HIT

Flgo. Mg.
vHIT Cristian Barraza
VEMPs
Interpretación de la prueba de
impulso cefálico (HIT/v-HIT).

Utilidad de los Potenciales Evocados

Miogénicos Vestibulares (VEMP).
32 2 Anatomy and Physiology of the Auditory System

Malleus
Ossicular
chain Incus
Stapes
Semicircular canals Vestibular
Attic nerve
Statoacoustic
(VIIth) cranial
nerve
Auditory
nerve

Pinna Ear
canal Cochlea
entrance Middle Vestibule
ear
Tympanic Eustachian tube
space
membrane
Footplate at
oval window
Round
External auditory meatus window
(ear canal)

Fig. 2.3 The major parts of the peripheral ear.

1. Gelfand S. Anatomy and Physiology of the Auditory System. In: Essentials of Audiology. 4th ed. New York: Thieme.; 2016. p. 30-69.
 Prueba
calórica

Pendientes
Tusa, R. en Herdman, S. (2007).
 head impulse to the left
Head movement
to left

Compensatory eye
movement to right

§ Test de Impulso Cefálico (Halmagyi y Eye muscles

Curthoys, 1988). +
Oculomotor nucleus
+ -
§ También llamado “Head Thrust Test”.
- - + +
Abducens nucleus
§ Evalúa VOR (Reflejo Vestíbulo-Ocular) en
cada oído, con estímulos a alta frecuencia II II

(velocidad) à movimientos cotidianos. - +

Vestibular nucleus
+ -
I I
§ Sirve para evidenciar déficit vestibular
unilateral o bilateral, incluso si está Primary afferents + -
compensado.
Horizontal
semicircular
canal
§ Evalúa sólo CSC laterales à Rama Midline
superior del nervio vestibular. Left Right

Figure 16–B–1. Some of the neural mechanisms by which a head turn generates a
1. Curthoys I, MacDougall H, McGarvie L, Weber K, Szmulewics D, Manzari L, Burgess A and Halmagyi M. The Video Head Impulse Test (vHIT). In Jacobson G
pensatory eye movement response. The neural connections in the brainstem which
and Shepard N, editors. Balance Function assessment and management. 2a ed. San Diego: Plural Publishing; 2016. p. 391-430.
been extensively documented by physiological studies (references in Curthoys,
 (a) 20°

154 Clinical Neurophysiology of the Vestibular System

20°
https://www.youtube.com/watch?v=rr-MFxDcwWs
(a)
https://www.youtube.com/watch?v=Wh2ojfgbC3I

Line of Eyes remain

sight fixed on target
Line of Eyes remain
Fixed sight fixed on target
target
Fixed
target

