Research in Vestibular Science

Complete ocular tilt reaction with subjective visual vertical tilt in a patient with a medial prefrontal cortex lesion: a case report: Hyung Lee, Hyun Ah Kim; Res Vestib Sci. 2024;23(1):24-27. Published online March 15, 2024; DOI: https://doi.org/10.21790/rvs.2023.136

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Abstract PDF: A 61-year-old male patient undergoing chemotherapy for esophageal cancer presented with symptoms of rightward tilting while both sitting and walking. A neurological examination revealed a head tilt, skew deviation with hypertrophy of the left eye, and a rightward shift in his gait. No spontaneous nystagmus was observed, and the vestibulo-ocular reflex was normal. Magnetic resonance imaging of the head revealed a suspected metastatic lesion in the right medial prefrontal cortex. Following the initiation of levetiracetam treatment, the patient demonstrated marked improvement, with the resolution of both head tilt and skew deviation within 1 month. Traditionally, the ocular tilt reaction has been attributed to unilateral or asymmetric dysfunction of the graviceptive pathways extending from the utricle to the upper midbrain lesions. However, this case highlights the potential involvement of the prefrontal cortex in the ocular tilt reaction. Further research is warranted on the role of the prefrontal cortex within the vestibular system.

Diffuse Cerebellar Dysfunction as a Permanent Neurological Sequela of Organophosphate Poisoning: A Case Report: Hyun Ah Kim, Hyung Lee; Res Vestib Sci. 2021;20(1):24-27. Published online March 11, 2021; DOI: https://doi.org/10.21790/rvs.2021.20.1.24

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Abstract PDF: The diffuse cerebellar dysfunction as a permanent neurological sequela of organophosphate poisoning has not yet been reported in the published literature. We report a diffuse cerebellar dysfunction as a permanent manifestation of organophosphate poisoning. A 55-year-old man diagnosed with acute organophosphate poisoning was brought to the emergency room of our hospital. He had slurred, monotonous scanning speech with irregularly distributed articulatory deficits, and prominent bilateral limb ataxia. He presented left-beating spontaneous nystagmus with a downbeat component and strong downbeating nystagmus after head shaking. He also showed saccadic hypometria with a normal saccadic velocity at fixed horizontal saccades and symmetrically impaired horizontal smooth pursuit on both sides. The poisoning of organophosphate poisoning may lead to a diffuse permanent cerebellar dysfunction as a neurological sequela event.

The Effect, Compliance and Satisfaction of Customized Vestibular Rehabilitation: A Single Center Experience: Hyung Lee, Hyun Ah Kim; Res Vestib Sci. 2019;18(1):14-18. Published online March 15, 2019; DOI: https://doi.org/10.21790/rvs.2019.18.1.14

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Abstract PDF

Objectives
Over the last decades, numerous studies on the effect of vestibular rehabilitation (VR) have been reported in western countries, but there has been no report about real experiences of customized VR in Korea. The aim of this study was to analyze of the efficacy, compliance and satisfaction in patients with acute and chronic dizziness.
Methods
Patients with dizziness were treated with a customized VR at least 4 weeks. Subjects were assessed before and after at least 4 weeks of customized VR for visual analogue scale (VAS) and disability scale (DS). Patients were asked to score the satisfaction of their treatment as 1 (very poor) to 5 (excellent). Compliance to exercise program were graded as 1 (regularly performed), 2 (frequently performed), or 3 (rarely performed).
Results
Thirty-two patients with dizziness were included. Diagnosis of patients were vestibular migraine (n=5), Meniere’s disease (n=2), vestibular neuritis (n=10), persistent perceptual positional dizziness (n=10), bilateral vestibulopathy (n=3), and central dizziness (n=2). Mean VAS and DS before VR were 15.3 and 2.4, respectively. Mean VAS and DS after VR were 4.5 and 0.7, respectively. Significant improvements in VAS and DS were observed after VR (p=0.00). Mean treatment satisfaction score was 3.3±1.0 and mean compliance score was 2.3±0.8. Satisfaction to VR showed positive correlation with patient’s compliance. (p=0.00, r=0.644)
Conclusions
Significant improvements were seen in symptom and disability in patients with acute and chronic dizziness after customized VR. Patients showed moderate compliance to exercise program and overall satisfaction was fair.

