Imperial College London

DrBarrySeemungal

Faculty of MedicineDepartment of Brain Sciences

Honorary Clinical Senior Lecturer
 
 
 
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Contact

 

+44 (0)20 3311 7042b.seemungal

 
 
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Assistant

 

Miss Lorna Stevenson +44 (0)20 3313 5525

 
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Location

 

10L17Lab BlockCharing Cross Campus

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Summary

 

Publications

Publication Type
Year
to

107 results found

Calzolari E, Chepisheva M, Smith RM, Mahmud M, Hellyer PJ, Tahtis V, Arshad Q, Jolly A, Wilson M, Rust H, Sharp DJ, Seemungal BMet al., 2021, Vestibular agnosia in traumatic brain injury and its link to imbalance., Brain, Vol: 144, Pages: 128-143

Vestibular dysfunction, causing dizziness and imbalance, is a common yet poorly understood feature in patients with TBI. Damage to the inner ear, nerve, brainstem, cerebellum and cerebral hemispheres may all affect vestibular functioning, hence, a multi-level assessment-from reflex to perception-is required. In a previous report, postural instability was the commonest neurological feature in ambulating acute patients with TBI. During ward assessment, we also frequently observe a loss of vertigo sensation in patients with acute TBI, common inner ear conditions and a related vigorous vestibular-ocular reflex nystagmus, suggesting a 'vestibular agnosia'. Patients with vestibular agnosia were also more unbalanced; however, the link between vestibular agnosia and imbalance was confounded by the presence of inner ear conditions. We investigated the brain mechanisms of imbalance in acute TBI, its link with vestibular agnosia, and potential clinical impact, by prospective laboratory assessment of vestibular function, from reflex to perception, in patients with preserved peripheral vestibular function. Assessment included: vestibular reflex function, vestibular perception by participants' report of their passive yaw rotations in the dark, objective balance via posturography, subjective symptoms via questionnaires, and structural neuroimaging. We prospectively screened 918 acute admissions, assessed 146 and recruited 37. Compared to 37 matched controls, patients showed elevated vestibular-perceptual thresholds (patients 12.92°/s versus 3.87°/s) but normal vestibular-ocular reflex thresholds (patients 2.52°/s versus 1.78°/s). Patients with elevated vestibular-perceptual thresholds [3 standard deviations (SD) above controls' average], were designated as having vestibular agnosia, and displayed worse posturography than non-vestibular-agnosia patients, despite no difference in vestibular symptom scores. Only in patients with impaired postural control (3 SD above c

Journal article

Smith R, Marroney N, Beattie J, Newdick A, Tahtis V, Burgess C, Marsden J, Seemungal Bet al., 2020, A mixed methods randomised feasibility trial investigating the management of benign paroxysmal positional vertigo in acute traumatic brain injury, Pilot and Feasibility Studies, Vol: 6, Pages: 1-10, ISSN: 2055-5784

BackgroundTraumatic brain injury (TBI) is the leading cause of long-term disability in working age adults. Recent studies show that most acute TBI patients demonstrate vestibular features of dizziness and imbalance, often from combined peripheral and central vestibular dysfunction. Effective treatment for vestibular impairments post-TBI is important given its significant adverse impact upon quality of life and employment prospects. The most frequent peripheral vestibular disorder in acute TBI is benign paroxysmal positional vertigo (BPPV), affecting approximately half of acute cases. Although there is effective treatment for idiopathic BPPV, there are no high quality clinical data for post-TBI BPPV regarding its prevalence, natural history, which treatment is most effective and when is the best time to treat. In particular, observational studies suggest post-TBI BPPV may be recurrent indicating that hyperacute treatment of BPPV may be futile. Given the potential hurdles and the lack of accurate post-TBI BPPV data, the current study was designed to provide information regarding the feasibility and the optimal design of future large-scale prospective treatment studies that would compare different interventions and their timing for post-TBI BPPV. MethodA multi-centre randomised mixed methods feasibility study design was employed. We aim to recruit approximately 75 acute TBI patients across a range of clinical severities, from three major trauma centres in London. Patients will be randomised to one of three treatment arms: (1) therapist-led manoeuvres; (2) patient-led exercises; and (3) advice. Participants will be re-assessed by blinded outcome assessors at 4 and 12 weeks. Acceptability of the intervention will be obtained by patient interviews at the end of their treatment, and therapist interviews at the end of the study. Primary outcomes relate to feasibility parameters including recruitment and retention rates, adverse events, and intervention fidelity. We will al

