Research in Vestibular Science

Volume 5 (2); December 2006

Original Articles

Role of the Peripheral Vestibular System on Neuroplasticity Induced by Hypergravity Stimulation: Jae Hyo Lee, Gyoung Wan Lee, Han Su Park, Jae Hee Lee, Dong Ok Choi, Myoung Ae Choi, Byung Rim Park; J Korean Bal Soc. 2006;5(2):213-223.

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Abstract PDF: Background
and Objectives: Altered environmental gravity, including both hypo- and hypergravity, may result in space adaptation syndrome. To explore the characteristics of this adaptive plasticity, the expression of immediate early gene c-fos mRNA in the vestibular system following an exposure to hypergravity stimulus was determined in rats. Materials and Method: The animals were subjected to 2 G force (two-fold earth's gravity) stimulus for 3 hours, and were examined at post-stimulus hours 0, 2, 6, 12, and 24. Real time reverse transcription-polymerase chain reaction (RT-PCR) was adopted to analyze temporal changes in the expression of c-fos mRNA.
Results
The hypergravity stimulation produced the expression of c-fos mRNA in the vestibular ganglion, medial vestibular nucleus, inferior vestibular nucleus, hippocampus, vestibulocerebellum, and vestibular cortex. The peak expression occurred at hour 6 in the animals hypergravity-stimulated for 3 hours. Bilateral labyrinthectomy significantly attenuated the degree of up-regulation in c-fos mRNA expression. MK-801, an NMDA receptor antagonist, also significantly attenuated the degree of up-regulation in c-fos mRNA expression.
Conclusion
These results indicate that the adaptive neuroplasticity in response to an altered gravity occurs in the vestibular-related organs in the central nervous system, in which peripheral vestibular receptors and NMDA receptors play an important role. Key Words : Hypergravity, Neuronal plasticity, Vestibule, c-fos gene

Body Lateropulsion as an Isolated or Predominant Symptom of a Pontine Infarction: Hyun Ah Kim, Hyung Lee, Byung Rim Park; J Korean Bal Soc. 2006;5(2):224-228.

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Abstract PDF: Background
and Objectives: Body lateropulsion with falling to one side is a well-known clinical feature of stroke in the posterior circulation. Body lateropulsion as an isolated or predominant manifestation of a pontine stroke has not previously been reported. To elucidate the possible mechanisms of patients presenting with body lateropulsion as an isolated or predominant symptom of isolated pontine infarction. Materials and Method: Between May 2004 and February 2006, out of 134 admitted patients with an isolated pontine stroke we identified 8 consecutive patients (6.0%) in the Keimyung University Stroke Registry who had body lateropulsion as the main presenting symptom.
Results
All lesions were localized to the paramedian tegmentum just ventral to the 4th ventricle. All except 1showed a uniform pattern of body lateropulsion, in which the direction of falling was away from the side of infarct. In 2 patients, body lateropulsion was the sole clinical manifestation, whereas the other patients had other neurological signs. All but 1 had contraversive tilting of the subjective visual vertical (SVV). In all cases, the direction of SVV tilt corresponded to the direction of body lateropulsion. The mean net tilt angle was 6.1
Conclusion
Based on the known anatomy of ascending vestibular pathways, the SVV tilting, and MRI findings, body lateropulsion probably results from damage to the graviceptive pathway ascending through paramedian pontine tegmentum. Key Words : Pons, Infarction

Clinical Manifestations of Cerebellar Infarction Mimicking Unilateral Vestibulopathy: Seung Suk Lee, Jae Ho Ban, Chee Yeul Park, No Hee Lee, Jong Kyu Lee; J Korean Bal Soc. 2006;5(2):229-234.

