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Research article

The Bucket Test Differentiates Patients with MRI Confirmed Brainstem/Cerebellar Lesions from Patients Having Migraine and Dizziness Alone

Tzu-Pu Chang, Ariel A Winnick, Yung-Chu Hsu, Pi-Yu Sung, Michael C Schubert
DOI: 10.21203/rs.2.10460/v2

Abstract

Background: Among the most challenging diagnostic dilemmas managing patients with vestibular symptoms (i.e. vertigo, nausea, imbalance) is differentiating dangerous central vestibular disorders from benign causes. Migraine has long been recognized as one of the most common causes of vestibular symptoms, but the clinical hallmarks of vestibular migraine are notoriously inconsistent and thus the diagnosis is difficult to confirm. Here we conducted a prospective study investigating the sensitivity and specificity of combining standard vestibular and neurological examinations to determine how well central vestibular disorders (CVD) were distinguishable from vestibular migraine (VM). Method: Twenty-seven symptomatic patients diagnosed with CVD and 36 symptomatic patients with VM underwent brain imaging and clinical assessments including; 1) SVV bucket test, 2) ABCD2, 3) headache/vertigo history, 4) presence of focal neurological signs, 5) nystagmus, and 6) clinical head impulse testing. Results: Mean absolute SVV deviations measured by bucket testing in CVD and VM were 4.8±4.1° and 0.7±1.0°, respectively. The abnormal rate of SVV deviations (>2.3°) in CVD was significantly higher than VM (p<0.001). Using the bucket test alone to differentiate CVD from VM, sensitivity was 74.1%, specificity 91.7%, positive likelihood ratio (LR+) 8.9, and negative likelihood ratio (LR-) 0.3. However, when we combined the SVV results with the clinical exam assessing gaze stability (nystagmus) with an abnormal focal neurological exam, the sensitivity (92.6%) and specificity (88.9%) were optimized (LR+ (8.3), LR- (0.08)). Conclusion: The SVV bucket test is a useful clinical test to distinguish CVD from VM, particularly when interpreted along with the results of a focal neurological exam and clinical exam for nystagmus.

Keywords
vestibular migraine, central vestibular disorder, subjective visual vertical, bucket test, nystagmus

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STATUS: Accepted

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Posted 13 Aug, 2019

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    On 20 Aug, 2019

  • Review #1 received

    Received 07 Aug, 2019

  • Reviewer #1 agreed

    On 06 Aug, 2019

  • Editor assigned

    On 01 Aug, 2019

  • 2 reviewer(s) invited

    Invitations sent on 01 Aug, 2019

  • Submission checks complete

    On 31 Jul, 2019

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    On 31 Jul, 2019

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Posted 19 Jun, 2019

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Neurology

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Preprint: Please note that this article has not completed peer review.
Research article

The Bucket Test Differentiates Patients with MRI Confirmed Brainstem/Cerebellar Lesions from Patients Having Migraine and Dizziness Alone

Tzu-Pu Chang, Ariel A Winnick, Yung-Chu Hsu, Pi-Yu Sung, Michael C Schubert

STATUS: Accepted

Comments: 0
PDF Downloads: 0
HTML Views: 5

Integrity Check:

  • Article

  • Peer Review Timeline

  • Related Articles

  • Comments

Abstract

Background: Among the most challenging diagnostic dilemmas managing patients with vestibular symptoms (i.e. vertigo, nausea, imbalance) is differentiating dangerous central vestibular disorders from benign causes. Migraine has long been recognized as one of the most common causes of vestibular symptoms, but the clinical hallmarks of vestibular migraine are notoriously inconsistent and thus the diagnosis is difficult to confirm. Here we conducted a prospective study investigating the sensitivity and specificity of combining standard vestibular and neurological examinations to determine how well central vestibular disorders (CVD) were distinguishable from vestibular migraine (VM). Method: Twenty-seven symptomatic patients diagnosed with CVD and 36 symptomatic patients with VM underwent brain imaging and clinical assessments including; 1) SVV bucket test, 2) ABCD2, 3) headache/vertigo history, 4) presence of focal neurological signs, 5) nystagmus, and 6) clinical head impulse testing. Results: Mean absolute SVV deviations measured by bucket testing in CVD and VM were 4.8±4.1° and 0.7±1.0°, respectively. The abnormal rate of SVV deviations (>2.3°) in CVD was significantly higher than VM (p<0.001). Using the bucket test alone to differentiate CVD from VM, sensitivity was 74.1%, specificity 91.7%, positive likelihood ratio (LR+) 8.9, and negative likelihood ratio (LR-) 0.3. However, when we combined the SVV results with the clinical exam assessing gaze stability (nystagmus) with an abnormal focal neurological exam, the sensitivity (92.6%) and specificity (88.9%) were optimized (LR+ (8.3), LR- (0.08)). Conclusion: The SVV bucket test is a useful clinical test to distinguish CVD from VM, particularly when interpreted along with the results of a focal neurological exam and clinical exam for nystagmus.

Figures

Background

Methods

Results

Discussion

Conclusions

Abbreviations

Declarations

References

Tables

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