nmpЖурнал им. Н.В. Склифосовского «Неотложная медицинская помощь»Russian Sklifosovsky Journal "Emergency Medical Care"2223-90222541-8017“N.V. Sklifosovsky Research Institute for Emergency Medicine”10.23934/2223-9022-2021-10-1-48-57nmp-1072Research ArticleОРИГИНАЛЬНЫЕ СТАТЬИORIGINAL ARTICLESКлиническая и инструментальная диагностика при остро возникшем головокруженииClinical and Instrumental Diagnostics in Patients With Acute Dizzinesshttps://orcid.org/0000-0001-9750-3509ШевченкоЕ. В.ShevchenkoE. V.

 врач-невролог, заведующий 

 Российская Федерация, 129090, Москва, Б. Сухаревская пл., д. 3 

Neurologist, Head, Junior Researcher at the Scientific Department of Emergency Neurology and Rehabilitation Treatment

 3 Bolshaya Sukharevskaya Square, Moscow 129090, Russian Federation 

shevchenkoev@sklif.mos.ruhttps://orcid.org/0000-0001-6824-4114РамазановГ. Р.RamazanovG. R.

 кандидат медицинских наук, заведующий научным отделением неотложной неврологии и восстановительного лечения, врач-невролог 

 Российская Федерация, 129090, Москва, Б. Сухаревская пл., д. 3 

Candidate of Medical Sciences, Head, Neurologist 

 3 Bolshaya Sukharevskaya Square, Moscow 129090, Russian Federation 

ramazanovgr@sklif.mos.ruhttps://orcid.org/0000-0003-3292-8789ПетриковС. С.PetrikovS. S.

член-корреспондент РАН, доктор медицинских наук, директор  

 Российская Федерация, 129090, Москва, Б. Сухаревская пл., д. 3 

 Corresponding Member of the Russian Academy of Sciences, Doctor of Medical Sciences, Director 

 3 Bolshaya Sukharevskaya Square, Moscow 129090, Russian Federation 

petrikovss@sklif.mos.ruНеврологическое отделение для больных с острыми нарушениями мозгового кровообращения с палатой реанимации и интенсивной терапии ГБУЗ «Научно-исследовательский институт скорой помощи им. Н.В. Склифосовского ДЗМ»РоссияNeurological Department with Intensive Care Unit for Patients with Acute Cerebrovascular Accidents N.V. Sklifosovsky Research Institute for Emergency Medicine of the Moscow Health DepartmentRussian Federation2021150420211014857Copyright © Шевченко Е.В., Рамазанов Г.Р., Петриков С.С., 20212021Шевченко Е.В., Рамазанов Г.Р., Петриков С.С.Shevchenko E.V., Ramazanov G.R., Petrikov S.S.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.jnmp.ru/jour/article/view/1072

ВВЕДЕНИЕ Остро возникшее головокружение (ОВГ) может быть проявлением большого числа заболеваний, среди которых как доброкачественная патология, так и жизнеугрожающие состояния, в том числе — инсульт. В  своем диагностическом поиске врач может придерживаться  двух тактик: исключения периферических  вестибулопатий (самой частой причины ОВГ) и выявления  симптомов поражения центральной нервной системы.

ЦЕЛЬ ИССЛЕДОВАНИЯ Сопоставление данных инструментальных методов исследования с клинической  картиной у пациентов с ОВГ.

МАТЕРИАЛ И МЕТОДЫ Обследовали 160 пациентов, поступивших в НИИ СП им. Н.В. Склифосовского с единственной или ведущей жалобой на головокружение.Всем больным исследовали неврологический статус, проводили позиционные маневры Дикса–Холлпайка (ДХ) и Пагнини–МакКлюра (ПМК), тест Хальмаги–Кертойза (ХК), выполняли дуплексное сканирование брахиоцефальных артерий, трансторакальную эхокардиографию, компьютерную томографию и магнитно-резонансную  томографию головного мозга. У больных с подозрением на кардиогенную причину головокружения диагностический поиск включал суточное мониторирование  электрокардиографии по Холтеру.

