Acute vestibular syndrome（AVS） accounts for about 5% of walk clinic, and 20% of neurology consultations in the emergency department. A central acute vestibular syndrome is of high-risk vertigo disorders or potentially life-threaten disorders. Some of the central vestibular vertigo, especially brainstem or cerebellar ischemic infarction, can be misdiagnosed due to the absence of focal neurological symptoms and signs. In the past decade, the diagnosis mode and diagnosis pathway of vestibular syndrome have been made great progress. The HINTS examination battery reported by Kattah et al. （2009）, the STANDING examination battery reported by Vanni et al. （2014） as well as the "Big five" step examination procedure reported by Brandt et al. （2017） have been used widely to identify stroke in clinic. The TiTrATE proposed by Newman Toker and Edlow（2015） as well as the ATTEST proposed by Gurley and Edlow（2019） have promoted the accuracy for AVS diagnosis. However, only about 50% of patients with cerebellar ischemic infarction have spontaneous nystagmus. The sensitivity of direction-changing nystagmus in diagnostic predicting stroke in acute vestibular syndrome was only 38%. The diagnostic predictive sensitivity of AICA stroke was only 62% when the horizontal head pulse test were normal. Therefore, the bed-side test battery for differentiating acute isolated vertigo as well as the diagnosis approach of AVS need to be further improved. Based on the SCD diagnosis strategy and the differentiating pathway for vestibular disorders proposed by the author, I propose further in this paper the step-rised SCD strategy for the acute vestibular syndrome, and the ABC mode for differentiating central vestibular vertigo[A: Associated neurological deficit（or: with headache=HAND）; B: Eye（E³） GAP examination battery; C: Combined warning battery of A³B²C²D²E³], as well as the differential diagnosis pathway of acute vestibular diseases. The history questioning of associated neurological deficit and the examining batteries for acute central vestibular disorders can be summarized as an illogical English phrase "HAND-Eye（E³） GAP" for memory.
Humans ; Vestibular Diseases/diagnosis* ; Vertigo/diagnosis* ; Diagnosis, Differential ; Nystagmus, Pathologic/diagnosis* ; Acute Disease

Objective:To evaluate the utility of the Rapid Axial Roll Test （RART）, Supine Roll Test （SRT）, and Lying-Down Test （LDT） in determining the affected semicircular canal in cases of horizontal semicircular canal benign paroxysmal positional vertigo （HSC-BPPV）. Methods:A total of 330 patients diagnosed with HSCBPPV from September 2022 to September 2023 were collected and divided into three groups based on the different positional tests received: ①SRT Group, ②LDT+SRT Group, ③RART+SRT Group. The trial was divided into two stages: LDT/RART for patients in the first stage, and SRT for patients in the second stage. The elicitation rate of nystagmus among the three groups was compared to evaluate the accuracy in determining the affected semicircular canal in HSCBPPV. Results:Nystagmus was elicited in 84.55% （279/330） of the patients by positional tests. The elicitation rate of nystagmus in the RART+SRT/LDT group was 94.55% （104/110）, in the LDT+SRT group it was 84.11% （90/107）, and in the SRT group it was 69.91% （79/113）. The differences among the three groups were statistically significant （χ²= 23.88, P<0.001）. In the ② and ③ groups, there was a statistically significant difference in the elicitation rate of nystagmus between stage Ⅰ （patients with LDT or RART） （χ²=43.842, P<0.001）. SRT was performed in the stage Ⅱ, and there was a statistically significant difference in nystagmus extraction rate between the two groups （χ² =4.690, P=0.030）. The difference in the proportion of agreement between stage Ⅰ（LDT or RART） and stageⅡ （SRT） in determining the affected side of the semicircular canal was also statistically significant （χ² =40.502, P<0.001）. For patients with a consistent diagnosis of the affected semicircular canal, the difference in cure rate was not significant （P=0.149）. The Kappa statistic indicated substantial agreement between RART and SRT in terms of eliciting nystagmus （agreement 96.36%, Kappa = 0.730, P<0.001）. Conclusion:RART and SRT show a high degree of agreement regarding the elicitation rate of nystagmus. RART is simple and safe, and it can effectively induce the characteristic nystagmus of HSC-BPPV, accurately identify the responsible semicircular canal and provide a more optimized examination protocol for clinical practice in HSCBPPV.
Humans ; Semicircular Canals/physiopathology* ; Benign Paroxysmal Positional Vertigo/diagnosis* ; Female ; Male ; Middle Aged ; Nystagmus, Pathologic/diagnosis* ; Vestibular Function Tests/methods* ; Aged ; Vertigo/diagnosis* ; Adult

