Research in Vestibular Science

Review Article

Treatment of hemodynamic orthostatic dizziness/vertigo: Hyun Ah Kim; Res Vestib Sci. 2024;23(3):79-88. Published online September 15, 2024; DOI: https://doi.org/10.21790/rvs.2024.017

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Abstract PDF: Orthostatic dizziness occurs when a person feels dizzy or lightheaded upon standing up. Hemodynamic orthostatic dizziness can result from autonomic dysfunction, such as orthostatic hypotension or postural tachycardia syndrome. The International Classification of Vestibular Disorders has established diagnostic criteria for hemodynamic orthostatic dizziness/vertigo. These criteria help clinicians understand the terminology associated with orthostatic dizziness/vertigo and differentiate it from dizziness caused by global brain hypoperfusion and other etiologies. Effective treatment involves interpreting the results of autonomic function tests, which can lead to improvements in orthostatic dizziness and help prevent falls related to this condition. This paper discusses general management strategies and specific treatments for orthostatic hypotension and postural tachycardia syndrome, highlighting the importance of tailored care based on the most recent clinical insights.

Case Report

Delayed Audio-Vestibular Symptoms in Spontaneous Intracranial Hypotension: Han-Sol Choi, Jae-Myung Kim, Hong Chan Kim, Hyong-Ho Cho, Seung-Han Lee; Res Vestib Sci. 2020;19(1):29-33. Published online March 15, 2020; DOI: https://doi.org/10.21790/rvs.2020.19.1.29

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Abstract PDF: Intracranial hypotension (IH) is a neurological disorder characterized by orthostatic headache due to cerebrospinal fluid (CSF) volume depletion. IH usually results from CSF leak caused by either spontaneous or traumatic dural injury and may also present nausea, neck stiffness, tinnitus or dizziness. We experienced a 52-year-old woman presenting with acute spontaneous vertigo, tinnitus and hearing impairment on both ears with right side predominancy which mimicked Meniere’s disease. Video-oculography revealed spontaneous left-beating nystagmus which was modulated by position change. There was binaural low-frequency sensorineural hearing loss (SNHL) in pure tone audiometry. Other neuro-otologic evaluations including caloric test, vestibular evoked myogenic potential, video head impulse tests were unremarkable. Of interest, she had been treated of orthostatic headache due to spontaneous IH 10 days before admission. Taken together the clinical and laboratory findings, audio-vestibular symptoms of the patient were thought to be related with insufficient treatment of IH. After massive hydration and bed rest, her symptoms were markedly improved and SNHL was also disappeared in the follow-up pure tone audiometry. IH should be considered as a differential diagnosis in dizzy patient with tinnitus, hearing impairment even the typical orthostatic headache is not accompanied.

Original Article

Application of Tetrode Technology for Analysis of Changes in Neural Excitability of Medial Vestibular Nucleus by Acute Arterial Hypotension: Young Kim, Ho Koo, Byung Rim Park, Se Jin Moon, Seung-Bum Yang, Min Sun Kim; Res Vestib Sci. 2018;17(4):142-151. Published online December 21, 2018; DOI: https://doi.org/10.21790/rvs.2018.17.4.142

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Abstract PDF: Objectives
Excitability o medial vestibular nucleus (MVN) in the brainstem can be affected by changes in the arterial blood pressure. Several animal studies have demonstrated that acute hypotension results in the alteration of multiunit activities and expression of cFos protein in the MVN. In the field of extracellular electrophysiological recording, tetrode technology and spike sorting algorithms can easily identify single unit activity from multiunit activities in the brain. However, detailed properties of electrophysiological changes in single unit of the MVN during acute hypotension have been unknown.
Methods
Therefore, we applied tetrode techniques and electrophysiological characterization methods to know the effect of acute hypotension on single unit activities of the MVN of rats.
Results
Twoor3typesofunitcouldbeclassifiedaccordingtothemorphologyofspikes and firing properties of neurons. Acute hypotension elicited 4 types of changes in spontaneous firing of single unit in the MVN. Most of these neurons showed excitatory responses for about within 1 minute after the induction of acute hypotension and then returned to the baseline activity 10 minutes after the injection of sodium nitroprusside. There was also gradual increase in spontaneous firing in some units. In contrast small proportion of units showed rapid reduction of firing rate just after acute hypotension. Conclusions: Therefore, application of tetrode technology and spike sorting algorithms is another method for the monitoring of electrical activity of vestibular nuclear during acute hypotension.

