The Relationship Between Paroxysmal Vertigoes and Right-To-Left Shunt: A Large Observational Study

Background The association between paroxysmal vertigo and right-to-left shunt (RLS) is rarely reported. We investigated the incidence and correlation of RLS in patients with different paroxysmal vertigo diseases. Methods This large observational study included patients with paroxysmal vertigo from seven different hospitals in China from 2017 to 2021 (NCT04939922). Migraine patients within the same period were included for comparison. Demographic data and medical history were collected, contrast transthoracic echocardiography (cTTE) was performed, and the clinical features, dizziness handicap inventory, and incidence of RLS in each group were recorded. Results This study used a consecutive sampling of 4536 patients from seven centres, and a total of 2751 patients were enrolled. The proportion of RLS in patients with migraine with aura (MA), migraine without aura (MoA), vestibular migraine (VM) with headache, VM without headache, and benign recurrent vertigo (BRV) was significantly higher than that in patients with benign paroxysmal positional vertigo (BPPV), Meniere’s disease (MD), and vestibular paroxysmia (VP) (P<0.05). There was no statistical difference between the frequency of RLS in patients with BRV and those with MoA (P=0.931), MA (P=0.997), VM with migrainous headache (P=0.787), and VM without migrainous headache (P=0.754). There was a positive correlation between the RLS grade and the dizziness handicap inventory scores of VM and BRV patients (P<0.01). Conclusions RLS was significantly associated with BRV and VM. RLS may be involved in the pathogeneses of BRV and VM and may serve as a reference index for the differential diagnosis of central and peripheral vertigo. Trial registration: CHRS, NCT04939922, registered 14 June 2021- retrospectively registered, https://register.clinicaltrials.gov

Az időskori szédülés életminőségre kifejtett hatása

Összefoglaló. Bevezetés: A szédülés időskorban gyakori panasz, amely jelentősen befolyásolja az életminőséget. Háttere sok esetben multifaktoriális, egyes esetekben azonban jól meghatározott ok kimutatható. Célkitűzés: Kutatásunk célja az időskori szédülő populáció panaszainak, valamint életminőségének felmérése volt. Anyag és módszer: Kutatásunkba 36 (13 férfi, 23 nőbeteg, átlagéletkor ± SD, 72,78 év ± 4,6), Otoneurológiai Ambulanciánkon szédülés miatt vizsgált, 65 év feletti beteget vontunk be. Ők az általunk összeállított, panaszokkal és rizikófaktorokkal kapcsolatos kérdőív mellett a Dizziness Handicap Inventory-t is kitöltötték. Az utóbbi alapján meghatározható volt az életminőség-romlás, illetve annak mértéke. A statisztikai elemzést az IBM SPSS V24 szoftver segítségével végeztük, Mann–Whitney U-teszt és khi-négyzet-próba alapján. Minden esetben p<0,05 értéket tekintettünk szignifikáns különbségnek. Eredmények: A leggyakoribb diagnózisként a Ménière-betegséget, valamint a centrális vestibularis eltéréseket detektáltuk. A betegek visszajelzése alapján a szédülés volt a legdominánsabb tünet, amely a leggyakrabban órákig, illetve napokig tartott, és fele arányban volt forgó jellegű. Emellett a fülzúgás, a halláscsökkenés, valamint a vegetatív tünetek is dominánsak voltak. A leggyakoribb társbetegségek közül gyakoriságuk miatt kiemelendők a mozgásszervi, illetve szemészeti eltérések, a hypertonia, valamint a pszichiátriai betegségek. A betegek 77,8%-a jelzett valamilyen mértékű életminőség-romlást, és kiemelendő, hogy 30%-uk a súlyos kategóriába esett. A Dizziness Handicap Inventory kérdőívek alapján a fizikális, funkcionális, valamint emocionális részpontszámok hasonló értéket mutattak. Következtetés: Az időskori szédülés lényeges a beteg romló életminősége szempontjából. A társuló komorbiditások mellett a háttérben álló vestibularis eltérések kizárása, illetve diagnosztizálása fontos feladat. Ennek függvényében tervezhető a terápia, amely kapcsán a kísérő tünetekre is fontos hangsúlyt fektetni. Így az érintett betegek életminősége javítható. Orv Hetil. 2021; 162(47): 1891–1896. Summary. Introduction: Vertigo is a common complaint in elderly, which has significant influence on the patients’ quality of life. In many cases its background is complex, although, in some cases specific diagnosis can be made. Objective: Our study aimed to analyze the symptoms and quality of life of old-age vertiginous population. Material and method: 36 patients (13 males, 23 females, mean age ± SD, 72.78 years ± 4.6) over 65 years, examined due to vertigo at our Neurotologic Department, were enrolled. A questionnaire including questions regarding the symptoms, risk factors, along with the Dizziness Handicap Inventory was used. Statistical analysis was carried out using IBM SPSS V24 software. Mann–Whitney U and chi square tests were used. Statistical significance was defined as p<0.05. Results: Ménière’s disease and central vestibular disorders were found as the most frequent diagnoses. Vertigo was the most tormenting symptom, which usually lasted for hours or days, and was defined as rotatory in 50%. Tinnitus, hearing loss and vegetative symptoms were also dominant. The most frequent comorbidities were musculoskeletal disorders, hypertension, ophthalmological diseases and psychiatric disorders. 77.8% of the patients have reported worsened quality of life, of which 30% was detected as severe. Based on the Dizziness Handicap Inventory, physical, functional and emotional scores showed similar results. Conclusion: Vertigo in elderly is important due to its influence on patients’ quality of life. Besides comorbidities, the diagnosis of vestibular pathologies is of great importance. Therefore, therapy planning is possible, and patients’ quality of life can be improved. Orv Hetil. 2021; 162(47): 1891–1896.

