Medical History
In September 2023, a 36 year-old male patient experienced a significant incidence of vertigo and blackouts while driving his car, following a stressful event at work. In the immediate emergency department visit, the following evaluations were conducted:
- ECG of the heart
- Ultrasound of the carotid artery
- MRI of the brain
- CT scan of the brain
- 48-hour ECG monitoring (Holter monitor), which showed no arrhythmia or heart rate changes
Although no physiological causes could be determined by the performed tests, the patient continued to experience severe vertigo even in the absence of visual stimuli and while lying down. Other symptoms included ataxia, inability to focus, and, at times, the inability to walk properly, necessitating crawling. This significantly impacted his daily life, restricting his ability to drive, tolerate lights, and engage in social settings. The continuous vertigo furthermore prevented him to sleep, eventually causing severe mental instability and depression.
Presenting Symptoms
- Dizziness and severe vertigo
- Loss of hearing
- Tinnitus
- Insomnia
Initial Consultations and Diagnosis Attempts
- Week Two after the Incidence: Consultations with an ENT specialist and a neurologist yielded no definitive diagnosis.
- Second ENT Diagnosis: The patient was diagnosed with Benign Paroxysmal Positional Vertigo (BPPV) and was prescribed betahistidine. After one month, there was no noticeable improvement.
- December 2023: Symptoms worsened, including squinted eyes for concentration, inability to drive, and difficulty with prolonged standing and turning.
- Third ENT Diagnosis: Diagnosed with left labyrinthitis and prescribed oral and intravenous cortisol which also proved ineffective.
During this period (September to December 2023), the patient experienced extreme debilitation, spending 20 days bedridden, neglecting personal hygiene, and experiencing suicidal ideation. Consultations with an ophthalmologist and a psychiatrist resulted in the prescription of neurotropic medication.
Further Developments and Deterioration
January 2024: The patient was assessed by a fourth ENT specialist who found a 90% hearing loss, necessitating a hearing aid. The patient continued to experience suicidal thoughts, insomnia, and constant vertigo.
Audiogram from January 2024 shows a hearing loss of 90% on the left ear. X-axis: Hearing Level in decibels (Db), Y-axis: Frequency in Hertz (Hz).
Tests and Examination at SOZO Brain Center
Upon presentation at SOZO Brain Center, the following clinical tests were conducted:
- Romberg Test: Positive
- Cranial Nerve Examination (H-Test): Positive for visual vertigo
- Glabellar Tap Sign Test: Positive, indicating midbrain involvement
- Corneal Light Reflex Test: Positive, indicating strabismus (ocular misalignment)
- Trigeminus and Facialis Nerve Test: Positive
- Dix-Hallpike Test: Negative, ruling out BPPV
In addition, validated assessment scales for quality of life (SF-12, COMPASS-31), mental health (DASS-21, BDI, GAD-7) revealed reduced quality of life scores affecting mental health and emotional sphere. Moreover, orthostatic intolerance, gastrointestinal dysregulation and dynamic ataxia were diagnosed by the respective questionnaires.
Treatment
- lFMS (low-Frequency Magnetic Stimulation): Administered in-clinic
- taVNS (transcutaneous auricular Vagus Nerve Stimulation) for Home Use: Alternated from left to right cymba concha every week for two weeks.
- tDCS (transcranial Direct Current Stimulation) for Home Use:
- Morning: O1 anode with Cz cathode (visual cortex)
- Noon: O2 anode with Cz cathode (visual cortex)
- Evening: Left F1 anode with right F2 cathode (for depression/anxiety)
- Protocol duration: 8 weeks, 7 days per week, 1.6 mA
Outcomes and Follow-Up
After 8 weeks of treatment, the patient showed significant improvement:
- All clinical tests returned negative results.
- Sleep quality improved.
- Resumed driving as well as co-driving.
- Able to work full-time.
- No longer provoked by lights or social settings.
Since the non-invasive brain stimulation already achieved great improvements in a short time, the treatment was continued as follows: combination of taVNS for 20 minutes at an intensity of 20 and tDCS with all three programs three times a week.
Conclusion
The patient presented with a complex vestibulo-ocular reflex disorder due to Post Traumatic Stress Disorder (PTSD). Initial attempts at diagnosis and treatment were unable to improve the patient's suffering. Through comprehensive testing at SOZO Brain Center and a targeted treatment regimen by a combination of neuromodulation techniques (lFMS, taVNS and tDCS), significant improvements in symptoms and overall quality of life were achieved. Continued management with taVNS and an adjusted tDCS protocol is recommended and currently used to maintain and promote these improvements.