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    Vestibular-Evoked Myogenic Potentials (VEMPs) Devin L. McCaslin and Gary P. Jacobson HISTORY AND SIGNIFICANCE OF THE ‘VESTIBULAR-EVOKED MYOGENIC POTENTIALS (VEMPS) Itis now well known that the vestibular system can be stimulated using sound. In 1929, Pietro Tullio ini- tiated the original investigations demonstrating the vestibular system's sensitivity to auditory stimuli Tullio’s experiments consisted of fenestrating the bony labyrinth of pigeons, subjecting them to sound produced by a flute, and observing the motion of the labyrinthine fluids (the frequency of the notes produced by the flute matched the frequency of the ‘movement of the endolymph) and eye movements. From these experiments Tullio was able to determine that the vestibular system could be stimulated using sound (Tullio, 1929). Von Békésy (1935) built on the findings of Tullio and observed that when human subjects were exposed to a high-intensity stimulus (122 to 134 dB SPL) there was a corresponding head displacement toward the stimulated ear. Von Békésy argued that :his reflexive movement of the head in to an auditory stimulus was likely due to ‘movement cf the endolymph stimulating the ves- tibular system. In the mid-1960s, Bickford, Jacobson, and Cody. (1964) reported the presence of a sound-evoked electrical potential (negative waveform peaking at ‘approximately 30 ms) that could be recorded from an active electrode placed on the inion. Initially this response was believed to be “neurogenic.” However, the investigators demonstrated that the earlier com- ponents of the response were significantly reduced in amplitude following administration of a muscle paralyzing agent. Additionally, it was noted that the response grew in amplitude with increases in the tonic level of electromyography (EMG) in the neck extensors. This evoked-potential response was sub- sequently named the inion potential. Further stud- ies by this group of investigators led to the theory that the vestibular system (Le., the saccule) was the peripheral origin of the inion potential (Cody, Jacob- son, Walker, & Bickford, 1964; Townsend & Cody, 1971), Finding no good clinical applica:ion for these responses, they were abandoned for almost 30 years. ‘Then, in 1992 when Colebatch and Halmagyi report- ed the presence of another short-latency large ampli- tude myogenic potential recorded in response to a loud click with an electrode (noninverting) placed over the belly of a contracted sternocieidomastoid ‘muscle (SCM). This response was characterized by a positive wave (P1) followed by a negative wave (N1) occurring ipsilateral to the ear that received the stimulus (Colebatch & Halmagyi, 1992; Colebatch, Halmagyi, & Skuse, 1994). Compelling evidence suggesting a vestibular origin was derived from studies showing that the response could be recorded inpatients who were completely deaf, yethad intact vestibular function (Colebatch & Hamagyi, 1992; ‘534 BALANCE FUNCTION ASSESSMENT AND MANAGEMENT, Colebatch et al, 1994). As with the inion poten- tial, this sonomotor response represented a sound- ‘evoked attenuation of tonic EMG activity in the SCM (Bickford et al., 1964; Colebatch & Halmagyi, 1992) thas been suggested that the sound-synchronized decrease n the tonic level of EMG that occurs during the response is interpreted by the central nervous system asa sudden loss in postural tone. The reflex- ive response from the vestibular system to compen- sate for this perceived decrease in muscle activity is to increase extensor muscle tone and decrease flexor ‘muscle tone (Carey & Amin, 2006). Therefore, ampli- ‘tude of tis inhibitory muscle response represents an interaction between the level of tonic EMG and the size of the inhibitory postsynaptic potential (IPSP) initiated at the end organ (Colebatch & Rothwell, 2004) (Figure 21-1). Colebatch and Halmagyi (1992) referred to this response as a vestibular-eooked myo- _genic potential (VEMP). In this case the response was recorded from the SCM and is now referred to as the cervical VEMP (CVEMP). ‘The cVEMP that is recorded using an evoked- potential system is the measurable output from the Surface EMG pts. Single Unit “50 0 25 50 effector organ (SCM) of the activated vestibulo- colic reflex (VCR) (Colebatch & Halmagyi, 1992; Colebatch et al, 1994). The VCR is an involuntary ‘muscle contraction that occurs when stimuli are introduced that are capable of translating the oto- lith organs. The corresponding changes inthe tonic background EMG level in the neck extensors that are observed during head movements represent a