(b) 20°
(b) 20°

Line of Line of sight Quick saccade

Line of Line of sight Quick saccade
sight moves back to target
sight moves back to target
with head
Fixed
with head movement
Fixed targetmovement
target
Figure 6–3. The head thrust test. The head thrust test is a test of vestibular function that can be easily done during the
Figure 6–3. The head thrust bedside
test.examination.
The head This thrustmaneuver
test is atests
testthe
of vestibulo-ocular reflexthat
vestibular function (VOR).
canThebe patient sits in during
easily done front of the
the examiner and
the examiner holds the patient’s head steady in the midline. The patient is instructed to maintain gaze on the nose of the
bedside examination. This maneuver tests the vestibulo-ocular reflex (VOR). The patient sits in front of the examiner and
the 1. Baloh R,theKerber K.toClinical Neurophisiology of theto Vestibular
examiner. The examiner then quickly turns the patients head about 10-15 degrees to one side and observes the ability of
examiner holds patient’s head
the patient steady
keep theineyes
the locked
midline. Theexaminer’s
on the patient isnose.
instructed maintain
If the patient’s gaze
eyes stay on the
locked nose
on the of the nose (i.e., no
examiner’s
System.
examiner. 4ª ed.then
The examiner Newquickly
corrective York:
saccade) Oxford;
turns (picture
the patients
a), then 2011.
head
the about 10-15
peripheral degreessystem
vestibular to oneisside and observes
assumed the. If,
to be intact ability of the patient’s
however,
the patient to keep the eyes locked
eyes moveon the
with theexaminer’s
head (picture nose. If the
b) and thenpatient’s eyes
the patient staya locked
makes voluntaryoneye
themovement
examiner’s backnose (i.e.,
to the no
examiner’s nose (i.e.,
a), then saccade),
corrective saccade) (picturecorrective the peripheral
then thisvestibular
indicates asystem
lesion ofis the
assumed to bevestibular
peripheral intact. If,system
however, andthe notpatient’s
the central nervous
system.bThus,
eyes move with the head (picture ) andwhen
thenathe patient presents
patient makes with the acute vestibular
a voluntary syndrome,
eye movement backthetotest
theresult shown innose
examiner’s picture A would suggest
(i.e.,
a CNS
corrective saccade), then this lesion (because
indicates a lesion the VOR
of the is intact), whereasvestibular
peripheral the test result in picture
system andB notwould thesuggest a peripheral
central nervous vestibular lesion
system. Thus, when a patient(because
presentsthe VOR
withisthenotacute
intact).
vestibular syndrome, the test result shown in picture A would suggest
a CNS lesion (because theWithVORpermission
is intact),from:
whereasEdlow JA, Newman-Toker DE, Savitz SI. Lancet Neurology. 2008; 7:951–964.
the test result in picture B would suggest a peripheral vestibular lesion
 Importante: sujeto no debe
presentar lesión cervical.

§ Sujeto sentado (idealmente) o de pie; examinador al frente.

§ Se inclina cabeza del sujeto 30º hacia abajo.

§ Sujeto mantiene la vista fija en un punto (nariz del evaluador).

§ Primero se mueve lentamente cabeza hacia los lados (descartando o

evitando rigidez cervical).

§ Se realizan movimientos rápidos y cortos hacia los lados, al azar. No mayor

a 20º o 30º de desplazamiento.
https://www.youtube.com/watch?v=rr-MFxDcwWs
https://www.youtube.com/watch?v=Wh2ojfgbC3I
§ (-)
= Normal. Ojos permanecen estables, mirando punto fijo…
(latencia real 7-10 mseg… imperceptible).

§ (+) =
§ Déficit unilateral. Ojos siguen el movimiento de cabeza y luego corrige
(movimiento sacádico) hacia mirada central. Sólo hacia un lado.

§ Déficit bilateral. Se observan sacadas correctivas en ambas direcciones.

 https://www.youtube.com/watch?v=My5uys6PodQ

Planos:

Right Anterior Left Anterior

Left Posterior Descargar app: aVOR (IOS) Right Posterior
§ Lentes de vHIT.
§ Cámara de alta velocidad.
§ 250 cuadros/seg.

§ Manos del evaluador.

§ PC con software.
 404 BALANCE FUNCTION ASSESSMENT AND MANAGEMENT

404 BALANCE FUNCTION ASSESSMENT AND MANAGEMENT

§ Evaluador se ubica detrás del usuario, de pie.

§ Toma con ambas manos la cabeza del usuario.

§ Sin tocar lentes ni banda elástica de ajuste. Figure 16–9. For testing horizontal head impulses, the operator’s hands
head, well away from the glasses straps and by pushing down slightly
deliver the small head abrupt head “turn and stop” with minimum of gl

