Methylprednisolone, Valacyclovir, or the Combination for Vestibular Neuritis

Strupp, Michael
Zingler, Vera Carina
Arbusow, Viktor
Niklas, Daniel
Maag, Klaus Peter
Dieterich, Marianne
Bense, Sandra
Theil, Diethilde
Jahn, Klaus
Brandt, Thomas.

From the Departments of Neurology (M.S., V.C.Z., V.A., D.N., D.T., K.J., T.B.) and Epidemiology and Biometrics (K.P.M.), University of Munich, Munich; and the Department of Neurology, University of Mainz, Mainz (M.D., S.B.) - both in Germany. Address reprint requests to Dr. Strupp at the Department of Neurology, University of Munich, Klinikum Grosshadern, Marchioninistr. 15, 81377 Munich, Germany, or at [email protected].

New England Journal of Medicine 351(4):p 354-361, July 22, 2004. | DOI: 10.1056/NEJMoa033280

Background

Vestibular neuritis is the second most common cause of peripheral vestibular vertigo. Its assumed cause is a reactivation of herpes simplex virus type 1 infection. Therefore, corticosteroids, antiviral agents, or a combination of the two might improve the outcome in patients with vestibular neuritis.

Methods

We performed a prospective, randomized, double-blind, two-by-two factorial trial in which patients with acute vestibular neuritis were randomly assigned to treatment with placebo, methylprednisolone, valacyclovir, or methylprednisolone plus valacyclovir. Vestibular function was determined by caloric irrigation, with the use of the vestibular paresis formula (to measure the extent of unilateral caloric paresis) within 3 days after the onset of symptoms and 12 months afterward.

Results

Of a total of 141 patients who underwent randomization, 38 received placebo, 35 methylprednisolone, 33 valacyclovir, and 35 methylprednisolone plus valacyclovir. At the onset of symptoms there was no difference among the groups in the severity of vestibular paresis. The mean (+/-SD) improvement in peripheral vestibular function at the 12-month follow-up was 39.6+/-28.1 percentage points in the placebo group, 62.4+/-16.9 percentage points in the methylprednisolone group, 36.0+/-26.7 percentage points in the valacyclovir group, and 59.2+/-24.1 percentage points in the methylprednisolone-plus-valacyclovir group. Analysis of variance showed a significant effect of methylprednisolone (P<0.001) but not of valacyclovir (P=0.43). The combination of methylprednisolone and valacyclovir was not superior to corticosteroid monotherapy.

Conclusions

Methylprednisolone significantly improves the recovery of peripheral vestibular function in patients with vestibular neuritis, whereas valacyclovir does not.

N Engl J Med 2004;351

354-61.