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"at0015" "detalle" => "Figure " "rol" => "short" ] ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "María San Millán-González, Ana Fernández-Rodríguez, Michael Bauer" "autores" => array:3 [ 0 => array:2 [ "nombre" => "María" "apellidos" => "San Millán-González" ] 1 => array:2 [ "nombre" => "Ana" "apellidos" => "Fernández-Rodríguez" ] 2 => array:2 [ "nombre" => "Michael" "apellidos" => "Bauer" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001651924000165" "doi" => "10.1016/j.otorri.2024.02.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001651924000165?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173573524000462?idApp=UINPBA00004N" "url" => "/21735735/0000007500000005/v1_202409190750/S2173573524000462/v1_202409190750/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2173573524000450" "issn" => "21735735" "doi" => "10.1016/j.otoeng.2024.01.013" "estado" => "S300" "fechaPublicacion" => "2024-09-01" "aid" => "1233" "copyright" => "Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello" "documento" => "article" "crossmark" => 1 "subdocumento" => "rev" "cita" => "Acta Otorrinolaringol Esp. 2024;75:324-34" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Review article</span>" "titulo" => "Variants of posterior semicircular canal involvement in benign paroxysmal positional vertigo" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "324" "paginaFinal" => "334" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Variantes de afectación del conducto semicircular posterior en el vértigo posicional paroxístico benigno" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1201 "Ancho" => 1207 "Tamanyo" => 146010 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Variants of posterior semicircular canal involvement: (1) Canalithiasis of the long arm, (2) Canalithiasis of the short arm, (3) Cupulolithiasis of the long arm, (4) Cupulolithiasis of the short arm, (5) Canalithiasis of the distal portion of the long arm, and (6) Canalithiasis limited to the periampullary segment of the long arm. Structures: Membranous labyrinth (green), Utricular macula (red), Cupula (yellow).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Octavio Garaycochea, Nicolás Pérez-Fernández" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Octavio" "apellidos" => "Garaycochea" ] 1 => array:2 [ "nombre" => "Nicolás" "apellidos" => "Pérez-Fernández" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0001651924000153" "doi" => "10.1016/j.otorri.2024.01.009" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001651924000153?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173573524000450?idApp=UINPBA00004N" "url" => "/21735735/0000007500000005/v1_202409190750/S2173573524000450/v1_202409190750/en/main.assets" ] "en" => array:16 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case study</span>" "titulo" => "Acute vertigo with diplopia: that’s central, right?" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "335" "paginaFinal" => "337" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Francisco Teixeira-Marques, Roberto Estêvão, Adriana Cunha, Nuno Lousan" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Francisco" "apellidos" => "Teixeira-Marques" "email" => array:1 [ 0 => "marquesjfrancisco@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Roberto" "apellidos" => "Estêvão" ] 2 => array:2 [ "nombre" => "Adriana" "apellidos" => "Cunha" ] 3 => array:2 [ "nombre" => "Nuno" "apellidos" => "Lousan" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Otorhinolaryngology, Tamega e Sousa Hospital Centre, Penafiel, Portugal" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Vértigo agudo con diplopía: eso es central, ¿verdad?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 804 "Ancho" => 3341 "Tamanyo" => 235153 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0305" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Video-Head Impulse Test (vHIT) of the left and right horizontal semicircular canals showing a reduced gain on the right (10% asymmetry) with the presence of overt saccades.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 54-year-old woman with history of high blood pressure presented in the emergency department (ED) with sudden onset of vertigo associated with nausea, vomiting and vertical diplopia. Neurological exam was normal apart from gait unsteadiness, a spontaneous left-beating horizontal nystagmus that was present in straight-ahead gaze and increased in leftward gaze with head impulse test (HIT) to the right side revealing catch-up saccades, and a subtle skew deviation with hypotropia on the right side with her head straight. Otoscopy and acoumetry were normal. Head/neck computed tomography (CT) angiography performed in the emergency department was normal. The patient was admitted for further investigation in the neurology department and had a head diffusion-weighed magnetic resonance imaging (DWI-MRI) six days later that did not find evidence of acute ischemia or other abnormalities. Right acute unilateral vestibulopathy was assumed, and the patient was started on a 10-day course of prednisone.</p><p id="par0010" class="elsevierStylePara elsevierViewall">After completing the systemic corticosteroid course, the patient indicated an improvement in gait stability, while binocular vertical diplopia was present only with rapid head movements. Vestibular evaluation with videonistagmography 2 months after onset showed right hyporeflexia in bithermal caloric testing and video-HIT (vHIT) of the horizontal semi-circular canal (SCC) showed a normal gain on the left side (0.86) and a decreased gain on the right side (0.77) with overt saccades (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The patient had vestibular rehabilitation and examination four months after onset revealed complete resolution of diplopia and normal gait stability.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Acute vestibular syndrome (AVS) is characterized by acute onset of dizziness or vertigo, most of the times associated with nausea/vomiting, nystagmus, and gait instability, that lasts days to weeks.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The perfect example of an AVS – and its most common cause - is acute unilateral vestibulopathy (AUVP), a benign peripheral vestibulopathy.