Objective:To investigate the classification of head shaking nystagmus（HSN） and its clinical value in vestibular peripheral diseases. Methods:Clinical data of 198 patients with peripheral vestibular disorders presenting with HSN were retrospectively analyzed. Video Nystagmograph（VNG） was applied to detect spontaneous nystagmus（SN）, HSN, and Caloric Test（CT）. The intensity and direction of SN and HSN as well as the unilateral weakness（UW） and direction preponderance（DP） values in caloric test was analyzed in patients. Results:Among the 198 patients with vestibular peripheral disease, there were 105 males and 93 females, with an average age of（49.1±14.4） years （range: 14-87 years）. One hundred and thirty seven patients were diagnosed as Vestibular Neuritis（VN）, 12 as Meniere's Disease（MD）, 41 as sudden deafness（SD） and 8 as Hunt's syndrome accompanied by vertigo. Among them, there were 116 patients in the acute phase, including 68 cases（58.6%） with decreased HSN, 4 cases（3.4%） with increased HSN, 5 cases（4.3%） with biphasic HSN, 38 cases（32.8%） with unchanged HSN, and 1 case（0.9%） with perverted HSN. There were 82 cases in the non-acute phase, 51 cases（62.2%） with decreased HSN, 3 cases（3.6%） with increased HSN, 9 cases（11.0%） with biphasic HSN, and 19 cases（23.2%） with unchanged HSN. In biphasic HSN, the intensity of phase I nystagmus was usually greater than that of phase II, and the difference was statistically significant（P<0.01）. There was no correlation between HSN type and course of disease or DP value. The intensity of HSN was negatively correlated with the course of disease（r=-0.320, P<0.001） and positively correlated with DP value（r=0.364, P<0.001）, respectively. The intensity of unchanged nystagmus and spontaneous nystagmus were（8.0±5.7） °/s and（8.5±6.4）°/s, respectively. There was no statistically significant difference in the intensity of nystagmus before and after shaking the head. Conclusion:HSN can be classified into five types and could be regarded as a potential SN within a specific frequency range （mid-frequency）. Similarly, SN could also be considered as a common sign of unilateral vestibular impairment at different frequencies. HSN intensity can reflect the dynamic process of vestibular compensation, and is valuable for assessing the frequency of damage in peripheral vestibular diseases and monitoring the progress of vestibular rehabilitation.
Male ; Female ; Humans ; Adult ; Middle Aged ; Vestibular Function Tests ; Retrospective Studies ; Nystagmus, Pathologic/diagnosis* ; Vertigo/diagnosis* ; Electronystagmography ; Vestibular Diseases/diagnosis*

Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory demyelinating autoimmune disease of central nervous system characterized by relapsing attacks that target the optic nerves and spinal cord, as well as aquaporin-4 (AQP4) enriched periventricular brain regions. The area postrema (AP), located in the dorsal medulla, is the chemosensitive vomiting center and has high AQP-4 expression. The AP syndrome with unexplained hiccups, nausea, and vomiting is one of the core clinical characteristics in the NMOSD and maybe the first presenting symptom. We experienced a 25-year-old woman presented with intractable vomiting, dizziness and oscillopsia. Upbeat nystagmus detected on the bedside examination led to comprehensive neurological workups including magnetic resonance imaging, and she was diagnosed as the AP syndrome. Ten months later, she experienced a recurrence as a longitudinally extensive transverse myelitis and the diagnosis was finally compatible with NMOSD without AQP4-IgG. NMOSD, especially the AP syndrome, should be considered in any dizzy patient with intractable vomiting, and detailed neuro-otologic and neuro-ophthalmologic examinations are warranted for the correct diagnosis.
Adult ; Area Postrema ; Autoimmune Diseases ; Brain ; Central Nervous System ; Diagnosis ; Dizziness ; Female ; Hiccup ; Humans ; Magnetic Resonance Imaging ; Myelitis, Transverse ; Nausea ; Neuromyelitis Optica ; Nystagmus, Pathologic ; Optic Nerve ; Recurrence ; Spinal Cord ; Vomiting

