Synergistic role of blood-labyrinth barrier permeability and endolymphatic hydrops: a comparative perspective in Ménière’s disease and vestibular migraine

Objective This study compares the delayed gadolinium-enhanced MRI characteristics of Ménière’s disease (MD) and vestibular migraine (VM) to develop a multiparametric model that incorporates endolymphatic hydrops (EH), blood-labyrinth barrier permeability, and their asymmetry. Additionally, it investigates the correlations between these imaging features and hearing loss across various frequencies. Methods A total of 79 patients—47 with MD and 32 with VM—were enrolled in the study between June 2023 and April 2025. All participants underwent a comprehensive medical history assessment, neurotologic evaluation, audiological testing, and a 3D SPACE FLAIR MRI conducted 4 h after the administration of intravenous gadolinium contrast agents. EH, the signal intensity ratio (SIR) of the cochlear basal turn, and the cochlear SIR asymmetry index (c-SIR AI) were assessed. Linear regression was employed to evaluate the contributions of EH and SIR to hearing loss. Additionally, a logistic regression model with ROC analysis was developed for diagnostic purposes. Results All ipsilateral ears in the MD group exhibited EH, with median cochlear and vestibular EH grades of 2 (1, 2) and 1 (1, 2), respectively. These grades were significantly higher than those observed in the VM group, where the median grades were 0 (0, 1) for both cochlear and vestibular EH (both p 0.001). MD demonstrated a unilateral predominance. The ipsilateral SIR and c-SIR AI were higher in MD compared to VM (1.39 ± 0.15 vs. 1.18 ± 0.18 and 17.24 ± 10.93 vs. 6.52 ± 3.74, both p 0.001). In MD, both EH and SIR predicted low-frequency hearing loss; with SIR being the primary predictor ( β = 68.717, p 0.001). SIR also predicted high-frequency loss (β = 80.139, p 0.001). In VM, SIR predicted thresholds across all frequencies, with the strongest correlation observed for high-frequency thresholds ( β = 79.551, p 0.001). A combined model (including cochlear EH, vestibular EH, SIR, and c-SIR AI) demonstrated high diagnostic performance, achieving a sensitivity of 76.6%, specificity of 100%, and an AUC of 0.954. Conclusion Delayed gadolinium-enhanced MRI of the inner ear facilitates the differentiation between MD and VM. The combination of EH, SIR, and c-SIR AI demonstrates excellent diagnostic performance. Notably, elevated SIR shows the strongest correlation with high-frequency hearing impairment, while cochlear EH primarily contributes to low- and mid-frequency hearing loss. By integrating imaging findings with audiological profiles, clinicians can accurately characterize cochlear pathology, enabling the development of tailored treatment strategies.