Top

Published in:

Open Access 18-07-2022 | Stroke | Original Communication

Capturing nystagmus in the emergency room: posterior circulation stroke versus acute vestibular neuritis

Authors: B. Nham, G. Akdal, A. S. Young, P. Özçelik, T. Tanrıverdizade, R. T. Ala, A. P. Bradshaw, C. Wang, S. Men, B. F. Giarola, D. A. Black, E. O. Thompson, G. M. Halmagyi, M. S. Welgampola

Published in: Journal of Neurology | Issue 2/2023

Abstract

Objectives

To compare acute nystagmus characteristics of posterior circulation stroke (PCS) and acute vestibular neuritis (AVN) in the emergency room (ER) within 24 h of presentation.

Methods

ER-based video-nystagmography (VNG) was conducted, recording ictal nystagmus in 101 patients with PCS (on imaging) and 104 patients with AVN, diagnosed on accepted clinical and vestibular test criteria.

Results

Patients with stroke in the brainstem (38/101, affecting midbrain (n = 7), pons (n = 19), and medulla (n = 12)), cerebellum (31/101), both (15/101) or other locations (17/101) were recruited. Common PCS territories included posterior-inferior-cerebellar-artery (41/101), pontine perforators (18/101), multiple-territories (17/101) and anterior-inferior-cerebellar-artery (7/101). In PCS, 44/101 patients had no spontaneous nystagmus. Remaining PCS patients had primary position horizontal (44/101), vertical (8/101) and torsional (5/101) nystagmus. Horizontal nystagmus was 50% ipsiversive and 50% contraversive in lateralised PCS. Most PCS patients with horizontal nystagmus (28/44) had unidirectional “peripheral-appearing” nystagmus. 32/101 of PCS patients had gaze-evoked nystagmus. AVN affected the superior, inferior or both divisions of the vestibular nerve in 55/104, 4/104 and 45/104. Most (102/104) had primary position horizontal nystagmus; none had gaze-evoked nystagmus. Two inferior VN patients had contraversive torsional-downbeat nystagmus. Horizontal nystagmus with SPV ≥ 5.8 °/s separated AVN from PCS with sensitivity and specificity of 91.2% and 83.0%. Absent nystagmus, gaze-evoked nystagmus, and vertical-torsional nystagmus were highly specific for PCS (100%, 100% and 98.1%).

Conclusion

Nystagmus is often absent in PCS and always present in AVN. Unidirectional ‘peripheral-appearing’ horizontal nystagmus can be seen in PCS. ER-based VNG nystagmus assessment could provide useful diagnostic information when separating PCS from AVN.

Available only for authorised users

Kerber KABD, Lisabeth LD et al (2006) Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke 37:2484–2487CrossRef

Goeldlin M, Gaschen J, Kammer C, Comolli L, Bernasconi CA, Spiegel R et al (2019) Frequency, aetiology, and impact of vestibular symptoms in the emergency department: a neglected red flag. J Neurol 266(12):3076–3086CrossRef

Machner B, Choi JH, Trillenberg P, Heide W, Helmchen C (2020) Risk of acute brain lesions in dizzy patients presenting to the emergency room: who needs imaging and who does not? J Neurol 267:126–135CrossRef

Abilleira S, Cardona P, Ribó M, Millán M, Obach V, Roquer J et al (2014) Outcomes of a contemporary cohort of 536 consecutive patients with acute ischemic stroke treated with endovascular therapy. Stroke 45(4):1046–1052CrossRef

Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE (2009) HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 40(11):3504–3510CrossRef

Kene MVBD, Vinson DR, Rauchwerger AS, Iskin HR, Kim AS (2015) Emergency physician attitudes, preferences, and risk tolerance for stroke as a potential cause of dizziness symptoms. West J Emerg Med 16(5):768–786CrossRef

Kim MBBS, Ban JH (2013) Nystagmus-based approach to vertebrobasilar stroke presenting as vertigo without initial neurologic signs. Eur Neurol 70:322–328CrossRef

Eggers SDZ, Bisdorff A, von Brevern M, Zee DS, Kim JS, Perez-Fernandez N et al (2019) Classification of vestibular signs and examination techniques: Nystagmus and nystagmus-like movements. J Vestib Res 29(2–3):57–87CrossRef

Mantokoudis G, Wyss T, Zamaro E, Korda A, Wagner F, Sauter TC et al (2021) Stroke prediction based on the spontaneous nystagmus suppression test in dizzy patients: a diagnostic accuracy study. Neurology 97(1):e42–e51CrossRef

10.

