The history of clinical studies on vestibular migraine (migraine associated vertigo) was reviewed. Archeological studies suggested that headache itself had already existed in the Neolithic era, because bony defects in the skull which could have arisen from trepanation had been found in the remains of this era. Medical observations on migraine were made by Hippocrates of Kos, and Aretaeus of Kappadocia described migraine-associated vertigo in the 2nd century A.D. Studies on migraine and migraine-associated vertigo (vestibular migraine) began in the modern era. As hypotheses on the pathophysiology of migraine, three theories have been proposed, including the vascular theory, the neural theory, and the trigemino-vascular theory. As important articles concerning the clinical studies, three papers were published. The first was published by Bickerstaff. He reported cases of basilar-type migraine, in which vertigo occurs as an aura of migrainous headache. The second was published by Kayan and Hood. In this paper, the authors described various characteristics of vestibular migraine, which are still valid. The third was published by Neuhauser et al., in which the authors proposed diagnostic criteria for vestibular migraine, which serve as the basis for the current official diagnostic criteria. Finally, the author remarked that clarification of the pathophysiology of vestibular migraine and association with Meniere's disease are the most important issues that need to be resolved.
Objectives: In 1975, Sakata et al., introduced the Caloric Eye Tracking Pattern Test (CETP), combining the caloric test with the eye-tracking test. They reported that CETP is useful for identifying the clinical features of central vestibular vertigo. We examined the significance of CETP for differentiating between peripheral and central vestibular vertigo.
Methods: The subjects consisted of 5 healthy subjects, 5 patients with peripheral vestibular disorder, and 29 patients with central vestibular disorder. We performed CETP, with the eye tracking test (ETT) during caloric nystagmus. The ear was irrigated for 20 seconds with 20 mL of water (20°C) with the patient in a supine position and the head anteflexed at 30 degrees. After 70 seconds, when the caloric responses were active, CETP was initiated using a target oscillating at an amplitude of 30 degrees and frequency of 0.3 Hz.
Results: In patients with central vestibular disorder, even though the conventional ETT pattern was smooth, the CETP pattern showed superimposed caloric nystagmus, resulting in a loss of smoothness. On the other hand, in healthy subjects and patients with peripheral vestibular disorder, both conventional ETT and CETP showed smooth movements.
Conclusion: CETP may be a useful diagnostic method to differentiate peripheral from central vestibular vertigo.
Objective: To investigate the background of hospitalized patients with vertebrobasilar insufficiency (VBI) over a 10-year period.
Methods: A retrospective study was conducted of the medical records of patients with VBI who were admitted to our hospital between January 2001 and December 2010.
Results: A total of 79 cases were hospitalized during this period. The reason for the hospital admission in all of the patients was vertigo. The study population was 38.0% male and 62.0% female. The average age of the patients was 60.6±14.8 (range 24-86) years. The age distribution showed a peak at 60 years. The proportion of patients that were 65 years or older was 45.6%. The season with the highest rate of onset was the summer (27 cases). The distribution of the onset time suggested a high incidence in the early morning. The duration of spontaneous nystagmus and of bed rest were 1.7±1.5 and 2.2±1.0 days, respectively. The prevalences of diabetes mellitus and hypertension were 34.2% and 3.8%, respectively.
Conclusion: This study revealed a tendency towards increased incidence of VBI with aging. It became clear that severe vertigo attacks that necessitated hospitalization were more likely occur in the early morning and in the summer. This study suggested that aging, summer time and hypertension are important factors predisposing to the development of VBI. It is useful to investigate the background of hospitalized patients in order to understand the pathology of VBI.
In Japan, few physical therapists (PTs) can provide VBRT (vestibular and balance rehabilitation therapy) for patients with vertigo and/or dizziness, whereas in other countries, there are many reports of VBRT provided by PTs. Promoting collaboration among the medical staff is essential to construct a support system for patients with vestibular disorders. Therefore, we decided to offer VBRT, working together with PTs and clinical laboratory technicians.
Our VBRT consists of three steps (Step 1 to 3) and the contents increase in difficulty from Step 1 to 3. Every step is also divided into three parts-therapy for postural control, therapy for recovery of the vestibular ocular reflex, and therapy for the vestibular spinal reflex or aerobic exercise. Patients undergo VBRT for 6 months (2 months per step). To evaluate the effects of VBRT objectively, we adopted posturography, Functional Gait Assessment, video Head Impulse Test, and Subjective Visual Vertical.
For establishment of evidence for VBRT provided by PTs, clinical trials and studies are necessary.
