A Young Patient with Horizontal Semicircular Cupulolithiasis with Immediate Response to the Therapeutic Head-Shaking Maneuver (HSM)

The apogeotropic variant of horizontal semicircular canal benign paroxysmal positional vertigo is attributed to either short anterior ampullary arm canalolithiasis or to the cupulolithiasis with the otoconial debris adhering to the cupula on utricular (Cup-U) or canal side (Cup-C), rendering it heavy and gravity sensitive. The treatment options for horizontal semicircular cupulolithiasis are not very well defined. A 25-year-old female patient with 8 days history of vertigo on rolling to either of the lateral recumbent position presented in the first week of November 2019. The supine roll test (SRT) on yawing head maximally to the right as well as to the left elicited an apogeotropic horizontal positional nystagmus lasting more than 1 minute, which was stronger on the right side and indicated a diagnosis of left horizontal semicircular cupulolithiasis. Two short-term follow-ups at 1 and 24 hours after head-shaking maneuver (HSM), with verifying SRT, were undertaken. During either of the two follow-ups, neither the previously elicited horizontal positional nystagmus was observed, nor did the patient have vertigo on rolling to lateral recumbent positions. She was telephonically questioned weekly regarding the recurrence of rotational vertigo for the next 4 weeks, and it was confirmed that she remained symptom free till then. The therapeutic HSM, owing to the inertial forces generated, can detach the otoconial debris from the cupula that renders it heavy and gravity sensitive. Successful offloading of cupula by HSM brings immediate cure in the Cup-U variant of the horizontal semicircular cupulolithiasis.

Acute Labyrinthitis Revealing COVID-19

An 84-year-old man presented to the emergency department for acute vomiting associated with rotational vertigo and a sudden right sensorineural hearing loss. A left peripheral vestibular nystagmus was highlighted. The patient was afebrile, without respiratory signs or symptoms. Blood sampling at admission showed lymphopenia, thrombopenia and neutrophil polynucleosis, without elevation of C reactive protein. Cerebral magnetic resonance imaging eliminated a neurovascular origin. Vestibule, right semicircular canals and cochlear FLAIR hypersignals were highlighted, leading to the diagnosis of right labyrinthitis. A nasopharyngeal swab sampled at admission returned positive for SARS CoV2 by polymerase chain reaction. The etiologic investigation, including syphilitic and viral research, was otherwise negative. An oral corticotherapy (prednisone 70 mg daily) was introduced, followed by a progressive clinical recovery. Although acute otitis media have already been highlighted as an unusual presentation of COVID-19, radiology-proven labyrinthitis had to our knowledge, never been described to date.

a Cardiac cephalalgia attacks provoked by Prinzmetal angina - a case report

A 51-year-old man with no past medical history of headache or risk factors for vascular diseases was diagnosed with supraventricular tachycardia (SVT) in 2005. In 2014 SVT attacks were longer and always followed by severe headache attacks. Accompanying symptoms were dizziness, non-rotational vertigo, confusion, episodes of double vision and tinnitus; these symptoms would last one day, followed by severe tiredness for 2 days. Neurologic and cardiologic evaluation as well as extensive diagnostic test between the attacks was normal. Catheter coronarography showed no stenoses but did show spasms in distal left anterior descending artery. A remarkable effect on SVT and headaches was shown after the introducement of diltiazem. The diagnosis cardiac cephalalgia (CC) was established. As our case report is unique, we hope that our observations will help cardiologists and neurologists to better understand and treat patients with CC. CC should be distinguished from migraine, to avoid prescribing triptans and vasoconstrictors.

Ataxic syndrome in a chronic phenytoin user

Introduction: Phenytoin is an anticonvulsant used routinely for about eight decades. However, depending on the dose and plasma concentration, its use may be associated with side effects due to toxicity, such as ataxic syndrome. Case report: We attended a 37-year-old patient, epileptic since childhood, who had been using Divalproate Sodium 250mg 8 / 8h, Phenobarbital 150mg once a day and Phenytoin 100mg 8/8 for a long time. He denied smoking and drinking. He was admitted due to acute rotational vertigo, nausea, motor incoordination and impaired speech and gait, progressing for 7 days. Neurological examination revealed drunken dysarthria, pendular patellar reflexes, signs of axial and appendicular incoordination and ataxic gait. Cranial nerves: there was decomposition of the eye movement and hypometric saccades to the vertical upward look, horizontal nystagmus with alternating phases to the extreme looks. Laboratory exams, cranial tomography with and without contrast, brain magnetic resonance with gadolinium): within the normal range. Given the above, our diagnostic hypothesis was Phenytoin Poisoning. After gradually replacing it, there was a progressive improvement in the neurological condition. His serum level was not determined due to the unavailability of this test in our service. Conclusion: In view of its routine use, excluding other etiologies, this diagnosis should always be remembered.

Conservative Treatment Possibilities of Ménière Disease, Involving Vertigo Diaries

Ménière disease is a disorder of the inner ear, characterized by rotational vertigo, hearing loss, tinnitus, and vegetative symptoms. The aim of the present research is to examine the effectiveness of betahistine and piracetam in the reduction of vertigo attacks in Ménière disease. To verify our hypothesis, 105 (31 male and 74 females, mean age [standard deviation], 57.4 [11.05]) adult patients with definite Ménière disease were enrolled in this investigation. Beside the analysis of the hospital records, the subjective complaints of the patients and the completed vertigo diaries were taken into consideration too. The statistical analysis was completed using the IBM SPSS version 24 software. Retrospective analysis, including a 12 years period was conducted. Based on our results, betahistine was successful in the reduction of attacks. Statistically significant decrease was achieved in frequency of dizziness ( P = .000331) and vertigo ( P < .00001) and in the duration of them ( P = .000098), although in the mean power of them was not ( P = .0887). The mean dose in the symptomatic treatment was determined as 87.5 ± 27.2 mg per day; however, there was no connection detected between the dose of the agent and the effectiveness of the symptomatic control. By using dual therapy (betahistine and piracetam), vertigo episodes appeared significantly less often ( P = .027, Odds ratio: 4.9, 95% confidence interval: 1.2-20.2). Finally, it can be concluded that betahistine is effective in Ménière disease, but the daily dose of it should be set up for every patient individually. The advantage of the dual therapy was also confirmed.

HEAD JOLTING NYSTAGMUS: HEAD-SHAKING-INDUCED OCCLUSION OF THE HORIZONTAL SEMICIRCULAR CANAL

Background and aimsWe report a new syndrome (head jolting nystagmus, HJN) that expands the differential diagnosis of head-movement induced paroxysmal vertigo.Methods and resultsTwo male patients (65 and 58 yrs) described rotational vertigo after violent and brief (1–2 s) oscillations of the head (head jolting) that triggered intense horizontal nystagmus lasting 45s. Accelerations of the head required to induce these episodes could only be achieved by the patients themselves. In Patient 1 the episodes gradually disappeared over a 6–year period. In Patient 2, 3–Tesla MRI suggested a filling defect in the left horizontal semicircular canal. He underwent surgical canal plugging that resolved the symptoms.Conclusion and relevanceWe attribute HJN to dislodged material within the horizontal semicircular canal, and provide a mechanistic model to explain its origin.