Transitory alternating saccade (TAS) proposed by Komatsuzaki is considered to be spontaneous abnormal eye movements caused by cerebellar dysfunction. We describe three patients progressive supranuclear palsy and TAS. TAS was present in the horizontal planes on ENG in all three cases when the eyes were closed and when they were open but covered, and it was suppressed by visual fixation. Square wave jerks (SWJ) accompanied by TAS were present in case 1 and case 3. These eye movements, TAS and SWJ, have much in common with each other. We considered that they might have the same etiology in the oculomotor system.
We previously reported that orthostatic dysregulation (OD) was relatively common in normal young females and that the Schellong test was a useful, practical procedure in the diagnosis of this condition. We carried out a survey and analyzed date from both the Yatabe-Guiford Personality test (Y-G test) and the Cornell Medical Index-Health Questionnaire (CMI) in 167 females aged 18 to 24 years (mean age =19.7 years). OD was confirmed in 38 and suspected in 32; the remaining 97 were considered to be normal from the results of the Questionnaire for OD. Of the 167 young females, 33 (19.8%) were type A in the Y-G test, 38 were type B (22.8%), 27 type C (16.1%), 52 type D (31.1%) and 17 type E (10.2%). Reports in the literature indicate that individuals with type B and type E Y-G results are apt to have mental and/or emotional “instability”. Of the 97 normal subjects, 28 were type B or type E (28.8%), of those with confirmed OD the number was 17 (44.7%) and of those with suspected OD it was 10 (31.2%). The difference between the normal subjects and those with confirmed OD was significant. Of 132 individuals with CMI types I and II 34 (25.8%) were Y-G types B and E and of 35 individuals with CMI type III and IV 21 (60%) were Y-G types B and E. These results suggest that there may be some correlation between OD and emotional and/or psychosomatic instability. Further studies on the practical implications of these testing procedures are necessary for the evaluation of individuals with OD.
Venous angioma of the cerebellum is a vascular malformation of the central nervous system, which is difficult to diagnose from the clinical symptoms alone. This paper describes a 37-year-old female who complained of rotatory vertigo. She had various type of nystagmus : Bruns-like nystagmus, rebound nystagmus and direction-changing vertical position nystagmus. ETT was saccadic pursuit. Acceleration of OKP was limited, and the velocity of its slow phase was low. Caloric tests showed unilateral canal paresis and limitation of visual suppression. Cerebral angiography and MRI revealed a cerebellar venous angioma. We followed her for over two years. As her clinical condition improved, OKP also improved, but saccade pursuit of ETT and limitation of VS remained. We speculate that the eye movement system of the cerebellum was directly and irreversibly damaged, while the brain stem was indirectly disturbed.
The central pathways for the subjective sensation of “turning” and nystagmus are different even though both rely on the same basic input. Thus a lesion of the primary vestibular projection area of the cerebral cortex could induce the phenomenon of the loss of subjective vestibular sensation during vestibular stimulation. This report describes a right handed 35-year-old male with adrenoleukodystrophy, who initially complained of hearing and visual disturbance and showed the vestibular agnosia. MRI showed sub-cortical lesions in the parietal, temporal and occipital areas. The main lesion was in the white matter, especially on the right side (non-dominant hemisphere). Neurological examination showed auditory agnosia and slight visual agnosia. Deep sensation was also impaired in both upper and lower exthemities, presumably because of cortical lesions. Neurotological examination revealed impaired smooth pursuit, optokinetic nystagmus and voluntary saccades. These abnormal eye movements suggested a parietal or occipital cortex disorder on the non-dominant side. Because a brain stem lesion could be ruled out “nystagmus-sensation dissociation”, which was observed during caloric tests in this case, was considered to be caused by a pure cortical lesion. This phenomenon appeared to be part of the “vestibular agnosia” caused by a lesion of the primary sensory cortex of vestibular sensation.
A study was conducted of children complaining of vertigo, dizziness and equilibrium disturbance who were examined at the Department of Otorhinolaryngology of Gifu University Hospital from January, 1985 to December, 1992. 1. Of the 3, 626 patients who visited our clinic with complaints of vertigo, dizziness and equilibrium disturbances, 98 (2.7%) were under 15 years of age. Their equilibrium and neurological status were evaluated. 2. Of the 98 patients, 26 (26.5%) had labyrinthine disturbances, 17 (17.3%) central nervous system disturbances, 2 (2.0%) both labyrinthine and central nervous system disturbances, and 42 (42.9%) vertigo or dizziness due to systemic diseases. In 11 patients (11.2%), the vertigo and dizziness were of unknown etiology. 3. Among the 26 patients with labyrinthine disturbances, 3 had Meniere's disease, 5 had vertigo with sudden deafness, 4 delayed hydrops and 4 circulatory insufficiency of the labyrinth. 4. Among the 17 patients with central nervous system disturbances, 4 had post-traumatic disorders, and the others had equilibrium disturbance due to brain tumor, hemorrhage, epilepsy, etc. 5. Eleven patients with dizziness of unknown etiology were almost free of symptoms shortly after the examinations, and none of them thereafter showed any abnormality of the central nervous system.
