischemic strokes (PCIS) and vertebrobasilar insufficiency (VBI) using color duplex sonography (DS).Methods: The study included DS data from 96 patients with verified PCIS (66 men and 30 women, aged 64±13 years) and 29 adults with VBI (17 men and 12 women, aged 66±11 years). The control group consisted of 65 healthy male volunteers of different ages.Results: In asymptomatic healthy volunteers, there was a significant decrease in BFV in the internal carotid artery (ICA) with age (502 ml/min in young people, 465 ml/min in the older subgroup) with rS = −0.24 ( p = 0.05), and the aggregated BFV in the vertebral arteries (VAs) turned out to be almost constant (141–143 ml/min). In patients with VBI, the aggregated BFV in the VAs (144 ml/min) did not differ from that in healthy volunteers, but the BFV values in the ICAs were significantly lower (325 ml/min). In patients with PCIS, the aggregated BFV in the ICAs was also significantly lower (399 ml/min) than in the control group but did not significantly differ from that in patients with VBI. In patients with PCIS, there was a significant decrease in the aggregated BFV in the VAs (105 ml/min), which distinguished this group from other examined patients.Conclusions: A significant decrease the BFV in the VA was observed only in patients with PCIS and was associated with the presence of steno-occlusive diseases (SOD) more often in the left VA. Patients with VBI had the most pronounced decrease in BFV in the ICA.

Manual therapy in patients with vertebrobasilar insufficiency

According to WHO statistics, from 40 to 80% of the world's adult population suffer from clinical syndromes of osteochondrosis of the spine. As one of the most common causes of temporary disability, they lead to significant economic losses.

Misdiagnosis of bradyarrhythmias in clinical practice in Iraq

Background and objective: Bradyarrhythmias are one of the many causes of syncope, pre-syncope, and dizzy spells. Missing the diagnosis of bradyarrhythmias, an underlying etiology of those symptoms, may lead to serious complications and even mortality. This study aimed to set a standard case definition of bradyarrhythmias, which will improve patient survival. Methods: Patients presented with partial or total loss of consciousness, who were misdiagnosed as other non-arrhythmic etiologies and later diagnosed as bradyarrhythmia, were included in this study. Diagnosis of bradyarrhythmias was reached by either 12 leads electrocardiography, Holter monitor, or electrophysiological study. Results: A total of 150 patients who fulfilled the definition of missed diagnosis of bradyarrhythmias were included. A total of 100 males and 50 females were collected over 10 years. The pre arrhythmic over-diagnosis included transient ischemic attacks in 35 patients, vertebrobasilar insufficiency in 40 patients, vertigo in 30 patients, and other nonspecific diagnoses in 45 patients. The final diagnosis of bradyarrhythmias was reached by electrocardiogram only in 45, Holter recording in 75, and electrophysiological study in 30. All the diagnosed cases of bradyarrhythmias received permanent pacemaker therapy. Conclusion: Misdiagnosis of bradyarrhythmias in patients presenting with syncope is not uncommon in clinical practice in Iraq, which may have a bad impact on patients' morbidity and mortality. Understanding the causative factors for the missed diagnosis can help set up an educational program to minimize this problem. Keywords: Misdiagnosis; Bradyarrhythmia; Syncope; Dizzy spells.

Our Experience in the Treatment of Vertebrobasilar Insufficiency Due to Cervical Spine Disorders

This article defines vertebra-related causes of vertebrobasilar insufficiency in patients with the signs of tortuosity of segment VI of the VA. The aim of this study is to present the results of diagnostics of discirculatory phenomena in the vertebrobasilar system and to show their importance for differentiated surgical treatment of stenotic lesions of segment V1 of VA in pathological disorders of cerebral circulation in the VBS caused by osteochondrosis of the cervical spine. The following traditional methods are used in diagnostics: Doppler ultrasonography, multispiral computed tomography with contrast enhancement. Also using developed by the author method for determining VA reactivity and circulatory insufficiency in the vertebrobasilar system (VBS). Based on our methodology and criteria, patients were selected for different types of surgical treatment with clinical outcome prediction following interventions on the arteries of the VBS. To determine the pathologies of the intracranial segments of the vertebral and basilar arteries, taking into account the pathways of collateral compensation in the VBS, cerebral angiography is recommended before surgery on the arteries of the VBS. Reconstructive techniques used on segment VI of the VA will predictably show the best long-term clinical results. The excision of a tortuous segment VI of the VA may be effective in obtaining reliable results of successful interventions in the early postoperative period. The conservative treatment of the patients with multiple VBD lesions is possible. early outcomes of their use are satisfactory.

Bow hunter syndrome in rheumatoid arthritis: illustrative case

BACKGROUND Rheumatoid arthritis (RA) frequently features degeneration and instability of the cervical spine. Rarely, this degeneration manifests as symptoms of bow hunter syndrome (BHS), a dynamic cause of vertebrobasilar insufficiency. OBSERVATIONS The authors reviewed the literature for cases of RA associated with BHS and present a case of a man with erosive RA with intermittent syncopal episodes attributable to BHS as a result of severe extrinsic left atlantooccipital vertebral artery compression from RA-associated cranial settling. A 72-year-old man with RA-associated cervical spine disease who experienced gradual, progressive functional decline was referred to a neurosurgery clinic for evaluation. He also experienced intermittent syncopal events and vertiginous symptoms with position changes and head turning. Vascular imaging demonstrated severe left vertebral artery compression between the posterior arch of C1 and the occiput as a result of RA-associated cranial settling. He underwent left C1 hemilaminectomy and C1–4 posterior cervical fusion with subsequent resolution of his syncope and vertiginous symptoms. LESSONS This is an unusual case of BHS caused by cranial settling as a result of RA. RA-associated cervical spine disease may rarely present as symptoms of vascular insufficiency. Clinicians should consider the possibility, though rare, of cervical spine involvement in patients with RA experiencing symptoms consistent with vertebral basilar insufficiency.