Journal article

Shaikh AG, Bronstein A, Carmona S, Cha Y-H, Cho C, Ghasia FF, Gold D, Green KE, Helmchen C, Ibitoye RT, Kattah J, Kim J-S, Kothari S, Manto M, Seemungal BM, Straumann D, Strupp M, Szmulewicz D, Tarnutzer A, Tehrani A, Tilikete C, Welgampola M, Zalazar G, Kheradmand Aet al., 2020, Consensus on virtual management of vestibular disorders: urgent versus expedited care, The Cerebellum: an international journal from neurosciences to clinical perspectives, Pages: 1-5, ISSN: 1473-4222

The virtual practice has made major advances in the way that we care for patients in the modern era. The culture of virtual practice, consulting, and telemedicine, which had started several years ago, took an accelerated leap as humankind was challenged by the novel coronavirus pandemic (COVID19). The social distancing measures and lockdowns imposed in many countries left medical care providers with limited options in evaluating ambulatory patients, pushing the rapid transition to assessments via virtual platforms. In this novel arena of medical practice, which may form new norms beyond the current pandemic crisis, we found it critical to define guidelines on the recommended practice in neurotology, including remote methods in examining the vestibular and eye movement function. The proposed remote examination methods aim to reliably diagnose acute and subacute diseases of the inner-ear, brainstem, and the cerebellum. A key aim was to triage patients into those requiring urgent emergency room assessment versus non-urgent but expedited outpatient management. Physicians who had expertise in managing patients with vestibular disorders were invited to participate in the taskforce. The focus was on two topics: (1) an adequate eye movement and vestibular examination strategy using virtual platforms and (2) a decision pathway providing guidance about which patient should seek urgent medical care and which patient should have non-urgent but expedited outpatient management.

Journal article

Murdin L, Seemungal BM, Bronstein AM, 2020, Assessment of dizziness in neurology, Medicine, ISSN: 1357-3039

Dizziness and vertigo are common symptoms. Because there are effective treatments for vestibular disorders, it is always important to make an accurate diagnosis. In acute vertigo, expert clinical assessment is critically important in discerning stroke from non-stroke causes because results of stroke-protocol brain magnetic resonance imaging, including diffusion-weighted imaging, can be falsely negative in the first 24 hours. It follows that acute medical services must have access to clinicians expert in assessing acute vertigo. Expertise in clinical examination and interpretation of findings requires appropriate training, but here we outline the basic diagnostic and therapeutic approach to patients with dizziness. Appropriate early management of these conditions is part of prevention of disabling chronic functional dizziness.

Journal article

Harris L, Hateley S, Tsang KT, Wilson M, Seemungal BMet al., 2020, Impact of anti-epileptic drug choice on discharge in acute traumatic brain injury patients, JOURNAL OF NEUROLOGY, Vol: 267, Pages: 1774-1779, ISSN: 0340-5354

Journal article

Lempert T, Seemungal BM, 2020, How to define migraine with brainstem aura?, Brain, ISSN: 1460-2156

Journal article

Marcus HJ, Paine H, Sargeant M, Wolstenholme S, Collins K, Marroney N, Arshad Q, Tsang K, Jones B, Smith R, Wilson MH, Rust HM, Seemungal BMet al., 2019, Vestibular dysfunction in acute traumatic brain injury, Journal of Neurology, Vol: 266, Pages: 2430-2433, ISSN: 0340-5354