We performed a questionnaire survey to evaluate the feeling of dizziness in the general population?. The participants were community dwellers who voluntarily participated in the Yakumo Study and managed their everyday lives by themselves. We compared the answers of female participants with those of male participants and found that the perception of dizziness in daily life was worse in female participants than in male participants. Feeling of dizziness of the female participants that those were not a dizziness sense came to feel dizziness newly ten years later, particularly 40 years old. Is in its 70s by comparing the result ten years later, the feeling of dizziness, it was statistically significantly to come feel dizziness newly in female participants. [Not corrected because the meaning of these sentences unclear] We propose to increase the number of items in the questionnaire in the future, in an attempt to better understand the perception of dizziness.
In order to comply with the amended act on the protection of personal information, a new technique to blur the iris pattern was developed using the public domain software, ImageJ. Gaussian blur was performed automatically on the iris pattern. Using this program, video movies were created with the iris blurred in five stages and we examined whether it was possible to analyze the torsional direction of nystagmus. The analysis revealed that when the σ of Gaussian blur was 4 or more, the accuracy of the analysis could no longer be maintained. Using this technique, it was possible to delete the information of the iris pattern for protection of personal information.
Imaging examinations, such as computed tomography (CT) or magnetic resonance imaging (MRI), could provide useful information in the diagnosis of peripheral disequilibrium. Visualization of the endolymphatic hydrops (EH) by 3-T MRI with gadolinium injection has contributed to the diagnosis of Meniere's disease. Investigation of the relationships between EH and the results of physiological examinations such as vestibular evoked myogenic potential, electrocochleography, and caloric response demonstrated that the results were related not only to the degree of EH, but also to the persistence and formation of EH. EH has also been detected in patients with superior canal dehiscence or large vestibular aqueduct syndrome. Moreover, we encountered a case in which EH was detected in the non-affected ear of a patient suffering from acute sensorineural hearing loss and disequilibrium, and such imaging analysis provided us with clues for treating her symptoms.
Effective canalith repositioning maneuvers for cases of Benign Paroxysmal Positional Vertigo (BPPV) - canalolithiasis are all characterized by head positioning via the healthy-ear-down 135° head position. The healthy-ear-down 135° head position is the key position that allows the dropped canaliths in the semicircular canal to easily fall back into the utricle. At present, there is no clear evidence to support the canalith repositioning maneuvers for BPPV - cupulolithiasis. The presumed reason is that the strength of adherence of the canaliths to the cupula is unknown, and it is often not apparent whether the canaliths adhere to the utricular or canal side of the cupula. The position and direction of the cupula can become a problem in cases of BPPV - cupulolithiasis. The cupula of the lateral semicircular canal is directed backward toward the outside. On the other hand, the cupulae of the posterior semicircular canal and anterior semicircular canal are directed backwards toward the upward direction. Therefore, in cases of BPPV - cupulolithiasis, a characteristic neutral position exists where the nystagmus disappears, because the direction of the heavy cupula is consistent with the direction of gravity. In this paper, I shall introduce the canalith repositioning maneuvers that I use (the Epley maneuver, the healthy-ear-down 135° maneuver, and the affected-ear-down 135° maneuver) and comment on the advantages and problems of each of these maneuvers.
Apogeotropic positional nystagmus can occur in association with both peripheral and central lesions. Although apogeotropic positional nystagmus in patients with central lesions is rare, such cases should not be missed. The pathophysiology of apogeotropic positional nystagmus caused by peripheral lesions involves the development of cupulolithiasis in the lateral semicircular canal, which is one subtype of benign paroxysmal positional vertigo. In patients with cupulolithiasis, otoconia released from the otolithic membrane settle on the cupula, which responds to gravity. By considering the relationship between the position of the affected cupula of the lateral semicircular canal and the direction of gravity, we can speculate what type of nystagmus will be induced. As long as the head is maintained in a right- or left-ear-down position while the patient is positioned supine, the affected cupula will maintain a constant deviated angle and the nystagmus will be persistent. Therefore, when nystagmus is transient, we should suspect a central lesion. The affected cupula deviates toward the ampullopetal direction and strong nystagmus is induced with the healthy ear down in the supine position; therefore, the affected side is the upper ear when strong nystagmus is seen in the supine position. The affected side is indicated by the direction of nystagmus that occurs when the patient is supine with a midline head position because the cupula deviates toward the ampullopetal direction in the supine position. The affected side should be identical between the above-described methods. When each method reveals a different affected side, we should suspect a central lesion. When leaning or bowing in the sitting position, patients with cupulolithiasis in the lateral semicircular canal show horizontal nystagmus because the affected cupula deviates when leaning and bowing. Therefore, when vertical nystagmus is seen by leaning and/or bowing the head in the sitting position, we should suspect a central lesion.