Objective:
To evaluate the utility of positional testing in peripheral and central acute vestibular syndrome (pAVS, cAVS, respectively).
Study design:
Prospective; observational.
Setting:
Tertiary referral center.
Patients:
Consecutive AVS patients.
Interventions:
Video-oculography in upright, supine and head hanging positions at presentation, 3-month and 1-year follow-up.
Main Outcome Measures:
Positional modulation of spontaneous nystagmus; co-occurrence of central paroxysmal positional nystagmus (CPPN).
Results:
Fifteen pAVS [mean age (SD), 53.3 (16.6) (11 males)] and 15 cAVS [mean age (SD), 56.5 (17.8) (11 males)] patients were included (p=0.49). Acutely, in supine, in patients whose nystagmus was present in both head rotation sides, 12 of 13 (93%) pAVS and only 4 of 12 (33%) cAVS patients showed direction-fixed positional nystagmus which was stronger when turning the head to the slow phase side. The remaining cAVS patients showed either direction-fixed positional nystagmus which was stronger when turning the head to the fast phase side (5), or direction-changing positional geotropic nystagmus (2). One patient in each group showed direction-changing positional apogeotropic nystagmus. During follow-up, direction-changing positional apogeotropic and geotropic nystagmus became common in both groups. Acutely, in head hanging, 5 (33%) cAVS patients showed vertical CPPN and 2 showed positional saccadic intrusions. Positional downbeat nystagmus and saccadic intrusions became chronic.
Conclusions:
The presence of acute direction-changing positional geotropic nystagmus, stronger direction-fixed positional nystagmus when turning the head to the fast phase side, and acute or chronic head hanging vertical CPPN should raise the suspicion for central AVS. Chronic geotropic and apogeotropic nystagmus following AVS constitute an underrecognized manifestation of vestibular compensation.
Background Cerebral edema is frequent in patients with acute ischemic stroke (AIS) who undergo reperfusion therapy and is associated with high mortality. The impact of collateral pial circulation (CPC) status on the development of edema has not yet been determined. Methods We studied consecutive patients with AIS and documented M1-middle cerebral artery (MCA) and/or distal internal carotid artery (ICA) occlusion who underwent reperfusion treatment. Edema was graded on the 24-hour non-contrast computed tomography (NCCT) scan. CPC was evaluated at the acute phase (≤6 hours) by transcranial color-coded Doppler, angiography and/or CT angiography. We performed an ordinal regression model for the effect of CPC on cerebral edema, adjusting for age, baseline National Institutes of Health Stroke Scale, Alberta Stroke Program Early Computed Tomography Score (ASPECTS) on admission, NCCT, parenchymal hemorrhagic transformation at 24 hours and complete recanalization at six hours. Results Among the 108 patients included, 49.1% were male and mean age was 74.2 ± 11.6 years. Multivariable analysis showed a significant association between cerebral edema and CPC status (OR 0.22, 95% CI 0.08-0.59, p = 0.003), initial ASPECTS (OR 0.72, 95% CI 0.57-0.92, p = 0.007) and parenchymal hemorrhagic transformation (OR 23.67, 95% CI 4.56-122.8, p < 0.001). Conclusions Poor CPC is independently associated with greater cerebral edema 24 hours after AIS in patients who undergo reperfusion treatment.
IMPORTANCE Accurate clinical differentiation between skew deviation and fourth nerve palsy (4NP) is critical in the acute and subacute settings.OBJECTIVE To determine the sensitivity and specificity of the upright-supine test to detect vertical misalignment changes using different head positions for the diagnosis of acute or subacute skew deviation vs 4NP.
We performed a retrospective study with the aim of investigating the association between blood pressure (BP) variability in the first 24 h after ischemic stroke and functional outcome, regarding arterial recanalization status. A total of 674 patients diagnosed with acute stroke and treated with revascularization therapies were enrolled. Systolic and diastolic BP values of the first 24 h after stroke were collected and their variation quantified through standard deviation. Recanalization state was evaluated at 6 h and clinical outcome at 3 months was assessed by modified Rankin Scale. In multivariate analyses systolic BP variability in the first 24 h post-stroke showed an association with 3 months clinical outcome in the whole population and non-recanalyzed patients. In recanalyzed patients, BP variability did not show a significant association with functional outcome.
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