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Frontiers in Neurology 2023For the assessment of patients presenting with acute prolonged vertigo meeting diagnostic criteria for acute vestibular syndrome (AVS), bedside oculomotor examinations...
OBJECTIVES
For the assessment of patients presenting with acute prolonged vertigo meeting diagnostic criteria for acute vestibular syndrome (AVS), bedside oculomotor examinations are essential to distinguish peripheral from central causes. Here we assessed patterns of spontaneous nystagmus (SN) observed in AVS and its diagnostic accuracy at the bedside.
METHODS
MEDLINE and Embase were searched for studies (1980-2022) reporting on the bedside diagnostic accuracy of SN-patterns in AVS patients. Two independent reviewers determined inclusion. We identified 4,186 unique citations, examined 219 full manuscripts, and analyzed 39 studies. Studies were rated on risk of bias (QUADAS-2). Diagnostic data were extracted and SN beating-direction patterns were correlated with lesion locations and lateralization.
RESULTS
Included studies reported on 1,599 patients, with ischemic strokes ( = 747) and acute unilateral vestibulopathy ( = 743) being most frequent. While a horizontal or horizontal-torsional SN was significantly more often found in peripheral AVS (pAVS) than in central AVS (cAVS) patients (672/709 [94.8%] vs. 294/677 [43.4%], < 0.001), torsional and/or vertical SN-patterns were more prevalent in cAVS than in pAVS (15.1 vs. 2.6%, < 0.001). For an (isolated) vertical/vertical-torsional SN or an isolated torsional SN specificity (97.7% [95% CI = 95.1-100.0%]) for a central origin etiology was high, whereas sensitivity (19.1% [10.5-27.7%]) was low. Absence of any horizontal SN was more frequently observed in cAVS than in pAVS (55.2 vs. 7.0%, < 0.001). Ipsilesional and contralesional beating directions of horizontal SN in cAVS were found at similar frequency (28.0 vs. 21.7%, = 0.052), whereas for pAVS a contralesional SN was significantly more frequent (95.2 vs. 2.5%, < 0.001). For PICA strokes presenting with horizontal SN, beating direction was ipsilesional more often than contralesional (23.9 vs. 6.4%, = 0.006), while the opposite was observed for AICA strokes (2.2 vs. 63.0%, < 0.001).
CONCLUSIONS
(Isolated) vertical and/or torsional SN is found in a minority (15.1%) of cAVS patients only. When present, it is highly predictive for a central cause. A combined torsional-downbeating SN-pattern may be observed in pAVS also in cases with isolated lesions of the inferior branch of the vestibular nerve. Furthermore, in cAVS patients the SN beating direction itself does not allow a prediction on the lesion side.
PubMed: 37396773
DOI: 10.3389/fneur.2023.1208902 -
Frontiers in Neural Circuits 2023Space Motion Sickness (SMS) is a syndrome that affects around 70% of astronauts and includes symptoms of nausea, dizziness, fatigue, vertigo, headaches, vomiting, and...
INTRODUCTION
Space Motion Sickness (SMS) is a syndrome that affects around 70% of astronauts and includes symptoms of nausea, dizziness, fatigue, vertigo, headaches, vomiting, and cold sweating. Consequences range from discomfort to severe sensorimotor and cognitive incapacitation, which might cause potential problems for mission-critical tasks and astronauts and cosmonauts' well-being. Both pharmacological and non-pharmacological countermeasures have been proposed to mitigate SMS. However, their effectiveness has not been systematically evaluated. Here we present the first systematic review of published peer-reviewed research on the effectiveness of pharmacological and non-pharmacological countermeasures to SMS.
METHODS
We performed a double-blind title and abstract screening using the online Rayyan collaboration tool for systematic reviews, followed by a full-text screening. Eventually, only 23 peer-reviewed studies underwent data extraction.
RESULTS
Both pharmacological and non-pharmacological countermeasures can help mitigate SMS symptoms.
DISCUSSION
No definitive recommendation can be given regarding the superiority of any particular countermeasure approach. Importantly, there is considerable heterogeneity in the published research methods, lack of a standardized assessment approach, and small sample sizes. To allow for consistent comparisons between SMS countermeasures in the future, standardized testing protocols for spaceflight and ground-based analogs are needed. We believe that the data should be made openly available, given the uniqueness of the environment in which it is collected.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021244131.
