A new ocular motor sign in acute vestibular syndrome: Is HINTS plus enough?

Vishal Pawar; Aishwarya Anand; Prasanna Kulkarni; Ji Soo Kim

doi:10.54029/2021zzt

A new ocular motor sign in acute vestibular syndrome: Is HINTS plus enough?

Neurology Asia ◽

10.54029/2021zzt ◽

2021 ◽

Vol 26 (4) ◽

pp. 853-857

Author(s):

Vishal Pawar ◽

Aishwarya Anand ◽

Prasanna Kulkarni ◽

Ji Soo Kim

Keyword(s):

Posterior Inferior Cerebellar Artery ◽

Head Impulse Test ◽

Medial Branch ◽

Radio Imaging ◽

Acute Vestibular Syndrome ◽

Cerebellar Artery ◽

Ct Brain ◽

The Right ◽

Unilateral Vestibulopathy ◽

Acute Unilateral Vestibulopathy

A 66-year-old hypertensive and diabetic male presented with acute vestibular syndrome for three days. HINTS plus examination was performed. The horizontal head impulse test was positive on the left side. Video oculography showed centripetal nystagmus on gaze testing in the dark and test of skew was negative. There was no new hearing loss on the finger rub test. On neurological examination, he had severe postural instability and saccadic smooth pursuit. Radio-imaging studies were conducted to rule out the possibility of stroke. CT brain showed infarction in the territory of the medial branch of the right posterior inferior cerebellar artery. MRI brain confirmed the diagnosis. Thus, posterior circulation stroke can present with acute vestibular syndrome mimicking acute unilateral vestibulopathy. However, the presence of associated neurological symptoms like gait ataxia, centripetal nystagmus and vascular risk factors pointed towards a central cause. Clinical evaluation suggesting a peripheral lesion should never be taken in isolation and needs to be correlated with other associated signs. We describe centripetal nystagmus without fixation as a new oculomotor sign in acute vestibular syndrome.

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Acute vestibular syndrome: is skew deviation a central sign?

Journal of Neurology ◽

10.1007/s00415-021-10692-6 ◽

2021 ◽

Author(s):

Athanasia Korda ◽

Ewa Zamaro ◽

Franca Wagner ◽

Miranda Morrison ◽

Marco Domenico Caversaccio ◽

...

Keyword(s):

Diagnostic Value ◽

Head Impulse Test ◽

Clinical Test ◽

Stroke Patients ◽

Acute Vestibular Syndrome ◽

Low Sensitivity ◽

A Prospective Study ◽

Unilateral Vestibulopathy ◽

Acute Unilateral Vestibulopathy ◽

Skew Deviation

Abstract Objective Skew deviation results from a dysfunction of the graviceptive pathways in patients with an acute vestibular syndrome (AVS) leading to vertical diplopia due to vertical ocular misalignment. It is considered as a central sign, however, the prevalence of skew and the accuracy of its test is not well known . Methods We performed a prospective study from February 2015 until September 2020 of all patients presenting at our emergency department (ED) with signs of AVS. All patients underwent clinical HINTS and video test of skew (vTS) followed by a delayed MRI, which served as a gold standard for vestibular stroke confirmation. Results We assessed 58 healthy subjects, 53 acute unilateral vestibulopathy patients (AUVP) and 24 stroke patients. Skew deviation prevalence was 24% in AUVP and 29% in strokes. For a positive clinical test of skew, the cut-off of vertical misalignment was 3 deg with a very low sensitivity of 15% and specificity of 98.2%. The sensitivity of vTS was 29.2% with a specificity of 75.5%. Conclusions Contrary to prior knowledge, skew deviation proved to be more prevalent in patients with AVS and occurred in every forth patient with AUVP. Large skew deviations (> 3.3 deg), were pointing toward a central lesion. Clinical and video test of skew offered little additional diagnostic value compared to other diagnostic tests such as the head impulse test and nystagmus test. Video test of skew could aid to quantify skew in the ED setting in which neurotological expertise is not always readily available.