OBJECTIVES: The purpose of this study is to investigate characteristics of nystagmus during attacks of vestibular migraine (VM), and to find a distinct clinical feature compared to other migraine and peripheral vestibular disorders. METHODS: This study is a retrospective chart review of 82 patients satisfied with VM criteria, which is formulated by the new Bárány Society. Spontaneous and positional nystagmus provoked by various head positions were examined with video-nystagmography in all patients. Bithermal caloric test and cervical vestibular evoked myogenic potential test (cVEMP) were also performed. The direction and peak slow-phase velocity (SPV) of nystagmus, unilateral caloric weakness and interaural difference of cVEMP were analyzed. Control groups were lesion side in acute VN for nystagmus results and healthy side in the patients with benign paroxysmal positional vertigo of posterior semicircular canal for caloric and cVEMP results. Chi-square test and Mann-Whitney U-test were used for statistical analysis. RESULTS: During the acute attack, nystagmus was seen in 71.9% (59 of 82) of patients. Horizontal nystagmus was the predominant type. Peak SPV in VM patients was much slower than in the control group (2.37±1.73 °/sec vs. 17.05±12.69 °/sec, p<0.0001). There was no significant difference on the result of both caloric and cVEMP test, compared to those of control groups. CONCLUSION: Nystagmus with horizontal directions and low SPV was dominant form in the attack of VM. Close observation of nystagmus can be helpful to make a correct diagnosis and to understand the pathomechanism of vertigo in VM.
Benign Paroxysmal Positional Vertigo ; Caloric Tests ; Diagnosis ; Head ; Humans ; Migraine Disorders ; Nystagmus, Pathologic ; Nystagmus, Physiologic ; Retrospective Studies ; Semicircular Canals ; Vertigo

To investigate the changes of vedionystamography(VNG)in patients with posterior circulation ischemia vertigo(PCIV).Fifty patients who complained of vertigo and imbalance with PCI were selected as experimental group for testing of visual nystamography(VNG).Thirty normal subjects were chosen as control group.The result was analyzed.The results of VNG in PCIV group and the control group were compared.The abnormal ratio were as follows:(4%,0;>0.05)for Spontaneous nystagmus,(68%,10%;<0.01)for Saccade Test,(42.0%,6.7%;<0.01)for Tracking Test,(44%,0;<0.01)for Optokinetic Test,(78%,10%;<0.01)for Positional Test,respectively.The intensity of positional nystagmus in those patients was(4.12±3.46)°/s,which was much higher than that of the control group(<0.01).One or more abnormal findings for visual-oculomotor system examination were shown in 37 patients(74%).Both vestibular central and peripheral system can be involved in PCIV.VNG test has clinical significance in differential diagnosis and lesion location.The abnormal ratio of visual nystamography in PCIV group reaches 92%(46/50).These results suggest that VNG be used as an important accessory diagnostic tool for patients with PCIV.
Humans ; Nystagmus, Pathologic ; Nystagmus, Physiologic ; Vertigo ; diagnosis ; Vestibular Function Tests ; Vestibule, Labyrinth