РЕЗУЛЬТАТЫ Частота некоторых симптомов отличалась у пациентов с острыми нарушениями мозгового  кровообращения (ОНМК) и другими заболеваниями. У  пациентов с ОНМК такой симптом, как сильная постуральная неустойчивость выявляли статистически значимо чаще, чем у больных с другими причинами головокружения (44% против 6%, p<0,05). Чувствительность и специфичность данного симптома у больных с инсультом составила 44% и 94% соответственно. Горизонтальный нистагм, меняющий направление в зависимости от установки взора, выявили у 5 пациентов с ОНМК (31%)и не наблюдали у пациентов с другими заболеваниями. Чувствительность симптома составила 31%, а специфичность — 100%. Позиционные маневры ДХ и ПМК были положительными только у пациентов с доброкачественным  пароксизмальным позиционным головокружением. 

ЗАКЛЮЧЕНИЕ Основными симптомами, позволяющими заподозрить инсульт у больных с остро возникшим  головокружением, являются постуральная неустойчивость и  горизонтальный нистагм, меняющий направление. Чувствительность и специфичность сильной постуральной  неустойчивости составила 44% и 94%, а нистагма,  меняющего направление — 31% и 100% соответственно. Положительные позиционные маневры Дикса–Холлпайка и  Пагнини–МакКлюра позволяют исключить инсульт и  установить диагноз доброкачественного пароксизмального  позиционного головокружения у пациентов с остро  возникшим головокружением. Тест Хальмаги-Кертойза может быть положительным как при периферических  вестибулопатиях (вестибулярный нейронит, синдром Меньера, лабиринтит), так и при инсульте в бассейне  передней нижней мозжечковой артерии и не может быть  применен для подтверждения периферической  вестибулопатии. Суточное мониторирование данных электрокардиографии по Холтеру позволяет выявить  нарушение проводимости сердца как причину  головокружения у пациентов с эпизодами несистемного  головокружения. 

 INTRODUCTION Acute dizziness (AD) can be a manifestation of a large number of diseases, including both benign pathology and life-threatening conditions, particularly stroke. In his diagnostic search, the doctor can adhere to two tactics: the exclusion of peripheral vestibulopathies (the most common cause of AD), and the identification of symptoms of damage to the central nervous system.

AIM OF STUDY Comparison of instrumental research methods data with the clinical picture in patients with AD.

MATERIAl AND METHODS We examined 160 patients admitted to N.V. Sklifosovsky with the only or leading complaint of dizziness. In all patients neurological status was assessed, Dix–Hallpike (DH) and Pagnini–McClure  (PMC) positional maneuvers, Halmagyi–Curthoys (HC) test, duplex scan of brachiocephalic arteries, transthoracic echocardiography, computed  tomography, and magnetic resonance imaging were performed. brain. In  patients with suspected cardiogenic cause of dizziness, the diagnostic search included 24-hour Holter ECG monitoring.

RESUlTS The frequency of some symptoms differed in patients with acute cerebrovascular accidents (ACVA) and other diseases. In patients with stroke such symptom, as postural instability was statistically more frequently detected than in patients with other causes of dizziness (44% vs. 6%, p<0.05). The sensitivity and specificity of this symptom in patients with stroke was 44% and 94%, respectively. Horizontal nystagmus, changing direction depending on the gaze setting, was detected in 5 patients with ACVA (31%) and was not observed in patients with other diseases. The sensitivity of the symptom was 31% and the specificity was 100%.Positional maneuvers of DH and PMC were positive only in patients with be-nign paroxysmal positional vertigo.

CONClUSION The main symptoms that make it possible to suspect a stroke in patients with acute dizziness are postural instability and horizontal nystagmus, which changes direction. The sensi-tivity and specificity of severe postural instability were 44% and 94%, and 31% and 100% for nystagmus  reversing direction. Positive Dix–Hallpike and Pagnini–McClure positional maneuvers can rule out stroke and establish the diagnosis of benign  paroxysmal positional vertigo in patients with acute dizziness. The Halmagyi–Curthoys test can be positive both in peripheral vestibulopathies (vestibular  neuronitis, Meniere’s syndrome, labyrinthitis), and in stroke in the basin of the anterior inferior cerebellar artery and cannot be used to confirm peripheral vestibulopathy. Holter daily monitoring of electrocardiography reveals cardiac conduction abnormalities as a cause of dizziness in patients  with episodes of non-systemic dizziness.