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A Survey of Educational, Clinical Background in Vestibular Rehabilitation Therapy of Korean Physical Therapists
Migyoung Kweon, Youn Bum Sung
The Journal of Korean Academy of Physical Therapy .2023; 30(2): 65. CrossRef
Factors Associated with Patient Satisfaction in Customized Vestibular Exercise: A Pilot Study
Hye Soo Ryu, Min Young Lee, Jae Yun Jung, Ji Eun Choi
Research in Vestibular Science.2019; 18(3): 71. CrossRef

맞춤전정재활운동의 효과, 순응도와 만족도: 단일 병원 경험: Hyung Lee, Hyun Ah Kim; Received February 19, 2019 Accepted March 11, 2019 Published online March 11, 2019; [Accepted]

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Abstract: Background
Over the last decades, numerous studies on the effect of Vestibular rehabilitation (VR) have been reported in western countries, but there has been no report about real experiences of customized VR in Korea. Objectives: The aim of this study was to analyze of the efficacy, compliance and satisfaction in patients with acute and chronic dizziness. Methods: Patients with dizziness were treated with a customized VR at least 4 weeks. Subjects were assessed before and after at least 4 weeks of customized VR for visual analog scale (VAS) and disability scale (DS). Patients were asked to score the satisfaction of their treatment as 1 (very poor) to 5 (excellent). Compliance to exercise program were graded as 1 (regularly performed), 2 (frequently performed) or 3 (rarely performed). Results: 32 patients with dizziness were included. Diagnosis of patients were vestibular migraine (n=5), Meniere’s disease (n=2), vestibular neuritis (n=10), persistent perceptual positional dizziness (n=10), bilateral vestibulopathy (n=3) and central dizziness (n=2). Mean VAS and DS before VR were 15.3 and 2.4, respectively. Mean VAS and DS after VR were 4.5 and 0.7, respectively. Significant improvements in VAS and DS were observed after VR. (p=0.00) Mean treatment satisfaction score was 3.3± 1.0 and mean compliance score was 2.3 ± 0.8. Satisfaction to VR showed positive correlation with patient’s compliance. (p=0.00, r=0.644) Conclusion: Significant improvements were seen in symptom and disability in patients with acute and chronic dizziness after customized VR. Patients showed moderate compliance to exercise program and overall satisfaction was fair.

Evaluation of Adrenergic Function: Tilt-Table and Valsalva Test: Hyung Lee, Hyun Ah Kim; Res Vestib Sci. 2018;17(1):8-12. Published online March 15, 2018; DOI: https://doi.org/10.21790/rvs.2018.17.1.8

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Abstract PDF

Orthostatic dizziness is a common dizziness syndrome characterized by nonvertiginous lightheadedness when patients rise to stand from a sitting or supine position. Orthostatic dizziness is commonly believed to derive from orthostatic hypotension (OH) or postural tachycardia syndrome (POTS). Tilt-table test and Valsalva maneuver are standardized methods for evaluating of adrenergic autonomic function and essential for diagnosis of OH and POTS. We described the guidelines and interpretations of the tilt-table test and Valsalva maneuver.

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Interpretation of Autonomic Function Test
Kee Hong Park, Eun Hee Sohn
Journal of the Korean Neurological Association.2021; 39(2): 61. CrossRef

Periodic Alternating Nystagmus in Patients with Cerebellar Abscess: Hyung Lee, Hyun Ah Kim; Res Vestib Sci. 2016;15(1):27-29.

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Abstract PDF: Periodic alternating nystagmus (PAN) is characterized by a periodical reversal in the direction of the nystagmus. Acquired PAN is caused by lesions of the inferior cerebellar vermis, causing disinhibition of the velocity storage mechanism, which is mediated by the vestibular nuclei. An eighty-year-old woman with abscess in midline cerebellum experienced dizziness and imbalance. We observed short period PAN with 7?8 seconds.

Vestibular Rehabilitation in Central Dizziness: Byung In Han, Pan Woo Ko, Ho Won Lee, Hyun Ah Kim, Hyung Lee; Res Vestib Sci. 2015;14(4):97-100.