vestibular-driven muscle coordination in the neck used to stabilize the head (Lysakowski, McCrea, & Tomlinson, 1998). The afferent and efferent limbs of the VCR have been described by several groups and. are considered to represent the pathway forthe clini- cal response we know as the cVEMP. ‘There have been many sound-evoked, signal- averaged muscle responses described ir the litera ture, and they may represent either sound-evoked onsets or offsets of EMG activity. Examples of sound-evoked EMG onset responses (or sonomotor responses) are the stapedial reflex, the pestauricular muscle potential (PAM) and the ocular vestibular- evoked myogenic potential (VEMP), that are dis- cussed later. Examples of sound-evoked attenuation 123 135, 20 pad 0 75ms Figure 21-1. Surface and snle motor unl (hitomuscuarsterocel domostold muscle) ecorcings smuttaneo.sy recordedinresporso to Cclekstimul The inl response « decrease in single unit activity ond is represented by “" From Colebatch, J.G., and Rothwell. R, 2000. Motor unit excitabiity changes mecicing vestbuiocalc reflexes the steznocleidemastold muscle, Clinical Neurophysiology, 115011, 2561-2573, Used wit permison fom the Intemational Federation of Cinical Neurophysiology. of existing EMG activity include the inion potential, the acoustic jaw reflex, and the cervical vestibular- evoked myogenic potential (CVEMP) that are dis- ‘cussed in this chapter. It is our objective to describe ‘the anatomy and physiology underlying the cVEMP. and oVEMP. Additionally, we describe how each of these responses are recorded and measured, and how normal and abnormal responses appear. A discussion of the common patterns of abnormalit and the diagnostic significance of these pattems is addressed in Chapter 24. CLINICAL PHYSIOLOGY OF THE ‘SACCULE AND UTRICLE ‘The macula utriculi and sacculi are one of the two types of sensory epithelia in the vestibular system (the other is the semicircular canals). The macula of the saccule and utricle have a specialized sensory epithelium that enables them to sense linear accel- eration. The otoliths are positioned in the otic cap- sule in such ¢ way that they respond to movements in the horizontal and vertical planes. Calcium car- Donate crystals with a specific gravity of 2.71 g/mL, are embedded in a gelatinous matrix known as the otolithic membrane (Gacek, 1982). The two primary ‘components of the otolithic membrane are the mass (ie, otoconia} and the neurosensory cells (Type and ‘Type I). The macula has an elastic connection to the skull, making the system sensitive to acceleration and gravitational forces during head movement. The saccile is located in the vestibule directly ‘beneath the stapes in the sagittal plane. This proxim- ity to the middle ear space makes the saccule sensi- tive to high-intensity air-conducted stimuli (ACS). In fact, in several animal species the saccule acts as a hearing receptor (Popper & Fay, 1973). However, the functional significance of the ability to stimu- late the sacctle acoustically is still not completely understood. Convincing physiologic evidence from animal ‘studies investigating the origin of the CVEMP now implicates the saccule as the primary end-organ generator of the response (Colebatch and Halma- gyi, 1992; Colebatch et al., 1994; Curthoys, 2010). In 1999, Kushiro, Zakir, Ogawa, Sato, and Uchino published a report describing the neural connee- \VESTIBULAR-EVOKED MYOGENIC POTENTIALS (VEMPS) 535. tions between the saccule and-the SCM in cats. Using electrical stimulation, the authors showed that when the vestibular afferents originating at the saccule were stimulated, an inhibitory postsyn- aptic potential (IPSP) in the ipsilateral SCM motor neurons was initiated. Following transection of the ‘medial vestibulo-spinal tract (MVST) in the brain- stem at the level ofthe obex, electrical stimulation of the saccular nerve failed to generate IPSPs that were present prior to the surgery. This classic series of animal studies laid the groundwork for understand- ing the functional significance of the sacculocollic reflex pathway. The orientation of the utricle is not quite hori- zontal, but rather tilted down and back approxi- ‘mately 25 030 degrees (Schwarz & Tomlinson, 2005). The structure of the utricleis identical to that of the saccule with two notable exceptions. First, the utri- cle is two times larger than the saccule (Rosenhall, 1973; Wright, Hubbard, & Clark, 1979). Adiitionally, the utricle is not affixed to the temporal tone in its entirety (Jaeger & Haslwanter, 2004; Uzun-Coruhlu, Curthoys, & Jones, 2007). These differences in size and stiffness