Hyperacute assessment of vertigo in suspected stroke

The management of patients with acute vertigo is most challenging in the hyperacute phase, both due to the complexity of vertigo as a symptom, the range of possible causes, and the lack of training in neuro-otology for non-specialists. Perhaps of greatest relevance is differentiating between peripheral (usually benign, e.g., inner ear) causes and central (potentially more sinister, e.g., stroke) causes. Several diagnostic algorithms have been introduced to help detect stroke in patients with acute vertigo. However, these algorithms have been largely validated in patients with an acute vestibular syndrome (with nystagmus) for whom symptoms have been present for a minimum of 24 h. The most challenging period within the diagnostic process is the hyperacute phase that determines triage and treatment, but where none of the established algorithms have been validated. In this review, we specifically describe practical implementation considerations for evaluating patients with hyperacute vertigo, including the timing of diagnostic testing within the emergency department pathway, resource availability, and pitfalls associated with current practices

Long-term use benefits of personal frequency-modulated systems for speech in noise perception in patients with stroke with auditory processing deficits: a non-randomised controlled trial study.

OBJECTIVES: Approximately one in five stroke survivors suffer from difficulties with speech reception in noise, despite normal audiometry. These deficits are treatable with personal frequency-modulated systems (FMs). This study aimed to evaluate long-term benefits in speech reception in noise, after daily 10-week use of personal FMs, in non-aphasic patients with stroke with auditory processing deficits. DESIGN: This was a prospective non-randomised controlled trial study. Patients were allocated to an intervention care group or standard care subjects group according to their willingness to use the intervention or not. SETTING: Tertiary care setting. PARTICIPANTS: Nine non-aphasic subjects with ischaemic stroke, normal/near-normal audiometry and auditory processing deficits and with reported difficulties understanding speech in background noise were recruited in the subacute stroke stage (3-12 months after stroke). INTERVENTIONS: Four patients (intervention care subjects) used the FMs in their daily life over 10 weeks. Five patients (standard care subjects) received standard care. PRIMARY OUTCOME MEASURES: All subjects were tested at baseline (visit 1) and 10 weeks later (visit 2) on a sentences in noise test with the FMs (aided) and without the FMs (unaided). RESULTS: Speech reception thresholds showed clinically and statistically significant improvements in intervention but not in standard care subjects at 10 weeks in aided and unaided conditions. CONCLUSIONS: 10-week use of FMs by adult patients with stroke may lead to benefits in unaided speech in noise perception. Our findings may indicate auditory plasticity type changes and require further investigation. TRIAL REGISTRATION NUMBER: Pre-results; NCT02889107

Long-term use benefits of personal frequency-modulated systems for speech in noise perception in patients with stroke with auditory processing deficits: a non-randomised controlled trial study.

OBJECTIVES: Approximately one in five stroke survivors suffer from difficulties with speech reception in noise, despite normal audiometry. These deficits are treatable with personal frequency-modulated systems (FMs). This study aimed to evaluate long-term benefits in speech reception in noise, after daily 10-week use of personal FMs, in non-aphasic patients with stroke with auditory processing deficits. DESIGN: This was a prospective non-randomised controlled trial study. Patients were allocated to an intervention care group or standard care subjects group according to their willingness to use the intervention or not. SETTING: Tertiary care setting. PARTICIPANTS: Nine non-aphasic subjects with ischaemic stroke, normal/near-normal audiometry and auditory processing deficits and with reported difficulties understanding speech in background noise were recruited in the subacute stroke stage (3-12 months after stroke). INTERVENTIONS: Four patients (intervention care subjects) used the FMs in their daily life over 10 weeks. Five patients (standard care subjects) received standard care. PRIMARY OUTCOME MEASURES: All subjects were tested at baseline (visit 1) and 10 weeks later (visit 2) on a sentences in noise test with the FMs (aided) and without the FMs (unaided). RESULTS: Speech reception thresholds showed clinically and statistically significant improvements in intervention but not in standard care subjects at 10 weeks in aided and unaided conditions. CONCLUSIONS: 10-week use of FMs by adult patients with stroke may lead to benefits in unaided speech in noise perception. Our findings may indicate auditory plasticity type changes and require further investigation. TRIAL REGISTRATION NUMBER: Pre-results; NCT02889107