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Abstract PDF: Vestibular rehabilitation therapy (VRT) is an exercise-based treatment program designed to promote vestibular adaptive and compensatory mechanisms already existing in the human brain. Although the evidence is sparse for improvement in subjects with central vestibular dysfunction following VRT, it improves postural stability in cerebellar diseases and reduces subjective complaints and fall risk in Parkinson disease. Possible mechanisms of recovery after central nervous system lesions may include neural sprouting, vicarious functions, functional reorganization, substitution, and plasticity. VRT regimens for patients with central causes should include balance and gait training, general strengthening and flexibility exercises, utilization of somatosensory and vision and utilization of alternate motor control strategies. VRT would be an option to relieve the symptoms of the many patients who have central dizziness.

Neurotological Aspect of Cerebellar Infarction: Hyung Lee; Res Vestib Sci. 2009;8(1):3-14.

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Neuro-otological aspects of cerebellar stroke: Hyung Lee; J Korean Bal Soc. 2008;7(2):227-227.

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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

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

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

Sleep and Vestibular Neuritis: Hyun Ah Kim, Hyung Lee; J Korean Bal Soc. 2006;5(1):44-48.

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Abstract PDF: Background
and Objectives: While it is known that sleep have influence on emergence of rapid eye movements(REMs), namely saccades including fast component of nystagmus, whether spontaneous nystagmus due to vestibular imbalance presents during sleep is still unclear. The purpose of our study was to investigate whether tonic vestibular imbalance appeared as spontaneous nystagmus during the wakeful state could present during REM sleep. Materials and Method: Overnight polysomnography (PSG) was performed in 7 patients with spontaneous nystagmus due to vestibular neuritis (VN) and 7 control patients without dizziness or any nystagmus. The numbers of horizontal saccades were counted, during 3 minutes samples of the alert state before and after the PSG and the first and last REM sleep.
Results
All patients with VN showed significantly more saccades (fast phases of spontaneous nystagmus) towards the side contralateral to their vestibular lesion in the awake state before and after the PSG compared with control group. By contrast, during REM sleep the patients with VN showed no preponderance in saccade direction (p<0.05). Some brief nystagmoid jerks showed during REM sleep in both patients and controls equally and also had no preponderance in direction.
Conclusion
The tonic vestibular imbalance at peripheral level observed during alert state does not appear at the brainstem level during REM sleep. It is suggested that a de-afferentation of the peripheral vestibular input to the REM sleep generating areas may explain an absence of nystagmus during REM sleep in patients with VN. Key Words : Vestibular imbalance, Nystagmus, REM sleep

Otologic Causes of Drop Attacks in Elderly Patients: Hyung Lee, Hyon Ah Yi, Jeong Geung Lim, Byung Hoon Ahn, Byung Rim Park; J Korean Bal Soc. 2004;3(2):372-378.

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Abstract PDF: Background
and Objectives : Many neurologists are unaware of the drop attack that may occur from an inner ear dysfunction especially in elderly. We performed this study to investigate the clinical features and results of quantitative audiovestibular tests in six elderly patients (≥65 years of age) who presented with drop attacks attributable to an inner ear pathology. Materials and Method : Group was divided into Meniere's syndrome (4) or non-Meniere peripheral vestibulopathy (2). Standard dizziness questionnaire and quantitative audiovestibular function testing were performed.
Results
: Episodes were described as a sudden push to the ground in four or a violent illusionary movement of environment leading to a fall in two. All cases gave a history of prior vertiginous episodes and vestibular testing revealed unilateral caloric paresis. Ipsilateral hearing loss was documented in four cases.
Conclusions
: Our results suggest that otologic causes should be considered in the differential diagnosis of the drop attack in elderly, even if the symptoms and signs were not consistent with Meniere's syndrome.

Clinical implication of an isolated sudden deafness with vertigo of vascular origin from a neurologist's standpoint: Hyung Lee, Yong Won Cho; J Korean Bal Soc. 2003;2(2):241-243.

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Abstract PDF: A 60-year-old man with hypertension presented with an acute onset of an isolated sudden deafness with vertigo. On admission, initial brain MRI, including diffusion images, was normal. During admission, the patient presented with an exacerbation of vertigo. A follow-up MRI revealed new infarcts involving the right middle cerebellar peduncle, the right dorsolateral pons, and right anterior cerebellum. In this patient, an acute onset of an isolated sudden deafness with vertigo may be a heralding manifestation of the pontocerebellar infarction.

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