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However, one must be aware that an ischemic vertebrobasilar stroke can mimic these symptoms. A rapid bedside assessment with the HINTS Plus examination (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) is an excellent way of predicting the etiology of acute vertigo – where the presence of a skew deviation suggests a central cause.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Also, other alarm signs for central nervous system involvement, such as the “dangerous Ds” - diplopia, dysphagia, dysarthria, or dysmetria - should be sought after.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Some exceptions, however, can be seen – a peripheral lesion, albeit rarely, can provoke a disturbance of the utriculo-ocular motor pathway, triggering an ocular tilt reaction (OTR) which might lead to vertical ocular misalignment (skew deviation) and eventually diplopia.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">While the occurrence of a temporary skew deviation in cases of vestibular nerve section is well studied, such as in unilateral vestibular neurectomy and labyrinthectomy, the same cannot be said for AUVP.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Since it is so rarely seen in clinical practice it might be easily forgotten by the physician – which is understandable, as in our literature review we found only three cases reporting similar findings.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,6,7</span></a> It is actually thought that an OTR is present in most AUVP where the superior vestibular nerve (SVN) is involved, but most of the times the skew deviation is so subtle that is not detected by the physician and rarely elicits diplopia.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In our patient, the presence of diplopia and a skew deviation pointed towards a vertebrobasilar stroke as the cause of an AVS. However, the absence of findings suggestive of stroke in the DWI-MRI performed six days after onset and the characteristics of the nystagmus and catch-up saccades in the HIT supported the diagnosis of AUVP, which was later confirmed by the findings in vestibular tests. There are a few limitations in our case report: a Maddox rod test was not available to confirm diplopia, and the vHIT was performed 2 months after onset and only showed the horizontal semicircular canals. Nonetheless, the acute beginning of diplopia in association with vertigo, and its resolution after vestibular rehabilitation, strongly suggest both are related.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conclusion</span><p id="par0030" class="elsevierStylePara elsevierViewall">This case highlights the diagnostic challenge of patients with acute vertigo. The HINTS Plus seems to be an excellent bedside examination to reach towards the correct diagnosis, but in rare occasions a skew deviation might also be present in a peripheral vestibulopathy that disturbs the otolith-ocular pathways. In such cases a stroke must be thoroughly sought for and excluded before assumption of a benign cause. However, if one happens to come across with a case of acute vertigo with skew deviation and vertical diplopia with no other alarm signs, a normal CT and subsequent DWI-MRI, physicians should be aware of the exception to the rule.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflict of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conclusion" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interest" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-08-29" "fechaAceptado" => "2024-01-14" "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 804 "Ancho" => 3341 "Tamanyo" => 235153 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0305" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Video-Head Impulse Test (vHIT) of the left and right horizontal semicircular canals showing a reduced gain on the right (10% asymmetry) with the presence of overt saccades.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0310" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">HINTS Plus</span> examination \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">INFARCT - Stroke</span> or other central causes if <span class="elsevierStyleBold">ANY</span> of these symptoms are present \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleBold">Benign peripheral</span> if <span class="elsevierStyleBold">ALL</span> these symptoms are present \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">H</span>ead <span class="elsevierStyleBold">I</span>mpulse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">I</span>mpulse <span class="elsevierStyleBold">N</span>egative (no catch-up saccades) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Impulse positive towards lesion side, requiring catch-up saccades to fixate on target \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">N</span>ystagmus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">F</span>ast-phase <span class="elsevierStyleBold">A</span>lternating (direction-changing or purely vertical or torsional) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fast phase of spontaneous nystagmus always beats away from lesion side; predominantly horizontal, with small torsional component \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">T</span>est of <span class="elsevierStyleBold">S</span>kew \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">R</span>efixation on <span class="elsevierStyleBold">C</span>over <span class="elsevierStyleBold">T</span>esting (vertical misalignment) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No skew deviation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hearing test \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleBold">Acute hearing loss is a red flag</span> for anterior inferior cerebellar artery (<span class="elsevierStyleBold">AICA</span>) <span class="elsevierStyleBold">stroke</span> even when other signs point toward a peripheral cause</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3660496.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">HINTS Plus examination. Adapted from Eggers et al.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "TiTrATE: a novel approach to diagnosing acute dizziness and vertigo" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D.E. Newman-Toker" 1 => "J.A. 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Journal Information
Case study
Acute vertigo with diplopia: that’s central, right?
Vértigo agudo con diplopía: eso es central, ¿verdad?
Francisco Teixeira-Marques
, Roberto Estêvão, Adriana Cunha, Nuno Lousan
Corresponding author
Department of Otorhinolaryngology, Tamega e Sousa Hospital Centre, Penafiel, Portugal