Bruns' nystagmus revisited: A sign of stroke in patients with the acute vestibular syndrome

Objective: Gaze-evoked nystagmus (GEN) is a central sign in patients with the acute vestibular syndrome (AVS); however, discriminating between a pathological and a physiologic GEN is a challenge. Here we evaluate GEN in patients with AVS. Methods: In this prospective cross-sectional study, we used video-oculography (VOG) to compare GEN in the light (target at 15° eccentric) in 64 healthy subjects with 47 patients seen in the emergency department (ED) who had AVS; 35 with vestibular neuritis and 12 with stroke. All patients with an initial non-diagnostic MRI received a confirmatory, delayed MRI as a reference standard in detecting stroke. Results: Healthy subjects with GEN had a time constant of centripetal drift >18 s. VOG identified pathologic GEN (time constant ≤ 18 s) in 33% of patients with vestibular strokes, specificity was 100%, accuracy was 83%. Results were equivalent to examination by a clinical expert. As expected, since all patients with GEN had a SN in straight-ahead position, they showed the pattern of a Bruns’ nystagmus. Conclusions: One third of patients with AVS due to central vestibular strokes had a spontaneous SN in straight-ahead gaze and a pathological GEN, producing the pattern of a Bruns’ nystagmus with a shift of the null position. The localization of the side of the lesion based on the null was not consistent, presumably because the circuits underlying gaze-holding are widespread in the brainstem and cerebellum. Nevertheless, automated quantification of GEN with VOG was specific, and accurately identified patients in the ED with AVS due to strokes.