Traumatic brain injury (TBI) is the commonest cause of disability in under-40-year-olds. Vestibular features of dizziness (illusory self-motion) or imbalance which affects 50% of TBI patients at 5 years, increases unemployment threefold in TBI survivors. Unfortunately, vestibular diagnoses are cryptogenic in 25% of chronic TBI cases, impeding therapy. We hypothesized that chronic adaptive brain mechanisms uncouple vestibular symptoms from signs. This predicts a masking of vestibular diagnoses chronically but not acutely. Hence, defining the spectrum of vestibular diagnoses in acute TBI should clarify vestibular diagnoses in chronic TBI. There are, however, no relevant acute TBI data. Of 111 Major Trauma Ward adult admissions screened (median 38-years-old), 96 patients (87%) had subjective dizziness (illusory self-motion) and/or objective imbalance were referred to the senior author (BMS). Symptoms included: feeling unbalanced (58%), headache (50%) and dizziness (40%). In the 47 cases assessed by BMS, gait ataxia was the commonest sign (62%) with half of these cases denying imbalance when asked. Diagnoses included BPPV (38%), acute peripheral unilateral vestibular loss (19%), and migraine phenotype headache (34%), another potential source of vestibular symptoms. In acute TBI, vestibular signs are common, with gait ataxia being the most frequent one. However, patients underreport symptoms. The uncoupling of symptoms from signs likely arises from TBI affecting perceptual mechanisms. Hence, the cryptogenic nature of vestibular symptoms in TBI (acute or chronic) relates to a complex interaction between injury (to peripheral and central vestibular structures and perceptual mechanisms) and brain-adaptation, emphasizing the need for acute prospective, mechanistic studies.

Journal article

Connor TA, Clark JM, Jayamohan J, Stewart M, McGoldrick A, Williams C, Seemungal BM, Smith R, Burek R, Gilchrist MDet al., 2019, Do equestrian helmets prevent concussion? A retrospective analysis of head injuries and helmet damage from real-world equestrian accidents, Sports Medicine - Open, Vol: 5, Pages: 19-19, ISSN: 2198-9761

OBJECTIVES: To collect and analyse helmets from real-world equestrian accidents. To record reported head injuries associated with those accidents. To compare damage to helmets certified to different standards and the injuries associated with them. METHODS: Two hundred sixteen equestrian helmets were collected in total. One hundred seventy-six helmets from amateur jockeys were collected via accident helmet return schemes in the UK and USA, while 40 helmets from professional jockeys were collected by The Irish Turf Club. All helmet damage was measured, and associated head injury was recorded. RESULTS: Eighty-eight percent (189) of equestrian fall accidents returned an injury report of which 70% (139) reported a head injury. Fifty-four percent (75) of head injury cases had associated helmet damage while 46% had no helmet damage. Reported head injuries consisted of 91% (126) concussion, 4% (6) skull fractures, 1 (0.7%) subdural hematoma, 1 (0.7%) cerebral edema and 5 (3.6%) diffuse axonal injury (DAI). It is also shown that helmets certified to the most severe standard are overrepresented in this undamaged group (p <0.001). CONCLUSIONS: It is clear that despite jockeys wearing a helmet, large proportions of concussion injuries still occur in the event of a jockey sustaining a fall. However, the data suggest it is likely that helmets reduce the severity of head injury as the occurrence of skull fracture is low. The proportion of undamaged helmets with an associated head injury suggests that many helmets may be too stiff relative to the surface they are impacting to reduce the risk of traumatic brain injury (TBI). It may be possible to improve helmet designs and certification tests to reduce the risk of head injury in low-severity impacts.

Journal article

Harris L, Hateley S, Seemungal B, 2019, PHENYTOIN VERSUS LEVETIRACETAM FOR POST TRAUMATIC BRAIN INJURY SEIZURE PROPHYLAXIS; A RETROSPECTIVE STUDY AT A UK MAJOR TRAUMA CENTRE, Joint Autumn Meeting of the Society-of-British-Neurological-Surgeons (SBNS)/Association-of-British-Neurologists (ABN), Publisher: BMJ PUBLISHING GROUP, Pages: E31-E31, ISSN: 0022-3050