Review

Autonomic Dysfunction in Dizziness Clinic: Eun Bin Cho, Ki-Jong Park; Res Vestib Sci. 2018;17(2):37-43. Published online June 15, 2018; DOI: https://doi.org/10.21790/rvs.2018.17.2.37

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2 Crossref

Abstract PDF

Orthostatic dizziness is a common type of dizziness. In general, orthostatic dizziness is provoked by standing or tilting, and subsided by supine position. The patient with orthostatic intolerance complains multiple symptoms such as dizziness, palpitation, lightheadness, fatigue and rarely syncope. Common orthostatic intolerance is orthostatic hypotension (classic, initial, transient, and delayed orthostatic hypotension) and postural orthostatic tachycardia syndrome. Transcranial Doppler is a noninvasive technique that provides real-time measurement of cerebral blood flow velocity. It can be useful for understanding the relationship between orthostatic symptoms and cerebral autoregulatory function. The reciprocal causal relationship between vestibular and autonomic dysfunction should always be kept in mind.

Citations

Citations to this article as recorded by

A Study on the Characteristics of Patients Treated for Dizziness with Jeoreongchajeonja-tang: A Retrospective Analysis of 63 Cases
Nu-ri Jung, Ki-tae Kim, Seon-mi Shin, Heung Ko
The Journal of Internal Korean Medicine.2019; 40(6): 1122. CrossRef
Pitfalls in the Diagnosis of Vertigo
Hyun Ah Kim, Hyung Lee
Journal of the Korean Neurological Association.2018; 36(4): 280. CrossRef

Original Article

Classification of Chronic Dizziness in Elderly People and Relation with Falls: Dong-Suk Yang, Da-Young Lee, Sun-Young Oh, Ji-Yun Park; Res Vestib Sci. 2018;17(1):13-17. Published online March 15, 2018; DOI: https://doi.org/10.21790/rvs.2018.17.1.13

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Abstract PDF: Objectives
Fall is a major cause of morbidity and mortality among older adults. Falls result from many various causes, and dizziness is important risk for falls, especially in the elderly. Research on the relationship between chronic dizziness and falls in elderly people has been rarely performed and these were no studies that analyzed the risk of falls according to subtypes of chronic dizziness.
Methods
We conducted a prospective study of the association between subtypes of chronic dizziness and falls in the elderly between 65 to 75 years. We divided dizzy patients into 5 groups according to the results of symptom, vestibular and autonomic function test. Falls and new events (acute dizziness or other medical conditions) were checked monthly by telephone or out patient department follow-up for 6 months.
Results
Thirty-four patients were enrolled and all completed follow-up for 6 months. Nine patients classified as the falling groups and 34 patients as nonfalling group. Whereas the frequencies of orthostatic hypotension (n=6, 67%) and vestibular dysfunction (n=1, 11%) were higher in fall group, psychogenic dizziness (n=12, 35%), and vestibular migraine (n=3, 9%) were more frequent in nonfall group.
Conclusions
The presence of dizziness in the elderly is a strong predictor of fall, especially orthostatic hypotension is an important predictor of fall. In order to lower the risk of falls in the elderly, an approach based on the cause of dizziness is needed.

Reviews

Treatment of Neurogenic Orthostatic Hypotension: Jung-Ick Byun, Sang Beom Kim; Res Vestib Sci. 2017;16(3):73-79. Published online September 15, 2017; DOI: https://doi.org/10.21790/rvs.2017.16.3.73

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1 Crossref

Abstract PDF

Orthostatic hypotension (OH) is a common feature of sympathetic autonomic dysfunction and can lead to lightheadedness, weakness, dizziness, and syncope. It is defined as decrease in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of at least 10 mm Hg within 3 minutes of standing. OH is associated with an increased incidence of cerebrovascular disease, myocardial infarction, and mortality. Non-pharmacological treatments may alleviate OH-related symptoms; however, are not sufficient when used alone. Pharmacological treatment is essential in managing OH. In this review, we aimed to discuss non-pharmacological and pharmacological treatment options for OH.