остро возникшее головокружениеинсультострое нарушение мозгового кровообращенияманевр Дикса–Холлпайкаманевр Пагнини–МакКлюратест Хальмаги–Кертойзааритмияacute dizzinessstrokeacute cerebrovascular accidentDix-Hallpike maneuverPagnini-McClureHalmagyi–Curthoys testarrhythmiaReferencesNewman-Toker DE, Hsieh YH, Camargo Jr CA, Pelletier AJ. Butchy GT, Edlow JA, et al. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc. 2008;83(7):765–775. PMID: 18613993 https://doi.org/10.4065/83.7.765Newman-Toker DE, Hsieh YH, Camargo Jr CA, Pelletier AJ. Butchy GT, Edlow JA, et al. Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc. 2008;83(7):765–775. PMID: 18613993 https://doi.org/10.4065/83.7.765Абдулина О.В. Частота, причины, дифференциальный диагноз, лечение и прогноз острого вестибулярного головокружения в неотложной неврологии: автореферат дис. ... канд. мед. наук. Москва; 2007. URL: https://search.rsl.ru/ru/record/01003163621 [Дата обращения 07.08.2020]Abdulina OV. Chastota, prichiny, differentsial’nyy diagnoz, lechenie i prognoz ostrogo vestibulyarnogo golovokruzheniya v neotlozhnoy nevrologii: cand. med. sci. diss. synopsis. Moscow; 2007. (in Russ.) Available at: https://search.rsl.ru/ru/record/01003163621 [Accessed 07 Aug, 2020]Herr RD, Zun L, Mathews JJ. A Directed Approach to the Dizzy Patient. Ann Emerg Med. 1989;18(6):664–672. PMID: 2729692 https://doi.org/10.1016/s0196-0644(89)80524-4Herr RD, Zun L, Mathews JJ. A Directed Approach to the Dizzy Patient. Ann Emerg Med. 1989;18(6):664–672. PMID: 2729692 https://doi.org/10.1016/s0196-0644(89)80524-4Kerber KA. Vertigo and Dizziness in the Emergency Department. Emerg Med Clin North Am. 2009;27(1):39–50. PMID: 19218018 https://doi.org10.1016/j.emc.2008.09.002Kerber KA. Vertigo and Dizziness in the Emergency Department. Emerg Med Clin North Am. 2009;27(1):39–50. PMID: 19218018 https://doi.org10.1016/j.emc.2008.09.002Saber Tehrani AS, Kattah JC, Mantokoudis FG, Pula JH, Nair D, Blitz A. et al. Small strokes causing severe vertigo Frequency of false-negative MRIs and nonlacunar mechanisms. Neurology. 2014;83(2):169–173. PMID: 24920847 https://doi.org/10.1212/wnl.0000000000000573Saber Tehrani AS, Kattah JC, Mantokoudis FG, Pula JH, Nair D, Blitz A, et al. Small strokes causing severe vertigo Frequency of false-negative MRIs and nonlacunar mechanisms. Neurology. 2014;83(2):169–173. PMID: 24920847 https://doi.org/10.1212/wnl.0000000000000573Kattah JC, Talkad AV, Wang DZ, Hsieh Yu-H, Newman-Toker DE. HINTS to Diagnose Stroke in the Acute Vestibular Syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504–3510. PMID: 19762709 https://doi.org/10.1161/strokeaha.109.551234Kattah JC, Talkad AV, Wang DZ, Hsieh Yu-H, Newman-Toker DE. HINTS to Diagnose Stroke in the Acute Vestibular Syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504–3510. PMID: 19762709 https://doi.org/10.1161/strokeaha.109.551234Newman-Toker DE, Kattah JC, Alvernia JE, David ZW, et al. Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology. 2008;70(24Pt2):2378-2385. PMID: 18541870 https://doi.org/ 10.1212/01.wnl.0000314685.01433.0dNewman-Toker DE, Kattah JC, Alvernia JE, David ZW, et al. Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology. 2008;70(24Pt2):2378–2385. PMID: 18541870 https://doi.org/ 10.1212/01.wnl.0000314685.01433.0dKerber KA, Brown DL, Lisabeth LD, Smith MA, Morgenstern LB. Stroke Among Patients with Dizziness, Vertigo, and Imbalance in the Emergency Department: a population based study. Stroke. 