Conference paper

Smith R, Chepisheva M, Cronin T, Seemungal BMet al., 2019, Diagnostic approaches techniques in concussion/mild traumatic brain injury: Where are we?, Neurosensory Disorders in Mild Traumatic Brain Injury, Pages: 247-277, ISBN: 9780128125489

Currently, sporting body consensus criteria consider concussion to be a mild traumatic brain injury (mTBI), which is indicated by a transient mental obtundation. Acute concussion diagnosis, thus, relies upon first-hand observation of the impact and the effect upon the patient (or recorded video), and clinical assessment including clinical history and examination. The diagnosis of a concussion can be difficult if there are no witnesses. Additionally, the inability of the patient to provide a clear account of the circumstances of the injury can make the diagnostic process more challenging, and on the other hand, is suggestive of a retrospective amnesia and, hence, supportive of a concussion. However, the converse may not be true, since some patients may provide a clear history of no concussion, but display objective signs of momentary mental obtundation, not recalled by the patient. Thus, since a concussion diagnosis by patient history is problematic, diagnosis should rely upon objective measures, including third-person witness account, clinical examination, and laboratory testing. We review the different means to make a diagnosis of concussion.

Book chapter

Rust HM, Seemungal BM, Kheradmand A, 2019, Vestibular Perception: From Bench to Bedside, Advances in Translational Neuroscience of Eye Movement Disorders, Publisher: Springer International Publishing, Pages: 43-71, ISBN: 9783030314064

Book chapter

Papathanasiou ES, Cronin T, Seemungal B, Sandhu Jet al., 2018, Electrophysiological testing in concussion: A guide to clinical applications, Journal of Concussion, Vol: 2, ISSN: 2059-7002

The diagnosis of mild traumatic brain injury in concussion is difficult since it is often unwitnessed, the patient’s recall is unreliable and initial clinical examination is often unrevealing, correlating poorly with the extent of brain injury. At present, there are no objective biomarkers of mild traumatic brain injury in concussion. Thus, a sensitive gold standard test is required to enable the effective and safe triage of patients who present to the acute services. As well as triage, objective monitoring of patients’ recovery over time and separate from clinical features that patients may develop following the injury (e.g. depression and migraine) is also needed. In contrast to neuroimaging, which is widely used to investigate traumatic brain injury patients, electrophysiology is readily available, is cheap and there are internationally recognized standardised methodologies. Herein, we review the existing literature on electrophysiological testing in concussion and mild traumatic brain injury; specifically, electroencephalogram, polysomnography, brainstem auditory evoked potentials, electro- and videonystagmography, vestibular evoked myogenic potentials, visually evoked potentials, somatosensory evoked potentials and transcranial magnetic stimulation.

Journal article

Sargeant M, Sykes E, Saviour M, Sawhney A, Calzolari E, Arthur J, McGoldrick A, Seemungal BMet al., 2018, The utility of the Sports Concussion Assessment Tool in hospitalized traumatic brain injury patients, Journal of Concussion, Vol: 2, ISSN: 2059-7002

The Sports Concussion Assessment Tool 3rd version is a sports screening tool that is often used to support return to play decisions following a head injury. The Sports Concussion Assessment Tool 3rd version is presumed to identify brain dysfunction (implying a degree of brain injury); however, the Sports Concussion Assessment Tool has never been validated with patients with definite acute brain injury. In this study, we found that all three Sports Concussion Assessment Tool 3rd version domains – symptoms, cognitive and balance assessments – were sensitive in discriminating traumatic brain injury patients (all with abnormal acute neuroimaging) from healthy controls. Through a correlation matrix (Bonferroni corrected), we found no correlation between the subjective (symptoms) and objective (examination) Sports Concussion Assessment Tool 3rd version assessments, e.g. complaints of imbalance and memory dysfunction were not correlated, respectively, with performance on testing balance and memory function. When relaxing the correction for multiple comparisons we found that of all Sports Concussion Assessment Tool 3rd version symptoms, a feeling of ‘pressure in the head’ had the largest number of co-correlations (including affective symptoms) and overwhelmingly in a pattern indicative of migraine. Taken together, that objective and subjective assessments in the Sports Concussion Assessment Tool 3rd version are poorly correlated, could suggest that symptoms in the Sports Concussion Assessment Tool 3rd version poorly reflect brain injury but rather indicate non-brain injury processes such as migraine. It follows that the current prominent orthodoxy of resting athletes following a head injury until their symptoms settle for fear of exacerbating brain injury may be unfavourable for their recovery – at least in some cases. Prospective clinical studies would be required to assess patient recovery from concussion with early active investigation and t