Figure 16–9. For testing horizontal head impulses, the operator’s hands are placed on the vertex of the patient’s
§ El evaluador le da al usuario un giro de cabeza de un pequeño ángulo, de manera
head, well away from the glasses straps and by pushing down slightly on the patient’s head, the operator can
table,
deliver the small head abrupt head “turn and stop” withsominimum
the operator can slip.
of glasses deliver the stimulus and
inesperada y abrupta. see the screen. In the ICS Impulse system, every
§ El inicio y término del movimiento debe ser abrupto. acceptable head impulse is displayed and stored on
theand
table, so the operator can deliver the stimulus screen so the operator can see if it is acceptable
§ Se recomienda comenzar desde el centro hacia algún lado
see the screen. In the ICS Impulse system, or what
every impredecible.
à they are doing wrong.
§ Se mide este estímulo pasivo
acceptable(involuntario) de movimiento
head impulse is displayed and stored onde la cabeza y la respuesta del
movimiento ocular. the screen so the operator can see if it is acceptable
or what they are doing wrong. The Image

To getM.accurate
1. Curthoys I, MacDougall H, McGarvie L, Weber K, Szmulewics D, Manzari L, Burgess A and Halmagyi The Videomeasures
Head Impulseof Test
the (vHIT).
pupil In
during theG
Jacobson
and ShepardThe Image
N, editors. head movement,
Balance Function assessment and management. the camera
2a ed. San Diego: must be stationary
Plural Publishing; with
2016. p. 391-430.
respect to the head during the whole head move-
 tral fixation point, so the eye is shifted to theviewed
left in from
the the fixation
other handpoint.
is on For
toptesting
of the the vertical
patient’s headcanals,
(Fig-the person’s hea
the orbit. A head pitch forward, toward the target, ure 16–16). Be careful that the fingers of the hand movement in th
is turned as shown and the movement of the head is a pitch
activates the left anterior canal, and a headplane pitchof the named canals as represented by the vertical arrows. For testing ho
under the chin do not wrap around and push the
zontal canals, the movement is in the plane of the horizontal canals as shown. The
back away from the target activates the right pos- patient’s
images are modified cheek since
from the that
free will lead iPhone
educational to movement of “aVOR,” dev
or iPad app
terior canal. To test the right anterior-left posterior the glasses. Both hands should be well away from
oped by Hamish MacDougall and available on iTunes. Reproduced with permissi
(RALP) pair of canals, the patient is rotated of soWolters
the the glasses
Kluwer Health and theH.strap.
from G. MacDougall, L. A. McGarvie, G. M. Halmagyi, I
Curthoys, and K. P. Weber, 2013, Application of the video head impulse test to dete
vertical semicircular canal dysfunction, Otology and Neurotology, 34(6), 974–979
Figure 16–15. The head movements for LARP (left anterior-right posterior) and RALP
RALP LATERAL LARP
(right anterior-left posterior) and lateral semicircular canal stimulation (arrows), as
viewed from the fixation point. For testing the vertical canals, the person’s head
is turned as shown and the movement of the head is a pitch movement in the
plane of the named canals as represented by the vertical arrows. For testing hori-
zontal canals, the movement is in the plane of the horizontal canals as shown. These

§ Mirar el objeto al frente.

images are modified from the free educational iPhone or iPad app “aVOR,” devel-
oped by Hamish MacDougall and available on iTunes. Reproduced with permission
of Wolters Kluwer Health from H. G. MacDougall, L. A. McGarvie, G. M. Halmagyi, I. S.
Curthoys, and K. P. Weber, 2013, Application of the video head impulse test to detect
§ Reajustar ubicación de la pupila en pantalla. vertical semicircular canal dysfunction, Otology and Neurotology, 34(6), 974–979.
Figure 16–15. The head movements for LARP (left anterior-right posterior) and RALP

§ Ubicación de las manos:

§ Siempre alejadas de lentes y banda elástica.
a) Una en el mentón y otra en la cabeza (imagen).
b) Ambas por sobre la cabeza.
§ Realizar impulsos hacia adelante y hacia atrás.
§ En la dirección del punto de fijación visual.Figure 16–16. The positions of the hands for testing the vertical canals. One hand is placed under the chin and
(right anterior-left posterior) and lateral semicircular canal stimulation (arrows), as
viewed from the fixation point. For testing the vertical canals, the person’s head
Figure 16–16. The positions of the hands for testing the vertical canals. One hand is placed un
is turned as shown and the movement of the head is a pitch movement in the
the other hand on top of the head, but well away from the glasses strap.
plane of the named canals as represented by the vertical arrows. For testing hori-
zontal canals, the movement is in the plane of the horizontal canals as shown. These
images are modified from the free educational iPhone or iPad app “aVOR,” devel-
oped by Hamish MacDougall and available on iTunes. Reproduced with permission
of Wolters Kluwer Health from H. G. MacDougall, L. A. McGarvie, G. M. Halmagyi, I. S.
Curthoys, and K. P. Weber, 2013, Application of the video head impulse test to detect
vertical semicircular canal dysfunction, Otology and Neurotology, 34(6), 974–979.
the other hand on top of the head, but well away from the glasses strap.

1. Curthoys I, MacDougall H, McGarvie L, Weber K, Szmulewics D, 16–16.

Figure Manzari L,positions
The BurgessofAthe
andhands
Halmagyi M. The
for testing the Video
verticalHead Impulse
canals. Testis (vHIT).
One hand In Jacobson
placed under the chinGand
and Shepard N, editors. Balance
theFunction
other handassessment and
on top of the management.
head, but well away2afrom
ed.the
Sanglasses
Diego:strap.
Plural Publishing; 2016. p. 391-430.
 § Rigidez cervical que impide movimiento rápido y repentino.

§ Dificultad en el registro de la pupila (cirugía de ojo).

§ Dificultad en seguir la instrucción de mirar al frente al

objeto.

§ Se deslizan los lentes (no quedan firmemente apretados).

1. Curthoys I, MacDougall H, McGarvie L, Weber K, Szmulewics D, Manzari L, Burgess A and Halmagyi M. The Video Head Impulse Test (vHIT). In Jacobson G
and Shepard N, editors. Balance Function assessment and management. 2a ed. San Diego: Plural Publishing; 2016. p. 391-430.
En ROJO à Movimiento de cabeza. En AZUL à Movimiento ocular.
«NORMAL» Patológico
§ Sacadas correctivas:
§ Covert à Durante el movimiento de cabeza, difícil de ver en el “HIT”.
§ Overt à Posterior al movimiento de cabeza, las que se ven en el “HIT”.

§ Ganancia:
§ Ganancia = relación de la velocidad de los ojos / velocidad de la cabeza.
§ En sujetos sanos, la ganancia del VOR es cercano a 1.
§ Rango aceptable: 0,79 a 1,20.
§ Hasta 0,8 en CSC Horizontales. Hasta 0,7 en CSC Verticales.

§ Asimetría:
§ Diferencia de ganancia entre CSC de cada lado.
§ Hasta 13,3%
1. Curthoys I, MacDougall H, McGarvie L, Weber K, Szmulewics D, Manzari L, Burgess A and Halmagyi M. The Video Head Impulse Test (vHIT). In Jacobson G
and Shepard N, editors. Balance Function assessment and management. 2a ed. San Diego: Plural Publishing; 2016. p. 391-430.
vHIT
 Usuario: TM. ALVARO DEL VALLE
Version: 1.0.5.3

Canalogramm by Walther

RP - - LP

HOR R 0,82 1% 0,83 HOR L

§. RA - - LA

Gain und Asymmetry

RA<>LA; Hor R<>Hor L; RP<>LP

Horizontal plane
Head impulse rightward - HOR Head impulse leftward - HOR
260 260
200 200

100 100

0 0

-100 -100

-200 -200
-260 -260
0 0,1 0,2 0,3 0,4 0,5 0 0,1 0,2 0,3 0,4 0,5
Tiempo [s] Tiempo [s]
LARP plane
 Usuario: TM. ALVARO DEL VALLE
Version: 1.0.5.3