2006;37(10):2484–2487. PMID: 16946161 https://doi.org/10.1161/01.str.0000240329.48263.0dKerber KA, Brown DL, Lisabeth LD, Smith MA, Morgenstern LB. Stroke Among Patients with Dizziness, Vertigo, and Imbalance in the Emergency Department: a population based study. Stroke. 2006;37(10):2484–2487. PMID: 16946161 https://doi.org/10.1161/01.str.0000240329.48263.0dNorrving B, Magnusson M, Holtis S. Isolated acute vertigo in the elderly; vestibular or vascular disease? Acta Neurol Scand. 1995;91(1):43–48. PMID: 7732773 https://doi.org/10.1111/j.1600-0404.1995.tb05841.xNorrving B, Magnusson M, Holtis S. Isolated acute vertigo in the elderly; vestibular or vascular disease? Acta Neurol Scand. 1995;91(1):43–48. PMID: 7732773 https://doi.org/10.1111/j.1600-0404.1995.tb05841.xLee H, Sohn S-I, Cho Y-W, Lee S-R, Ahn B-H, Park B-R, et al. Cerebellar infarction presenting isolated vertigo: frequency and vascular topographical patterns. Neurology. 2006;67(7):1178–1183. PMID: 17030749 https://doi.org/10.1212/01.wnl.0000238500.02302.b4Lee H, Sohn S-I, Cho Y-W, Lee S-R, Ahn B-H, Park B-R, et al. Cerebellar infarction presenting isolated vertigo: frequency and vascular topographical patterns. Neurology. 2006;67(7):1178–1183. PMID: 17030749 https://doi.org/10.1212/01.wnl.0000238500.02302.b4Dieterich M, Brandt T. Why acute unilateral vestibular cortex lesions mostly manifest without vertigo. Neurology. 2015;84(16):1680–1684. PMID: 25817840 https://doi.org/10.1212/wnl.0000000000001501Dieterich M, Brandt T. Why acute unilateral vestibular cortex lesions mostly manifest without vertigo. Neurology. 2015;84(16):1680–1684. PMID: 25817840 https://doi.org/10.1212/wnl.0000000000001501Kase CS, White JL, Joslyn JN, Williams JP, Mohr JP. Cerebellar infarction in the superior cerebellar artery distribution. Neurology. 1985;35(5):705–711. PMID: 3990968 https://doi.org/10.1212/wnl.35.5.705Kase CS, White JL, Joslyn JN, Williams JP, Mohr JP. Cerebellar infarction in the superior cerebellar artery distribution. Neurology. 1985;35(5):705–711. PMID: 3990968 https://doi.org/10.1212/wnl.35.5.705Шевченко Е.В., Рамазанов Г.Р., Петриков С.С. Причины голово¬кружения у больных с подозрением на острое нарушение мозгового кровообращения. Журнал им. Н.В. Склифосовского «Неотложная медицинская помощь». 2018;7(3):217–221. https://doi.org/10.23934/2223-9022-2018-7-3-217-221Shevchenko EV, Ramazanov GR, Petrikov SS. Сauses of Dizziness in Patients with Suspected Stroke. Russian Sklifosovsky Journal Emergency Medical Care. 2018;7(3):217–221. https://doi.org/10.23934/2223-9022-2018-7-3-217-221Derebery MJ. The diaganosis and treatment of dizziness. Med Clin North Am. 1999;83(1):163–177. PMID: 9927968 https://doi.org/10.1016/s0025-7125(05)70095-xDerebery MJ. The diaganosis and treatment of dizziness. Med Clin North Am. 1999;83(1):163–177. PMID: 9927968 https://doi.org/10.1016/s0025-7125(05)70095-xRubenstein RL, Norman DM, Schindker RA, Kaseff L. Cerebellar infarction: a presentation of vertigo. Laryngoscope. 1980;90(3):505-514. PMID:7359972 https://doi.org/10.1002/lary.5540900319Rubenstein RL, Norman DM, Schindker RA, Kaseff L. Cerebellar infarction: a presentation of vertigo. Laryngoscope. 1980;90(3):505–514. PMID: 7359972 https://doi.org/10.1002/lary.5540900319Strupp M, Brandt T. Diagnosis and Treatment of Vertigo and Dizziness. Dtsch Arztebl Int. 2008;105(10):173–180. PMID: 19629221 https://doi.org/10.3238/arztebl.2008.0173Strupp M, Brandt T. Diagnosis and Treatment of Vertigo and Dizziness. Dtsch Arztebl Int. 2008;105(10):173–180. PMID: 19629221 https://doi.org/10.3238/arztebl.2008.0173Cnyrim CD, Newman-Toker D, Karch C, Brandt T, Struppet M. Bedside differentiation of vestibular neuritis from central ‘‘vestibular pseudoneuritis’’. J Neurol Neurosurg Psychiatry. 