Journal article

Xiang M, Glasauer S, Seemungal BM, 2018, Quantitative postural models as biomarkers of balance in Parkinson’s disease, Brain, Vol: 141, Pages: 2824-2827, ISSN: 1460-2156

Journal article

Seemungal BM, Passamonti L, 2018, Persistent postural-perceptual dizziness: a useful new syndrome, Practical Neurology, Vol: 18, Pages: 3-4, ISSN: 1474-7766

Journal article

Cronin T, Arshad Q, Seemungal BM, 2017, Vestibular deficits in neurodegenerative disorders: balance, dizziness, and spatial disorientation, Frontiers in Neurology, Vol: 8, ISSN: 1664-2295

The vestibular system consists of the peripheral vestibular organs in the inner ear and the associated extensive central nervous system projections—from the cerebellum and brainstem to the thalamic relays to cortical projections. This system is important for spatial orientation and balance, both of critical ecological importance, particularly for successful navigation in our environment. Balance disorders and spatial disorientation are common presenting features of neurodegenerative diseases; however, little is known regarding central vestibular processing in these diseases. A ubiquitous aspect of central vestibular processing is its promiscuity given that vestibular signals are commonly found in combination with other sensory signals. This review discusses how impaired central processing of vestibular signals—typically in combination with other sensory and motor systems—may account for the impaired balance and spatial disorientation in common neurodegenerative conditions. Such an understanding may provide for new diagnostic tests, potentially useful in detecting early disease while a mechanistic understanding of imbalance and spatial disorientation in these patients may enable a vestibular-targeted therapy for such problems in neurodegenerative diseases. Studies with state of the art central vestibular testing are now much needed to tackle this important topic.

Journal article

Allen D, Ribeiro L, Arshad Q, Seemungal BMet al., 2017, Age-Related Vestibular Loss: Current Understanding and Future Research Directions, Frontiers in Neurology, Vol: 8, ISSN: 1664-2295

The vestibular system sub-serves a number of reflex and perceptual functions, comprisingthe peripheral apparatus, the vestibular nerve, the brainstem and cerebellarprocessing circuits, the thalamic relays, and the vestibular cerebral cortical network.This system provides signals of self-motion, important for gaze and postural control,and signals of traveled distance, for spatial orientation, especially in the dark. Currentevidence suggests that certain aspects of this multi-faceted system may deteriorate withage and sometimes with severe consequences, such as falls. Often the deterioration investibular functioning relates to how the signal is processed by brain circuits rather thanan impairment in the sensory transduction process. We review current data concerningage-related changes in the vestibular system, and how this may be important for cliniciansdealing with balance disorders.

Journal article

Allen D, Ribeiro L, Arshad Q, Seemungal BMet al., 2017, Age-Related Vestibular Loss: Current Understanding and Future Research Directions (vol 7, 231, 2016), FRONTIERS IN NEUROLOGY, Vol: 8, ISSN: 1664-2295

Journal article

Ahmad H, Roberts E, Patel M, Lobo R, Seemungal B, Arshad Q, Bronstein Aet al., 2017, Downregulation of early visual cortex excitability mediates oscillopsia, Neurology, Vol: 89, Pages: 1179-1185, ISSN: 0028-3878