Topics: Humans; Randomized Controlled Trials as Topic; Space Flight; Space Motion Sickness; Vestibule, Labyrinth; Weightlessness
PubMed: 37396400
DOI: 10.3389/fncir.2023.1150233 -
Therapeutic Advances in Neurological... 2023Magnetic Resonance-guided Focused Ultrasound (MRgFUS) is an innovative therapeutical approach for medically refractory tremor. It is currently under investigation for... (Review)
Review
BACKGROUND
Magnetic Resonance-guided Focused Ultrasound (MRgFUS) is an innovative therapeutical approach for medically refractory tremor. It is currently under investigation for other neurological diseases including refractory neuropathic pain (NP).
OBJECTIVE
The objective of this systematic review is to analyze available evidence about the effectiveness and safety profile of MRgFUS in the treatment of refractory NP.
METHODS
Eligible studies were identified by searching published studies in PubMed and Scopus databases from inception to December 2022 and by identifying ongoing studies registered on the clinicaltrials.gov website. The study was registered in PROSPERO (ID: CRD42021277154).
RESULTS
We found three published observational studies and nine ongoing studies. In published studies, the involved population ranged from 8 to 46 patients with overall 66 patients being included with NP or trigeminal neuralgia. The target lesion was in the posterior part of the central lateral nucleus of the thalamus, bilaterally. Outcomes were assessed at different times through the Visual Analog Scale, showing a variable degree of improvement. Adverse events were rare, mild, and transient (vertigo, paresthesias, and dysesthesias) with intracerebral bleeding being reported as major adverse event in one case only. Among ongoing studies, we found three prospective, randomized, sham-controlled, crossover trials (RCTs) and six observational studies. Inclusion criteria are previous failure of more than three pharmacological treatments and NP duration longer than 6 months. The thalamus is the main proposed target and measured outcomes are accuracy of the procedure and pain relief, with a follow-up period ranging from 1 week to 1 year.
CONCLUSION
This systematic review suggests that, although high-quality studies are lacking, available evidence endorses the effectiveness and safety of MRgFUS in the management of NP. Ongoing RCTs will provide more robust data to understand benefits and risks of the procedure.
REGISTRATION
PROSPERO (ID: CRD42021277154).
PubMed: 37363184
DOI: 10.1177/17562864231180729 -
Experimental Brain Research Jul 2023This qualitative systematic review presents an overview of the state of the research relating to visual motion hypersensitivity (VMH) and offers a reference tool for... (Review)
Review
This qualitative systematic review presents an overview of the state of the research relating to visual motion hypersensitivity (VMH) and offers a reference tool for future studies in the field. The study set out to identify and collate articles investigating risk groups with aberrant responses to visual motion as compared to healthy control groups, presenting evidence for risk factors associated with visual motion hypersensitivity. Data were synthesized into the state of the research and analyzed in the context of the clinical characteristics of each risk factor. Literature searches were performed on Medline Ovid, EMBASE, Web of Science, and Cinahl, identifying a total of 586 studies of which 54 were finally included. Original articles published between the dates of commencement for each database and 19th January 2021 were included. JBI critical appraisal tools were implemented for each corresponding article type. In total, the following number of studies was identified for each respective risk factor: age (n = 6), migraines (n = 8), concussions (n = 8), vestibular disorders (n = 13), psychiatric conditions (n = 5), and Parkinson's disease (n = 5). Several studies described VMH as the primary concern (n = 6), though these primarily included patients with vestibulopathies. There were considerable differences in the nomenclature employed to describe VMH, depending largely on the investigating group. An overview of investigated risk factors and their evaluation methods was presented in a Sankey diagram. Posturography was the most implemented methodology but due to diverse measurements meta-analyses were not possible. One may however note that while the easily implemented Vestibular Ocular Motor Screening (VOMS) was designed for concussed patients, it may prove useful for other risk groups.
Topics: Humans; Vestibular Diseases; Motion; Brain Concussion; Mental Disorders; Migraine Disorders
PubMed: 37341755
DOI: 10.1007/s00221-023-06652-3 -
Otology & Neurotology : Official... Jun 2023To conduct a scoping systematic review of the literature on the use of telemedicine to evaluate, diagnose, and manage patients with dizziness.
OBJECTIVES
To conduct a scoping systematic review of the literature on the use of telemedicine to evaluate, diagnose, and manage patients with dizziness.
DATA SOURCES
Web of Science, SCOPUS, and MEDLINE PubMed databases.
STUDY SELECTION
The inclusion criteria included the following: pertaining to telemedicine and the evaluation, diagnosis, treatment, or management of dizziness. Exclusion criteria included the following: single-case studies, meta-analyses, and literature and systematic reviews.
DATA EXTRACTION
Outcomes recorded for each article included the following: study type, patient population, telemedicine format, dizziness characteristics, level of evidence, and quality assessment.