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Abstract PDF: Background
and Objectives: Pseudo-labyrinthine symptom without any other accompanying neurologic symptoms or signs occur with cerebellar infarction. The prognosis and management of cerebellar infarction differ from those of vertigo associated with unilateral vestibulopathy. The objective of study was to analyze the clinical symptoms of cerebellar infarction mimicking unilateral vestibulopathy according to the infarction territory. Materials and Method: Among 273 patients who showed pseudo-labyrinthine symptoms or signs, 28 patients were diagnosed cerebellar infarction on MRI between January 2003 and October 2006. Out of the 28 patients, 9 patients accompanying with focal neurologic symptoms or signs in early stage were excluded, and a retrospective analysis of total 19 patients was done through chart reviews. Using diffusion-weighted imaging, we divided 19 patients into two groups, AICA and PICA territory infarction. Clinincal features, outcome of audiologic and vestibular function test were compared between the groups.
Results
Among the 19 subjects, 10 were males and 9 were females, the mean age was 63.1±4.0. On MRI, 5 (26.3%) subjects showed infarction in unilateral AICA territory, 14(73.7%) in unilateral PICA territory. In the patients with AICA territory infarction, audiological tests confirmed unilateral sensorineuronal hearing loss in all 5 subjects. On V-ENG, 4/5 (80%) demonstrated horizontal or mixed horizontal torsional spontaneous nystagmus, and 4/5 (80%) had a canal paresis to caloric stimulation. In several days of hospital stay, 3/5 (60%) showed new neurologic signs, facial numbness. In the patients with PICA infarction, there was no hearing change. On V-ENG, 12/14(85.7%) demonstrated horizontal or mixed horizontal torsional spontaneous nystagmus, and 7/14 (50%) had a canal paresis to caloric stimulation. In several days of hospital stay, 10/14 (71.4%) accompanied with cerebellar ataxia.
Conclusion
Cerebellar infarction simulating unilateral vestibulopathy is more common than previously thought. Early recognition of the cerebellar infarction showing pseudo-vestibular symptom may allow specific management. Also taking into account that clinical features differ by infarction territory will assist in determining the patient’s status of the disease. Key Words : Cerebellum, Infarction

Isolated Positional Downbeat Nystagmus: Central or Peripheral Positional Nystagmus?: Sun Young Oh; J Korean Bal Soc. 2006;5(2):235-241.

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Abstract PDF: Background
and Ojbectives: Nystagmus produced by static placement of the head in different orientations is termed positional nystagmus and in most instances the cause is a peripheral vestibular disorder, as in benign paroxysmal positioning vertigo (BPPV). However, the physiologic basis of the isolated positional downbeat nystagmus has not been fully understood. The goal was to find a possible pathomechanism of dizzy patients who showed isolated positional downbeat nystagmus (pDBN). Materials and Method: Twelve consecutive patients with isolated positional DBN and 50 normal volunteers underwent evaluation of spontaneous, head-shaking and positional nystagmus, smooth pursuit, saccades, and VOR. The patients with focal neurologic signs, abnormal hearing, caloric paresis or acute lesion on brain imaging were excluded.
Results
Positional downbeat nystagmus was developed during lying down, straight head-hanging and/or Dix-Hallpike position. Perverted head-shaking nystagmus was observed in seven patients (58.3%). Gait disturbance revealed in six patients. Other cerebellar manifestations including saccadic dysmetria and gaze-evoked nystagmus were not observed. The gains of VOR were increased than normal controls. However, the gains of visual enhancement and visual cancellation of the VOR were not different from controls and OKN/OKAN were normal. The mean VOR time constants did not differ between patients and normal controls. However, tilt suppression of the post-rotatory nystagmus was impaired in the patients (p<0.01). All patients showed normal findings in head thrust test, caloric response, BAEPs, and brain imaging.
Conclusion
Isolated positional downbeat nystagmus (pDBN) in patients complained intermittent dizziness showed frequently accompanied perverted head-shaking nystagmus (HSN) and increased gain of VOR and impaired tilt suppression. This finding tells us that isolated positional downbeat nystagmus (pDBN) reflects pathologic central nystagmus results from cerebellar (uvulonodular) dysfunction. Key Words : Nystagmus, Positional vertigo, Vestibulo-ocular reflex

Clinical Characteristics of Dizziness in Children: Joon Ho Kim, Kwon Hyo Bok, Won Ho Chung; J Korean Bal Soc. 2006;5(2):242-247.