Objective; Identifying the neurophysiological mechanisms that mediate adaptation to oscillopsia in patients with bilateral-vestibular failure (BVF); an observational study. Methods; We directly probe the hypothesis that adaptive changes which mediate oscillopsia suppression implicate the early visual-cortex (V1/V2). Accordingly, we investigated (V1/V2) excitability using transcranial magnetic stimulation (TMS) in 12 avestibular patients and 12 healthy controls. Specifically, we assessed TMS-induced phosphene thresholds at baseline and cortical excitability changes whilst performing a visual-motion adaptation paradigm during the following conditions: (i) BASELINE measures (i.e. static), (ii) during visual-motion (i.e. MOTION PRE ADAPTATION) and, (iii) during visual-motion following 5 minutes of unidirectional visual-motion adaptation (i.e. MOTION ADAPTED). Results: Patients had significantly higher baseline phosphene-thresholds, reflecting an underlying adaptive mechanism. Individual thresholds were correlated with oscillopsia symptom load. During the visual-motion adaptation condition, no differences in excitability at BASELINE were observed but, during both MOTION PRE ADAPTATION and MOTION ADAPTED conditions, we observed significantly attenuated cortical excitability in patients. Again this attenuation in excitability was stronger in less symptomatic patients.Conclusion; Our findings provide neurophysiological evidence that cortically-mediated adaptive mechanisms in V1/V2 play a critical role in suppressing oscillopsia in patients with bilateral vestibular failure.

Journal article

Cousins S, Kaski D, Cutfield N, Arshad Q, Ahmad H, Gresty MA, Seemungal BM, Golding J, Bronstein AMet al., 2017, Predictors of clinical recovery from vestibular neuritis: a prospective study, Annals of Clinical and Translational Neurology, Vol: 4, Pages: 340-346, ISSN: 2328-9503

We sought to identify predictors of symptomatic recovery in vestibular neuritis. Forty VN patients were prospectively studied in the acute phase (median = 2 days) and 32 in the recovery phase (median = 10 weeks) with vestibulo-ocular reflex, vestibular-perceptual, and visual dependence tests and psychological questionnaires. Clinical outcome was Dizziness Handicap Inventory score at recovery phase. Acute visual dependency and autonomic arousal predicted outcome. Worse recovery was associated with a combination of increased visual dependence, autonomic arousal, anxiety/depression, and fear of bodily sensations, but not with vestibular variables. Findings highlight the importance of early identification of abnormal visual dependency and concurrent anxiety.

Journal article

Arshad Q, Roberts RE, Ahmad H, Lobo R, Patel M, Ham T, Sharp DJ, Seemungal BMet al., 2017, Patients with chronic dizziness following traumatic head injury typically have multiple diagnoses involving combined peripheral and central vestibular dysfunction, CLINICAL NEUROLOGY AND NEUROSURGERY, Vol: 155, Pages: 17-19, ISSN: 0303-8467

Journal article

, 2017, The Components of Vestibular Cognition — Motion Versus Spatial Perception, Vestibular Cognition, Publisher: BRILL, Pages: 25-42, ISBN: 9789004342231

Book chapter

Roberts RE, Arshad Q, Patel M, Dima D, Leech R, Seemungal BM, Sharp DS, Bronstein AMet al., 2016, Functional neuroimaging of visuo-vestibular interaction, Brain Structure & Function, Vol: 222, Pages: 2329-2343, ISSN: 1863-2661

The brain combines visual, vestibular and proprioceptive information to distinguish between self-and world-motion. Often these signals are complementary and indicate that the individual is moving or stationary with respect to the surroundings. However, conflicting visual motion and vestibular cues can lead to ambiguous or false sensations of motion. In this study, we used functional magnetic resonance imaging to explore human brain activation when visual and vestibular cues were either complementary or in conflict. We combined a horizontally moving optokinetic stimulus with caloric irrigation of the right ear to produce conditions where the vestibular activation and visual motion indicatedthe same (congruent) or opposite directions of self-motion (incongruent). Visuo-vestibular conflict was associated with increased activation in a network of brain regions including posterior insular and transverse temporal areas, cerebellar tonsil, cingulate and medial frontal gyri. In the congruent condition there was increased activation in primary and secondary visual cortex. These findings suggest that when sensory information regarding self-motion is contradictory, there is preferential activation of multisensoryvestibular areas to resolve this ambiguity. When cues are congruent there is a bias towards visual cortical activation. The data support the view thata network of brain areas including the posterior insular cortex may play animportant role in integrating and disambiguating visual and vestibular cues.