DATA SYNTHESIS
The search returned 15,408 articles, and a team of four screened the articles for inclusion criteria status. A total of 9 articles met the inclusion criteria and were included for review. Of the nine articles, four were randomized clinical trials, three were prospective cohort studies, and two were qualitative studies. The telemedicine format was synchronous in three studies and asynchronous in six studies. Two of the studies involved acute dizziness only, four involved chronic dizziness only, one involved both acute and chronic dizziness, and two did not specify dizziness type. Six of the studies included the diagnosis of dizziness, two involved the evaluation of dizziness, and three involved treatment/management. Some of the reported benefits of telemedicine for dizziness patients included cost savings, convenience, high patient satisfaction, and improvement in dizziness symptoms. Limitations included access to telemedicine technology, Internet connectivity, and dizziness symptoms interfering with the telemedicine application.
CONCLUSIONS
Few studies investigate the evaluation, diagnosis, or management of dizziness using telemedicine. The lack of protocols and standards of care for telemedicine evaluation of dizzy patients creates some challenges in care delivery; however, these reviewed studies provide examples of the breadth of care that has been provided remotely.
Topics: Humans; Dizziness; Prospective Studies; Telemedicine; Vertigo
PubMed: 37072912
DOI: 10.1097/MAO.0000000000003876 -
The Cochrane Database of Systematic... Apr 2023Vestibular migraine is a form of migraine where one of the main features is recurrent attacks of vertigo. These episodes are often associated with other features of... (Review)
Review
BACKGROUND
Vestibular migraine is a form of migraine where one of the main features is recurrent attacks of vertigo. These episodes are often associated with other features of migraine, including headache and sensitivity to light or sound. The unpredictable and severe attacks of vertigo can lead to a considerable reduction in quality of life. The condition is estimated to affect just under 1% of the population, although many people remain undiagnosed. A number of pharmacological interventions have been used, or proposed to be used, at the time of a vestibular migraine attack to help reduce the severity or resolve the symptoms. These are predominantly based on treatments that are in use for headache migraine, with the belief that the underlying pathophysiology of these conditions is similar. OBJECTIVES: To assess the benefits and harms of pharmacological interventions used to relieve acute attacks of vestibular migraine.
SEARCH METHODS
The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 23 September 2022.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) and quasi-RCTs in adults with definite or probable vestibular migraine comparing triptans, ergot alkaloids, dopamine antagonists, antihistamines, 5-HT3 receptor antagonists, gepants (CGRP receptor antagonists), magnesium, paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) with either placebo or no treatment. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vertigo (assessed as a dichotomous outcome - improved or not improved), 2) change in vertigo (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) improvement in headache, 6) improvement in other migrainous symptoms and 7) other adverse effects. We considered outcomes reported at three time points: < 2 hours, 2 to 12 hours, > 12 to 72 hours. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS: We included two RCTs with a total of 133 participants, both of which compared the use of triptans to placebo for an acute attack of vestibular migraine. One study was a parallel-group RCT (of 114 participants, 75% female). This compared the use of 10 mg rizatriptan to placebo. The second study was a smaller, cross-over RCT (of 19 participants, 70% female). This compared the use of 2.5 mg zolmitriptan to placebo. Triptans may result in little or no difference in the proportion of people whose vertigo improves at up to two hours after taking the medication. However, the evidence was very uncertain (risk ratio 0.84, 95% confidence interval 0.66 to 1.07; 2 studies; based on 262 attacks of vestibular migraine treated in 124 participants; very low-certainty evidence). We did not identify any evidence on the change in vertigo using a continuous scale. Only one of the studies assessed serious adverse events. No events were noted in either group, but as the sample size was small we cannot be sure if there are risks associated with taking triptans for this condition (0/75 receiving triptans, 0/39 receiving placebo; 1 study; 114 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS: The evidence for interventions used to treat acute attacks of vestibular migraine is very sparse. We identified only two studies, both of which assessed the use of triptans. We rated all the evidence as very low-certainty, meaning that we have little confidence in the effect estimates and cannot be sure if triptans have any effect on the symptoms of vestibular migraine. Although we identified sparse information on potential harms of treatment in this review, the use of triptans for other conditions (such as headache migraine) is known to be associated with some adverse effects. We did not identify any placebo-controlled randomised trials for other interventions that may be used for this condition. Further research is needed to identify whether any interventions help to improve the symptoms of vestibular migraine attacks and to determine if there are side effects associated with their use.