2008;79(4):458–460. PMID: 18344397 https://doi.org/10.1136/jnnp.2007.123596Cnyrim CD, Newman-Toker D, Karch C, Brandt T, Struppet M. Bedside differentiation of vestibular neuritis from central ‘‘vestibular pseudoneuritis’’. J Neurol Neurosurg Psychiatry. 2008;79(4):458–460. PMID: 18344397 https://doi.org/10.1136/jnnp.2007.123596Брандт Т., Дитерих М., Штрупп М. Головокружение. Москва: Практика; 2009.Brandt T, Diterikh M, Shtrupp M. Golovokruzhenie. Moscow: Praktika Publ.; 2009. (in Russ.)Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg, 2017;156(3 Suppl):S1–S47. PMID: 28248609 https://doi.org/10.1177/0194599816689667Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017;156(3 Suppl):S1–S47. PMID: 28248609 https://doi.org/10.1177/0194599816689667Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusae RJ, at al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008;70(22):2067–2074. PMID: 18505980 https://doi.org/10.1212/01.wnl.0000313378.77444.acFife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusae RJ, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008;70(22):2067–2074. PMID: 18505980 https://doi.org/10.1212/01.wnl.0000313378.77444.acHanley K, O’Dowd T. Symptoms of vertigo in general practice: a prospective study of diagnosis. Br J Gen Pract. 2002;52(483):809–812. PMID: 12392120Hanley K, O’Dowd T. Symptoms of vertigo in general practice: a prospective study of diagnosis. Br J Gen Pract. 2002;52(483):809–812. PMID: 12392120Evren C, Demirbilek N, Elbistanl MS, Köktürk F, Mustafa Ç. Diagnostic value of repeated Dix-Hallpike and roll maneuvers in benign paroxysmal positional vertigo. Braz J Otorhinolaryngol. 2016; 83(3):243–248. PMID: 27170347 https://doi.org/10.1016/j.bjorl.2016.03.007Evren C, Demirbilek N, Elbistanl MS, Köktürk F, Mustafa Ç. Diagnostic value of repeated Dix-Hallpike and roll maneuvers in benign paroxysmal positional vertigo. Braz J Otorhinolaryngol. 2016; 83(3):243–248. PMID: 27170347 https://doi.org/10.1016/j.bjorl.2016.03.007Alvarenga GA, Barbosa MA, Porto СС. Benign Paroxysmal Positional Vertigo without nystagmus: diagnosis and treatment. Braz J Otorhinolaryngol. 2011;77(6):799–804. PMID: 22183288Alvarenga GA, Barbosa MA, Porto СС. Benign Paroxysmal Positional Vertigo without nystagmus: diagnosis and treatment. Braz J Otorhinolaryngol. 2011;77(6):799–804. PMID: 22183288Strupp M, Brandt T. Vestibular Neuritis. Semin Neurol. 2009;29(5):509–519. PMID: 19834862 https://doi.org/10.1055/s-0029-1241040Strupp M, Brandt T. Vestibular Neuritis. Semin Neurol. 2009;29(5):509–519. PMID: 19834862 https://doi.org/10.1055/s-0029-1241040Jeong SH, Kim HJ, Kim JS. Vestibular neuritis. Semin Neurol. 2013;33(3):185–194. PMID: 24057821 https://doi.org/10.1055/s-0033-1354598Jeong SH, Kim HJ, Kim JS. Vestibular neuritis. Semin Neurol. 2013;33(3):185–194. PMID: 24057821 https://doi.org/10.1055/s-0033-1354598Sekitani T, Imate Y, Noguchi T, Inokuma T. Vestibular neuronitis: epidemiological survey by questionnaire in Japan. Acta Otolaryngol Suppl. 1993;503:9–12. PMID: 8470507 https://doi.org/10.3109/00016489309128061Sekitani T, Imate Y, Noguchi T, Inokuma T. Vestibular neuronitis: epidemiological survey by questionnaire in Japan. Acta Otolaryngol Suppl. 1993;503:9–12. PMID: 8470507 https://doi.org/10.3109/00016489309128061Aw ST, Fetter M, Cremer PD, Karlberg M, Halmagyi GM, et al. Individual semicircular canal function in superior and inferior vestibular neuritis. Neurology. 