vestibular bedside testing - ean.org...1 konrad p. weber interdisciplinary center for vertigo and...
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KonradP.Weber
Interdisciplinary Centerfor Vertigo andNeurologicalVisualDisorders
UniversityHospitalZürich
EANSpringSchool2018
Stare Splavy,12May2018
Ocularmotorandvestibularbedsidetesting
A. Bradshaw
VestibularBedsideTesting
1. SpontaneousNystagmus2. HeadImpulseTest3. SkewDeviation4. RombergTestonFoam5. DynamicVisualAcuity6. Polyneuropathy7. Reposition,Reposition,Reposition!
HINTS
Cerebellum
Labyrinth
Vision
Proprioception
Help,my vision is jiggling!
Oszillopsia
DownbeatNystagmus Bilateralvestibularloss
Atrest Withheadmovement
CourtesyM.Strupp
1.SpontaneousNystagmus
Chronic Downbeat Nystagmus
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Cerebellar Atrophy Acute Upbeat Nystagmus
Courtesy Alexander Tarnutzer, M.D.
Pontomesencephalic stroke HeadShakingNystagmus
NystagmusWaveforms
Constantvelocityslowphase(e.g.vestibularnystagmus)
Decreasingvelocityslowphase(e.g.gaze-evokednystagmus)
Increasingvelocityslowphase(e.g.congenitalnystagmus)
Pendular Nystagmus(e.g.congenital/acquired)
VideoOculography
Investigation is Key
Gaze-evoked nystagmusdetectad atage 14.
Eye Doctor
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2.HeadImpulseTest
Weberetal.Neurology 2008
EyeVelocity
VestibularNeuritis OvertSaccades
Vestibulo-OcularReflex
NormalSubject Vestibulo-OcularReflex
EyeVelocity
False Positive False Negative
Acute Vestibular Syndrome• Vertigo• Nausea• Vomiting
PeripheralVestibular Syndrome
• Vestibular Neuritis
Central Vestibular Syndrome
• Cerebellar or Brainstem Stroke
Head Impulse Test
Unnecessary MRIStroke missed!
9% False Positives (Newman-Toker et al. Neurology 2008)
+ _
HINTS?HI Head Impulse testN NystagmusTS Test of Skew
INFARCT!IN Impulse NormalFA Fast phase Alternating nystagmusRCT Refixation on Cover Test
• 100% Sensitivity, 96% Specificity• More sensitive than early MRI (72%)• Skew predicts brainstem stroke in
false positive head impulse test Kattah et al, Stroke 2009
Nystagmus Test of Skew
Romberg*Test
visual
proprioceptive
vestibular cerebellum
*Moritz Heinrich Romberg 1795-1873
Fromberg*Test
*RombergTestonFoam
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FrombergTest
Gentamicin Vestibulotoxicity!
Polyneuropathy HepatitisC-associatedPolyneuropathy
Encouragewalkingsticks&goodfootwear Dynamicvisual acuity DVA
• Headshaking atleast2Hertz
• Lossof3or more linesis indicative ofbilateralvestibular loss
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DynamicVisualAcuity Test
VitalD2010Arch Otolaryngol Bockisch etal.2014Curing a96-year-oldpatient afflicted with benign paroxysmalpositional vertigo onamotorized turntable..
96-yearoldlady
• Short-lastingvertigowhenstooping
• Hospitalizedafterafall
• Fractureofherpubicbone
• RightposteriorBPPV
• Referralforrepositioningonourmotorizedturntable
BPPVEpidemiologyintheElderly
• 10%cumulativeincidenceat80y
• Upto9%unrecognizedBPPVingeriatricoutpatientclinics
• Fallslead,directlyorindirectly,to12%ofalldeathsinelderly
Cum
ulat
ive
inci
denc
e of
BPP
V
0.10
0.08
0.06
0.04
0.02
0.00
0 10 20 30 40 50 60 70 80Age (years)
CumulativeBPPVincidence
Baraff LJAnnEmerg Med 1997.VonBevern Metal.JNeurol Neurosurg Psychiatry 2007.Oghalai JSetal.Otolaryngol HeadNeckSurg 2000.
TheFosterManeuver
www.halfsomersaultmaneuver.com
Summary
Diagnosis• Vestibular• Visualinput• Proprioception• Cerebellum
ExaminationSteps1. SpontaneousNystagmus2. HeadImpulseTest3. SkewDeviation4. RombergTestonFoam5. DynamicVisualAcuity6. Polyneuropathy7. Reposition,Reposition,
Reposition!
HINTS
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VideoHeadImpulseTest VideoHead-Impulse-Test
Acute vestibular neuritisAffected sideHealthy side
Ocular MotorBedside Testing
Here's looking atyou,kid!
6Classes of EyeMovements
• Stabilizing gaze onthe retina (non-volitional)• Fixation->while stationary• Vestibulo-ocular reflex ->during self-motion• Optokinetic nystagmus ->moving environment
• Directinggazetoatarget(volitional)• Smoothpursuit->following amoving target• Saccades->fastgazeshift• Vergence ->binocularcontrol
Alternate CoverTest HeadImpulseTest
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Optokineticnystagmus
Impairedsmoothpursuiteyemovements
stimulus
eye
catch-upsaccades
Impairedsmoothpursuiteyemovements
LeighandZee.Neurologyofeyemovements,4thed.OxfordUniversityPress2006
Cerebellar Atrophy
Saccadic eye movements
• Fasteye movements for shifting gaze
• Triggered by brainstem nuclei andunder cerebellar control
• Disorders of• Velocity (slow)• Metrics (hypo/hypermetric)• Latency (increased)
Slowsaccadesspino-cerebellar ataxia type2
Leighand Zee.Neurology ofeye movements,4thed.OxfordUniversityPress2006
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Convergencespasm Discourageprogressivelenses
6ClassesofEyeMovements
• Stabilizing gaze onthe retina (non-volitional)• Fixation->while stationary• Vestibulo-ocular reflex ->during self-motion• Optokinetic nystagmus ->moving environment
• Directinggazetoatarget(volitional)• Smoothpursuit->following amoving target• Saccades->fastgazeshift• Vergence ->binocularcontrol
Questions?