Topics: Adult; Female; Humans; Male; Migraine Disorders; Anti-Inflammatory Agents, Non-Steroidal; Vertigo; Headache; Tryptamines
PubMed: 37042545
DOI: 10.1002/14651858.CD015322.pub2 -
The Cochrane Database of Systematic... Apr 2023Vestibular migraine is a form of migraine where one of the main features is recurrent attacks of vertigo. These episodes are often associated with other features of... (Review)
Review
BACKGROUND
Vestibular migraine is a form of migraine where one of the main features is recurrent attacks of vertigo. These episodes are often associated with other features of migraine, including headache and sensitivity to light or sound. These unpredictable and severe attacks of vertigo can lead to a considerable reduction in quality of life. The condition is estimated to affect just under 1% of the population, although many people remain undiagnosed. A number of interventions have been used, or proposed to be used, as prophylaxis for this condition, to help reduce the frequency of the attacks. Many of these interventions include dietary, lifestyle or behavioural changes, rather than medication. OBJECTIVES: To assess the benefits and harms of non-pharmacological treatments used for prophylaxis of vestibular migraine.
SEARCH METHODS
The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 23 September 2022.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) and quasi-RCTs in adults with definite or probable vestibular migraine comparing dietary modifications, sleep improvement techniques, vitamin and mineral supplements, herbal supplements, talking therapies, mind-body interventions or vestibular rehabilitation with either placebo or no treatment. We excluded studies with a cross-over design, unless data from the first phase of the study could be identified. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vertigo (assessed as a dichotomous outcome - improved or not improved), 2) change in vertigo (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) improvement in headache, 6) improvement in other migrainous symptoms and 7) other adverse effects. We considered outcomes reported at three time points: < 3 months, 3 to < 6 months, > 6 to 12 months. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS: We included three studies in this review with a total of 319 participants. Each study addressed a different comparison and these are outlined below. We did not identify any evidence for the remaining comparisons of interest in this review. Dietary interventions (probiotics) versus placebo We identified one study with 218 participants (85% female). The use of a probiotic supplement was compared to a placebo and participants were followed up for two years. Some data were reported on the change in vertigo frequency and severity over the duration of the study. However, there were no data regarding improvement of vertigo or serious adverse events. Cognitive behavioural therapy (CBT) versus no intervention One study compared CBT to no treatment in 61 participants (72% female). Participants were followed up for eight weeks. Data were reported on the change in vertigo over the course of the study, but no information was reported on the proportion of people whose vertigo improved, or on the occurrence of serious adverse events. Vestibular rehabilitation versus no intervention The third study compared the use of vestibular rehabilitation to no treatment in a group of 40 participants (90% female) and participants were followed up for six months. Again, this study reported some data on change in the frequency of vertigo during the study, but no information on the proportion of participants who experienced an improvement in vertigo or the number who experienced serious adverse events. We are unable to draw meaningful conclusions from the numerical results of these studies, as the data for each comparison of interest come from single, small studies and the certainty of the evidence was low or very low. AUTHORS' CONCLUSIONS: There is a paucity of evidence for non-pharmacological interventions that may be used for prophylaxis of vestibular migraine. Only a limited number of interventions have been assessed by comparing them to no intervention or a placebo treatment, and the evidence from these studies is all of low or very low certainty. We are therefore unsure whether any of these interventions may be effective at reducing the symptoms of vestibular migraine and we are also unsure whether they have the potential to cause harm.
Topics: Adult; Female; Humans; Male; Cognitive Behavioral Therapy; Migraine Disorders; Headache; Vertigo
PubMed: 37042522
DOI: 10.1002/14651858.CD015321.pub2 -
Medicine Mar 2023To evaluate the efficacy of Epley's maneuver plus betahistine in the management of patients with posterior canal benign paroxysmal positional vertigo (PC-BPPV). (Meta-Analysis)
Meta-Analysis
BACKGROUND
To evaluate the efficacy of Epley's maneuver plus betahistine in the management of patients with posterior canal benign paroxysmal positional vertigo (PC-BPPV).
METHODS
Electronic databases including PubMed, Embase, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure, and Wanfang were searched from their inception to April, 2022. The effect size was analyzed by calculating the pooled risk ratio estimates of efficacy rate, recurrence rate, and standardized mean differences (SMD) of dizziness handicap inventory (DHI) score with a 95% confidence interval (CI). Sensitive analysis was performed simultaneously.