2001;57(5):768–774. PMID: 11552001 https://doi.org/10.1212/wnl.57.5.768Aw ST, Fetter M, Cremer PD, Karlberg M, Halmagyi GM, et al. Individual semicircular canal function in superior and inferior vestibular neuritis. Neurology. 2001;57(5):768–774. PMID: 11552001 https://doi.org/10.1212/wnl.57.5.768Halmagyi GM, Aw ST, Cremer PD, Curthoys IS, Toddet MJ. Impulsive testing of individual semicircular canal function. Ann NY Acad Sci. 2001;942:192–200. PMID: 11710461 https://doi.org/10.1111/j.1749-6632.2001.tb03745.xHalmagyi GM, Aw ST, Cremer PD, Curthoys IS, Toddet MJ. Impulsive testing of individual semicircular canal function. Ann NY Acad Sci. 2001;942:192–200. PMID: 11710461 https://doi.org/10.1111/j.1749-6632.2001.tb03745.xHalmagyi GM, Black RA, Thurtell MJ, Curthoys IS. The human horizontal vestibulo-ocular reflex in response to active and passive head impulses after unilateral vestibular deafferentation. Ann NY Acad Sci. 2003;1004:325–336. PMID: 14662472 https://doi.org/ 10.1196/annals.1303.030Halmagyi GM, Black RA, Thurtell MJ, Curthoys IS. The human horizontal vestibulo-ocular reflex in response to active and passive head impulses after unilateral vestibular deafferentation. Ann NY Acad Sci. 2003;1004:325–336. PMID: 14662472 https://doi.org/10.1196/annals.1303.030Jorns-Häderli M, Straumann D, Palla A. Accuracy of the bedside head impulse test in detecting vestibular hypofunction. J Neurol Neurosurg Psychiatry. 2007;78(10):1113–1118. PMID: 17220287 https://doi.org/10.1136/jnnp.2006.109512Jorns-Häderli M, Straumann D, Palla A. Accuracy of the bedside head impulse test in detecting vestibular hypofunction. J Neurol Neurosurg Psychiatry. 2007;78(10):1113–1118. PMID: 17220287 https://doi.org/10.1136/jnnp.2006.109512Perez N, Rama-Lopez J. Head-impulse and caloric tests in patients with dizziness. Otol Neurotol. 2003;24(6):913–917. PMID: 14600474 https://doi.org/10.1097/00129492-200311000-00016Perez N, Rama-Lopez J. Head-impulse and caloric tests in patients with dizziness. Otol Neurotol. 2003;24(6):913–917. PMID: 14600474 https://doi.org/10.1097/00129492-200311000-00016Lopez-Escamez JA, Carey J, Chung W-H, Goebel JA, Magnusson M, Mandalà M, et al. Diagnostic criteria for Menière’s disease. J Vestib Res. 2015;25(1):1–7. PMID: 25882471 https://doi.org/10.3233/VES-150549Lopez-Escamez JA, Carey J, Chung W-H, Goebel JA, Magnusson M, Mandalà M, et al. Diagnostic criteria for Menière’s disease. J Vestib Res. 2015;25(1):1–7. PMID: 25882471 https://doi.org/10.3233/VES-150549Kingma H, Meulenbroeks A, De Jong I. Vestibular ocular reflexes in Ménière’s disease patients evaluated by passive high frequency head rotation (yaw) and sidewards acceleration. Acta Otolaryngol Suppl. 2000;544:19–26. PMID: 10904797 https://doi.org/10.1080/000164800750044443-1Kingma H, Meulenbroeks A, De Jong I. Vestibular ocular reflexes in Ménière’s disease patients evaluated by passive high frequency head rotation (yaw) and sidewards acceleration. Acta Otolaryngol Suppl. 2000;544:19–26. PMID: 10904797 https://doi.org/10.1080/000164800750044443-1Lee SU, Kim HJ, Koo JW, Kim Ji-S. Comparison of caloric and head-impulse tests during the attacks of Meniere’s disease. Laryngoscope. 2017;127(3):702–708. PMID: 27311766 https://doi.org/10.1002/lary.26103Lee SU, Kim HJ, Koo JW, Kim Ji-S. Comparison of caloric and head-impulse tests during the attacks of Meniere’s disease. Laryngoscope. 