Citations

Citations to this article as recorded by

Classification of Chronic Dizziness in Elderly People and Relation with Falls
Dong-Suk Yang, Da-Young Lee, Sun-Young Oh, Ji-Yun Park
Research in Vestibular Science.2018; 17(1): 13. CrossRef

Positional Dizziness and Vertigo without Nystagmus and Orthostatic Hypotension: Jae Han Park; Res Vestib Sci. 2016;15(4):107-111. Published online December 12, 2016; DOI: https://doi.org/10.21790/rvs.2016.15.4.107

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Abstract PDF: According to the Barany Society classification of vestibular symptoms, positional dizziness or vertigo is defined as dizziness or vertigo triggered by and occurring after a change of head position in space relative to gravity. Thus, positional dizziness or vertigo should be differentiated from orthostatic dizziness or vertigo, which is triggered by and occurs upon rising. Benign paroxysmal positional vertigo (BPPV) is the most common positional vertigo and accompanied by a characteristic paroxysmal positional nystagmus. But a problem occasionally encountered in clinical practice is the presence of a positive history of BPPV with a negative diagnostic maneuver for positional nystagmus. Orthostatic hypotension may be dependent upon various neurogenic and non-neurogenic disorders and conditions. Combination of non-pharmacological and pharmacological treatment improve orthostatic tolerance.

Original Articles

Pathways of Neurogenic and Humoral Control in the Vestibulosympathetic Reflex of Conscious Rats: Guang Shi Jin, Gyoung Wan Lee, Sang Eon Park, Yuan Zhe Jin, Byung Rim Park; Res Vestib Sci. 2015;14(4):110-116.

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Abstract PDF: Objective: The vestibular system contributes control of blood pressure during postural changes through the vestibulosympathetic reflex. In the vestibulosympathetic reflex, afferent signals from the peripheral vestibular receptors are transmitted to the vestibular nuclei, rostral ventrolateral medullary nuclei, and then to the intermediolateral cell column of the thoracolumbar spinal cord. Physiological characteristics of the vestibulosympathetic reflex in terms of neurogenic and humoral control of blood pressure were investigated in this study.
Methods
Conscious rats with sinoaortic denervation were used for removal of baroreceptors in reflex control of blood pressure, and hypotension was induced by intravenous infusion of sodium nitroprusside (SNP). Expression of c-Fos protein was measured in the medial vestibular nuclei (MVN), rostral vestrolateral medullary nuclei (RVLM), and intermediolateral cell column (IMC) in T4-7, and levels of blood epinephrine were measured following SNP-induced hypotension.
Results
SNP-induced hypotension significantly increased expression of c-Fos protein in the MVN, RVLM, and IMC, also significantly increased level of blood epinephrine compared to normotensive control animals.
Conclusion
These results suggest that the vestibulosympathetic reflex regulates blood pressure through neurogenic control including MVN, RVLM, and IMC, also through humoral control including epinephrine secretion by the adrenal medulla following SNP-induced hypotension. The physiological characteristics of the reflex may contribute to basic treatment of impairment of blood pressure control during postural changes.

Expression of Metabotropic Glutamate Receptors in the Medial Vestibular Nucleus Following Acute Hypotension in Rats: Myoung Ae Choi, Nari Kim, Sang Eon Park, Byung Geon Park, Min Sun Kim, Byung Rim Park; Res Vestib Sci. 2012;11(4):131-137.