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Abstract PDF: Background
and Objectives: The children who are complaining of dizziness are difficult to manage. Because the incidence is quite low and the diagnostic spectrum is different from the adult. The purpose of this study is to analyze the clinical characteristics and vestibular function test in dizzy children, leading to provide a proper diagnostic approach. Materials and Method: A total of 57 children with dizziness who underwent vestibular function test were included in this study. Theses patients were retrospectively reviewed based on clinical charts. The average age of the patients was 11.1 years (range: 4-15). Caloric and rotation chair tests were performed in 57 and 31 patients respectively. Imaging study such as computed tomography and magnetic resonance imaging was performed in selective cases.
Results
Recurrent vertigo (49.1%) is the most common symptoms in dizzy children. Most common diagnostic entity in dizzy children is benign positional vertigo (BPV) (31.6%). Compared to adults, BPPV is relatively uncommon. Uncertain diagnosis is also common in dizzy children. Caloric test suggested that 19.3% of dizzy patients showed unilateral weakness. However, among normal caloric responders who underwent rotation chair test simultaneously, 11 out of 23 (47.8%) showed abnormal VOR gain and oculomotor abnormality.
Conclusion
Most common diagnosis of dizzy children is BPV, although many patients were remained uncertain. Abnormality of oculomotor test and VOR is relatively common, that suggests abnormal visual vestibular interaction is related with dizzy symptoms in children. The evaluation of vertigo in children should include a complete history and vestibular function test related with visual vestibular interaction. Key Words : Vertigo, dizziness, Child, Caloric test, Vestibulo-ocular reflex

Correlation between Spontaneous Nystagmus and Vestibular Function Test Parameters according to Gender and Age in Vestibular Neuritis: Jae Yun Jung, Eun Seok Lim, Young Saeng Kim, Min Young Lee, Yong Won Chung, Chung Ku Rhee; J Korean Bal Soc. 2006;5(2):248-252.

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Abstract PDF: Background
and Objectives: There are caloric test, SCEP, DP in Step velocity and VOR asymmetry in SHA test as parameters for evaluation in unilateral peripheral vestibulopathy in parameter of vestibular function test. The aim of this study is to assess the correlation between these parameters and intensity of spontaneous nystagmus in vestibular neuritis. Materials and Method: We evaluated 75 patients who were diagnosed as vestibular neuritis with 3 degree spontaneous nystagmus at vestibular function test lab from January 2000 to July 2005 in Dankook university hospital. The correlations between direction and intensity of spontaneous nystagmus and monothermal caloric test, SCEP and DP in step velocity, VOR asymmetry (0.01, 0.04, 0.16 Hz) in SHA test were analysed. And correlations according to sex, age were also analysed.
Results
The correlation coefficient between intensity of spontaneous nystagmus and monothermal caloric test was 0.60. The correlation coefficient between intensity of spontaneous nystagmus and SCEP was 0.35. The correlation coefficient between intensity of spontaneous nystagmus and Tc DP was 0.36 and it showed no significant correlation. The correlation coefficient between intensity of spontaneous nystagmus and VOR asymmetry (0.01, 0.04, 0.16) was 0.57, 0.46, 0.51, respectively and there was higher correlation in man, age under 60.
Conclusion
Intensity of spontaneous nystagmus showed close relations to monothermal caloric test, VOR asymmetry of SHA, Tc DP, SCEP DP in sequence. In addition, young male patients tends to be closely related to intensity of spontaneous nystagmus. Key Words : Spontaneous nystagmus, Vestibular function test, Vestibular neuritis

Results of Vestibular Function Tests in Patients with Cerebello-Pontine Aangle Tumors: Hyang Ae Shin, Yong Soo Jeong, Jin Suk Yoo, HongJu Park; J Korean Bal Soc. 2006;5(2):253-261.

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Abstract PDF: Background
and Objectives: Acoustic neuroma (AN) is commonly encountered in the cerebello-pontine angle (CPA) and AN arises principally from the vestibular division of the nerve, which can show not only hearing disturbance but also various vestibular symptoms and laboratory findings by affecting central and peripheral vestibular system. Vestibular testing is reported not to be a useful screening test for AN, but can be helpful in defining whether the tumor arises from the superior or inferior division and identifying the cause of dizziness or vertigo. Materials and Method: We are presenting four patients with CPA tumors accompanied by various abnormal findings of vestibular function tests including head-shaking nystagmus, vibration-induced nystagmus, hyperventilation- induced nystagmus and vestibular evoked myogenic potential and subjective visual vertical, which can enable us to understand the pathomechanism of the abnormal results.
Results
All patients presented hearing loss and mild dizziness. Caloric test, head thrust test and vibration-induced nystagmus was helpful in localizing the disease, but head-shaking nystagmus and hyperventilation-induced nystagmus was less helpful. Otolith tests did not always show abnormal results.
Conclusion
We should consider abnormal results of the vestibular function tests in a whole to estimate the status of vestibular compensation in patients with CPA tumors. Key Words : Nystagmus, Subjective visual vertical, Acoustic neuroma

Recurrent Vestibulopathy: Clinical Characteristics and Efficacy of Combination Therapy: Shi Nae Park, Kyoung Ho Park, Dong Jae Im, Jong Hoon Kim, Jun Yop Kim, Sang Won Yeo; J Korean Bal Soc. 2006;5(2):262-268.

