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Acute Unilateral Vestibulopathy

Augusto Pietro Casani


Acute unilateral vestibulopathy (AUV) is the recommended term (rather than the more widely used vestibular neuritis) for all pathologies involving sudden impairment of the unilateral peripheral vestibular function regardless of the exact location of the lesion. The clinical picture of AUV is characterized by acute severe rotatory vertigo, nausea, vomiting and static and dynamic postural instability. The diagnosis is based on the presence of spontaneous nystagmus (horizontal/torsional, unidirectional), gait imbalance (falling toward the side of lesion) and a positive head impulse test. Typically, no associated auditory or neurological symptoms and signs are present. AUV is thought to be caused by a viral or post-viral inflammation of the vestibular nerve (vestibular neuritis), but a vascular origin of the disease cannot be excluded, especially in the presence of several vascular risk factors.  A careful bedside examination and a complete battery of instrumental test (video head impulse test, cervical and ocular VEMPs) could provide accurate information enabling to correctly diagnose AUV, both in acute and chronic stage of the disease also allowing to exclude a possible central nervous system involvement (vertebrobasilar stroke syndromes may mimic peripheral disorders). After a short course of symptomatic treatment with vestibular suppressants to alleviate the patient’s neurovegetative symptoms and intense rotatory vertigo, vestibular rehabilitation is the treatment of choice although recent reports suggest that an early steroid treatment may improve long-term outcome.


acute vertigo, vestibular neuritis, spontaneous nystagmus, video head impulse test, vestibulopathy, stroke

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Kerber KA. Acute Vestibular Syndrome. Semin Neurol. 2020; 40:59–66.

Ruttin B. Differentialdiagnose der Labyrinthu. Hornerverkrankugen. Z Ohrenheilkd 1909;57:327-331.

Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Ann Otol Rhinol Laryngol. 1952;6:987-1016.

Bohmer A. Acute unilateral peripheral vestibulopathy. In: Baloh RW, Halmagyi GM, editors. Disorders of the vestibular system. Oxford: Oxford University Press;1996. p. 318-327.

Baloh RW. Vestibular Neuritis. N Engl J Med. 2003;348:1027-1032.

Strupp M, Magnusson M. Acute Unilateral Vestibulopathy. Neurol Clin. 2015;33:669-685.

Strupp M, Mandalà M, López-Escámez JA. Peripheral vestibular disorders: an update. Curr Opin Neurol. 2019;32:165-173.

Rujescu D, Hartmann AM, Giegling I, et al. Genome-Wide Association Study in Vestibular Neuritis: Involvement of the Host Factor for HSV-1 Replication. Front Neurol. 2018;9:591.

Arbusow V, Derfuss T, Held K, et al. Latency of herpes simplex virus type-1 in human geniculate and vestibular ganglia is associated with infiltration of CD8+ T cells. J Med Virol. 2010;82:1917-1920.

Himmelein S, Lindemann A, Sinicina I, et al. Differential Involvement during Latent Herpes Simplex Virus 1 Infection of the Superior and Inferior Divisions of the Vestibular Ganglia: Implications for Vestibular Neuritis. J Virol. 2017;26;91:e00331-17.

Schuknecht HF, Kitamura K. Vestibular neuritis. Ann Otol Rhinol Laryngol. 1981; Suppl 78:1-19.

Greco A, Macri GF, Gallo A, et al. Is vestibular neuritis an immune related vestibular neuropathy inducing vertigo? J Immunol Res. 2014;2014:459048.

Murakami S, Mizobuchi M, Nakashiro Y et al. Bell palsy and herpes simplex virus: identification of viral DNA in endoneural fluid and muscle. Ann Intern Med. 1996;124:27-30.

Karlberg M, Annertz M, Magnusson M. Acute Vestibular Neuritis Visualized by 3-T Magnetic Resonance with High-Dose Gadolinium. Arch Otolaryngol Head Neck Surg. 2004;130:229-232.