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Case Report: Bow Hunter's Syndrome Caused by Compression of Extracranially Originated Posterior Inferior Cerebellar Artery

Frontiers in Neurology ◽

10.3389/fneur.2021.756838 ◽

2021 ◽

Vol 12 ◽

Author(s):

Noriya Enomoto ◽

Kenji Yagi ◽

Shunji Matsubara ◽

Masaaki Uno

Keyword(s):

Case Report ◽

Posterior Inferior Cerebellar Artery ◽

Head Rotation ◽

Radiographic Examination ◽

Posterior Decompression ◽

First Case ◽

Cerebellar Artery ◽

Cervical Approach ◽

The Right ◽

Hunter's Syndrome

Bow hunter's syndrome (BHS) is most commonly caused by compression of the vertebral artery (VA). It has not been known to occur due to an extracranially originated posterior inferior cerebellar artery (PICA), the first case of which we present herein. A 71-year-old man presented with reproducible dizziness on leftward head rotation, indicative of BHS. On radiographic examination, the bilateral VAs merged into the basilar artery, and the left VA was predominant. The right PICA originated extracranially from the right VA at the atlas–axis level and ran vertically into the spinal canal. During the head rotation that induced dizziness, the right PICA was occluded, and a VA stenosis was revealed. Occlusion of the PICA was considered to be the primary cause of the dizziness. The patient underwent surgery to decompress the right PICA and VA via a posterior cervical approach. Following surgery, the patient's dizziness disappeared, and the stenotic change at the right VA and PICA improved. The PICA could be a causative artery for BHS when it originates extracranially at the atlas–axis level, and posterior decompression is an effective way to treat it.

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Neurosurgery (Neuro Interventional)

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2015.197 ◽

2015 ◽

Vol 42 (S1) ◽

pp. S43-S44

Author(s):

JJ Shankar ◽

L Hodgson

Keyword(s):

Vertebral Artery ◽

Retrospective Analysis ◽

Posterior Inferior Cerebellar Artery ◽

Artery Aneurysm ◽

The Third ◽

Cerebellar Artery ◽

Incomplete Coverage ◽

Negative Findings ◽

The Right

Purpose: CTA is becoming the frontline modality to reveal aneurysms in patients with SAH. However, in about 20% of SAH patients no aneurysm is found. In these cases, intra-arterial DSA is still performed. Our aim was to evaluate whether negative findings on CTA can reliably exclude aneurysms in patients with acute SAH. Materials and Method: We conducted a retrospective analysis of all DSA performed from August 2010 to July 2014 in patients with various indications. We selected patient who presented with SAH and had a negative CTA. Findings of the CTA were compared with DSA. Results: 857 DSA were performed during the study period. 51(5.95%) patients with SAH and negative findings on CTA who underwent subsequent DSA were identified. Of these, only 3(5.9%) of patients had positive findings on the DSA. One patient had a posterior inferior cerebellar artery aneurysm on the DSA, not seen on CTA due to the incomplete coverage of the head. Second patient’ CTA did not show any evidence of aneurysm. DSA showed suspicious dissection of the right vertebral artery, potentially iatrogenic. The third patient’s DSA showed suspicious tiny protuberance from left ICA, possibly infundibulum. Conclusion: In patients with SAH, negative CTA findings are reliable in ruling out aneurysms in any pattern of SAH on CT.

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Direct puncture of the V3 segment of the vertebral artery in acute basilar artery stroke: an alternative approach in desperate circumstances

BMJ Case Reports ◽

10.1136/bcr-2019-231335 ◽

2019 ◽

Vol 12 (8) ◽

pp. e231335 ◽

Cited By ~ 1

Author(s):

Sean Thomas O’Reilly ◽

Ian Rennie ◽

Jim McIlmoyle ◽

Graham Smyth

Keyword(s):

