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      Classification of vestibular signs and examination techniques: Nystagmus and nystagmus-like movements : Consensus document of the Committee for the International Classification of Vestibular Disorders of the Bárány Society

      research-article
      a , * , b , c , d , e , f , g , h , d , h
      Journal of Vestibular Research
      IOS Press

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          Abstract

          This paper presents a classification and definitions for types of nystagmus and other oscillatory eye movements relevant to evaluation of patients with vestibular and neurological disorders, formulated by the Classification Committee of the Bárány Society, to facilitate identification and communication for research and clinical care. Terminology surrounding the numerous attributes and influencing factors necessary to characterize nystagmus are outlined and defined. The classification first organizes the complex nomenclature of nystagmus around phenomenology, while also considering knowledge of anatomy, pathophysiology, and etiology. Nystagmus is distinguished from various other nystagmus-like movements including saccadic intrusions and oscillations.

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          Most cited references166

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          Benign paroxysmal positional vertigo: Diagnostic criteria.

          This article presents operational diagnostic criteria for benign paroxysmal positional vertigo (BPPV), formulated by the Committee for Classification of Vestibular Disorders of the Bárány Society. The classification reflects current knowledge of clinical aspects and pathomechanisms of BPPV and includes both established and emerging syndromes of BPPV. It is anticipated that growing understanding of the disease will lead to further development of this classification.
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            HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging.

            Acute vestibular syndrome (AVS) is often due to vestibular neuritis but can result from vertebrobasilar strokes. Misdiagnosis of posterior fossa infarcts in emergency care settings is frequent. Bedside oculomotor findings may reliably identify stroke in AVS, but prospective studies have been lacking. The authors conducted a prospective, cross-sectional study at an academic hospital. Consecutive patients with AVS (vertigo, nystagmus, nausea/vomiting, head-motion intolerance, unsteady gait) with >or=1 stroke risk factor underwent structured examination, including horizontal head impulse test of vestibulo-ocular reflex function, observation of nystagmus in different gaze positions, and prism cross-cover test of ocular alignment. All underwent neuroimaging and admission (generally <72 hours after symptom onset). Strokes were diagnosed by MRI or CT. Peripheral lesions were diagnosed by normal MRI and clinical follow-up. One hundred one high-risk patients with AVS included 25 peripheral and 76 central lesions (69 ischemic strokes, 4 hemorrhages, 3 other). The presence of normal horizontal head impulse test, direction-changing nystagmus in eccentric gaze, or skew deviation (vertical ocular misalignment) was 100% sensitive and 96% specific for stroke. Skew was present in 17% and associated with brainstem lesions (4% peripheral, 4% pure cerebellar, 30% brainstem involvement; chi(2), P=0.003). Skew correctly predicted lateral pontine stroke in 2 of 3 cases in which an abnormal horizontal head impulse test erroneously suggested peripheral localization. Initial MRI diffusion-weighted imaging was falsely negative in 12% (all <48 hours after symptom onset). Skew predicts brainstem involvement in AVS and can identify stroke when an abnormal horizontal head impulse test falsely suggests a peripheral lesion. A 3-step bedside oculomotor examination (HINTS: Head-Impulse-Nystagmus-Test-of-Skew) appears more sensitive for stroke than early MRI in AVS.
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              Sound- and/or pressure-induced vertigo due to bone dehiscence of the superior semicircular canal.

              To present symptoms, patterns of nystagmus, and computed tomographic scan identification of patients with sound- and/or pressure-induced vertigo due to dehiscence of bone overlying the superior semicircular canal. To describe anatomical findings and outcome in 2 patients undergoing plugging of the superior semicircular canal for treatment of these symptoms. Prospective study of a case series in a tertiary care referral center. Eight patients with vertigo, oscillopsia, and/or disequilibrium related to sound, changes in middle ear pressure, and/or changes in intracranial pressure were identified in a 2-year period. Seven of these patients also had vertical-torsional eye movements induced by these sound and/or pressure stimuli. The direction of the evoked eye movements could be explained by excitation or inhibition of the superior semicircular canal in the affected ear. Computed tomographic scans of the temporal bones identified dehiscence of bone overlying the affected superior semicircular canal in each case. Disabling disequilibrium in 2 patients prompted plugging of the dehiscent superior canal through a middle cranial fossa approach. Symptoms were improved in each case. One patient developed recurrent symptoms requiring an additional plugging procedure and developed sensorineural hearing loss several days after this second procedure. We have identified patients with a syndrome of vestibular symptoms induced by sound in an ear or by changes in middle ear or intracranial pressure. These patients can also experience chronic disequilibrium. Eye movements in the plane parallel to that of the superior semicircular canal were evoked by stimuli that have the potential to cause ampullofugal or ampullopetal deflection of this canal's cupula in the presence of a dehiscence of bone overlying the canal. The existence of such deshiscences was confirmed with computed tomographic scans of the temporal bones. Surgical plugging of the affected canal may be beneficial in patients with disabling symptoms.
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                Author and article information

                Journal
                J Vestib Res
                J Vestib Res
                VES
                Journal of Vestibular Research
                IOS Press (Nieuwe Hemweg 6B, 1013 BG Amsterdam, The Netherlands )
                0957-4271
                1878-6464
                14 June 2019
                25 July 2019
                2019
                : 29
                : 2-3
                : 57-87
                Affiliations
                [a ]Department of Neurology, Mayo Clinic , Rochester, MN, USA
                [b ]Department of Neurology, Centre Hospitalier Emile Mayrisch , Esch-sur-Alzette, Luxembourg
                [c ]Private Practice of Neurology and Department of Neurology, Charité, Berlin, Germany
                [d ]Department of Neurology, The Johns Hopkins University School of Medicine , Baltimore, MD, USA
                [e ]Department of Neurology, Seoul National University College of Medicine , Seoul National University Bundang Hospital, Seoul, Korea
                [f ]Department of Otorhinolaryngology, Clínica Universidad de Navarra, Madrid, Spain
                [g ]Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Central Clinical School, University of Sydney , Sydney, Australia
                [h ]Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine , Baltimore, MD, USA
                On behalf of the Committee for the International Classification of Vestibular Disorders of the Bárány Society
                Author notes
                [* ]Corresponding author: Scott D.Z. Eggers, MD, Department of Neurology, Mayo Clinic 200 First St. SW, Rochester, MN 55905, USA. Tel.: +1 507 284 1005; Fax: +1 507 284 4074; E-mail: eggers.scott@ 123456mayo.edu .
                Article
                VES190658
                10.3233/VES-190658
                9249296
                31256095
                41e03692-dff2-4d96-894b-e9ebe25148d6
                © 2019 – IOS Press and the authors. All rights reserved

                This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial (CC BY-NC 4.0) License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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