Byun H, Chung JH, Lee SH et al. Clinical value of 4-hour delayed gadolinium-Enhanced 3D FLAIR MR Images in Acute Vestibular Neuritis. Laryngoscope. 2018;128:1946-1951.

Oron Y, Shemesh S, Shushan S, et al. Cardiovascular Risk Factors Among Patients With Vestibular Neuritis. Ann Otol Rhinol Laryngol. 2017;126:597-601.

Han W, Wang D, Wu Y, et al. Correlation between vestibular neuritis and cerebrovascular risk factors. Am J Otolaryngol. 2018;39:751-753.

Grad A, Baloh RW. Vertigo of vascular origin: clinical and electronystagmographic features in 84 cases. Arch Neurol. 1989;46:281-284.

Lindsay J, Hemenway W. Postural vertigo due to unilateral sudden partial loss of vestibular function. Ann Otol Rhinol Laryngol. 1956;65:692-706.

Buchele W, Brandt T. Vestibular neuritis - A horizontal semicircular canal paresis? Adv Oto-Rhino-Laryng. 1988;42:57-61.

Hegemann SCA, Wenzel A. Diagnosis and Treatment of Vestibular Neuritis/Neuronitis or Peripheral Vestibulopathy (PVP)? Open Questions and Possible Answers. Otol Neurotol. 2017;3:626-631.

Arbusow V, Schulz P, Strupp M et al. Distribution of herpes simplex virus type 1 in human geniculate and vestibular ganglia: implications for vestibular neuritis. Ann Neurol. 1999; 46:416-419.

Goebel JA, O’Mara W, Gianoli G. Anatomic considerations in vestibular neuritis. Otol Neurotol. 2001;22:512-518.

Kim JS, Kim HJ. Inferior vestibular neuritis. J Neurol. 2012;259:1553-1560.

Navari E, Casani AP. Lesion Patterns and Possible Implications for Recovery in Acute Unilateral Vestibulopathy. Otol Neurotol. 2020;41:250-255.

Büki B, Hanschek M, Jünger H. Vestibular neuritis: Involvement and long-term recovery of individual semicircular canals. Auris Nasus Larynx. 2017;44:288-293.

Jeong SH, Kim HJ, Kim JS. Vestibular neuritis. Semin Neurol. 2013;33:185-194.

Neuhauser HK. The epidemiology of dizziness and vertigo. In Furman J.M. and Lempert T, Editors. Handbook of Clinical Neurology, Vol. 137 (3rd series). Amsterdam: Elsevier; 2016. p. 91-101.

Adamec I, Krbot Skorić M, Handžić J, et al. Incidence, seasonality and comorbidity in vestibular neuritis. Neurol Sci. 2015;36:91-95.

von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry. 2007;78:710-715.

Nuti D, Biagini C, Passali D. Incidence and prevalence of Menière’s disease in Tuscany. In: Filipo R and Barbara M editors. Menière’s Disease: Perspectives in the ‘90s. Amsterdam: Kugler; 1993. p. 47-49.

Kattah JC. Use of HINTS in the acute vestibular syndrome. An Overview. Stroke Vasc Neurol. 2018;23:190-196.

Kim HA, Lee H. Recent advances in central acute vestibular syndrome of vascular cause. J Neurol Sci. 2012;321:17-22.

Chen L, Halmagyi GM. Video Head Impulse Testing: From Bench to Bedside. Semin Neurol. 2020;40:5-17.

Curthoys IS. The interpretation of clinical tests of peripheral vestibular function. Laryngoscope. 2012;122:1342–1352.

Dumas G, Curthoys IS, Lion A, Perrin P, Schmerber S. The skull vibration-induced nystagmus test of vestibular function-A review. Front Neurol. 2017;8:41.

Kim HA, Hong JH, Lee H et al. Otolith dysfunction in vestibular neuritis. Recovery pattern and a predictor of symptom recovery. Neurology. 2008;70:449-53.