Halmagyi GM, McGarvie LA, Strupp M (2020) Nystagmus goggles: how to use them, what you find and what it means. Pract Neurol 20(6):446–450CrossRef

11.

Kumral E, Kisabay A, Ataç C, Calli C, Yunten N (2005) Spectrum of the posterior inferior cerebellar artery territory infarcts. Clinical-diffusion-weighted imaging correlates. Cerebrovasc Dis (Basel, Switzerland). 20(5):370–380CrossRef

12.

Choi KD, Oh SY, Park SH, Kim JH, Koo JW, Kim JS (2007) Head-shaking nystagmus in lateral medullary infarction: patterns and possible mechanisms. Neurology 68(17):1337–1344CrossRef

13.

Baier B, Dieterich M (2011) Incidence and anatomy of gaze-evoked nystagmus in patients with cerebellar lesions. Neurology 76(4):361–365CrossRef

14.

Kim HA, Lee H (2010) Isolated vestibular nucleus infarction mimicking acute peripheral vestibulopathy. Stroke 41(7):1558–1560CrossRef

15.

Lee HKJ, Chung EJ, Yi HA, Chung IS, Lee SR, Shin JY (2009) Infarction in the territory of anterior inferior cerebellar artery spectrum of audiovestibular loss. Stroke 40(12):3745–3751CrossRef

16.

Kheradmand A, Colpak AI, Zee DS (2016) Eye movements in vestibular disorders. Handb Clin Neurol 137:104–117

17.

Lee HKH (2013) Nystagmus in SCA territory cerebellar infarction: pattern and a possible mechanism. J Neurol Neurosurg Psychiatry 84(4):446–451CrossRef

18.

Kataoka S, Hori A, Shirakawa T, Hirose G (1997) Paramedian pontine infarction. Neurol Topograph Correl Stroke 28(4):809–815

19.

Young ASLC, Bradshaw AP, MacDougall HG, Black DA, Halmagyi GM, Welgampola MS (2019) Capturing acute vertigo: A vestibular event monitor. Neurology 92:e1–e11CrossRef

20.

Young AS, Lechner C, Bradshaw AP, MacDougall HG, Black DA, Halmagyi GM et al (2019) Capturing acute vertigo: a vestibular event monitor. Neurology 92(24):e2743–e2753CrossRef

21.

Tatu L, Moulin T, Bogousslavsky J, Duvernoy H (1996) Arterial territories of human brain: brainstem and cerebellum. Neurology 47(5):1125–1135CrossRef

22.

Kerber KAMW, Brown DL, Burke JF, Hofer TP, Tsodikov A, Hoeffner EG, Fendrick AM, Adelman EE, Morgenstern LB (2015) Stroke risk stratification in acute dizziness presentations: a prospective imaging-based study. Neurology 85:18691878CrossRef

23.

Choi J, Park MG, Choi SY, Park KP, Baik SK, Kim JS, Choi KD (2017) Acute transient vestibular syndrome: prevalence of stroke and efficacy of bedside evaluation. Stroke 48:556–562CrossRef

24.

Choi KDKJ (2018) Vascular vertigo: updates. J Neurol 266:1835–1843CrossRef

25.

Nham B, Reid N, Bein K, Bradshaw AP, McGarvie LA, Argaet EC et al (2021) Capturing vertigo in the emergency room: three tools to double the rate of diagnosis. J Neurol 269:294–306CrossRef

26.

Leigh JZ, Zee DS (2015) The neurology of eye movements. 5 Ed. Oxford University Press, New York

27.

Highstein SM, Holstein GR (2006) The anatomy of the vestibular nuclei. Prog Brain Res 151:157–203CrossRef

28.