Acute positional vertigo in the emergency department—peripheral vs. central positional nystagmus

IntroductionBenign paroxysmal positional vertigo (BPPV) is the most common cause of positional vertigo. However, positional vertigo can also be due to diseases affecting the central vestibular pathways, such as vestibular migraine. Accurate and timely diagnosis enables effective triage and management.ObjectivesTo evaluate diagnoses made by emergency clinicians compared to acute vertigo specialists, in patients presenting to an emergency department (ED) with positional vertigo.MethodsFollowing routine ED care, patients with a primary complaint of dizziness, vertigo, light-headedness or unsteadiness, underwent detailed neuro-otological assessment by acute vertigo specialists. Demographics and final diagnoses were recorded and analyzed.ResultsOf 71 consented patients (21−91 years; mean 56 years, ±16.7 years, 40 females), ED identified 13 with a peripheral cause of positional vertigo (mean 48.85 years, ±16.19, 8 females). Central positional nystagmus was not noted in any of the patients with positional vertigo seen by the ED clinicians. Acute vertigo specialists diagnosed nine patients with BPPV (age range 50-88 years, mean 66 years, ±12.22, 5 females), and six with central positional nystagmus (age range 23−59 years, mean 41.67 years, ±15.78, 6 females).ConclusionPositional vertigo should be assessed with positional maneuvers such as Dix-Hallpike and Roll tests in the ED to identify peripheral and central nystagmus features. Central causes are more common in younger females, with the presence of vomiting, and/or a background of motion sensitivity

A Hearing Screening Protocol for Stroke Patients: An Exploratory Study.

Background: Auditory impairment post stroke is common and may be due to both peripheral hearing loss and or central auditory processing disorder (CAPD). When auditory impairment remains untreated, it may impact on patient communication and rehabilitation after stroke. Offering a comprehensive audiological assessment to all stroke patients would be both costly and time-consuming. A brief hearing screening is thus required. Objective: The aim of this study was to determine whether a two-tiered hearing screening approach, with use of a handheld hearing screener and two validated hearing questionnaires could be used as a hearing screening for peripheral hearing loss and CAPD in stroke survivors. The sensitivity and specificity of the screening method was analyzed. Methods: This was a prospective study conducted in a tertiary neurology hospital. Forty-two consecutive stroke patients were recruited and tested within 3-12 months post-onset of their stroke. Three screening tools for the identification of hearing impairment were evaluated in this study: A handheld hearing screener for determination of peripheral audiometric hearing loss and two validated questionnaires (The Amsterdam Inventory Auditory for Disability (AIAD) and the Hearing Handicap Inventory for Elderly (HHIE) questionnaires) for determination of peripheral hearing loss and/or CAPD. Results: The hearing screener had a sensitivity of 92. 59% detecting a hearing loss and specificity of 100%. The greatest test accuracy in identifying a central auditory processing type hearing impairment in stroke patients was found when the handheld hearing screener and the AIAD questionnaire were combined. Conclusion: This study is a first step toward addressing the complex auditory needs of stroke survivors in a systematic manner, with the ultimate aim to support their communication needs and long-term recovery and wellbeing. Registration: Project Identification number 11/0469 and REC ref 11/LO/1675

Reflexive and volitional saccadic eye movements and their changes in age and progressive supranuclear palsy

