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Modern vestibular tests can accurately separate stroke and vestibular neuritis

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Abstract

Objectives

To separate posterior-circulation stroke (PCS) and vestibular-neuritis (VN) using quantitative vestibular tests.

Methods

Patients were prospectively recruited from the emergency room within 72 h of presentation. Video-nystagmography (VNG), three-dimensional video head-impulse testing (vHIT), vestibular-evoked myogenic potentials (VEMPs), and subjective visual-horizontal (SVH) were performed.

Results

There were 128 PCS and 134 VN patients. Common stroke-territories were: posterior–inferior cerebellar artery, basilar-perforators, multi-territory and anterior–inferior cerebellar artery (41.4%, 21.1%, 14.1%, 7.8%). VN included superior, inferior and pan-neuritis (53.3%, 4.2%, and 41.5%). Most VN and stroke patients presented with acute vestibular syndrome (96.6%, 61.7%). In VN, we recorded horizontal (98.5%) or vertical/torsional spontaneous nystagmus (1.5%) and in PCS, absent-nystagmus (53.9%), horizontal (32%) or vertical/torsional (14.1%) nystagmus. The mean slow-phase velocity of horizontal nystagmus was faster in VN than PCS (11.8 ± 7.2 and 5.2 ± 3.0°/s, p < 0.01). Ipsilesional horizontal-canal (HC) vHIT-gain was lower in VN than in stroke (0.47 ± 0.24, 0.92 ± 0.20, p < 0.001). Ipsilesional catch-up saccades occurred earlier, and their amplitude, prevalence, and velocity were greater in VN than PCS (p < 0.01). Ipsilesional SVH deviation > 2.5° occurred more often in VN than in stroke (97.6% and 24.3%, p < 0.01). Abnormal bone-conducted ocular-VEMP asymmetry ratio was more common in VN than PCS (50% and 14.4%, p < 0.01). Using the ten best discriminators (VNG, vHIT, SVH, and oVEMP metrics), VN was separated from PCS with a sensitivity of 92.9% and specificity of 89.8%. Adding VNG and vHIT to the bedside head-impulse-nystagmus-and-test-of-skew (HINTS) test enhanced sensitivity and specificity from 95.3% and 63.4% to 96.5% and 80.6%.

Conclusion

Quantitative vestibular testing helps separate stroke from vestibular neuritis and, when used, could improve diagnostic accuracy in the emergency room.

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Funding

This research was supported by the Garnett Passe and Rodney Williams Memorial Foundation and the National Health and Medical Research Council of Australia.

Author information

Authors and Affiliations

  1. Department of Neurology, The Sutherland Hospital, Sydney, Australia

    Benjamin Nham

  2. Central Clinical School, The University of Sydney, Sydney, Australia

    Benjamin Nham, Chao Wang, Belinda Y. C. Kwok, Andrew Bradshaw, GMichael Halmagyi & Miriam S. Welgampola

  3. Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, Australia

    Chao Wang, Nicole Reid, Belinda Y. C. Kwok, Andrew Bradshaw, GMichael Halmagyi & Miriam S. Welgampola

  4. Department of Neurology, Liverpool Hospital, Sydney, Australia

    Zeljka Calic

  5. Faculty of Medicine and Health, The University of Sydney, Sydney, Australia

    Deborah A. Black

Authors
  1. Benjamin Nham
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  2. Chao Wang
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  3. Nicole Reid
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  4. Zeljka Calic
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  5. Belinda Y. C. Kwok
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  6. Deborah A. Black
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  7. Andrew Bradshaw
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  8. GMichael Halmagyi
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  9. Miriam S. Welgampola
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Corresponding author

Correspondence to Miriam S. Welgampola.

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Conflicts of interest

B. Nham, C. Wang, N. Reid, Z. Calic, BYC Kwok, D. A. Black, and A. P. Bradshaw have no disclosures relevant to this manuscript. G.M. Halmagyi is an unpaid consultant for Otometrics. M. S. Welgampola have no disclosures relevant to this manuscript.

Ethics and consent

This study received local ethics committee approval for human participants, and written informed consent was obtained from all participants as per the Helsinki Declaration of 1964.

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Nham, B., Wang, C., Reid, N. et al. Modern vestibular tests can accurately separate stroke and vestibular neuritis. J Neurol 270, 2031–2041 (2023). https://doi.org/10.1007/s00415-022-11473-5

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  • DOI: https://doi.org/10.1007/s00415-022-11473-5

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