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Here is the distal carotid doppler:. So this is done in the upper neck, just distal to the bifurcation, so while extra cranial, the internal carotid nonetheless represents a view into the relationship between arterial flow and intracranial hemodynamics. It takes virtually no experience to see the radical difference in flow between the internal and the external carotid. The EC shows a beautiful systolic peak and diastolic flow. On the other hand, the IC shows a small systolic peak, a bit of retrograde flow, and essentially minimal or no diastolic flow.

That is telling us, physiologically, that the ICP elevation has radically limited diastolic flow. This right away tells us there is a massive ICP elevation explaining the lack of awakening, and a dismal prognosis. Great case presentation into ruling out some of the other cases of prolonged emergence from general anesthestics. Looks like TCD is a difficult technique at the best of times. Really thought-provoking stuff.

Neurology at the Bedside

This is a brililant diagnosis! A colleague of mine is collecting data since a few years comparing optic nerve dilation and intracranial hypertension in patients with one ore more ICP monitoring, but the correlation is not so strong so far. Thanks Marco! In terms of your question, since TCD is not yet formally used as an unequivocal test for brain death, we would still have to do the rest apnea, etc to declare brain death for the purpose of donation, but in terms of withdrawal, I consider it sufficient to establish a dismal prognosis. You are commenting using your WordPress. You are commenting using your Google account.

You are commenting using your Twitter account. You are commenting using your Facebook account. Notify me of new comments via email. Notify me of new posts via email. This site uses Akismet to reduce spam. Sensitivity of novices was lower In contrast to sensitivity, specificity of unexperienced novices was much better but still lower of HITs, Specific symptoms e.

However, does history of organ-related symptoms improve the sensitivity and specificity of organ-related bedside examination in depicting its mal function? The changes in confidence led to the correct diagnosis in vHIT in the majority However, the increased level of confidence did not help in pathological post-bHIT evaluations. The changes in polarity did overall not improve the correct evaluations of post-bHIT. However, they depended on the level of expertise since polarity changes of clinical experts revealed a greater proportion of correct post-bHIT.

However, this differed as a function of clinical neuro-otological experience in our clinical investigators.

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In our study, novice clinicians confirmed a pathological pre-bHIT much more often than the expert did. This led to the high incidence of false pathological findings in the unexperienced investigators. In turn, the expert changed a pathological pre-bHIT more often than the other groups and showed a higher rate of true pathological post-bHIT evaluations However, even the expert showed a significant number of false normal and pathological assignments in pathological vHIT.

Table 3. There are several approaches to analyze vestibular hypofunction. Procedural methods range from different time points e. Our four independent and blinded experienced HIT raters classified the inspection of traces of eye and head velocity as the most helpful sign in discriminating normal from pathological vHIT.

Clinicians and neuro-otologists are advised to look at the original eye and head velocity curves rather than at refixation saccades alone or the gain at a given latency after head movement onset or interval which is highly variable depending on the performance, i. The moderate sensitivity of bHIT has been shown to depend on the severity of unilateral vestibular failure and the magnitude of VOR asymmetries 5 , 7 : it increases with decreasing gain thresholds and larger VOR asymmetries.

This was not our primary objective in this study, but for better comparability we compared our results with a cut-off gain often chosen in related studies on vestibular hypofunction gain 0. There are two limitations of the study. First, this study investigated patients with chronic vertigo symptoms.

At present, it is unknown whether the results also hold for acute vestibular syndromes which inherently bear more risks of false evaluations both of bHIT and vHIT Second, the results are confined to bHIT of the horizontal canals. Since there is less adaptation in vertical canals sensitivity of bHIT of vertical canals might increase, in particular in bilateral vestibular failure. In conclusion, medical history of symptoms may lead to false diagnostic assumptions and may influence the clinical examination bHIT in false and correct directions. In all other conditions i.

CH contributed to conceptualization and study design, project administration, data acquisition, supervision, drafting, editing, and approving the final writing of the manuscript. PT contributed to data acquisition and reviewing the manuscript. JK and AF contributed to methodology, data acquisition, and reviewing of the manuscript. AS contributed to study design, methodology, statistical analysis, reviewing, and editing of the manuscript.

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The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. A clinical sign of canal paresis.

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Arch Neurol —9. The video head impulse test vHIT detects vertical semicircular canal dysfunction. PLoS One 8:e Evaluation of quantitative head impulse testing using search coils versus video-oculography in older individuals.

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Otol Neurotol —8. Covert anti-compensatory quick eye movements during head impulses. PLoS One 9:e Accuracy of the bedside head impulse test in detecting vestibular hypofunction. J Neurol Neurosurg Psychiatry —8. Value of the video head impulse test in assessing vestibular deficits following vestibular neuritis. Eur Arch Otorhinolaryngol —8.

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Comparison of the bedside head-impulse test with the video head-impulse test in a clinical practice setting: a prospective study of outpatients. Front Neurol A new method to improve the imbalance in chronic unilateral vestibular loss: the organization of refixation saccades. Acta Otolaryngol — Clinical and video-assisted examination of the vestibulo-ocular reflex: a comparative study.

Acta Otorrinolaringol Esp — Nervenarzt — Importance for routine diagnostics of patients with vertigo]. Straumann D. Bedside examination. Handb Clin Neurol — Hippocampal gray matter volume in bilateral vestibular failure. Hum Brain Mapp — Head impulse testing using video-oculography. Ann N Y Acad Sci —3.

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Altered resting-state functional connectivity in patients with chronic bilateral vestibular failure. Neuroimage Clin — Clinical diagnosis of bilateral vestibular loss: three simple bedside tests. Ther Adv Neurol Disord —5. EyeSeeCam: an eye movement-driven head camera for the examination of natural visual exploration.

Ann N Y Acad Sci —7.

The human horizontal vestibulo-ocular reflex in response to active and passive head impulses after unilateral vestibular deafferentation. Ann N Y Acad Sci — Quantifying the vestibulo-ocular reflex with video-oculography: nature and frequency of artifacts. Audiol Neurootol — The video head impulse test: diagnostic accuracy in peripheral vestibulopathy.

Neurology — The video head impulse test vHIT of semicircular canal function — age-dependent normative values of VOR gain in healthy subjects. Hayes AF, Krippendorff K. Answering the call for a standard reliability measure for coding data. Commun Methods Meas — Optimizing the sensitivity of the head thrust test for identifying vestibular hypofunction. Phys Ther —8. Head impulse test in unilateral vestibular loss: vestibulo-ocular reflex and catch-up saccades. The use, distribution or reproduction in other forums is permitted, provided the original author s or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice.

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Forgot Password? Suggest a Research Topic. Introduction The vestibulo-ocular reflex VOR stabilizes retinal images during head motion. Patients and Methods Participants We tested consecutive outpatients males, age range: 17—94; All Rights Reserved.