Dizziness is one of the most common chief complaints in both the ambulatory care setting and the emergency department. These symptoms may be representative of a broad range of entities. Therefore, ...any attempt at treatment must first start with determining the etiology. In this current perspective, we focus specifically on the diagnosis of and treatment of vestibular migraine, which is common and overlaps clinically with a variety of other diagnoses. We discuss the traditional treatments for vestibular migraine in addition to the recent explosion of novel migraine therapeutics. Because vestibular migraine can mimic, or co-exist with, a variety of other vestibular diseases, we discuss several of these disorders including persistent postural-perceptual dizziness, benign paroxysmal positional vertigo, post-concussive syndrome, Ménière's disease, and cerebrovascular etiologies. We discuss the diagnosis of each, as well as overlapping and distinguishing clinical features of which the reader should be aware. Finally, we conclude with evidence based as well as expert commentary on management, with a particular emphasis on vestibular migraine.
Purpose of Review
Mild traumatic brain injury, or concussion, is a major cause of disability. Vestibular and visual dysfunction following concussion is common and can negatively affect patients’ ...well-being and prolong recovery. Etiologies of visual and vestibular symptoms are numerous, including ocular, neuro-ophthalmic, otologic, and neuro-vestibular conditions. Some etiologies are benign and may be treatable, while others are potentially vision or life-threatening, making a focused history and examination essential. This review offers an approach to the evaluation and treatment of the most common neuro-visual and vestibular impairments that may result from concussion.
Recent Findings
Treatment of concussion including exercise, computerized programs, transcranial magnetic stimulation, gene therapy, stem cell therapy, and nanoparticles has shown promise.
Summary
Many novel therapies are in the pipework for visual and vestibular recovery after concussion; however, the treatment mainstay remains therapy and evaluation for co-existing diseases.
Updates in neuro-otology Murphy, Olwen C; Hac, Nicholas E F; Gold, Daniel R
Current opinion in neurology,
02/2023, Letnik:
36, Številka:
1
Journal Article
Recenzirano
Recent updates with clinical implications in the field of neuro-otology are reviewed.
Important updates relating to several neuro-otologic disorders have been reported in recent years. For benign ...positional paroxysmal vertigo (BPPV), we provide updates on the characteristics and features of the short arm variant of posterior canal BPPV. For the acute vestibular syndrome, we report important updates on the use of video-oculography in clinical diagnosis. For autoimmune causes of neuro-otologic symptoms, we describe the clinical and paraclinical features of kelch-like protein 11 encephalitis, a newly-identified antibody associated disorder. For cerebellar ataxia, neuropathy, vestibular areflexia syndrome, we report recent genetic insights into this condition.
This review summarizes important recent updates relating to four hot topics in neuro-otology.
A 68-year-old woman with positional dizziness and progressive imbalance presented for vestibular evaluation. Examination was notable for spontaneous downbeat nystagmus (DBN), horizontal and vertical ...gaze-evoked nystagmus (GEN) with centripetal and rebound nystagmus, and positional apogeotropic nystagmus. There was also mild-moderate slowing of saccades horizontally and vertically and poor fast phases with an optokinetic stimulus. Further consultation by a movement disorder specialist uncovered asymmetric decrementing bradykinesia and rigidity, masked facies, and a wide-based stance without camptocormia. Screening serum laboratory results for metabolic, rheumatologic, infectious, heavy metal, endocrine, or vitamin abnormalities was normal. Surveillance imaging for neoplasms was unremarkable, and cerebrospinal fluid (CSF) analysis was negative for 14-3-3 and real-time quaking-induced conversion (RT-QuIC). However, her anti-glutamic acid decarboxylase-65 (GAD65) immunoglobulin G (IgG) level was markedly elevated in serum to 426,202 IU/mL (reference range 0-5 IU/mL) and in CSF to 18.1 nmol/L (reference range <0.03 nmol/L). No other autoantibodies were identified on the expanded paraneoplastic panel. The patient was referred to neuroimmunology, where torso rigidity, spasticity, and significant paravertebral muscle spasms were noted. Overall, the clinical presentation, examination findings, and extensive workup were consistent with a diagnosis of anti-GAD65-associated stiff person syndrome-plus (musculoskeletal plus cerebellar and/or brainstem involvement). She was subsequently treated with intravenous immunoglobulin (IVIg) and has been stable since commencing this therapy. In patients with centripetal nystagmus, especially in association with other cerebellar findings, an autoimmune cerebellar workup should be considered.
