[Vestibular rehabilitation for peripheral vestibular hypofunction: an interdisciplinary consensus]. / Vestibulyarnaya reabilitatsiya pri perifericheskoi vestibulyarnoi gipofunktsii: mezhdistsiplinarnyi konsensus.

The literature review presents approaches to the management of patients with vestibular disorders. The principles of organization of vestibular rehabilitation in peripheral vestibular hypofunction, indications for appointment, factors influencing its implementation, technique, methods of evaluating effectiveness are considered in detail. Attention is drawn to the fact that the selection of exercises and the duration of vestibular rehabilitation is carried out individually and depends on many factors, including the nature of vestibular deficiency and the specific characteristics of the patient. The possibilities of using additional pharmacological therapy with histamine preparations, which can accelerate the onset of vestibular compensation, are shown. It is noted that vestibular rehabilitation is a safe and effective method of treating peripheral vestibular hypofunction and should be recommended to patients of all ages with vestibular disorders leading to limited social and physical activity.

[Bilateral peripheral vestibulopathy]. / Dvustoronnyaya perifericheskaya vestibulopatiya.

Bilateral vestibulopathy is a relatively widespread and at the same time rarely diagnosed cause of chronic postural instability. Numerous toxic factors, dysmetabolic, autoimmune and neurodegenerative processes can lead to this condition. The main clinical manifestations of bilateral vestibulopathy are balance disorders and visual disturbances (oscillopsia), which can significantly increase the risks of falls in such patients. In addition, cognitive and affective disorders, which also reduce the quality of life in patients with bilateral vestibulopathy, have been described and actively studied in recent years. The diagnosis of bilateral vestibulopathy is based on the results of a clinical neurovestibular study, including a dynamic visual acuity test and a Halmagyi test. A video head impulse test, a bithermal caloric test and a sinusoidal rotation test are used as instrumental methods confirming the dysfunction of the peripheral vestibular system. However, they are still not widespread in neurological practice. Treatment of bilateral vestibulopathy is reduced to vestibular rehabilitation. Encouraging results have been obtained in a number of studies using galvanic vestibular stimulation and the use of vestibular implants. In addition, cognitive rehabilitation methods are currently being developed, which presumably can also improve compensation for bilateral vestibular loss.

[The role of cognitive impairment in the development of balance disorders in cerebrovascular diseases]. / Rol' kognitivnykh narushenii v razvitii rasstroistv ravnovesiya pri tserebrovaskulyarnykh zabolevaniyakh.

Cerebrovascular diseases and, in particular, ischemic stroke, are an important medical and social problem, remaining not only one of the leading causes of mortality, but also often leading to severe and irreversible disability. Cerebrovascular diseases, in addition to obvious focal neurological symptoms, are manifested by cognitive disorders of varying modality and severity, among which visual-spatial disorders remain almost the least studied. Many areas of the brain are responsible for providing visual-spatial functions, some of which also take part in maintaining balance. In addition, in recent years, data have appeared on the role of damage to the vestibular system in the development of visual-spatial disorders. That is, an important condition for ensuring visual-spatial functions is probably the preservation of vestibular afferent pathways. The mechanisms of the development of visual-spatial disorders with damage to vestibular structures and their relationship with the function of maintaining balance remain almost unexplored. Disorders of visual-spatial functions in patients with cerebrovascular diseases, apparently, can make a significant contribution to the development of balance disorders and make it difficult to carry out full-fledged therapeutic and rehabilitation measures in this category of patients. Currently, the diagnosis of visual-spatial disorders is insufficiently developed. There are no universal approaches to the correction of this type of vascular (including post-stroke) cognitive disorders, as well as balance disorders that have arisen as a result of visual-spatial dysfunction. Thus, further research in this area is needed to clarify the mechanisms of formation of visual-spatial disorders, their relationship with the function of maintaining balance in cerebrovascular diseases and to develop optimal ways to correct them.

[Dizziness in Parkinson's disease]. / Golovokruzhenie pri bolezni Parkinsona.

