ReviewVestibular evoked myogenic potentials (VEMPs) in central neurological disorders
Introduction
In the last two decades vestibular evoked myogenic potentials (VEMPs) came into use as a test suitable for detailed physiological assessment of the vestibular system. VEMPs can be evoked by short intense auditory stimuli (i.e. tone bursts or clicks), bone-conducted vibration, forehead taps, and galvanic stimulation (Curthoys, 2010a, Papathanasiou et al., 2014, Rosengren et al., 2010, Rosengren and Kingma, 2013, Welgampola and Colebatch, 2005). In daily practice, air-conducted acoustic stimuli are used most often, followed by bone-conducted vibration and forehead taps. The responses can be divided into a cervical response and an ocular response.
The cervical vestibular evoked myogenic potential (cVEMPs) can be recorded by placing an active surface electrode over the upper middle part of the sternocleidomastoid muscles with a reference electrode on the sternal manubrium. The sternocleidomastoid muscles, however, both have to be activated by flexing the neck, or they have to be ipsilaterally activated by rotating the head contralaterally away from the stimulated ear (when cVEMPs are acoustically elicited by air-conducted clicks or tone bursts, AC-cVEMPs). cVEMPs measure the integrity of the vestibulo-collic reflex from the saccular afferents to the brainstem vestibular nuclei (through the inferior vestibular nerve), evoking an inhibitory motor response in the ipsilateral sternocleidomastoid muscle (through the medial vestibulospinal tract, upper cervical motor neurons and the accessory nerve) (Curthoys, 2010a, Eleftheriadou and Koudounarakis, 2011, Rosengren et al., 2010, Rosengren and Kingma, 2013) (Fig. 1).
The ocular vestibular evoked myogenic potential (oVEMP) measures the function of the vestibulo-ocular reflex arc from the otolith end-organ(s) to the brainstem vestibular nuclei through the superior vestibular nerve and medial longitudinal fasciculus, evoking an excitatory oculomotor response in the inferior oblique muscle mainly in the contralateral eye. The precise localization of the end-organ involved in the origin of the oVEMP is controversial and has been debated extensively in the literature (i.e. whether the end-organ is predominantly the sacculus, the utriculus, or a combination of both), however there is consensus that the relevant afferents travel through the superior division of the vestibular nerve (Colebatch, 2010, Curthoys, 2010a, Curthoys, 2010b, Eleftheriadou and Koudounarakis, 2011, Papathanasiou, 2012, Papathanasiou, 2013, Rosengren and Kingma, 2013, Rosengren et al., 2010, Todd, 2014) (Fig. 1). By maintaining an upward gaze during the stimulation oVEMPs can be recorded by an active electrode just below the middle of the infraorbital margin with the reference electrodes 1–2 cm below the active electrode (Curthoys, 2010a, Walter et al., 2011).
The cVEMP’s morphology can be divided into two parts. The early biphasic positive–negative component (p13–n23) is presumed to be of mainly saccular origin. The second biphasic negative–positive complex (n34–p44) is thought to be auditory in acoustic stimulation and of an unknown origin in forehead tap evoked responses (possibly a stretch reflex) (Fig. 2). The oVEMP’s morphology consists of a quadriphasic negative–positive deflection (n1–p1 and n2–p2 complex) (Fig. 2).
Historically, the clinical research concerning VEMPs focused on peripheral neurovestibular disorders. However the field of VEMP testing is rapidly expanding with an increasing focus on central neurological disorders. For an overview on VEMP abnormalities in mainly peripheral vestibular disorders we refer to Brantberg (2009). Reviews concerning VEMP abnormalities in central neurological conditions are scarce, despite the growing number of clinical studies. In this paper, we present an overview concerning VEMP abnormalities in central neurological disorders, the interpretation of these VEMP results, and their clinical application. In addition, we stress the importance of applying a correct methodological procedure in future clinical VEMP research and clinical VEMP testing in individual patients. We critically assessed the available literature concerning VEMP abnormalities in central neurological disorders in order to get an impression of the applied technical aspects as well as the methodology and the interpretation of the studies aiming to estimate the level of diagnostic evidence.
Section snippets
Demyelinating disease
Multiple sclerosis (MS) is a chronic, demyelinating disease of the central nervous system. MS is a leading cause of disability in young adults with a prevalence of 1 out of 1000 persons living in northern Europe (Compston and Coles, 2008).
The presence of AC-cVEMPs abnormalities varies from 31% to 70% in the literature; delayed p13, often in combination with increased n23 latencies, are the most common abnormalities, followed by absent responses. There was a significant correlation between
In summary
VEMP abnormalities in central neurological disorders may be seen rather often, but are not disease specific and usually do not give any information about the underlying aetiology. In contrast however, VEMPs may give important localizing information (Table 1).