We present a case of new onset bilateral lower extremity weakness, paresthesia, urinary retention and bowel incontinence in a 51-year-old man. He had a complicated history of acute myelogenous ...leukemia with known central nervous system (CNS) and leptomeningeal involvement status post allogenic stem cell transplant complicated by chronic graft versus host disease (GVHD). We review the differential diagnosis as the physical exam and diagnostic results evolved. We also provide a review of the relevant literature supporting our favored diagnosis, as well as other competing diagnoses in this complicated case. The ultimate differential diagnosis included viral myelitis, treatment-related myelopathies, and CNS GVHD. The case provides a sobering reminder that even with an appropriate diagnostic workup, some cases remain refractory to therapeutic efforts. It also underscores the importance of a sensitive neurologic exam, given the significant clinico-radiological delay, and reviews the complex differential diagnosis for myelopathy.
Dayglow emissions are signatures of both the energy deposition into an atmosphere and the abundances of the species from which they arise. The first N2 dayglow emissions from Mars, the (0,5) and ...(0,6) bands of the N2 Vegard‐Kaplan band system, were detected by the Spectroscopy for Investigations of the Characteristics of the Atmosphere of Mars (SPICAM) UV spectrometer on board the Mars Express spacecraft. The Vegard‐Kaplan band system arises from the transition from the lowest N2 triplet state (A3Σu+;v′) to the electronic ground state (X1Σg+;v″). It is populated by direct electron‐impact excitation and by cascading from higher triplet states. The Venus UV dayglow is currently being probed by an instrument similar to SPICAM, the Spectroscopy for the Investigations of the Characteristics of the Atmosphere of Venus (SPICAV) UV spectrometer on Venus Express, but no N2 emissions have been detected. Because the N2 mixing ratios in the Venus thermosphere are larger than those in the thermosphere of Mars and the solar flux is greater at the orbit of Venus than that at Mars, we expect the Venus N2 emissions to be significantly more intense than those of Mars. A prediction of the intensities of various N2 emissions from Venus could be used to guide observations by the SPICAV and other instruments that are used to measure the Venus dayglow. Employing updated data, we here construct models of the low and high solar activity thermospheres of Venus, and we compute the integrated overhead intensities of 17 N2 band systems and limb profiles of the Vegard‐Kaplan bands. The ratios of the predicted intensities of the various N2 bands at Venus to those at Mars are in the range 5.5–9.5.
Key Points
We have modeled the electron‐excited N2 dayglow in the Venus thermosphere
We report intensities of 17 band systems and several individual bands
The predicted intensities are larger than those for Mars by factors of 5.5‐9.5
Abstract
The first N
2
emissions in the Martian dayglow were detected by the SPICAM UV spectrograph on board the Mars Express spacecraft. Intensities of the (0,5) and (0,6) Vegard‐Kaplan bands were ...found to be about one third of those predicted more than 35 years ago. The Vegard‐Kaplan band system arises from the transition from the lowest N
2
triplet state (
) to the electronic ground state (
). It is excited in the Martian dayglow by direct electron‐impact excitation of the ground N
2
(
X
) state to the
A
state and by excitation to higher triplet states that populate the
A
state by cascading. Using revised data, we compute here updated intensities of several of the bands in the N
2
triplet systems and those involving the
a
1
Π
g
state, the upper state of the Lyman‐Birge‐Hopfield bands. We find that the predicted limb intensities for the (0,5) and (0,6) Vegard‐Kaplan bands are consistent with the measured values.
Key Points
We have computed the intensities of 15 band systems of N2 on Mars
The intensities of the VK emissions agree with SPICAM limb profiles
Our calculations do not require that the mixing ratio of N2 be reduced
PDF