Gufoni M. Uphill/downhill nystagmus. Acta Otorhinolaryngol Ital. 2017;37:513-518.

Colebatch JG, Rosengren SM, Welgampola MS. Vestibular-evoked myogenic potentials. In Furman J.M. and Lempert T, Editors. Handbook of Clinical Neurology, Vol. 137 (3rd series). Amsterdam: Elsevier; 2016. p. 133-155.

Shin BS, Oh SY, Kim JS et al. Cervical and ocular vestibular-evoked myogenic potentials in acute vestibular neuritis. Clin Neurophysiol. 2012;123:369-375.

Manzari L, Burgess AM, Curthoys IS. Ocular and cervical vestibular evoked myogenic potentials in response to bone-conducted vibration in patients with probable inferior vestibular neuritis. J Laryngol Otol. 2012;126:683-691.

Silvoniemi P. Vestibular neuronitis: an oto-neurological evaluation. Acta Otolaryngol 1988;Suppl 453:1-72.

Cerchiai N, Navari E, Casani AP et al. Predicting the Outcome after Acute Unilateral Vestibulopathy: Analysis of Vestibulo-ocular Reflex Gain and Catch-up Saccades. Otolaryngol Head Neck Surg. 2018;158:527-533.

Staab JP. Functional and psychiatric vestibular disorders. In Furman J.M. and Lempert T, Editors. Handbook of Clinical Neurology, Vol.137 (3rd series). Amsterdam: Elsevier; 2016. p. 341-351.

Schubert MC, Helminski J, Zee DS, et al. Horizontal semicircular canal jam: Two new cases and possible mechanisms. Laryngoscope Investig Otolaryngol. 2020;5:163-167.

Casani AP, Dallan I, Cerchiai N, et al. Cerebellar infarctions mimicking acute peripheral vertigo: how to avoid misdiagnosis? Otolaryngol Head Neck Surg. 2013;148:475–481

Lee H, Sohn SI, Cho YW et al. Cerebellar infarction presenting isolated vertigo. Frequency and vascular topographical patterns. Neurology. 2006;67:1178-1183.

Huh YE, Koo JW, Lee H, Kim JS. Head-Shaking aids in the diagnosis of acute audiovestibular loss due to anterior inferior cerebellar artery infarction. Audiol Neurotol. 2013;18:114-124.

Vanni S, Pecci R, Edlow JA. Differential Diagnosis of Vertigo in the Emergency Department: A Prospective Validation Study of the STANDING Algorithm. Front Neurol. 2017;8:590.

Marril KA, Walsh MJ, Nelson BK. Intravenous lorazepam versus dimenhydrinate for the treatment of vertigo in the emergency department: a randomized clinical trial. Ann Emerg Med. 2000;36:310-319.

Irving C, RichmanPP, Kaiafas C et al. Intra-muscular droperidol versus intramuscular dimenhydrinate for the treatment of acute peripheral vertigo in the emergency department: a randomized clinical trial. Acad Emerg Med. 2002;9:650-653.

Navari E, Cerchiai N, Casani AP. Assessment of Vestibulo-ocular Reflex Gain and Catch-up Saccades During Vestibular Rehabilitation. Otol Neurotol. 2018;39:e1111-e1117.

Sjögren J, Fransson PA, Karlberg M, et al. Functional Head Impulse Testing Might Be Useful for Assessing Vestibular Compensation After Unilateral Vestibular Loss. Front Neurol. 2018;9:979.

Strupp M, Zingler VC, Arbusow V et al. Methylprednisolone, Valacyclovir, or the combination for vestibular neuritis. N Engl J Med. 2004;351:354-361.

Sjögren, J, Magnusson, M, Tjernström, F, Karlberg, M. Steroids for acute vestibular neuronitis—the earlier the treatment, the better the outcome? Otol Neurotol. 2019;40:372-374.


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