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The fixation suppression test can uncover vertical nystagmus of central origin in some patients with dizziness

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Abstract

Background

Identifying dangerous causes of dizziness is a challenging task for neurologists, as it requires interpretation of subtle bedside exam findings, which become even more subtle with time. Nystagmus can be instrumental in differentiating peripheral from central vestibular disorders. Conventional teaching is that peripheral vestibular nystagmus is accentuated by removal of visual fixation. We sought to systematically test the hypothesis that, in some cases, vertical nystagmus due to central vestibular disorders may also be easier to identify when fixation is removed.

Methods

To identify patients with vertical nystagmus, we retrospectively reviewed clinical, MRI, and VNG data of consecutive patients undergoing VNG in our vestibular clinic over a 9-month period. We analyzed clinical features, bedside neuro-otological examination, MRI results, and VNG findings in fixation as well as those with fixation removed.

Results

Two hundred and fourteen charts were reviewed. Twenty-six patients had vertical nystagmus with fixation removed on VNG. Only three (11.5%) of these patients had vertical nystagmus apparent with fixation (and only two had nystagmus observed clearly at the bedside with the unaided eye). Thirteen (50%) of the patients had posterior fossa lesions on MRI and eight of the rest (30.8%) were diagnosed with central vestibular disorders. Of the 13 patients with MRI-confirmed lesions, 3 patients (23.1%) had no neurological signs or conventional bedside oculomotor signs; in these cases, vertical nystagmus without fixation was the only sign of a central lesion.

Conclusions

Our findings go against conventional teaching and show that removing fixation can uncover subtle vertical nystagmus due to central vestibular disease, particularly from focal or chronic lesions.

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Data availability

Data are available from the corresponding author on reasonable request.

Code availability

Not applicable.

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Acknowledgements

We would like to thank the research team of Neurobit Technologies Co., Ltd (Chun-Chen Yang, Wei-Cheng Chen, and Chin-Hsun Huang) for hel** to collect and analyze the data.

Author information

Authors and Affiliations

  1. Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, Canada

    Anand K. Bery

  2. Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Hsinchu, Taiwan

    Ching-Fu Wang

  3. Neurobit Technologies Co., Ltd., Taipei, Taiwan

    Ching-Fu Wang

  4. Department of Neurology, Ophthalmology, Neurosurgery, Otolaryngology - Head & Neck Surgery, Emergency Medicine, and Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Daniel R. Gold

  5. Department of Neurology/Neuro-medical Scientific Center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, No.88, Sec. 1, Fengxing Rd., Tanzi Dist., Taichung, 427, Taiwan

    Tzu-Pu Chang

  6. Department of Neurology, School of Medicine, Tzu Chi University, Hualien, Taiwan

    Tzu-Pu Chang

Authors
  1. Anand K. Bery
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Contributions

A. K. B. contributed to analysis and interpretation of the data and drafting of the manuscript.

C. W. contributed to collection and analysis of the data.

D. R. G. contributed to interpretation of the data and revision of the manuscript.

T. C. contributed to collection, analysis, interpretation of the data, and drafting of the manuscript.

Corresponding author

Correspondence to Tzu-Pu Chang.

Ethics declarations

Ethics approval

This study was approved by the Institutional Review Board of the Research Ethics Committee of Taichung Tzu Chi Hospital (REC109-64) and performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.

Consent to participate

Not applicable (anonymized retrospective study).

Consent for publication

The authors are responsible for correctness of the statements provided in the manuscript.

Conflict of interest

Ching-Fu Wang is a shareholder of Neurobit Technologies, which is a Taiwanese multinational corporation that designs and manufactures comprehensive neuro-otological diagnostic system for better patient care.

Other authors declare no competing interests.

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Bery, A.K., Wang, CF., Gold, D.R. et al. The fixation suppression test can uncover vertical nystagmus of central origin in some patients with dizziness. Neurol Sci 42, 5343–5352 (2021). https://doi.org/10.1007/s10072-021-05676-3

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  • DOI: https://doi.org/10.1007/s10072-021-05676-3

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