J Clin Neurol.  2016 Jan;12(1):65-74. 10.3988/jcn.2016.12.1.65.

Bilaterally Abnormal Head Impulse Tests Indicate a Large Cerebellopontine Angle Tumor

• Kim HJ
• Park SH
• Kim JS
• Koo JW
• Kim CY
• Kim YH
• Han JH

• KMID: 2364921
• DOI: http://doi.org/10.3988/jcn.2016.12.1.65

Abstract

BACKGROUND AND PURPOSE
Tumors involving the cerebellopontine angle (CPA) pose a diagnostic challenge due to their diverse manifestations. Head impulse tests (HITs) have been used to evaluate vestibular function, but few studies have explored the head impulse gain of the vestibulo-ocular reflex (VOR) in patients with a vestibular schwannoma. This study tested whether the head impulse gain of the VOR is an indicator of the size of a unilateral CPA tumor.
METHODS
Twenty-eight patients (21 women; age=64+/-12 years, mean+/-SD) with a unilateral CPA tumor underwent a recording of the HITs using a magnetic search coil technique. Patients were classified into non-compressing (T1-T3) and compressing (T4) groups according to the Hannover classification.
RESULTS
Most (23/28, 82%) of the patients showed abnormal HITs for the semicircular canals on the lesion side. The bilateral abnormality in HITs was more common in the compressing group than the non-compressing group (80% vs. 8%, Pearson's chi-square test: p<0.001). The tumor size was inversely correlated with the head impulse gain of the VOR in either direction.
CONCLUSIONS
Bilaterally abnormal HITs indicate that a patient has a large unilateral CPA tumor. The abnormal HITs in the contralesional direction may be explained either by adaptation or by compression and resultant dysfunction of the cerebellar and brainstem structures. The serial evaluation of HITs may provide information on tumor growth, and thereby reduce the number of costly brain scans required when following up patients with CPA tumors.

Keyword

vertigo; vestibulo-ocular reflex; cerebellopontine-angle tumor; head impulse test; flocculus

MeSH Terms

Brain
Brain Stem
Cerebellopontine Angle*
Classification
Female
Head Impulse Test*
Head*
Humans
Neuroma, Acoustic*
Reflex, Vestibulo-Ocular
Semicircular Canals
Vertigo

Figure

• 

  Fig. 1 MRI of patients with bilaterally abnormal head impulse test (HIT) findings. Twelve patients (P1-P12) belong to the compressing group, and only one (P16) is from the non-compressing group.

• 

  Fig. 2 Polar plots of the vestibulo-ocular reflex (VOR) gains during head impulses for all six semicircular canals (SCCs) show decreased gains for SCCs except the contralesional anterior SCC in the compressing group. In contrast, only the gains for ipsilesional horizontal and posterior SCCs are reduced in the non-compressing group. The head impulse VOR gains for all six SCCs are significantly lower in the compressing group than the non-compressing group (t-test: p<0.05). CA: contralesional anterior SCC, CH: contralesional horizontal SCC, CP: contralesional posterior SCC, IA: ipsilesional anterior SCC, IH: ipsilesional horizontal SCC, IP: ipsilesional posterior SCC.

• 

  Fig. 3 Correlation between tumor size and gain of the vestibulo-oclar reflex (VOR) during Head impulse tests. HC: horizontal semicircular canal.

• 

  Fig. 4 Comparison of other neurotologic findings. Patients with bilaterally abnormal Head impulse tests (HIT) findings show gaze-evoked nystagmus (GEN), caloric paresis, and abnormalities of brainstem auditory evoked potentials (BAEP), cervical vestibular evoked myogenic potentials (cVEMPs), and ocular vestibular evoked myogenic potentials (oVEMPs) more frequently than those with normal or only ipsilesionally abnormal HIT findings (chi-square, *p<0.05). SN: spontaneous nystagmus.

• 

  Fig. 5 Neurotologic findings in the index case (patient 1). A: Bithermal caloric tests show a left-side caloric paresis of 74%. B: Pure-tone audiometry shows complete hearing loss on the left side. No cervical (C) or ocular (D) vestibular-evoked myogenic potentials can be evoked when stimulating the left ear. MRI reveals a large tumor (3.4×3.2 cm) involving the left cerebellopontine angle (E). F: Performing HITs using a magnetic search coil technique show decreased gains for all six semicircular canals. AC: anterior semicircular canal, HC: horizontal semicircular canal, PC: right posterior semicircular canal.

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