2017;127(3):702–708. PMID: 27311766 https://doi.org/10.1002/lary.26103Pula JH, Newman-Toker DE, Kattah JC. Multiple sclerosis as a cause of the acute vestibular syndrome. J Neurol. 2013;260(6):1649–1654. PMID: 23392781 https://doi.org/10.1007/s00415-013-6850-1Pula JH, Newman-Toker DE, Kattah JC. Multiple sclerosis as a cause of the acute vestibular syndrome. J Neurol. 2013;260(6):1649–1654. PMID: 23392781 https://doi.org/10.1007/s00415-013-6850-1Jauch EC, Saver JL, Adams Jr HP, Bruno A, Connors B JJ, Demaerschalk BM, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870–947. PMID: 23370205 https://doi.org/10.1161/STR.0b013e318284056aJauch EC, Saver JL, Adams Jr HP, Bruno A, Connors B JJ, Demaerschalk BM, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44(3):870–947. PMID: 23370205 https://doi.org/10.1161/STR.0b013e318284056aМинистерство Здравоохранения. Приказ N 928н от 15.11.2012. Об утверждении Порядка оказания медицинской помощи больным с острыми нарушениями мозгового кровообращения. URL: https://base.garant.ru/70334856/ [Дата обращения 07.08.2020]Ministerstvo Zdravookhraneniya. Prikaz No 928n ot 15.11.2012. “Ob utverzhdenii Poryadka okazaniya meditsinskoy pomoshchi bol’nym s ostrymi narusheniyami mozgovogo krovoobrashcheniya”. (in Russ.) Available at: https://base.garant.ru/70334856/ [Accessed 07 Aug, 2020]Kerber KA, Burke JF, Brown DL, Meurer WJ, Smith MA, Lisabeth LD, et al. Does Intracerebral Hemorrhage Mimic Benign Dizziness Presentation? A Population Based Study. Emerg Med J. 2012;29(1):43–46. PMID: 21245473 https://doi.org/10.1136/emj.2010.104844Kerber KA, Burke JF, Brown DL, Meurer WJ, Smith MA, Lisabeth LD, et al. Does Intracerebral Hemorrhage Mimic Benign Dizziness Presentation? A Population Based Study. Emerg Med J. 2012;29(1):43–46. PMID: 21245473 https://doi.org/10.1136/emj.2010.104844Amarenco P, Hauw JJ. Cerebellar infarction in the territory of the superior cerebellar artery: a clinicopathologic study of 33 cases. Neurology. 1990;40(9):1383–1390. PMID: 2392223 https://doi.org/10.1212/wnl.40.9.1383Amarenco P, Hauw JJ. Cerebellar infarction in the territory of the superior cerebellar artery: a clinicopathologic study of 33 cases. Neurology. 1990;40(9):1383–1390. PMID: 2392223 https://doi.org/10.1212/wnl.40.9.1383Rane NJ, McAuley D. Vertebral artery dissection presenting as isolated vertigo. Emerg Med J. 2007;24(10):732. PMID: 17901283 https://doi.org/10.1136/emj.2007.046946Rane NJ, McAuley D. Vertebral artery dissection presenting as isolated vertigo. Emerg Med J. 2007;24(10):732. PMID: 17901283 https://doi.org/10.1136/emj.2007.046946Gordon M. Occult Cardiac Arrhvthmias Associated with Falls and Dizziness in the Elderly: Detection by Holter Monitoring. J Am Geriatr Soc. 1978;26(9):418–423. PMID:681659 https://doi.org/10.1111/j.1532-5415.1978.tb05390.xGordon M. Occult Cardiac Arrhvthmias Associated with Falls and Dizziness in the Elderly: Detection by Holter Monitoring. J Am Geriatr Soc. 1978;26(9):418–423. PMID:681659 https://doi.org/10.1111/j.1532-5415.1978.tb05390.xLipski J, Coher L, Espinoza J, Motro M, Dack S, Donoso E, et al. Value of Holter Monitoring in Assessing Cardiac Arrhythmias in Symptomatic Patients. Am J Cardiol. 1976;37(1):102–107. PMID: 1244726 https://doi.org/10.1016/0002-9149(76)90507-5Lipski J, Coher L, Espinoza J, Motro M, Dack S, Donoso E, et al. Value of Holter Monitoring in Assessing Cardiac Arrhythmias in Symptomatic Patients. Am J Cardiol. 1976;37(1):102–107. PMID: 1244726 https://doi.org/10.1016/0002-9149(76)90507-5

The authors declare that there are no conflicts of interest present.