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Abstract PDF: Background and Objectives: Acute hypotension induces expression of c-Fos protein and phosphorylated extracellular signal-regulated kinase (pERK), and glutamate release in the vestibular nuclei. Expression of c-Fos protein and pERK is mediated by the excitatory neurotransmitter, glutamate. In this study, the signaling pathway of glutamate in the vestibular nuclei following acute hypotension was investigated. Materials and Methods: Expression of metabotropic glutamate receptors (mGluRs) was measured by Western blotting in the medial vestibular nucleus following acute hypotension in rats. Results: Expression of pGluR1 Ser831, a subtype of α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptors, peaked at 30 minutes after acute hypotension insult, and expression of pNR2B, a subtype of N-methyl-D-aspartate (NMDA) receptors, peaked at 2 hours after acute hypotension insult. Acute hypotension induced expression of Homer1a and group I mGluR in the medial vestibular nucleus. Expression of mGluR1 and mGluR5 peaked at 6 hours following acute hypotension insults. Conclusion: These results suggest that afferent signals from the peripheral vestibular receptors, resulting from acute hypotension insult, are transmitted through group I mGluRs as well as AMPA and NMDA receptors in the vestibular system.

Expression of Glutamate Receptors in the Medial Vestibular Nuclei following Acute Hypotension: Jae Hee Lee, Myoung Ae Choi, Dong Ok Choi, Bo Kyoung Kim, Seok Min Hong, Byung Rim Park; J Korean Bal Soc. 2007;6(1):29-35.

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Abstract PDF: Acute hypotension induced excitation of electrical activities and expression of c-Fos protein and pERK in the vestibular nuclei. In this study, to investigate the excitatory signaling pathway in the vestibular nuclei following acute hypotension, expression of NR2A and NR2B subunits of glutamate NMDA receptor and GluR1 subunit of glutamate AMPA receptor was determined by RT-PCR and Western blotting in the medial vestibular nucleus 30 min after acute hypotension in rats. Acute hypotension increased expression of NR2A, NR2B, and pGluR1 in the medial vestibular nuclei. These results suggest that both of NMDA and AMPA glutamate receptors take part in transmission of excitatory afferent signals following acute hypotension.

Role of Central Vestibular Pathway on Control of Blood Pressure During Acute Hypotension in Rats: Yuan Zhe Jin, Guang Shi Jin, Min Sun Kim, Byung Rim Park; J Korean Bal Soc. 2005;4(2):189-200.

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Abstract PDF: Background
and Objectives: Central role of the vestibular system on control of blood pressure and interrelationships between the vestibular nucleus and solitary nucleus during acute hypotension were investigated in bilateral labyrinthectomized (BLX) or sinoaortic denervated (SAD) rats. Changes of electrical activity in the medial vestibular nucleus (MVN), solitary tract nucleus (STN), and rostral ventrolateral medullary nucleus (RVLM) were investigated in rats in while acute hypotension was induced by sodium nitroprusside (SNP).
Results
Evoked potential in MVN neuron caused by electrical stimulation of the peripheral vestibular system was composed of 3 waves with latencies of 0.48±0.10 ms, 1.04±0.09 ms and 1.98±0.19 ms. Electrical stimulation to MVN or RVLM increased blood pressure. MVN at the induction of acute hypotension showed excitation in 61% of type I neurons and inhibition in 68% of type II neurons. In STN, acute hypotension produced excitation in 62.1% of neurons recorded in intact abyrinthine animals, inhibition in 72.3% of neurons recorded in BL animals, and excitation in 60% of recorded neurons in SAD animals. In RVLM, acute hypotension produced excitation in 66.7% of neurons recorded in intact labyrinthine animals and inhibition in 64.9% of neurons recorded in BL animals. In spatial distribution of STN neurons responded to acute hypotension, excitatory responses were mainly recorded in rostral and ventral portion, and inhibitory responses were mainly recorded in caudal and lateral portion. In RVLM, excitatory responses were mainly recorded in rostral and dorsomedial portion, and inhibitory responses were mainly recorded in caudal and ventrolateral portion.
Conclusion
These results suggest that afferent signals from the peripheral vestibular receptors are transmitted to STN through the vestibular nuclei and assist to the baroreceptors for controlling blood pressure following acute hypotension.

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