RESULTS
A total of 9 randomized controlled trials with 860 PC-BPPV patients were included in the meta-analysis, in which 432 were treated with Epley's maneuver plus betahistine, and 428 received Epley's maneuver alone. The meta-analysis revealed that Epley's maneuver plus betahistine significantly improved DHI score than Epley's maneuver alone (SMD = -0.61, 95% CI -0.96 to -0.26, P = .001). In addition, both Epley's maneuver plus betahistine and Epley's maneuver groups had comparable outcomes in efficacy rate and recurrence rate.
CONCLUSION
This meta-analysis shows that Epley's maneuver plus betahistine in PC-BPPV patients had favorable effects on DHI score.
Topics: Humans; Benign Paroxysmal Positional Vertigo; Betahistine; Treatment Outcome; Randomized Controlled Trials as Topic
PubMed: 37000080
DOI: 10.1097/MD.0000000000033421 -
Journal of Clinical Medicine Mar 2023Dizziness and vertigo are among the most prevalent complaints in the elderly and have a major negative influence on (i) the perception of the quality of life; and (ii)... (Review)
Review
Dizziness and vertigo are among the most prevalent complaints in the elderly and have a major negative influence on (i) the perception of the quality of life; and (ii) the risk of falling. Due to population aging, particularly in wealthy nations, vertigo represents a growing issue and a serious public health concern. In order to approach the patient correctly and to offer the best treatment options, it is mandatory to identify vertigo's underlying causes. The aim of this paper was to identify the different etiologies of vertigo and possibly their frequency in the elderly population, by reviewing the scientific literature of the last decade (2012-2022). A systematic review was performed according to PRISMA guidelines, searching the Medline database from January 2012 through to December 2022. The search identified 1025 candidate papers, but after the application of specific selection criteria, only five were considered for further analysis. A total of 2148 elderly patients (60-90 y old) presenting with vertigo were reported in the selected papers. A total of 3404 conditions were identified as the cause of vertiginous symptoms, (some patients presented multiple etiologies). All major diagnoses were categorized into different subgroups: the most common origin of vertigo was represented by audio-vestibular disorders (28.4%), followed by cardiovascular (20.4%) and neurological diseases (15.1%). Furthermore, 9.1% of patients were diagnosed with psychiatric conditions, whilst ophthalmologic and musculoskeletal disorders accounted for 7.5% and 6.3% of the cases respectively. Medication adverse effects and metabolic-related diseases were also considered among the causes. For 3.4% of cases the etiology remains unclear. Conclusions: Audio-vestibular disorders represent the most frequent cause of vertigo in the elderly. The etiologies affecting the vertigo patient must be defined in order to identify potential life-threatening conditions, such as cardiovascular and neurological disorders, which according to the data of this review constitute the second and third common causes of vertigo. A multidisciplinary strategy, involving different specialists (such as ENTs, Neurologists, Cardiologists, Geriatricians) is recommended for the correct assessment of these disorders.
PubMed: 36983184
DOI: 10.3390/jcm12062182 -
Biomedicines Feb 2023(1) Background: Epilepsy is a frequent comorbidity in patients with brain tumors, in whom seizures are often drug-resistant. Current evidence suggests that excess of... (Review)
Review
(1) Background: Epilepsy is a frequent comorbidity in patients with brain tumors, in whom seizures are often drug-resistant. Current evidence suggests that excess of glutamatergic activity in the tumor microenvironment may favor epileptogenesis, but also tumor growth and invasiveness. The selective non-competitive α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor antagonist perampanel (PER) was demonstrated to be efficacious and well-tolerated in patients with focal seizures. Moreover, preclinical in vitro studies suggested a potential anti-tumor activity of this drug. In this systematic review, the clinical evidence on the efficacy and tolerability of PER in brain tumor-related epilepsy (BTRE) is summarized. (2) Methods: Five databases and two clinical trial registries were searched from inception to December 2022. (3) Results: Seven studies and six clinical trials were included. Sample size ranged from 8 to 36 patients, who received add-on PER (mean dosage from 4 to 7 mg/day) for BTRE. After a 6-12 month follow-up, the responder rate (% of patients achieving seizure freedom or reduction ≥ 50% of seizure frequency) ranged from 75% to 95%, with a seizure freedom rate of up to 94%. Regarding tolerability, 11-52% of patients experienced non-severe adverse effects (most frequent: dizziness, vertigo, anxiety, irritability). The retention rate ranged from 56% to 83%. However, only up to 12.5% of patients discontinued the drug because of the adverse events. (4) Conclusions: PER seems to be efficacious, safe, and well-tolerated in patients with BTRE. Further randomized studies should be conducted in more homogeneous and larger populations, also evaluating the effect of PER on tumor progression, overall survival, and progression-free survival.
PubMed: 36979629
DOI: 10.3390/biomedicines11030651