BACKGROUND AND OBJECTIVES: To analyze the clinical correlation between perverted nystagmus and brain magnetic resonance imaging (MRI) abnormal findings and to evaluate whether perverted nystagmus is clinically significant results of brain abnormal lesions or not. SUBJECTS AND METHODS: We performed medical charts review from January 2008 to July 2014, retrospectively. Patients who were suspected central originated vertigo at Frenzel goggles test were included among patients who visited our hospital. To investigate the correlation with nystagmus suspected central originated vertigo and brain MRI abnormal findings, we confirmed whether performing brain MRI or not. Then we exclude that patients not performed brain MRI. RESULTS: The number of patients with perverted nystagmus was 15, upbeating was 1 and down-beating was 14. Among these patients, 5 patients have brain MRI abnormal findings. However, 2 patients with MRI abnormal findings were not associated correctly with perverted nystagmus and only 3 patients with perverted nystagmus were considered central originated vertigo and further evaluation and treatment was performed by the department of neurology. CONCLUSIONS: Perverted nystagmus was considered to the abnormalities at brain lesions, especially cerebellum, but neurologic symptoms and further evaluation were needed for exact diagnosis of central originated vertigo.
Brain* ; Cerebellum ; Diagnosis ; Dizziness ; Eye Protective Devices ; Humans ; Magnetic Resonance Imaging* ; Neurologic Manifestations ; Neurology ; Nystagmus, Pathologic ; Retrospective Studies ; Vertigo

PURPOSE: To describe the clinical course of congenital aniridia and to evaluate prognostic factors for visual outcome after long-term follow-up. METHODS: The medical records of 120 eyes from 60 patients with congenital aniridia were retrospectively reviewed. The prevalence and clinical course of ophthalmic characteristics, systemic disease, refractive errors, and visual acuity were assessed. Prognostic factors for final visual outcomes were analyzed. RESULTS: Aniridic keratopathy developed in 82 (69%) of 119 eyes. Macular hypoplasia was observed in 70 eyes of 35 patients (91%). Cataract was observed in 63 of 120 eyes (53%). Nystagmus was present in 41 patients (68% of 60 patients) at the initial visit but decreased in five patients (8% of 60 patients). Ocular hypertension was detected in 19 eyes (20% of 93 eyes), six (32% of 19 eyes) of which developed secondarily after cataract surgery. The mean changes in spherical equivalent and astigmatism during the follow-up period were -1.10 and 1.53 diopter, respectively. The mean final visual acuity was 1.028 logarithm of minimal angle of resolution. Nystagmus and ocular hypertension were identified as prognostic factors for poor visual outcome. CONCLUSIONS: Identification of nystagmus and ocular hypertension was important to predict final visual outcome. Based on the high rate of secondary ocular hypertension after cataract surgery, careful management is needed.
Adolescent ; Adult ; Aniridia/*diagnosis/physiopathology ; Cataract/diagnosis ; Child ; Child, Preschool ; Corneal Diseases/diagnosis ; Eye Abnormalities/diagnosis ; Eye Diseases/*diagnosis/physiopathology ; Follow-Up Studies ; Humans ; Infant ; Infant, Newborn ; Nystagmus, Pathologic/diagnosis ; Ocular Hypertension/diagnosis ; Prognosis ; Retina/abnormalities ; Retrospective Studies ; Visual Acuity/*physiology ; Young Adult

Child, Preschool ; Diagnosis, Differential ; Electroencephalography ; Electroretinography ; Eye Movements ; Head Movements ; Humans ; Infant ; Infant, Newborn ; Nystagmus, Pathologic ; diagnosis ; etiology ; physiopathology ; Retinal Diseases ; diagnosis ; physiopathology ; Risk Factors ; Spasms, Infantile ; diagnosis ; etiology ; physiopathology ; Torticollis ; etiology ; physiopathology

As the infrared image gray distribution of nystagmus video is uneven, the accuracy of pupil edge detection could not be high enough. A pupil location method based on morphology and Canny algorithm was presented in this paper. Some meaningless regions were removed by morphology, and target was smoothed. The connected regions were separated, and the largest connected region-pupil was found. Then the pupil edges were extracted by the designed Canny edge detection algorithm. The coordinates of pupil for each frame images were calculated and the pupil movement tracking was fitted. Finally, desired clinical diagnostic information would be obtained from the tracking. Experimental results showed that the method could be adapted to different gray values for different objects, and could accurately detect the edge of the pupil. As the pupil was tracked well, the experimental results could reflect the eye movement. The method provides a practical way for the pupil location of existing domestic researches in video-nystagmograph.
Algorithms ; Electronystagmography ; instrumentation ; methods ; Eye Movements ; physiology ; Humans ; Infrared Rays ; Iris ; anatomy & histology ; Nystagmus, Pathologic ; diagnosis ; Videotape Recording