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Abstract PDF: Background
and Objectives: Recurrent vestibulopathy is defined a disease characterized by more than a single episode of vertigo of duration characteristic of endolymphatic hydrops but without auditory or clinical neurological symptoms or signs. To investigate the clinical characteristics and the efficacy of combination therapy, we analyzed the clinical records of the patients diagnosed as recurrent vestibulopathy. Materials and Method: Clinical records of sixty four patients diagnosed as recurrent vestibulopathy were retrospectively reviewed. The data on age, sex distribution, natural history, family history of recurrent vestibulopathy, concurrent headache, caloric response was analyzed. The efficacy of combination therapy for vertigo control in the patients with a minimum 24-month follow-up was also evaluated.
Results
Mean onset age of recurrent vestibulopathy was 43 years and there was a female preponderance. Concurrent headache and elevated SP/AP ratio in electrocochleogram was frequently observed in these patients. After the combination medical therapy, patients with severe recurrent vestibulopathy showed significant decrease in the number of vertigo spells with 37.5% of complete control of vertigo.
Conclusion
As a distinctive clinical disorder with unknown cause, recurrent vestibulopathy should be always considered to the patients complaining recurrent episodic vertigo. Combination therapy individualized to the symptoms and signs of the patients with recurrent vestibulopathy might be effective in reducing the frequency of vertigo attacks. Further case-control studies with large population should be necessary. Key Words : Recurrent vestibulopathy, Therapy ∙

Benign Paroxysmal Positional Vertigo of Childhood: Seong Jun Choi, Dong Hyun Kim, You Ree Shin, Hun Yi Park, Tae Yun Kim, Yun Hoon Choung; J Korean Bal Soc. 2006;5(2):269-273.

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Abstract PDF: Background
and Objectives: Episodic vertigo and/or dizziness in children are not frequent symptoms. Causes of benign episodic vertigo in pediatric age include bengin paroxysmal vertigo of childhood(BPV) and bengin paroxysmal positional vertigo(BPPV). While BPPV has been frequently observed in adult, less frequently observed in children. The aim is to review the clinical manifestations in children with BPPV. Materials and Method: 154 children with dizziness or vertigo, who visited the Dizziness Clinic in the Department of Otolaryngology, Ajou University Hospital, Suwon, Korea between January 2001 and November 2006 were selected for this study. From all the patients, a comprehensive history was obtained, followed by clinical examination of the ears, nose, and throat and a complete audiologic and neurotologic examination including electronystagmography. All patients were treated with an appropriate canalith repositioning maneuver(CRP), depending on the type of BPPV.
Results
Seven (4.5%) of 154 children with dizziness or vertigo showed typical BPPV. The mean age was 11.8 years old (9-15 years). The horizontal and anterior semicircular canals were involved in 6 (85.8%) whereas the multiple semicircular canals were involved in 1 (14.2%) patients. Vertigo symptom subsided immediately in 6 (85.7%) patients after one or two trials of CRP, but 1(28.6%) patient showed recurred vertigo, that was treated with retrial of CRP.
Conclusion
The incidence of BPPV in children were much lower than that of adult BPPV, but it was higher than we expected before. We recommend that clinical tests such as Dix-Hallpike maneuver and head rolling test should be performed on all children with dizziness to establish the diagnosis of BPPV. Key Words : Positional vertigo, Child

Case Reports

Vestibular Neuritis of Vascular Cause: Hyun Ah Kim, Hyung Lee, Byung Rim Park; J Korean Bal Soc. 2006;5(2):277-280.

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Abstract PDF: Vestibular neuritis (VN) is an idiopathic peripheral vestibular syndrome characterized by acute isolated prolonged vertigo. In most cases, it results from inflammation of the vestibular nerve presumably of viral origin. There has been no previous report of VN associated with a vascular cause. We here report a patient with VN of vascular origin who presented with acute onset of prolonged isolated vertigo, a unilateral decreased caloric response, and simultaneously with acute infarcts on brain MRI that were unrelated to patient's vertigo. Key Words : Vestibular neuritis, Cerebral infarction

A Rostro-Caudal Arrangement of the Oculomotor Fascicles Based on MR Findings of Midbrain Infarctions in Two Cases: Jeong Ho Park, Won Hee Chung, Tae Kyeong Lee, Ki Bum Sung; J Korean Bal Soc. 2006;5(2):281-284.