Journal article

Patel M, Agarwal K, Arshad Q, Hariri M, Rea P, Seemungal BM, Golding JF, Harcourt JP, Bronstein AMet al., 2016, Intratympanic methylprednisolone versus gentamicin in patients with unilateral Ménière's disease: a randomised, double-blind, comparative effectiveness trial, The Lancet, Vol: 388, Pages: 2753-2762, ISSN: 0140-6736

BACKGROUND: Ménière's disease is characterised by severe vertigo attacks and hearing loss. Intratympanic gentamicin, the standard treatment for refractory Ménière's disease, reduces vertigo, but damages vestibular function and can worsen hearing. We aimed to assess whether intratympanic administration of the corticosteroid methylprednisolone reduces vertigo compared with gentamicin. METHODS: In this double-blind comparative effectiveness trial, patients aged 18-70 years with refractory unilateral Ménière's disease were enrolled at Charing Cross Hospital (London, UK) and Leicester Royal Infirmary (Leicester, UK). Patients were randomly assigned (1:1) by a block design to two intratympanic methylprednisolone (62·5 mg/mL) or gentamicin (40 mg/mL) injections given 2 weeks apart, and were followed up for 2 years. All investigators and patients were masked to treatment allocation. The primary outcome was vertigo frequency over the final 6 months (18-24 months after injection) compared with the 6 months before the first injection. Analyses were done in the intention-to-treat population, and then per protocol. This trial is registered with ClinicalTrials.gov, number NCT00802529. FINDINGS: Between June 19, 2009, and April 15, 2013, 256 patients with Ménière's disease were screened, 60 of whom were enrolled and randomly assigned: 30 to gentamicin and 30 to methylprednisolone. In the intention-to-treat analysis (ie, all 60 patients), the mean number of vertigo attacks in the final 6 months compared with the 6 months before the first injection (primary outcome) decreased from 19·9 (SD 16·7) to 2·5 (5·8) in the gentamicin group (87% reduction) and from 16·4 (12·5) to 1·6 (3·4) in the methylprednisolone group (90% reduction; mean difference -0·9, 95% CI -3·4 to 1·6). Patients whose vertigo did not improve after injection (ie, non-responders)

Journal article

Ahmad H, Arshad Q, Roberts R, Patel M, Ham T, Sharp D, Seemungal Bet al., 2016, CHRONIC DIZZINESS POST TRAUMATIC BRAIN INJURY: A CROSS-SECTIONAL STUDY, Annual Meeting of the Association-of-British-Neurologists (ABN), Publisher: BMJ PUBLISHING GROUP, ISSN: 0022-3050

Conference paper

Seemungal BM, Yousif N, Abou-El-Ela-Bourquin B, Fu R, Bhrugubanda V, Schultz SRet al., 2016, Dopamine activation preserves visual motion perception despite noise interference of human V5/MT, Journal of Neuroscience, Vol: 36, Pages: 9303-9312, ISSN: 1529-2401

When processing sensory signals, the brain must account for noise, both noise in the stimulus and that arising from within its own neuronal circuitry. Dopamine receptor activation is known to enhance both visual cortical signal-to-noise-ratio (SNR) and visual perceptual performance; however, it is unknown whether these two dopamine-mediated phenomena are linked. To assess this, we used single-pulse transcranial magnetic stimulation (TMS) applied to visual cortical area V5/MT to reduce the SNR focally and thus disrupt visual motion discrimination performance to visual targets located in the same retinotopic space. The hypothesis that dopamine receptor activation enhances perceptual performance by improving cortical SNR predicts that dopamine activation should antagonize TMS disruption of visual perception. We assessed this hypothesis via a double-blinded, placebo-controlled study with the dopamine receptor agonists cabergoline (a D2 agonist) and pergolide (a D1/D2 agonist) administered in separate sessions (separated by 2 weeks) in 12 healthy volunteers in a William's balance-order design. TMS degraded visual motion perception when the evoked phosphene and the visual stimulus overlapped in time and space in the placebo and cabergoline conditions, but not in the pergolide condition. This suggests that dopamine D1 or combined D1 and D2 receptor activation enhances cortical SNR to boost perceptual performance. That local visual cortical excitability was unchanged across drug conditions suggests the involvement of long-range intracortical interactions in this D1 effect. Because increased internal noise (and thus lower SNR) can impair visual perceptual learning, improving visual cortical SNR via D1/D2 agonist therapy may be useful in boosting rehabilitation programs involving visual perceptual training.

