Capturing nystagmus in the emergency room: posterior circulation stroke versus acute vestibular neuritis

B Nham; G Akdal; A S Young; P Özçelik; T Tanrıverdizade; R T Ala; A P Bradshaw; C Wang; S Men; B F Giarola; D A Black; E O Thompson; G M Halmagyi; M S Welgampola

doi:10.1007/s00415-022-11202-y

Capturing nystagmus in the emergency room: posterior circulation stroke versus acute vestibular neuritis

J Neurol. 2023 Feb;270(2):632-641. doi: 10.1007/s00415-022-11202-y. Epub 2022 Jul 18.

Authors

B Nham^{1

2}, G Akdal^{3

4}, A S Young², P Özçelik⁴, T Tanrıverdizade⁴, R T Ala³, A P Bradshaw¹, C Wang^{1

2}, S Men⁵, B F Giarola⁶, D A Black⁷, E O Thompson⁶, G M Halmagyi^{1

2}, M S Welgampola^{8

9}

Affiliations

¹ Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia.
² Faculty of Medicine and Health, Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Central Clinical School, University of Sydney, Sydney, Australia.
³ Faculty of Medicine, Department of Neurology, Dokuz Eylül University, İzmir, Turkey.
⁴ Department of Neuroscience, Institute of Health Sciences, Dokuz Eylül University, İzmir, Turkey.
⁵ Faculty of Medicine, Department of Radiology, Dokuz Eylül University, İzmir, Turkey.
⁶ Department of Radiology, Royal Prince Alfred Hospital, Sydney, Australia.
⁷ Faculty of Medicine and Health, University of Sydney, Sydney, Australia.
⁸ Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia. miriam@icn.usyd.edu.au.
⁹ Faculty of Medicine and Health, Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Central Clinical School, University of Sydney, Sydney, Australia. miriam@icn.usyd.edu.au.

Abstract

Objectives: To compare acute nystagmus characteristics of posterior circulation stroke (PCS) and acute vestibular neuritis (AVN) in the emergency room (ER) within 24 h of presentation.

Methods: ER-based video-nystagmography (VNG) was conducted, recording ictal nystagmus in 101 patients with PCS (on imaging) and 104 patients with AVN, diagnosed on accepted clinical and vestibular test criteria.

Results: Patients with stroke in the brainstem (38/101, affecting midbrain (n = 7), pons (n = 19), and medulla (n = 12)), cerebellum (31/101), both (15/101) or other locations (17/101) were recruited. Common PCS territories included posterior-inferior-cerebellar-artery (41/101), pontine perforators (18/101), multiple-territories (17/101) and anterior-inferior-cerebellar-artery (7/101). In PCS, 44/101 patients had no spontaneous nystagmus. Remaining PCS patients had primary position horizontal (44/101), vertical (8/101) and torsional (5/101) nystagmus. Horizontal nystagmus was 50% ipsiversive and 50% contraversive in lateralised PCS. Most PCS patients with horizontal nystagmus (28/44) had unidirectional "peripheral-appearing" nystagmus. 32/101 of PCS patients had gaze-evoked nystagmus. AVN affected the superior, inferior or both divisions of the vestibular nerve in 55/104, 4/104 and 45/104. Most (102/104) had primary position horizontal nystagmus; none had gaze-evoked nystagmus. Two inferior VN patients had contraversive torsional-downbeat nystagmus. Horizontal nystagmus with SPV ≥ 5.8 °/s separated AVN from PCS with sensitivity and specificity of 91.2% and 83.0%. Absent nystagmus, gaze-evoked nystagmus, and vertical-torsional nystagmus were highly specific for PCS (100%, 100% and 98.1%).

Conclusion: Nystagmus is often absent in PCS and always present in AVN. Unidirectional 'peripheral-appearing' horizontal nystagmus can be seen in PCS. ER-based VNG nystagmus assessment could provide useful diagnostic information when separating PCS from AVN.

Keywords: Emergency medicine; Nystagmus; Stroke; Vertigo; Vestibular neuritis.

MeSH terms

Emergency Service, Hospital
Humans
Nystagmus, Pathologic* / diagnosis
Nystagmus, Pathologic* / etiology
Pons
Vestibular Nerve
Vestibular Neuronitis* / complications
Vestibular Neuronitis* / diagnosis