Vestibular Rehabilitatiоn in Vestibular Migraine

The search for possible ways to minimize dizziness in patients with vestibular migraine is especially relevant in the aspect of individualized complex vestibular rehabilitation. Aim. To study the possibilities of complex individualized vestibular rehabilitation in patients with vestibular migraine. Material and methods. The study included 122 patients (40 men and 82 women) aged 18 to 50 years, with significant vestibular migraine. We used the Dizziness Handicap Inventory scale for assessing dizziness and a 5-point Scale for subjective assessment of the severity of dizziness and a special complex method including a set of vestibular exercises, a method of the computer stabilometry with biofeedback. Objective control of vestibular rehabilitation was carried out with the help of stabilometric testing. Results and discussion. Positive dynamics were observed when analyzing the data of the physical, functional and emotional subscales of the Dizziness Handicap Inventory and the Scale of Subjective Assessment of the Dizziness Severity. In addition, the presented stabilometric diagnostics made it possible to fix the difference between the initial condition of patients with vestibular dysfunction and after 3 months of the special vestibular rehabilitation.Тhere was a statistically significant decrease in the basic stabilometric parameters: the area of the statokinesiogram (median area, mm² – 254 (95% CI 222-285)) and the rate of deviation of the center of pressure (median speed, mm/s – 21 (95% CI 17-24)) as well as a decrease in the shifts of the spectrum energy in the low-frequency and high-frequency spectrum that indicates an improvement in stability. The presented method for influencing the compensatorycapabilities of regulatory mechanisms in patients with vestibular migraine positively affects the efficiency of the equilibrium system as a whole, optimizing postural stability in this category of patients. Conclusion. An individually selected comprehensive program of vestibular gymnastics and hardware rehabilitation techniques on the stabilographic platform with biofeedback helps to improve postural stability and minimize dizziness in patients with vestibular migraine.

Relationship between vestibulo-ocular reflex gain and dizziness handicap inventory score to predict effectiveness of vestibular rehabilitation

Background and Aim: Evaluating the effective­ness of vestibular rehabilitation (VR) in patients with vestibular lesions has always been a challe­nge. The questionnaires that are used for this pur­pose mostly show the degree of vestibular dis­ability rather than providing information about improvement of vestibular dysfunction. This study aimed to evaluate whether video head imp­ulse test (vHIT) that is used for the examination of vestibulo-ocular reflex (VOR), is a useful method for predicting the effectiveness of VR and has a correlation with dizziness handicap inventory (DHI) score. Methods: Participants were 42 patients with unilateral peripheral vestibular hypofunction (UPVH) undergoing VR. Patients were assessed before and after rehabilitation by the vHIT in all ipsilesional and contralesional semicircular can­als (SCCs) and the DHI. The changes in DHI score and VOR gain before and after rehabili­tation, were shown as ΔDHI and ΔVOR and their correlation was evaluated. Results: VOR gain from ipsilesional and contra­lesional SCCs was improved significantly after VR. There was a significant strong negative correlation between ΔVOR gain from ipsile­sional SCCs and ΔDHI score but no significant correlation was found between the ΔDHI score and ΔVOR gain from contralesional SCCs. Conclusion: vHIT test is a useful tool to evaluate the effectiveness of VR. VOR gain is correlated with the DHI score. Therefore, the improvement in vHIT results in all three SCCs after VR may be a good predictor of the degree of improvement in dizziness-related disability. Keywords: Vestibular rehabilitation; follow-up; unilateral vestibular hypofunction; video head impulse test; dizziness handicap inventory

Correlation between Residual Dizziness and Modified Clinical Test of Sensory Integration and Balance in Patients with Benign Paroxysmal Positional Vertigo