would be expected to effect differences in the tuning characteristics of the utricle and sac- cule. As observed for the saccule, the utricie consists of an otolith membrane whose porous characteris tics enable otolith crystals to remain in place acting as a mass. Stereocilia and kinocilia project from the sensory cells and supporting cells up into the otolith. membrane. In effect, Newton's first law of motion which states “an object either remains at rest ot con- tinues to move at a constant velocity, urless acted upon by an external force.” As such, linear, tangen- tial, or centrifugal acceleration in the leteral (i.e, left to right, or right to left) and vertical planes (i.e, anterior /posterior planes) causes the otolth mass to lag behind the movement of the head. This results in shearing of the kinocilia and neural transduction. Like the saccule and unlike the semicirctlar canals, the utricleis polarized in sucha way that each utricle is capable of responding to linear horizcntal accel- eration and deceleration. This provides a degree of redundancy should disease result in the loss of one utricle, Studies of the neural response properties of ofo- lith projections have also been investigated. Muro- fushi et al, (1995) recorded extracellular responses from single neurons in the vestibular nerves in ‘596 BALANCE FUNCTION ASSESSMENT AND MANAGEMENT. guinea pigs in an effort to show that primary ves- {ibular neurons were capable of being activated by airconducted stimuli. When stimulated using sound, vestibular afferents projecting from the oto. lith organs were shown to manifesta variety of tonic resting discharge rates based on the type of hair cell they originated from (i.e,, Type I or Type Il). Ves- tibular afferents projecting from Type I hair cells demonstrated irregular firing rates while those that synapsed on Type If hair cells typically produced a ‘more regular firing rate (Gresty & Lempert, 2001; Minor & Goldberg, 1991). It is now known that the ‘majority of projections sent from the saccule’s mac- ula demonstrate irregular firing rates and are highly sensitive to air-conducted stimuli (Curthoys, Kim, McPhedran, & Camp, 2006; Murofushi & Curthoys, 1997) (Figure 21-2). The fact that the saccule, utricle, and cochlea are in close proximity to one another led to an entire line of research showing that the early components, of the VEMP response were largely independent of auditory function. Many of the early investigations involved studying patients with specific impair- ‘ments in the vestibular and auditory system. For example, the cVEMP was abolished in patients who +had undergone a vestibular nerve section (i, infe- riot vestibular nerve) yet had normal auditory func- tion (Brantberg & Mathiesen, 2004). Conversely, the asym- ‘metry when a single EMG target was employed. In some instances, amplitude normalization ccnverted Figure 21. ‘Aner Amplitude Normalization Example of ¢ subject with cxymmetrical EMG during the cVEMP recording and whose hnteraural ‘asymmetry vclue was transformed by amplitude normalization. an “abnormal” cVEMP into a “normal” cVEMP although the opposite effect occurred as well, sug- gesting thatthe amplitude normalization teluiqure ‘was valuable in a subset of patients in their sample ‘but not enough to reach statistical significance. In a follow-up study designed to further investigate the effectiveress of amplitude normalization on asym- ‘metrical EMG, the investigators recorded cVEMPs ‘while having patients maintain four different levels, of EMG (ie., 100, 200, 300, and 400 HV) amplitude for each ear. This method enabled the investigators tocompare cVEMP responses obtained with varying levels of background EMG and evaluate the effec- tiveness of amplitude normalization. For each ear jin each condition the P1 to N1 IAA ratios were cal- culated. As was expected, when responses obtained using dramatically different EMG target levels were ‘compared (e.g,, 100 pV target versus 400 pV target), large were noted (Figure 21-19). Fol- Towing the application of amplitude normalization, ‘cVEMP amplitude did not change significantly with ‘changes in RMS EMG or EMG target levels for any condition (see Table 21-2). This study confirmed the benefits of using amplitude normalization and also ‘helped determine the degree of tonic EMG asymime- _try that is required in order to generate an abnormal amplitude asymmetry result in normal subjects, ‘One fact that has come to light recently is that the relationship between EMG amplitude and P1~ NI amplitude is not entirely linear. Thet is, the input-output growth function for €VEMP