Vertebral Artery ◽

Basilar Artery ◽

Posterior Inferior Cerebellar Artery ◽

Left Vertebral Artery ◽

Basilar Artery Thrombosis ◽

Direct Puncture ◽

Alternative Approach ◽

Cerebellar Artery ◽

First Pass ◽

The Right

A patient in his mid-40s presented with acute basilar artery thrombosis 7 hours postsymptom onset. Initial attempts to perform mechanical thrombectomy (MT) via the femoral and radial arterial approaches were unsuccessful as the left vertebral artery (VA) was occluded at its origin and the right VA terminated in the posterior inferior cerebellar artery territory, without contribution to the basilar system. MT was thus performed following ultrasound-guided direct arterial puncture of the left VA in its V3 segment, with antegrade advancement of a 4 French radial access sheath. First pass thrombolyisis in cerebral infarction (TICI) 3 recanalisation achieved with a 6 mm Solitaire stent retriever and concurrent aspiration on the 4 French sheath. Vertebral closure achieved with manual compression.

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Stent-assisted coil embolization for an unruptured vertebral artery–posterior inferior cerebellar artery aneurysm with retrograde access via type 1 persistent primitive proatlantal artery: A case report

Interventional Neuroradiology ◽

10.1177/1591019920973848 ◽

2020 ◽

pp. 159101992097384

Author(s):

Yasuhiko Nariai ◽

Tomoji Takigawa ◽

Ryotaro Suzuki ◽

Akio Hyodo ◽

Kensuke Suzuki

Keyword(s):

Carotid Artery ◽

Vertebral Artery ◽

Coil Embolization ◽

Posterior Inferior Cerebellar Artery ◽

External Carotid ◽

Proatlantal Artery ◽

Cerebellar Artery ◽

The Right ◽

Pica Aneurysms

Vertebral artery (VA)-posterior inferior cerebellar artery (PICA) aneurysms are rare lesions that are difficult to treat with both endovascular and surgical techniques. Tight angulation of the PICA from VA may make access to the PICA difficult from ipsilateral VA if adjunctive techniques are needed. Recently, the safety and efficacy of retrograde access have been reported. We report a case of endovascular treatment for a VA-PICA aneurysm with a stent-assisted technique using retrograde access via contralateral persistent primitive proatlantal artery (PPA). The patient was a 76-year-old woman with an unruptured VA-PICA aneurysm on the dominant VA side. Coil embolization with a stent-assisted technique using retrograde access seemed appropriate. However, the origin of the left VA was not confirmed. Left common carotid artery angiography demonstrated that the PPA (type 1) branching from external carotid artery joined the VA V4 segment. Retrograde access via the PPA for stenting was performed. A microcatheter for stenting was retrogradely advanced to the right PICA at ease. After deploying the stent, coil insertion was completed from the right VA, and the final angiogram showed adequate occlusion of the aneurysm with preservation of the PICA. Thus, PPA may be an approach route in the treatment of VA-PICA aneurysms with unconfirmed contralateral VA orifice and apparent PPA on angiography, when retrograde access is needed.

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OCCLUSION OF THE RIGHT POSTERIOR INFERIOR CEREBELLAR ARTERY AND RIGHT VERTEBRAL ARTERY

Archives of Neurology And Psychiatry ◽

10.1001/archneurpsyc.1931.02230080152011 ◽

1931 ◽

Vol 26 (2) ◽

pp. 396 ◽

Cited By ~ 8

Author(s):

Titus H. Harris

Keyword(s):

Vertebral Artery ◽

Posterior Inferior Cerebellar Artery ◽

Cerebellar Artery ◽

The Right

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Delayed Retraction of the Pipeline Embolization Device and Corking Failure: Pitfalls of Pipeline Embolization Device Placement in the Setting of a Ruptured Aneurysm

Operative Neurosurgery ◽

10.1227/neu.0b013e31827fc9be ◽

2012 ◽

Vol 72 (2) ◽

pp. onsE245-onsE251 ◽

Cited By ~ 4

Author(s):

Ryan A. McTaggart ◽

Justin G. Santarelli ◽

Mary L. Marcellus ◽

Gary K. Steinberg ◽

Robert L. Dodd ◽

...