OBJECTIVE: To study clinical features of vestibular disorders in patients with Parkinson's disease (PD) and to develop methods of their treatment. MATERIAL AND METHODS: The study included 90 patients with PD who were divided into two groups: the main group (60 patients with PD and vestibular symptoms (VS)) and the control group (30 patients with PD without VS). All patients underwent clinical neurological examination, assessment of cognitive functions, affective and autonomic disorders as well as neurovestibular examination. RESULTS: In some cases, dizziness was due to concomitant diseases of the vestibular system. Among the rest of the patients of the main group, signs of disorders of the central mechanisms of gaze control, otolith dysfunction, anxiety disorder and visuospatial dysfunction were recorded significantly more often than in the control group. The addition of vestibular rehabilitation to the complex treatment of patients of the main group helped to reduce postural instability and decreased the risk of falls. CONCLUSION: Vestibular disorders are significantly more common in patients with PD who complain of dizziness. An early detection of these disorders is feasible with the help of neurovestibular research. It is reasonable to add individually selected vestibular exercises to the complex treatment of these disorders.

[Betahistine in vestibular disorders: current concepts and perspectives]. / Sovremennye predstavleniya o roli betagistina v lechenii zabolevanii vestibulyarnoi sistemy.

The goal of this paper is to review the pharmacological profile of betahistine and evidence for using it in the treatment of common vestibular disorders. Betahistine is a weak agonist for histamine H1 receptors and strong antagonist for histamine H3 receptors. It demonstrates the maximum benefit in different types of peripheral vertigo, especially in Meniere's disease. The best results in decreasing intensity of vertigo, frequency of attacks and stimulation of vestibular compensation were obtained in daily dose 48 mg during 3 months. In benign paroxysmal positional vertigo betahistine is used to treat residual dizziness after successful treatment of otolithiasis and to reduce the severity of vertigo during repositioning maneuvers. In vestibular neuritis betahistine stimulates central compensation during vestibular rehabilitation. A new once-daily drug formulation of modified-release betahistine is non-inferior to traditional and has a comparable safety profile, and could improve patient adherence. The implication of betahistine in the treatment of central vestibular disorders is under-researched. The efficacy of betahistine in increasing of vestibular compensation in post-stroke central vestibular disorders, persistent postural-perceptual dizziness and its role in vestibular migraine need further investigation.

[Various types of vertigo and balance disorders in patients with Meniere's disease]. / Razlichnye formy golovokruzheniya i narusheniya ravnovesiya pri bolezni Men'era.

Vertigo and balance disorders in Meniere's disease (MD) may have various etiology. The aim of the review is discussing pathogenetic mechanisms of the typical vertiginous paroxysms in MD, resulting from endolymphatic hydrops as well as analysis of etiology, pathogenesis, clinical course and basic treatment of paroxysmal and permanent forms of vertigo and balance disorders, caused by other conditions, associated with MD. We discussed the course of MD complicated by vestibular migraine, benign positional paroxysmal vertigo, functional dizziness, bilateral vestibulopathy and vestibular drop-attacks.

[Bilateral vestibulopathy in elderly patients]. / Dvustoronnyaya vestibulopatiya u patsientov pozhilogo vozrasta.

Balance disorders and recurring falls are the most frequent causes of medical treatment in old age. Chronic cerebral vascular insufficiency is considered to be the cause of instability in most of these cases, and its role in the development of postural instability in old age is likely to be greatly overrated. At the same time, the role of chronic peripheral vestibular disorders, by contrast, is underestimated. The emergence in recent years of sensitive, specific and, at the same time, relatively accessible methods of diagnosing peripheral vestibulopathies has led to a much more frequent diagnosis of peripheral vestibulopathies, and their role in the development of postural instability in elderly patients is being revisited. This review considers current approaches to the diagnosis and treatment of bilateral vestibulopathy.

[Ramsay Hunt syndrome]. / Sindrom Ramseya­Khanta.

Ramsay Hunt syndrome is a complication of varicella-zoster virus infection, which manifests by geniculate ganglion involvement. Clinical presentation of Ramsay Hunt syndrome includes virus affecting external ear by vesicular rash on the ear, ear pain and peripheral facial nerve paralysis. The review presents an analysis of etiology, clinical picture and diagnosis of the disease. The clinical features of combined cranial nerve involvement, contemporary treatment and prophylaxis options are described. Early diagnosis and medical therapy is a crucial factor for positive prognosis to improve damaged nerves in Ramsay Hunt syndrome.