Journal article

Patel M, Agarwal K, Arshad Q, Hariri M, Rea P, Seemungal BM, Golding JF, Harcourt JP, Bronstein AMet al., 2016, Intratympanic steroids vs. gentamicin in unilateral Ménière's disease: a randomised double-blind comparative effectiveness trial, Lancet, ISSN: 1474-547X

Background: Ménière’s disease (MD) is characterised by severe vertigo attacks and deafness. Intratympanic gentamicin ablates vestibular function, quells vertigo and is the standard treatment for refractory MD - but it can worsen hearing. Intratympanic corticosteroids may reduce vertigo without harming hearing but no RCT comparing steroids versus gentamicin is available.Methods: In this comparative effectiveness trial, refractory unilateral MD patients, defined according to the American Academy of Otolaryngology, were double-blindly randomised (1:1 block-design) to intratympanic methylprednisolone (n=30, 62·5mg/ml) or gentamicin (n=30, 40mg/ml) and followed-up over two years at Charing Cross Hospital (Imperial NHS, London) and Leicester Royal Infirmary, Leicester, UK. Primary outcome was vertigo frequency over the final 6-months (18-24months post-injection) compared to a 6-month pre-injection baseline. Secondary outcomes were vestibular and auditory symptoms (validated questionnaires) and hearing preservation (audiometry). ClinicalTrials.gov:NCT00802529.Findings: For intention-to-treat analysis i.e., all 60 patients, number of vertigo attacks/6months (primary outcome) fell from 19·9 to 2·5 [87%] in the gentamicin arm and 16·4 to 1·6 [90%] in the steroid arm (difference in absolute number of attacks in the final 6months -0·9; 95%CI -3·4 to 1·6). Both drugs reduced the number of vertigo attacks at 2 years (P<0·0001), with equal efficacy (P=0·51). For hearing preservation (secondary outcome), there was no difference (P=0·18) between drugs for hearing thresholds (final difference -2·45decibels, 95%CI -13·4 to 8·5). Both drugs reduced auditory and vestibular symptoms equally. As protocol, patients whose vertigo did not respond post-injection (‘non-responders’) were considered for additional injections by an unblinded physician (8 patients ge

Journal article

Murdin L, Seemungal BM, Bronstein AM, 2016, Dizziness, Medicine (United Kingdom), Vol: 44, Pages: 484-487, ISSN: 1357-3039

© 2016 Elsevier Ltd Dizziness and vertigo are common symptoms. Because there are effective treatments for vestibular disorders, it is always important to make an accurate diagnosis. In acute vertigo, expert clinical assessment is critically important in discerning stroke from non-stroke causes because stroke-protocol brain magnetic resonance imaging results, including diffusion-weighted imaging, can be falsely negative in the first 24 hours. It follows that acute medical services must have access to clinicians expert in assessing acute vertigo. Expertise in clinical examination and the interpretation of findings requires appropriate training, but in this article we outline the basic diagnostic and therapeutic approach to patients with dizziness.

Journal article

Yousif N, Fu R, Abou-El-Ela-Bourquin B, Bhrugubanda V, Schultz S, Seemungal BMet al., 2016, Dopamine preserves visual motion perception despite noise interference of human V5/MT, European Academy of Neurology, Publisher: WILEY, Pages: 874-874, ISSN: 1351-5101

Conference paper

Seemungal BM, 2016, Screening for BPPV in falls: an easy but big clinical "win", British Medical Journal, Vol: 353, ISSN: 1468-5833

Journal article

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