In peripheral labyrinthine disorders like Menière’s disease or labyrinthine infarction one may expect a reduction in amplitude or even a disappearance of the ipsilateral cVEMP response and/or contralateral oVEMP response. In contrast to
Acknowledgments
The authors received no financial support with respect to the research, authorship, and/or publication of this article. Conflict of interest: None of the authors have potential conflicts of interest to be disclosed.
References (72)
- et al.
Abnormal cervical vestibular-evoked myogenic potential in anterior inferior cerebellar artery territory infarction: frequency, pattern, and a determinant
J Neurol Sci
(2011) Sound conclusions?
Clin Neurophysiol
(2010)- et al.
Two distinct patterns of VEMP changes with age
Clin Neurophysiol
(2013) - et al.
Multiple sclerosis
Lancet
(2008) A critical review of neurophysiological evidence underlying clinical vestibular testing using sound, vibration and galvanic stimulation
Clin Neurophysiol
(2010)- et al.
Hallazgos de potenciales vestibulares miogénicos evocados en la esclerosis multiple
Acta Otorrinolaringol Esp
(2013) - et al.
Ocular and cervical vestibular evoked myogenic potentials in multiple sclerosis patients
Clin Neurophysiol
(2012) - et al.
Auditory evoked myogenic potentials and vestibular evoked myogenic potentials in evaluation of brainstem lesions in multiple sclerosis
J Neurol Sci
(2013) - et al.
Ocular vestibular evoked myogenic potentials to head tap and cervical vestibular evoked myogenic potentials to air-conducted sounds in isolated internuclear ophthalmoplegia
Clin Neurophysiol
(2014) - et al.
Ocular vestibular evoked myogenic potentials induced by air-conducted sound in patients with acute brainstem lesions
Clin Neurophysiol
(2013)
Ocular vestibular evoked myogenic potentials (OVEMPs): saccule or utricle?
Clin Neurophysiol
Vestibular evoked myogenic potentials: the fuzzy picture of different stimulation types is beginning to come into focus
Clin Neurophysiol
International guidelines for the clinical application of cervical vestibular evoked myogenic potentials: an expert consensus report
Clin Neurophysiol
Vestibular evoked myogenic potentials in patients suffering from an unilateral acoustic neuroma: a study of 170 patients
Clin Neurophysiol
Diagnostic value of vestibular evoked myogenic potentials in cerebellar and lower-brainstem strokes
Neurophysiol Clin
Vestibulocervical reflexes in idiopathic Parkinson disease
Neurophysiol Clin
Ocular vestibular evoked myogenic potentials are abnormal in internuclear ophthalmoplegia
Clin Neurophysiol
Ocular and cervical vestibular evoked myogenic potentials produced by air- and bone-conducted stimuli: comparative properties and effects of age
Clin Neurophysiol
Vestibular evoked myogenic potentials: past, present and future
Clin Neurophysiol
Vestibular-evoked myogenic potentials: a method to assess vestibulo-spinal conduction in multiple sclerosis patients
Brain Res Bull
Vestibular evoked myogenic potential (VEMP) in patients with acoustic neuromas
Auris Nasus Larynx
The ocular vestibular evoked myogenic potential (OVEMP), ten years old
Clin Neurophysiol
The diagnostic value of vestibular-evoked myogenic potential in patients with vestibular schwannoma
Clin Neurophysiol
Vestibular evoked myogenic potentials in multiple sclerosis patients
Clin Neurophysiol
Vestibular evoked myogenic potentials in multiple sclerosis: clinical and imaging correlations
Mult Scler
Vestibular-evoked myogenic potentials in “Vestibular migraine” and Menière’s disease. A sign of an electrophysiological link?
Ann N Y Acad Sci
The diagnostic value of vestibular evoked myogenic potentials in multiple sclerosis
J Neurol
Sacculocolic reflex in patients with dementia: is it possible to use it for early diagnosis?
Neurol Sci
Vestibular sensitivity in vestibular migraine: VEMPs and motion sickness susceptibility
Cephalalgia
Vestibular evoked myogenic potentials (VEMPs): usefulness in clinical neurotology
Semin Neurol
Vestibular evoked myogenic potentials in brainstem stroke
Laryngoscope
The role of cervical and ocular vestibular evoked myogenic potentials in the assessment of patients with vestibular schwannomas
PLoS One
Impaired modulation of the otolithic function in acute unilateral cerebellar infarction
Cerebellum
Clinical presentation of posterior fossa epidermoid cysts
Eur Arch Otorhinolaryngol
Myogenic potentials generated by a click-evoked vestibulocollic reflex
J Neurol Neurosurg Psychiatry
A balanced view of the evidence leads to sound conclusions. A reply to J.G. Colebatch “Sound conclusions?”
Clin Neurophysiol
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