[A study of the efficacy and safety of a new modified-release betahistine formulation in the treatment of vestibular vertigo and Meniere's disease]. / Issledovanie effektivnosti i bezopasnosti novoi formy Betagistina s modifitsirovannym vysvobozhdeniem v lechenii vestibulyarnogo golovokruzheniya i bolezni Men'era.

OBJECTIVE: To evaluate the efficacy and safety of modified-release (MR) betahistine (48 mg once daily) versus betaserc (24 mg twice daily) in patients with Meniere's disease or vestibular vertigo. MATERIAL AND METHODS: A multicentre, double-blind, randomized clinical study in patients with an established diagnosis of Meniere's disease (35%) or vestibular vertigo (65%) was carried out. A total of 264 patients were randomized (132 in each group).The inclusion criteria were a Dizziness Handicap Inventory (DHI) total score of more than 30 points and at least 2 vertigo attacks within the previous 4 weeks. The primary efficacy variable was the change in the DHI total score from baseline to after 12 weeks of treatment. The predefined non-inferiority margin was set at 9 points for the DHI total score. RESULTS: After 12 weeks of treatment, the DHI total score was significantly (p<0.001) decreased compared with baseline, by 32.0±20.7 in the betahistine MR group and by 31.8±19.8 in the betaserc group. The adjusted difference in the change in the DHI total score with a one-sided 97.5% CI was 0.9 (--; 5.3) points, the upper confidence limit (+5.3) fell below the predefined margin of non-inferiority of 9 points, and the non-inferiority of betahistine MR to betaserc was established. The treatment groups were comparable in terms of reduced scores for the functional, emotional and physical subdomains of DHI; reduced frequency, intensity and duration of vertigo attacks; decreased proportion of patients with prolonged attacks and severe symptoms during attacks; and scores on the Clinical Global Impression - Improvement scale. The safety profile of betahistine MR was comparable to that of betaserc, the most frequently reported adverse event was headache in both treatment groups. CONCLUSION: Betahistine MR (48 mg once daily) is non-inferior to betaserc (24 mg twice daily) in patients with Meniere's disease or vestibular vertigo and has a comparable safety profile.

[Persistent postural perceptual dizziness of the elderly]. / Persistiruiushchee postural'noe pertseptivnoe golovokruzhenie v pozhilom vozraste.

Persistent postural perceptual dizziness (PPPD) is a common cause of complaints to dizziness and unitability among patients of all-ages. The disease is characterized by a permanent feeling of non-rotatory dizziness or unsteadiness that at first can be caused by an acute vestibular dizziness, somatic disturbance that causes sudden unsteadiness and loss of balance or, for example, by a panic attack. Despite the permanent feeling of unsteadiness and dizziness, a regular instrumental examination cannot reveal important changes that can explain personal feeling. The diagnosis can be made according to the diagnostic criteria developed by the International Barani Society. Treatment consists of psychotherapy, drug therapy and vestibular rehabilitation.

[A role of vascular risk factors in the development of peripheral vestibulopathy]. / Rol' faktorov serdechno-sosudistogo riska v razvitii perifericheskikh vestibulopatii.

The development of peripheral vestibular disorders are often thought to be associated with vascular mechanisms, taking into account terminal type of inner ear blood supply and other predisposing factors. A number of studies indicates a high frequency of vascular risk factors in the patients with vestibular neuronitis and benign paroxysmal positional vertigo (BPPV). According to other results, migraine is widely spread among patients with Meniere's disease and BPPV. However currently there is no evidence for casual relationship between vascular factors and development of peripheral vestibulopathy. The only exclusion is labyrinthine infarction, which develops as a result of posterior circulation disorder. More research is needed in this area.

[Acute vestibular disorder in the elderly: stroke or peripheral vestibulopathy]. / Ostroe vestibuliarnoe golovokruzhenie v pozhilom vozraste: insul't ili perifericheskaia vestibulopatiia.

