Acute vestibular syndrome in emergency departments : Clinical differentiation of peripheral and central vestibulopathy

• Published in: HNO Vol. 68; no. 5; pp. 367 - 378
• Main Authors: Pudszuhn, A, Heinzelmann, A, Schönfeld, U, Niehues, S M, Hofmann, V M
• Format: Journal Article
• Language: German
• Published: Germany 01.05.2020
• Subjects: Acute Disease; Emergency Service, Hospital; Head Impulse Test; Humans; Retrospective Studies; Vertigo; Vestibular Neuronitis - diagnosis; Pseudoneuritis vestibularis; Neuritis vestibularis; Infarction; Neuropathia vestibularis; Rescue center; Vertigo
• ISSN: 1433-0458
• DOI: 10.1007/s00106-019-0721-8

The differentiation between central and peripheral vestibular disorders is difficult in some cases, especially during the clinical routine of an emergency department (ED) without otoneurological diagnostic equipment. This study evaluated the frequency of vestibular pseudoneuritis as distinguished from acute peripheral vestibular disorders in patients who were admitted to hospital with the suspicion of vestibular neuropathy (VN). This retrospective study analyzed the results of anamnestic and clinical examinations of 315 patients admitted to the emergency department and the inpatient otoneurological examination results as well as the imaging of morphological alterations. In the ED, the clinical examination by a neurologist and an otorhinolaryngologist resulted in the characteristic signs of peripheral VN but no further evidence of a neurological disorder. Patients without signs of a peripheral vestibular disorder in the otoneurological diagnostics subsequently underwent cerebral magnetic resonance imaging scans (cMRI). Suspected isolated VN could be confirmed in 69% of the patients; however, in a further 29% of the patients neither the suspected isolated VN nor an ischemic pathology of the central nervous system as a cause of the vertigo could be confirmed. Additional cMRI scans revealed that 2% of patients suffered from an infarction of the mesencephalon, the pons, the medulla oblongata and the cerebellum. In rare cases central cerebral disorders mimic the pattern of a peripheral vestibular disorder. Despite thorough history taking, neurological and otolaryngological clinical examinations, it is not always possible to distinguish central and peripheral vestibular disorders of patients in emergency care suffering from acute vertigo. Video oculography-assisted caloric testing and the video head impulse test are recommended to confirm a peripheral VN. In cases without confirmation of suspected NV in otoneurological diagnostics, infarction of the mesencephalon, brain stem and cerebellum should be excluded by diffusion-weighted cMRI.