It is difficult to diagnose cerebellar infarction in the territory of the posterior inferior cerebellar artery (PICA) except in cases of Wallenberg's syndrome, because CT and angiography (except with MRI) show no definite abnormalities. There have been few neurootological studies on the relationship between vertigo and cerebellar infarction in the PICA area. We did neurootological studies on 5 patients in the early stage of cerebellar infarction in the PICA area. Their chief complaints were rotatory vertigo with occipital headache. All 5 were over 40 years of age and had risk factors for cerebrovascular disorder : hypertension, diabetes mellitus, hyperlipidemia and or arrhythmia. In 2 of the 5 patients, abnormal neurootological findings had already disappeared when they were examined in the hospital. Therefore, it was particularly important to ask them about their medical history in detail. The other 3, had significant neurootological findings : lateral gaze nystagmus and severe equilibrium disturbance due to truncal ataxia (3 patients); spontaneous horizontal rotatory nystagmus (the rotatory component was dominant) and direction-changing positional nystagmus towards the uppermost ear and positioning downbeat nystagmus (2 patients); spontaneous downbeat nystagmus (1 patient); extension of duration time on caloric testing; reduction of visual suppression on visual suppression test (1 patient). Two patients when MRI showed an abnormal region in the cerebellar vermis had many abnormal neurootological findings. In most cases of cerebellar infarction of the PICA, MRI is necessary for the final confirmation of the diagnosis; however, we consider the medical history and neurootological examinations are also very valuable tools to be used in the clinical diagnosis.
Vertigo was induced by oxygen of hyperbaric pressure therapy (OHP therapy) in three patients. Case 1 : A 60-year-old woman with sudden deafness received OHP therapy, after which she complained of exacerbation of vertigo. Exploratory tympanotomy confirmed round window rupture. Case 2 : A 73-year-old man received OHP therapy because of retinal edema. He had rotatory vertigo immediately after OHP therapy. Because this patient had temporary left ear fullness and left low-tone hearing loss, endolymphatic hydrops on the left side was suspected. Case 3 : A 46-year-old man with sudden deafness on the left received OHP therapy after failure of steroid therapy to improve his hearing. He complained of exacerbation of vertigo after OHP therapy. Because dizziness persisted for one and a half years, perilymphatic fistula was suspected and exploratory tympanotomy was performed. No perilymphatic leakage was seen but connective tissue covered the round window. These findings suggest that perilymphatic fistula or endolymphatic hydrops may induce vertigo in patients receiving OHP therapy.
A new method was developed for specific labeling of vestibular afferent and efferent neurons from selected end-organs. Biocytin solution was applied to the inner ear after the surface of the sensory neuroepithelium of an end-organ had been scratched. After 24 hours, the animal was perfused with a fixative and its brainstem was removed. The brainstem and vestibular nerves were serially sectioned with a freezing microtome, and 40 μm slices were processed with ABC solution. Diaminobenzidine (DAB) was used as the chromagen. Sections were mounted on slides and coverslipped for light microscopic observation. The distribution of primary afferent fibers from the horizontal semicircular canal (HSC) and the saccule (SAC) in the brainstem was as previously reported (Lee WS, 1992). The selectivity of efferent labeling was verified by the distribution of afferent fibers labeled simultaneously. A group of vestibular efferent neurons was found in the dorsal area of the brainstem ventromedial to the medial vestibular nucleus and lateral to the facial genu. Another group of efferents was situated ventrally in the reticular formation. Dorsal group efferent neurons innervating HSC were located more caudally than SAC efferents and were primarily on the contralateral side. In the reticular formation, SAC efferents were found more on the contralateral side, while HSC efferents were found bilaterally. This method may contribute to the detailed anatomical study of the vestibular efferent system.