Acute vestibular disorder is a frequent cause of urgent hospitalization in elderly patients. A CNS vascular disorder is often thought to be a cause of vertigo and a patient is diagnosed with stroke or transitory ischemic attack (TIA) or vertebral-basilar insufficiency. Despite the higher risk of cerebrovascular disease in the elderly, stroke and TIA are not the only cause of acute vestibular disorder. Hyperdiagnosis of cerebrovascular diseases in patients with acute vertigo often leads to underdiagnosis of peripheral vestibular disorders that could be successfully treated if timely diagnosed. The differential diagnosis of the lesions of central and peripheral vestibular systems is based on clinical examination of patients with acute vertigo including an analysis of cerebrovascular risk factors, characteristics of vertigo, nystagmus and careful identification of focal neurological symptoms.

[Vestibular disorders in patients with Parkinson's disease]. / Vestibuliarnye narusheniia pri bolezni Parkinsona.

The article addresses causes of dizziness and a role of vestibular dysfunction in the instability structure in patients with Parkinson's disease. An analysis of recent studies using various methods of neurovestibular examination suggests the development of both peripheral and central vestibular dysfunction in patients with Parkinson's disease.

[Vestibular vertigo in hemispheric strokes]. / Vestibuliarnoe golovokruzhenie pri polusharnykh insul'takh.

The literature on cases of hemispheric stroke manifesting with acute vertigo is reviewed. The authors describe a 56-year-old patient with recurrent acute vestibular syndrome due to hemispheric ischemic stroke. Imaging study revealed ischemic stroke with lesions in a parietal-occipital region of the left hemisphere. Possible mechanisms of vestibular symptoms in hemispheric lesions are discussed.

[Metavestibular disorders and disorders of higher vestibular function]. / Metavestibuliarnye rasstroistva i vestibuliarnye narusheniia vysshego urovnia.

Vertigo, instability, oscillopsia and concomitant autonomic disorders are classical and well-known symptoms of vestibular disorders. At the same time, recent studies suggest that there are more complicated vestibular dysfunctions caused by the cortical projections of the vestibular system. The central vestibular system includes parietal temporal cortex and insular, anterior intraparietal sulcus, posterior parietal and medial parts of the superior temporal gyrus, singular gyrus retrosplenial cortex, hippocampus and parahippocampal area. The central part of the vestibular system closely interacts with other afferent systems forming a multisensory structure of higher brain functions. Dysfunctions of higher vestibular function play an important role in the development of clinical syndromes including pusher syndrome, room tilt illusion, unilateral spatial neglect syndrome, impairment of spatial memory and navigation. These syndromes can develop due to the direct damage of the cortical vestibular system or as a result of disconnection between the vestibular cortex and other parts of the sensory cortex.

[Functional (psychogenic) vertigo]. / Funktsional'noe (psikhogennoe) golovokruzhenie.

Psychogenic (functional) vertigo is in second place by frequency after benign positional paroxysmal vertigo. It is often difficult to make the diagnosis, diagnostic program is expensive and traditional treatment often is not effective. This literature review covers current concepts on the terminology, clinical signs, pathogenesis and treatment approaches with regard to functional vertigo. Special attention is given to cerebral mechanisms of the pathogenesis including cognitive aspects.

[The peripheral vestibular disorders encountered in the routine out-patient practical work]. / Perifericheskie vestibuliarnye rasstroistva v ambulatornoi praktike.

The objective of the present study was to elucidate the frequency of causes underlying the development of dizziness and vertigo in the patients seeking advice and care at an outpatient healthcare facility. A total of 590 patients with complaints of dizziness and vertigo were examined. It was found out that the peripheral disorders of the vestibular analyzer were the most frequent causes of dizziness and vertigo in the majority of the examined patients. These conditions were documented to occur in more than 65% of the patients. The most common forms of peripheral vestibular disorders were benign paroxysmal positional vertigo, Meniere's disease, and vestibular neuronitis. The central vestibular disorders occurred considerably less frequently than peripheral ones and were diagnosed only in 10.9% of the patients. The results of the study provided a basis for the development of the algorithm forthe bedside examination of the patients presenting with vertigo and dizziness associated with peripheral vestibular disorders. It is emphasized that such examination should include, besides the standard neurological studies, the neuro-otological tests making it possible to detect the most common forms of peripheral vestibular disorders.