peak to-peak amplitude has been shown to saturate at supramaximal SCM contraction levels (Bozle et al., 2013, McCaslin et al., 2014). The point where fur- ther increases in background SCM EMG do not ‘yield corresponding increases in PI-N1 amplitude is important to know when amplitude normaliza- tion techniques are being applied to responses. The ‘underlying assumption thats used when enploying. amplitude normalization is that EMG level and peak- to-peak amplitude of the cVEMP are linearly corre- lated. However, McCaslin et al. 2014) reported that ‘when increasing the EMG target level from 300 nV to 400 ji, there continue to be significent differ- ences in tonic SCM EMG amplitude with no observ- able differences in cVEMP peak-to-peak amplitude. Although amplitude normalization techniques have been shown to be highly effective at control- ling for moderate levels of EMG, collecting cVEMP responses at supramaximal levels and tien using ‘amplitude correction may produce invalid responses and lead to misinterpretation. We suggested that itis, safe to use an EMG target that is between50 pV and 300 pV RMS (McCaslin, Fowler, & Jacobson, 2014). ‘Asummary of cVEMP recording parame:ers is pre- sented in Table 21-3. Interaural Amplitude Asymmetry (Grror bars: +/-250) Figure 21-19, Effect of amaltude correction on cVEMP interaural ampitude ‘symmetry with varying degrees of EMG ampitude osymmety. Folowing ‘empltude corection, mean group ompitude asymmetry date for ail cond ‘fons did not exceed 18%, From McCasin, . L Fowles A., and Jacobson, G. P2014), Ampiude normalization reduces cervical vestioulor evoked myo- ‘genic potential (CVEMP) ampltude asymmetie in normal supjects: Proof of Concept, Journal of he American Academy of Audiology. 25(8), 268-277. {404 10.3766/)000.25.36, Used with permission. Table 21-3. cVEMP Recording Protocol Invering electiode (reference) Stemociavicur junction Noninvettng electrode (active) Midpoint or upper third of SCM mastoid muscle Ground (Earth) cere tsra ss fops) Electrode Impeconces +1000 ohms Channels ‘Two channels (eft ond right scm) “Ampiication (gain) 5000 Astfect rejection Disabled Fiter bondposs 1010 1000 He Epoch 100ms Number of cccepted samples 10040 200 Number of completed Two minimum to ensure averages repeatobilty fat sace FUNCTION ASSESSMENT AND MANAGEMENT Effect of Age on cVEMP Measurement Parameters Beginning early on in the lifespan, there are signifi cant maturational changes that occur in the periph- eral and central vestibular systems. Therefore, it is cctitically important to account for these age-related ifferences in laboratory normative data when judg- ments are being made as to whether a response is normal or abnormal. Numerous studies have been Published describing the age-related changes in cVEMP measurement parameters. To date, the ‘majority of CVEMP studies have focused on deserb- ing the degenerative changes that occur, as patients ‘grow older. A few of the findings that are consis- tently reported are an overall decrease in peak-to- peak cVEMP amplitude, decreased EMG amplitude, and higher thresholds (Akin etal, 2011; Lee, Cha, cet al, 2008; McCaslin etal, 2013; Su, Huang, Young, & Cheng, 2004; Welgampola & Colebatch, 2001b; ‘Zapala é Brey, 2004). An additional finding thathas ‘been resorted is the high percentage of bilaterally absent :VEMP responses in some patient popula- tions. In fact, it has been reported that up to 4U‘% of neurologically and otologically intact people between. 60 and 75 years of age do not generate a cVEMP (Su et al., 2004). This inability to record CVEMPs has also been reported in very young subjects. For example, Chen, Wang, Wang, Fisieh, and Young (2007) reported that cVEMPs recorded irom new- ‘bors were absent in 33% of the ears evaluated. This most likely occurred because unlike adults, infants are unable to follow the commands that are neces- sary to activate the SCM. Even though both of these studies highlight findings from the extreme ends of the aging continuum, it is important to remember that an absent cVEMP response may rot simply be due to pathology affecting the peripheral com- ponents of the system (ie., saccule and/or inferior vestibular nerve). Rather, the absence of recordable cVEMP responses may represent impairment occur- ring anywhere along the cVEMP pathway. In an attempt to describe the effects of age on ‘ eFerent limb, or both limbs of the reflex. One proach that has been used to answer this question is to use a standard EMG target and then teas Doth the tonic activity ofthe i activity of the SCM EMG and PI-NI amplitude in subjects of different ages (Akin et al, 2011; McCaslin etal, 2013). Using this methodology, ‘McCaslin and colleagues (2013) reported decreased ‘SCM EMG amplitude with increasing age across the three age groups when a similar EMG target level was used. The investigators designed the study to determine whether the significantly increased peak-to-peak amplitudes observed in the younger ‘groups were a direct effect ofthe tonic EMG that was recorded during the cVEMP recording The results, infact showed that there were significant dlferences in SCM RMS tonic EMG activity between the pediat- ric and older adult groups, and between the young adult and older adult groups. Tat is, even when the visual target (ie. 50 uV) was provided tothe patient, level of EMG varied with age. Intrestingly there ‘was mo difference in EMG activity recorded from the pediatric and young adults suggesting thatthe SCM tonic activity is largely equivalent in the two ‘groups. The finding that there isa difference in the SCM EMG between younger and older populations ‘using the same target has also been reported by Akin et al, (2011). The authors reported that when older and younger groups were compared using a simi- Jar ENG target, EMG amplitude was significantly ‘smaller for the older group. The results of these two studies support the idea that the smaller cVEMP amplitudes noted throughout the literature are most likely a function of age-related changes in both the ‘SCM end vestibular system. ‘Age Effects of cVEMP Tuning ‘The frequency “tuning” of the otolith system has bbeen the subject of a number of recent investiga- tions, In healthy subjects, when VEMP responses are elicited with different frequency acoustic sig- nals, ome stimuli elicit larger aenplitude VEMPs than others Chikara et al, 280, MeCue& Guinan, 1995; Piker et al, 2013; Rauch, Zhou, Kyjawa, Gui- nan, & Herrmann, 2004; Todd, Rosengren, Goven- der, & Colebatch, 2009; Welgampola & Colebatch, 20012). In the majority of studies, itis a stimulus frequency close to 500 Hz that produces the largest ‘VEMP amplitude and lowest VEMP threshcld (Akin et al, 2003; Murofushi et al, 1999; Timmer et a, 2006). It is precisely for this reason that ¢ 500-Ez, tone-burst has been selected as the stimulus of choice in most clinics. However, there is speculation that age-related changes in the vestibula: system may change the “best” frequency. As such, stud~ ies have been conducted evaluating how the tun- ing ofthe vestibular system changes as we age. In 2008, Janky and Shepard described the age-related changes in the tuning ofthe vestibular system using. CVEMPs. Subjects enrolled in the study consisted of five age categories spanning 20 to 60+ years of age. The investigators used clicks, 50-, 51-, 750-, and 1000-Hz tone-bursts and reported on changes in cVEMP response amplitude, threshold, and latency. There were no differences detected between eas for any ofthe metrics tested, but significant d ferences ‘were identified for latency and thresholc. cVEMP threshold was reported to be positively correlated with age (Le, thresholds increased with increasing, age). However, peak-to-peak amplitude was shown, tobe negatively correlated with age (ie. F13 ampli- tude decreased with increasing age). The lowest threshold responses were obtained using te 500-Hz stimuli and, as mentioned previously the presence ‘of measurable responses were found to decrease ‘with increasing age. These findings prompted the authors to conclude that age should always be con- sidered when interpreting ¢VEMP thresholds. This has important implications for the identification of disorders that manifest themselves w:th signifi cantly low cVEMP thresholds (eg, superior canal dehiscence). In a similar study, Piker, Jacobson, Burkard, McCaslin, and Hood (2013), characterize the effects ‘of age on the optimal frequency, or frequencies, used. to record the cVEMP. Thirty-nine study participants were divided into three groups based on age (1, 18 t0 39 years, 40 to 59 years, >60 years of age). AS had been shown in previous studies, the vestibular system in all three age groups showed broad tun- ing unlike the auditory system that is finely tuned. igators reported that stimulus f Fea equenis icantly larger 1500-, and 200s et, No significant dif B65 in mean amplitude were observed: sisted #0, and 1000 Hz. In the youngest group of 3 the “best” frequency was 750 Hz (ie, the f the tuning curve), while in the oldest group fbest” frequency was 1000 Hz (Figure 21-22), @s the author's contention that these findings Bsentecl evidence of age-related tuning shifts in fibular system. That is, the “best” frequency {to a higher frequency for the oldest group. {cal utility of this finding is that 500 Hz may sys be the ideal frequency to elicit a cCVEMP, ly when age is considered. When assessing ‘who are older, 750- or 1000-Hz tone-burst ay yield better responses. Band 1000 Hz. produced s Rides than 125., 250., frequencies. Howev onally, the analysis of cVEMP responses con- Efour key measures: interaural latency dif- ‘asymmetry ratio (AR). The data presented Mean PLNLAmpltede (4) Bacrese ee 125250500 -100 VESTBULAR-EVOKED MYOGENIC POTENTIALS (VEMPS) 885 in this chapter represent normative data from sev- eral different laboratories, Each clinical site should have its own age- and gender-adjusted normative data with upper and lower limits (eg, 2.5 standard deviations). It has been recently recommended that ‘normative data should be collected using recordings from at least 10 healthy subjects from each decade of life (Papathanasiou et al., 2014). Investigators have evaluated the use of absolute amplitude of P1-N1 response, but the large degree of interindividual variability has limited the clinical utility of absolute amplitude measures (Li, Houl- den, & Tomlinson, 1999). In order to control for the {ntersubject variability in the amplitude of cVEMP responses, side-to-side differences can be expressed. as percent asymmetry (Welgampola & Colebatch, 2001a). This is a similar approach tc how caloric responses are analyzed using the Jongkees formula Gongkees, 1964). The VEMP asymmetry ratio is determined by the following equation. (Amplitude right €VEMP ~ Amplitude eft €VEMP) (Amplitude right cVEMP + Amplitude left cVEMP) x100 ‘Table 21-4 shows our laboratory upper limits of percent cVEMP asymmetry (mean + 2 SD) by age in healthy subjects. When the cVEMP asymme- ‘uy exceeds the upper limit for the appropriate age —eroung ada eMidale age Row Ade 750 1000 5c 2000 Frequency (2) Figure 21-22. The peaicto-peak amplitude of the cVEMP os a func- tion of stimulus frequency for diferent age groups. From Pier E.G Jacobson, 6. P, Burkard, RF, MeCasin, D. Lond Hood, L J. (2013). Effects of age on the tuning of the cVEMP and oVEMP. Ear and Hear- ing, 346), 65-73, Used with permission. N ASSESSMENT AND MANAGEMENT 21-4. CVEMP interaural | oer 1 Amplitude Asymmetry S) Asymmetry % Mean +2SD 1287 33.75 1672 42.84 20.72 87.86 group, we consider the examination to be abnormal. ‘The weaker side (1e,, side with the smaller response) is typically considered the impaired side but not in all cases (eg., superior canal dehiscence). Interaural asymmetry measures can also be calculated follow- ing a correction for the EMG level (McCaslin et al, 2014; Miyamoto, Seo, Node, Hashimoto, & Saka- ‘gami, 2006; Welgampola & Colebatch, 20012). Side- to-side amplitude differences in healthy subjects have typically been reported to be in the range of 20% to~45% depending on the technique used (eg, ‘monoraural or binaural stimulation) and whether or ‘not EMG amplitude correction was used (Brantberg & Franson, 2001; Li et al., 1999; McCaslin et al, 2013; Welgampola & Colebatch, 20012; Zapala & Brey, 2004). Latency Peak latency has also been used to identify pathol- ogy in the cVEMP pathway. Investigators have reported on the diagnostic usefulness of signifi- ‘cantly prolonged cVEMP responses (Murofushi, Shimizu, Takegoshi, & Cheng, 2001; Shimizu, Muro- fushi, Sakurai, & Halmagyi, 2000). In a retrospective study, cVEMP latencies were measured in 134 (61 ren and 73 women) patients with a variety of dis- ‘orders. The diagnoses included vestibular neuritis (VN), Meniere's disease (MD), vestibular schwan- ‘noma (VS), and multiple sclerosis (MS). The results of latency were varied depending on the disorder. Specifcaly, there was very little change in latency for patients suffering from Méniére’s disease or ‘vestibular neuritis. Only four patients with acous- ‘ic neuromas showed a significantly prolonged PI. Interestingly, all ofthe patients diagnosed with MS significantly late P1 responses. It was the contention of the authors based on these find- ‘ngs that prolonged cVEMP latencies are suggestive of retrolabyrinthine impairments localized to the vestibulospinal tract. Findings from studies such as these have led to the recommendation that the latency of PI and N1 be reported. Prolonged later cies can be suggestive of retolabyrinthine or central impairments. Threshold CVEMP thresholds are also an important measure ment parameter when interpreting, the response, and can add greatly to the differential diagnosis. ‘The cVEMP threshold is the lowest level that a

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