Two patients with peripheral vestibular disorders received vestibular training by a method of 18 exercises developed in Kitasato University, Japan. The effects of training were evaluated by the EquiTest system. As already reported in many papers, postural stability based on vestibular function can be tested by conditions 5 and 6 in the sensory organization test (SOT). We used equilibrium and strategy scores as measures in this study. Case 1 (female, aged 70 years) showed severely reduced caloric response in the left ear. She had complained of dizziness and gait disturbance for 8 years. Before training, her equilibrium score was 0 in conditions 5 and 6. After training for about 2 months, these scores became normal. Case 2 (female, aged 46 years) had dizziness for two years because of bilaterally reduced vestibular function. Her equilibrium score was 0 in conditions 5 and 6 before training. Although these scores did not became completely normal, they gradually improved during a 4.5 month training period. Furthermore, there was a significant change in her strategy score in condition 5. She had used ankle strategy before training but changed to hip strategy mainly during the course of training. This suggests that one of the effective points in the training of such a patient is the learning of useful strategies under unstable circumstances. As shown in these two cases, it seems that good effects from vestibular training can be expected even in patients with chronic vestibular disorders of many years duration.
It is well known that in 30% of patients with atrial fibrillation (AF) who complain of vertigo there is a high risk of cerebral infarction. From 1982 to 1991 24 patients with AF and vertigo (AF group) were diagnosed as having vertebrobasilar insufficiency (VBI). Their otoneurological findings were compared with those of 175 patients with vertigo due to VBI but no AF (VBI group). The incidence was much higher than that in the VBI group (4.6%). The AF group with cerebral infarction had a higher incidence of nystagmus (42.3%) than did the VBI group (7.7%), so it is suspected that nystagmus in AF patients with vertigo is a predictor of cerebral infarction.
In order to examine the relationship between Meniere's disease (MD) and autonomic nerve function, we analyzed sympathetic and parasympathetic nerve functions in 23 patients with MD using pulse wave velocity, RR interval and thermography. Fifty-seven patients with autonomic nerve dysfunction (AND) were also analyzed and compared with the MD patients. The parameters examined were 1. pulse wave velocity (to evaluate sympathetic nerve, SN, function) 2. coefficient of variation of RR interval in static position (to evaluate parasympathetic nerve, PN, function) 3. thermography (to evaluate SN function) Eight (34.8%) of the MD patients showed SN dysfunction (hyperfunction 3, hypofunction 5) and 2 patients with SN hypofunction showed duplicated PN dysfunction (hyperfunction 1, hypofunction 1). On the other hand, 37 (64.8%) of the AND patients showed various types of SN and PN dysfunction (28 patients with SN dysfunction-hyperfunction 20, hypofunction 8-and normal PN function, 6 patients with PN hypofunction and normal SN function, 2 patients with SN hyperfunction and PN hypofunction and 1 patient with SN and PN hypofunction). These results suggest that the AND in both groups was mainly SN dysfunction, differing from previous reports which indicated that PN hypofunction causes AND in MD. We conclude that our study evaluated SN function mainly and did not sufficiently examine PN function. Thus, further examination of PN function may be necessary.
Four tests, were administered to three groups of patients : Cornell Medical Index (CMI), Manifest Anxiety Scale (MAS), Self-rating Depression Scale (SDS), Yatabe-Guilford Personality Test (Y-G). Group I contained vertigo patients 65 years of age and older, group II vertigo patients less than 65 years of age, and group III healthy persons 65 years of age and older. The second and third groups served as controls. 1. In group I, CMI, MAS and SDS test results showed significantly more psychosomatic problems than in group III. 2. In group I, CMI, MAS and SDS test results showed more psychosomatic problems than in group II. 3. It is concluded that older patients with vertigo have more psychosomatic problems than do younger patients with vertigo.
To assess the efficacy of Ibudilast in Meniere's desease, we randomly selected 15 patients with this desease seven males and eight females aged 30 - 73 years. We administered three capsules of Ketas® every day to these patients and investigated the following : 1) effect of treatment on vertigo, 2) effect of treatment on damage to the inner ear, 3) effect of treatment on recurrent attacks of vertigo. The effect of treatment on recurrent attacks of vertigo was evaluated by comparing the number of attacks a months after the start of treatment with the number before treatment. Treatment reduced recurrent attacks of vertigo in 11 patients (73%). No side effects were reported in this study. We conclude that Ketas® may be an effective drug for Meniere's disease.
The therapeutic effect of ibudilast, a cerebral vasodilator, was evaluated in 106 patients with vertigo or dizziness. The patients were given a 10 mg capsule of ibudilast 3 times a day for over 4 weeks. In 77 patients (72.6%), symptoms and/or signs were reduced. Mild side-effects were noted in 3 patients (2.8%). These results suggest that ibudilast is a clinically useful drug for the treatment of vertigo or dizziness. A questionnaire consisting of 14 questions was used to evaluate the handicaps in everyday life due to dizziness in 25 patients. A discrepancy was noted between the doctor's evaluation of improvement and the patient's selfassesment. It appeared that patients with emotional disturbances and limited social activity due to dizziness perceived greater handicaps.