BACKGROUND AND OBJECTIVES: Saccades, rapid movements of the eyes towards a visual or remembered target, are useful in understanding the healthy brain and the pathology of neurological conditions such as progressive supranuclear palsy (PSP). We set out to investigate the parameters of horizontal reflexive and volitional saccades, both visually guided and memory-guided, over a 1 min epoch in healthy individuals and PSP patients. METHODS: An experimental paradigm tested reflexive, volitional visually guided, and volitional memory-guided saccades in young healthy controls (n = 14; 20-31 years), PSP patients (n = 11; 46-75 years) and older age-matched healthy controls (n = 6; 56-71 years). The accuracy and velocity of saccades was recorded using an EyeBrain T2® video eye tracker and analyses performed using the MyEyeAnalysis® software. Two-way analysis of variance (ANOVA) was used to identify significant effects (p < 0.01) between young and older controls to investigate the effects of ageing upon saccades, and between PSP patients and age-matched controls to study the effects of PSP upon saccades. RESULTS: In both healthy individuals and PSP patients, volitional saccades are slower and less accurate than reflexive saccades. In PSP patients, accuracy is lower across all saccade types compared to age-matched controls, but velocity is lower only for reflexive saccades. Crucially, there is no change in accuracy or velocity of consecutive saccades over short (one-minute) timescales in controls or PSP patients. CONCLUSIONS: Velocity and accuracy of saccades in PSP does not decrease over one-minute timescales, contrary to that previously observed in Parkinson's Disease (PD), suggesting a potential clinical biomarker for the distinction of PSP from PD

Neuroinflammatory disorders of the brain and inner ear: a systematic review of auditory function in patients with migraine, multiple sclerosis, and neurodegeneration to support the idea of an innovative ‘window of discovery’

BackgroundHearing can be impaired in many neurological conditions and can even represent a forme fruste of specific disorders. Auditory function can be measured by either subjective or objective tests. Objective tests are more useful in identifying which auditory pathway (superior or inferior) is most affected by disease. The inner ear’s perilymphatic fluid communicates with the cerebrospinal fluid (CSF) via the cochlear aqueduct representing a window from which pathological changes in the contents of the CSF due to brain inflammation could, therefore, spread to and cause inflammation in the inner ear, damaging inner hair cells and leading to hearing impairment identifiable on tests of auditory function.MethodsA systematic review of the literature was performed, searching for papers with case–control studies that analyzed the hearing and migraine function in patients with neuro-inflammatory, neurodegenerative disorders. With data extracted from these papers, the risk of patients with neurological distortion product otoacoustic emission (DPOAE) was then calculated.ResultsPatients with neurological disorders (headache, Parkinson’s disease, and multiple sclerosis) had a higher risk of having peripheral auditory deficits when compared to healthy individuals.ConclusionExisting data lend credence to the hypothesis that inflammatory mediators transmitted via fluid exchange across this communication window, thereby represents a key pathobiological mechanism capable of culminating in hearing disturbances associated with neuroimmunological and neuroinflammatory disorders of the nervous system

Auditory processing disorder: an online survey of hearing healthcare professionals’ knowledge and practices

To investigate (1) the current level of awareness and knowledge on Auditory Processing Disorder (APD) among Audiologists and other hearing healthcare professionals; (2) current practices in screening, diagnosis, and management of APD in children and adults across the UK; (3) professional’s acceptance of APD assessment and diagnosis. An online survey was disseminated through the British Academy of Audiology and ENT UK. A total of 191 hearing healthcare professionals responded to the survey. Overall, while 63% of the respondents considered themselves to be adequately informed about APD, only 4% viewed themselves as very informed on the topic. Fewer than half of the respondents report screening (31%), diagnosing (14%), or managing (36%) cases of APD. For screening APD, professionals most commonly use auditory processing tests in adults and take case histories in children, whereas routine audiological procedures are the primary method for diagnosing APD in both adults and children. Although modifying the listening environment is a widely recommended management strategy for APD, half of the respondents indicated that a diagnosis of APD has no implications for patient management. There is a critical need to promote APD-related training to ensure they can provide appropriate referrals and management.</p