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Abstract PDF: A rostro-caudal topography of the oculomotor nerve fascicles is relatively well known in animal but not in human. We experienced two cases of midbrain infarctions presenting with isolated oculomotor nerve palsies. The MRI of the patient who had monocular elevation palsy with ptosis revealed a lesion in the middle to lower midbrain, whereas that of the other who had monocular depression and adduction palsy with pupillary mydriasis showed a discrete lesion in the upper to middle midbrain. We present the rostro-caudal arrangement of the oculomotor fascicles within midbrain based on MRI findings. Key Words : Oculomotor nerve palsies, Magnetic resonance imaging

Unilateral Peripheral Vestibulopathy associated with Cerebral Venous Infarction: Hyun Ah Kim, Hyung Lee, Byung Rim Park; J Korean Bal Soc. 2006;5(2):285-287.

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Abstract PDF: Cerebral venous infarction is associated with a wide variety of clinical symptoms and signs, which may often delay appropriate diagnosis. Unilateral vestibular deficit as a presenting sign of cerebral venous infarction has rarely been reported. We report a patient with cerebral venous infarction who had severe prolonged vertigo, vomiting, occipital headache, positive head thrust testing, and unilateral caloric weakness as main clinical features. Although the patient had occipital headache, overall symptoms and signs closely mimicked those of acute peripheral vestibulopathy. Key Words : Peripheral vestibulopathy, Brain infarction

Cerebello-Pontine Angle Lipoma: Case Report and Review of the Literature: HongJu Park, M.D.; J Korean Bal Soc. 2006;5(2):288-291.

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Abstract PDF: Intracranial lipomas located in the cerebellopontine angle are extremely rare. These tumors are maldevelopmental lesions which can cause slowly progessive neurological symptoms. The clinical management of these tumours differs significantly from other lesions in this region. A 45 year old man presented with a 3-month history of vertigo and tinnitus in the left ear. In T1-weighted magnetic resonance imaging, the lesion was hyperintense and did not enhance after application of gadolinium. The patient was treated with medical therapy with good response. We present a review of the literature, with particular regard to management. Conservative treatment is recommended and limited surgery is usually indicated if the patients suffer from disabling neurological symptoms and signs e.g., vertigo, nausea, trigeminal neuralgia, facial weakness or facial spasm. Key Words : Cerebellopontine angle, Lipoma, Mgnetic resonance imaging

Partial Oculomotor Nerve Palsy due to Different Fascicular Involvements in Recurrent Midbrain Infarctions: Jeong Ho Park, Won Hee Chung, Tae Kyeong Lee, Ki Bum Sung; J Korean Bal Soc. 2006;5(2):292-295.

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Abstract PDF: We experienced a patient with partial oculomotor palsy who had initially manifested pupillary mydriasis and inferior rectus palsy which were attributed to an ipsilateral fascicular lesion in midbrain. She developed ipsilateral ptosis and monocular elevation palsy due to a new lesion on MRI one month later. This case could be the first neuroimaging evidence which support the hypothesis that fascicles of the oculomotor nerve for inferior oblique, superior rectus, and levator palphebrae muscle fibers are located more laterally and caudally than fascicles for pupil and inferior rectus muscle within midbrain tegmentum. Key Words : Oculomotor nerve, Infarction, Midbrain

Specific MRI and MRA findings of Dural Carotid Cavernous Sinus Fistula -A Case Report-: Won Hee Chung, Jong Se Lee, Tae Kyeong Lee, Ki Bum Sung; J Korean Bal Soc. 2006;5(2):296-298.

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Abstract PDF: Dural carotid-cavernous sinus fistula (d-CCF) is a rare cause of ophthalmoplegia, and it may be overlooked when the prominent external orbito-ocular sign is lacking. Conventional angiography is the gold standard in the diagnosis of d-CCF. Recently, the specific MR findings of d-CCF have increasingly been reported. We report a patient with spontaneous d-CCF presenting with an isolated fourth-nerve palsy in whom magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) demonstrated d-CCF. Key Words : Carotid cavernous sinus fistula, Ophthalmoplegia, Angiography, Magnetic resonance imaging, Magnetic resonance angiography

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