Objectives: This study was performed to investigate the correlation between subjective residual dizziness and objective postural imbalance after successful canalith repositioning procedure (CRP) in benign paroxysmal positional vertigo (BPPV) by using questionnaires and modified Clinical Test of Sensory Integration and Balance (mCTSIB). Methods: A total of 31 patients with BPPV were included prospectively in the study. All included patients were successfully treated after initial CRP and their symptoms and nystagmus disappeared. Two weeks after CRP, all patients were asked to fill out the questionnaire including both Dizziness Handicap Inventory (DHI) and visual analog scale (VAS). We also conducted mCTSIB 2 weeks after CRP. We divided patients into two groups according to VAS: RD (residual dizziness) group, VAS＞0; non-RD group, VAS=0. We compared age, number of CRP, rates associated with three semicircular canals, DHI score and mCTSIB results between two groups. In addition, we analyzed the correlation between DHI score and mCTSIB results. Results: There were no significant differences in age, number of CRP, and rates associated with three semicircular canals between the two groups. RD group showed significantly higher DHI score and abnormal mCTSIB results than the non-RD group (<i>p</i>＜0.05). DHI score and the number of abnormal mCTSIB showed a statistically significant correlation. Conclusions: We demonstrated the correlation between DHI score and mCTSIB after successful CRP for BPPV. It also represents that subjective residual dizziness is correlated with objective postural imbalance even after successful CRP. Therefore, mCTSIB would be a useful test to evaluate both residual dizziness and postural imbalance after CRP in BPPV.

A sürgősségi osztályon szédüléses panaszokkal megjelent betegek életminőségének vizsgálata

Összefoglaló. Bevezetés: A szédülés gyakori panasz, amellyel a betegek felkeresik a sürgősségi osztályt. Emellett fontos tünet, hiszen kihívást jelent mind a diagnosztika, mind a terápia szempontjából, és nagy hatással lehet a betegek életminőségére. Célkitűzés: Kutatásunk célja annak vizsgálata, hogy mennyire befolyásolta a szédülés a betegek életminőségét a sürgősségi osztály elhagyását követően. Módszer: A vizsgálat időtartama alatt 879, szédülést panaszoló beteg jelent meg a Semmelweis Egyetem sürgősségi osztályán. Részükre kérdőív került kiküldésre, amely tartalmazta a ’Dizziness Handicap Inventory’ (DHI-) kérdőívet is. Megkeresésünkre 308 beteg (110 férfi, 198 nő; átlagéletkor: 61,8 ± 12,31 SD) válaszolt, az általuk visszaküldött kérdőíveket részletesen elemeztük. Eredmények: A leggyakoribb diagnózisok közé a benignus paroxysmalis positionalis vertigo, a centrális egyensúlyrendszeri eltérések és a szédülékenység tartoztak. Az elemzés alapján különbség volt látható a fizikális, a funkcionális és az emocionális pontszámok között. Kiemelendő, hogy a legmagasabb értékeket a fizikális csoportban regisztráltuk. A részletes otoneurológiai kivizsgáláson átesett betegek DHI-értékeit összevetettük azokéival, akik nem jártak ilyen vizsgálaton, a két csoport értékei között azonban nem volt szignifikáns különbség (p = 0,97). Emellett a DHI-érték emelkedése volt látható a végleges diagnózisig eltelt idő függvényében. Következtetés: A végleges diagnózisig eltelt idő, illetve a megfelelő kivizsgálás hiánya jelentős hatással van a szédülő betegek életminőségére. Lényeges a kivizsgálás, a mielőbbi diagnózis és a részletes egyensúlyrendszeri vizsgálat szerepe, ugyanakkor az utóbbi indokolt esetben kell, hogy történjen. Orv Hetil. 2021; 162(30): 1216–1221. Summary. Introduction: Dizziness and vertigo are among the most common complaints in the emergency department. This may require interdisciplinary cooperation due to their complex presentation in the department and the effects on the patients’ quality of life. Objective: Our study aimed to assess the effect of an acute vertigo episode on the quality of life after patients’ discharge from the emergency department. Method: 879 patients examined at the Semmelweis University emergency department with vertigo and dizziness were included in the study. A questionnaire, including the Dizziness Handicap Inventory (DHI), was addressed to this population. We received 308 answered questionnaires back (110 males, 198 females; mean age 61.8 years ± 12.31 SD), which were further analyzed. Results: The most frequent diagnoses were benign paroxysmal positional vertigo, central lesions and dizziness. According to the analysis of the DHI questionnaire, a difference between physical, functional and emotional scores was shown, whereas the highest scores were registered in the physical group. The DHI questionnaire scores of patients undergoing a neurotological examination and those who did not were further compared, whereas no significant statistical difference was indicated (p = 0.97). In addition, an increase in DHI scores was seen depending on the time elapse for the definitive diagnosis. Conclusion: The absence of adequate examination and a late diagnosis of the dizziness cause have a significant impact on the quality of life of patients. Therefore, substantial investigation, early diagnosis, and detailed vestibular examination are essential, but the latter should take place in justified cases. Orv Hetil. 2021; 162(30): 1216–1221.