Keyword(s):

Clinical Presentation ◽

Dual Antiplatelet Therapy ◽

Posterior Inferior Cerebellar Artery ◽

Dissecting Aneurysm ◽

Pipeline Embolization Device ◽

Cerebellar Artery ◽

Device Placement ◽

Potential Risks ◽

The Right ◽

Ruptured Intracranial Aneurysms

Abstract BACKGROUND AND IMPORTANCE: The safety of flow-diverting stents for the treatment of ruptured intracranial aneurysms is unknown. CLINICAL PRESENTATION: A 35-year-old woman with a ruptured dissecting aneurysm of the intradural right vertebral artery and incorporating the right posterior inferior cerebellar artery was treated with a Pipeline Embolization Device (PED). Five days after reconstruction of the diseased right vertebral segment, she was treated for vasospasm, and retraction of the PED was observed, leaving her dissecting aneurysm unprotected. A second PED was placed with coverage of the aneurysm, but vasospasm complicated optimal positioning of the device. CONCLUSION: In addition to the potential risks of dual antiplatelet therapy in these patients, this case illustrates 2 pitfalls of flow-diverting devices in vessels in vasospasm: delayed retraction of the device and difficulty positioning the device for deployment in the setting of vasospasm.

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A CASE OF OCCLUSION OF THE RIGHT POSTERIOR INFERIOR CEREBELLAR ARTERY

Journal of Neurology Neurosurgery & Psychiatry ◽

10.1136/jnnp.s1-4.13.43 ◽

1923 ◽

Vol s1-4 (13) ◽

pp. 43-49 ◽

Cited By ~ 1

Author(s):

D. R. Gowler ◽

B. M. Hope

Keyword(s):

Posterior Inferior Cerebellar Artery ◽

Cerebellar Artery ◽

The Right

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Clinical Implication of Corrective Saccades in the Video Head Impulse Test for the Diagnosis of Posterior Inferior Cerebellar Artery Infarction

Frontiers in Neurology ◽

10.3389/fneur.2021.605040 ◽

2021 ◽

Vol 12 ◽

Author(s):

Gi-Sung Nam ◽

Hyun-June Shin ◽

Jin-Ju Kang ◽

Na-Ri Lee ◽

Sun-Young Oh

Keyword(s):

Semicircular Canal ◽

Posterior Inferior Cerebellar Artery ◽

Mean Amplitude ◽

Head Impulse Test ◽

Stroke Patients ◽

Horizontal Semicircular Canal ◽

Head Impulse ◽

Cerebellar Artery ◽

Corrective Saccades ◽

The Mean

Objective: In the present study, we characterized the vestibulo-ocular reflex (VOR) gain and properties of corrective saccades (CS) in patients with posterior inferior cerebellar artery (PICA) stroke and determined the best parameter to differentiate PICA stroke from benign peripheral vestibular neuritis (VN). In particular, we studied CS amplitude and asymmetry in video head impulse tests (vHITs) to discriminate these two less-studied disease conditions.Methods: The vHITs were performed within 1 week from symptom onset in patients with PICA stroke (n = 17), patients with VN (n = 17), and healthy subjects (HS, n = 17).Results: PICA stroke patients had bilaterally reduced VOR gains in the horizontal semicircular canal (HC) and the posterior semicircular canal (PC) compared with HSs. When compared with VN patients, PICA stroke patients showed preserved gains in the HC and anterior semicircular canal (AC) bilaterally (i.e., symmetric VOR gain). Similar to VOR gain, smaller but bilaterally symmetric CS in the HC and AC were observed in PICA stroke patients compared with VN patients; the mean amplitude of CS for the ipsilesional HC was reduced (p < 0.001, Mann–Whitney U-test), but the mean amplitude of CS for the contralesional HC was increased (p < 0.03, Mann–Whitney U-test) in PICA stroke compared with VN. The receiver operating characteristic (ROC) curve showed that CS amplitude asymmetry (CSs) and VOR gain asymmetry (Gs) of HC are excellent parameters to distinguish PICA stroke from VN.Conclusion: In the current study, we quantitatively investigated the VOR gain and CS using vHITs for three semicircular canals in PICA stroke and VN patients. In addition to VOR gain, quantitative assessments of CS using vHITs can provide sensitive and objective parameters to distinguish between peripheral and central vestibulopathies.

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