Canalogramm by Walther

RP - - LP

HOR R 0,56 30% 0,43 HOR L

§.
RA - 0,05 LA

Gain und Asymmetry

RA<>LA; Hor R<>Hor L; RP<>LP

Horizontal plane
Head impulse rightward - HOR Head impulse leftward - HOR
400 400

200 200

0 0

-200 -200

-400 -400
0 0,1 0,2 0,3 0,4 0,5 0 0,1 0,2 0,3 0,4 0,5
Tiempo [s] Tiempo [s]
 Poder determinar si lesión es:

• Vestibular.
• Uni o bilateral.
• Rama superior, inferior o total del nervio
vestibular.
1. Curthoys I, MacDougall H, McGarvie L, Weber K, Szmulewics D, Manzari L, Burgess A and Halmagyi M. The Video Head Impulse Test (vHIT). In Jacobson G and Shepard N,
editors. Balance Function assessment and management. 2a ed. San Diego: Plural Publishing; 2016. p. 391-430.
§ Vestibular Evoked Myogenic Potential test (Potencial Evocado Miogénico Vestibular).

§ Es una respuesta (refleja) de los músculos del cuello o de los ojos, ante una
estimulación acústica de alta intensidad. Algo similar al reflejo acústico y al PEAT.

• https://www.youtube.com/watch?v=CVS6LgwWcFk
§ Permiten evaluar función otolítica.

§ 2 Tipos:
§ cVEMP (cervical).
§ oVEMP (ocular).

Tusa, R. en Herdman, S.
(2007).
§ Evalúa mácula del sáculo à rama inferior del nervio vestibular.

§ Procedimiento:
§ Paciente acostado o sentado, cabeza girada a un lado.
§ Se colocan electrodos (frente y ECM a la vista) y fono (tono ipsilateral al ECM).
§ Debe elevar/adelantar su cabeza (sin apoyar) para ejercer contracción del músculo ECM.
§ Se envía estímulo click o tono burst corto, de baja frecuencia (500 Hz), a alta intensidad
(95 dB nHL).
§ Se registra respuesta à Potencial de inhibición en la tonicidad del ECM ipsilateral.

§ Respuesta: onda (+) p13 y (-) n23, que indica inhibición del músculo ante el sonido.
• https://www.youtube.com/watch?v=Op1dcU9E-bg
• https://www.youtube.com/watch?v=vDRJpGIG4XI Tusa, R. en Herdman, S. (2007).
§ Evalúa mácula del utrículo à rama superior del nervio vestibular.

§ Procedimiento:
§ Metodología similar a cVEMP.
§ Varía el electrodo de registro à musculatura ocular contralateral à recto inferior y
oblicuo inf.
§ Sujeto debe mirar hacia arriba.
§ Estímulo acústico de 500 Hz, por vía aérea u ósea. Es mejor por V.O. (V.A. necesita mayor
intensidad). 70 dB SL vía ósea. Otros trabajos 95 dB nHL (vía aérea).
§ Se registra respuesta à Potencial de contracción en de músculos recto inferior y
oblicuo inferior contralaterales. P. ej. Estímulo oído der., registro en ojo izq.
• https://www.youtube.com/watch?v=HyxUeX-LVW4
• https://www.youtube.com/watch?v=iaMYT_1hZqA
• https://www.youtube.com/watch?v=-_Q4AHRBe68
§ Respuesta:
§ Ondas N1 y P1
§ Hipoacusia sensorioneural no importa.
§ Es un fenómeno utrículo-sacular, la cóclea no está
relacionada.

§ Hipoacusia de conducción si es una limitación.

§ Sonido no llega al utrículo/sáculo.

§ Pacientes
mayores de 65 años, menor sensibilidad en
cVEMP, por musculatura cervical más hipotónica.
Examen vestibular objetivo.

Evalúa utrículo y sáculo.

• Estructuras difíciles de evaluar en

exámenes subjetivos clínicos.