[Diagnosis and treatment of benign paroxysmal positional vertigo in common clinical practice]. / Diagnostika i lechenie bol'nykh s dobrokachestvennym paroksizmal'nym pozitsionnym golovokruzheniem v povsednevnoi klinicheskoi praktike.

AIM: To analyze typical medical practice in managing patients with benign paroxysmal positional vertigo (BPPV). SUBJECTS AND METHODS: 33 patients (5 men and 28 women; mean age, 58 years) with BPPV who had been referred for consultation to the Medical Diagnostic Department, Clinic of Nervous Diseases, I.M. Sechenov First Moscow State Medical University, regarding for vertigo, were examined. Information about the disease before visiting the clinic, such as the duration of vertigo, its pattern, and triggers, previously established diagnoses, prescribed treatment and its efficacy, concomitant diseases, was analyzed. RESULTS: BPPV was not timely diagnosed in 93.9% of cases. The cause of vertigo was most commonly mistakenly assumed to be cerebrovascular disease (66.6%) and cervical spine pathology (15.1%). During a primary examination, none of the patients underwent positional tests (otoneurological examination) that formed the basis for the diagnosis of BPPV. Alternatively, 90.3% of cases underwent instrumental examination: magnetic resonance imaging of the brain, X-ray of the cervical spine, and ultrasonic duplex scanning of the brachiocephalic arteries. Ineffective diagnosis led to the choice of nonoptimal treatment tactics: instead of therapeutic repositioning maneuvers (RM), the patients received therapy with drugs, such as various vasoactive agents (84.8%), nootropic and chondroprotective drugs (12%), or muscle relaxants (9.1%). After BPPV was detected, all patients underwent curative RM, which resulted in regression of the disease. One-year follow-up of the patients showed that the therapeutic effect of RM persisted. CONCLUSION: Lack of effective and timely diagnosis of BPPV reflects physicians' poor awareness that this condition is the most common cause of vestibular vertigo. The role of vascular and cervicogenic factors in the development of vertigo is overestimated. Most patients with BPPV undergo unreasonable examinations and receive ineffective treatment. It is necessary to raise awareness of BPPV among of physicians and to set up specialized centers for the management of patients with dizziness.

[Seven principles in the treatment of vestibular vertigo and results of the study of VIRTUOSO]. / Sem' printsipov lecheniia vestibuliarnogo golovokruzheniia i rezul'taty issledovaniia.

This article reports the results of the international post-marketing observational program VIRTUOSO aimed at the evaluation of the efficacy of betahistine dihydrochloride at the dose of 48 mg/day for 1-2 months in patients with paroxysmal vertigo of various origins. The clinical response was rated as good, very good or excellent in 74.1% of the patients (p<0.001). Monthly vertigo attack frequency with betahistine decreased in average from 8.0 to 3.0 (p<0.001). Vertigo attack frequency further decreased during the 2-month follow-up after the end of betahistine treatment. No serious adverse effects of betahistine have been reported.

[Dizziness and anxiety disorders in the elderly]. / Golovokruzhenie i trevozhnye rasstroistva u lits pozhilogo vozrasta.

Perhaps each dizzy patient feels anxiety. Varying emotional disorders are particularly common in elderly patients with dizziness. The causes of the frequent concurrence of dizziness and mental disorders (anxiety and depression) are diverse. Amongst these there are two chief conditions: 1) vestibular vertigo may cause anxiety to a greater extent than many other symptoms; 2) anxiety and depression are themselves frequently manifested by the sensations resembling vestibular ones that patients are inclined to call dizziness. On the contrary, anxiety may appear in some cases as the sensations resembling dizziness. Besides the latter, the patient may present a lot of complaints, which serves as a manifestation of psychoautonomic syndrome (the basis for which is anxiety and depression). At the same time, the term 'phobic postural instability' is proposed to describe psychogenic disorders, in which dizziness becomes virtually the only chief complaint. The treatment of dizziness and anxiety disorders in the elderly encompasses a few areas: vestibular rehabilitation, drug therapy, and psychotherapy. The paper describes the possibilities of using anvifen as a pathogenetically sound treatment in patients with anxiety disorders, as anvifen is a GABA-ergic medication.