Lee SH, Kim JM, Schuknecht B, Tarnutzer AA (2020) Vestibular and ocular motor properties in lateral medullary stroke critically depend on the level of the medullary lesion. Front Neurol 11:390CrossRef

29.

Zee DS, Friendlich AR, Robinson DA (1974) The mechanism of downbeat nystagmus. Arch Neurol 30(3):227–237CrossRef

30.

Zee DS, Yamazaki A, Butler PH, Gücer G (1981) Effects of ablation of flocculus and paraflocculus of eye movements in primate. J Neurophysiol 46(4):878–899CrossRef

31.

Pierrot-Deseilligny C, Milea D (2005) Vertical nystagmus: clinical facts and hypotheses. Brain 128(Pt 6):1237–1246CrossRef

32.

Park HK, Kim JS, Strupp M, Zee DS (2013) Isolated floccular infarction: impaired vestibular responses to horizontal head impulse. J Neurol 260(6):1576–1582CrossRef

33.

Kim JS, Yoon B, Choi KD, Oh SY, Park SH, Kim BK (2006) Upbeat nystagmus: clinicoanatomical correlations in 15 patients. J Clin Neurol 2(1):58–65CrossRef

34.

Helmchen C, Rambold H, Kempermann U, Büttner-Ennever JA, Büttner U (2002) Localizing value of torsional nystagmus in small midbrain lesions. Neurology 59(12):1956–1964CrossRef

35.

Rambold H, Helmchen C (2005) Spontaneous nystagmus in dorsolateral medullary infarction indicates vestibular semicircular canal imbalance. J Neurol Neurosurg Psychiatry 76(1):88–94CrossRef

36.

Kim SH, Kim JS (2019) Eye movement abnormalities in middle cerebellar peduncle strokes. Acta Neurol Belg 119(1):37–45CrossRef

37.

Searls DE, Pazdera L, Korbel E, Vysata O, Caplan LR (2012) Symptoms and signs of posterior circulation ischemia in the new England medical center posterior circulation registry. Arch Neurol 69(3):346–351CrossRef

38.

Ling XSW, Shen B, Li K, Si L, Yang X (2019) Diagnostic value of eye movement and vestibular function tests in patients with posterior circulation infarction. Acta oto-laryng 139(2):135–145CrossRef

39.

Ogawa YOK, Hagiwara A, Inagaki T, Shimizu S, Nagai N, Konomi U, Itani S, Kondo T, Suzuki M (2016) Clinical evaluation of acute phase nystagmus associated with cerebellar lesions. J Laryngol Otol 130(6):536–540CrossRef

40.

Lemos J, Martins AI, Duque C, Pimentel S, Nunes C, Goncalves AF (2019) Positional testing in acute vestibular syndrome: a transversal and longitudinal study. Otol Neurotol 40(2):e119–e129CrossRef

Title: Capturing nystagmus in the emergency room: posterior circulation stroke versus acute vestibular neuritis
Authors: B. Nham
G. Akdal
A. S. Young
P. Özçelik
T. Tanrıverdizade
R. T. Ala
A. P. Bradshaw
C. Wang
S. Men
B. F. Giarola
D. A. Black
E. O. Thompson
G. M. Halmagyi
M. S. Welgampola
Publication date: 18-07-2022
Publisher: Springer Berlin Heidelberg
Keywords: Stroke
Pica Syndrome
Nystagmus
Gaze-Evoked Nystagmus
Published in: Journal of Neurology / Issue 2/2023
Print ISSN: 0340-5354
Electronic ISSN: 1432-1459
DOI: https://doi.org/10.1007/s00415-022-11202-y

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Capturing nystagmus in the emergency room: posterior circulation stroke versus acute vestibular neuritis

Abstract

Objectives

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Objectives

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 2/2023

Correction to: Communicating the relevance of neurodegeneration and brain atrophy to multiple sclerosis patients: patient, provider and researcher perspectives

Gustaw Bikeles (1861–1918)

Health-related quality of life in Japanese patients with multiple sclerosis

Adult motor neuron disease death rates in Finland 1998–2019

SARS-CoV-2 in patients with Friedreich ataxia

Clinical and paraclinical features of small fiber neuropathy in Sjögren’s syndrome