I have developed "tennis elbow" from lugging this book around the past four weeks, but it is worth the pain, the effort, and the aspirin. It is also worth the (relatively speaking) bargain price. Including appendixes, this book contains 894 pages of text. The entire panorama of the neural sciences is surveyed and examined, and it is comprehensive in its scope, from genomes to social behaviors. The editors explicitly state that the book is designed as "an introductory text for students of biology, behavior, and medicine," but it is hard to imagine any audience, interested in any fragment of neuroscience at any level of sophistication, that would not enjoy this book. The editors have done a masterful job of weaving together the biologic, the behavioral, and the clinical sciences into a single tapestry in which everyone from the molecular biologist to the practicing psychiatrist can find and appreciate his or

Principles of Neural Science

Benign paroxysmal positional vertigo (BPPV) is characterized by brief recurrent episodes of vertigo triggered by changes in head position. BPPV is the most common etiology of recurrent vertigo and is caused by abnormal stimulation of the cupula by free-floating otoliths (canalolithiasis) or otoliths that have adhered to the cupula (cupulolithiasis) within any of the three semicircular canals. Typical symptoms and signs of BPPV are evoked when the head is positioned so that the plane of the affected semicircular canal is spatially vertical and thus aligned with gravity. Paroxysm of vertigo and nystagmus develops after a brief latency during the Dix-Hallpike maneuver in posterior-canal BPPV, and during the supine roll test in horizontal-canal BPPV. Positioning the head in the opposite direction usually reverses the direction of the nystagmus. The duration, frequency, and symptom intensity of BPPV vary depending on the involved canals and the location of otolithic debris. Spontaneous recovery may be expected even with conservative treatments. However, canalithrepositioning maneuvers usually provide an immediate resolution of symptoms by clearing the canaliths from the semicircular canal into the vestibule.

/pdf/benign-paroxysmal-positional-vertigo-1zak06s8wa.pdf

Benign Paroxysmal Positional Vertigo

OBJECTIVE: To evaluate patients after blunt trauma of the head, neck, and craniocervical junction (without fractures) with vertigo and to report the results of treatment after extensive diagnostics. STUDY DESIGN: Prospective study of consecutive new cases with vertigo after trauma at different periods of onset. During 2000-2002, 63 patients were examined and treated. SETTING: Regional trauma medical center for the greater Berlin Area, tertiary referral unit. RESULTS: The primary disorders included labyrinthine concussion (18), rupture of the round window membrane (6), and cervicogenic vertigo (12). The secondary disorders included otolith disorders (5), delayed endolymphatic hydrops (12), and canalolithiasis (9). The patients were free of vertigo symptoms (except cervicogenic and otolith disorder) after treatment, which consisted of habituation training, medical and surgical therapy options. The follow-up was 1 year. CONCLUSION: Posttraumatic vertigo can be treated with a high success rate once the underlying disorder has been identified. The extent of the neurotological test battery determines the precision and quality of diagnostics. Surgical measures should be an integral part of treatment modalities if conservative treatment is not effective. SIGNIFICANCE: Minor trauma of the head, neck, and craniocervical junction can have major impact on the vestibular system at different sites. Patients need to be carefully diagnosed, even if the onset of vertigo occurs a few weeks or months after the initial trauma.

Management of posttraumatic vertigo.

The prevalence of vertigo and dizziness in people aged more than 60 years reaches 30%, and due to aging of world population, the number of patients is rapidly increasing. The presence of dizziness in the elderly is a strong predictor of falls, which is the leading cause of accidental death in people older than 65 years. Balance disorders in the elderly constitute a major public health problem, and require an adequate diagnosis and management by trained physicians. In the elderly, common causes of vertigo may manifest differently, as patients tend to report less rotatory vertigo and more nonspecific dizziness and instability than younger patients, making diagnosis more complex. In this mini review, age-related degenerative processes that affect balance are presented. Diagnostic and therapeutic approaches oriented to the specific impaired system, including visual, proprioceptive, and vestibular pathways are proposed. In addition, presbystasis -the loss of vestibular and balance functions associated with aging-, benign paroxysmal positional vertigo, and stroke (in acute syndromes) should always be considered.

/pdf/vertigo-and-dizziness-in-the-elderly-1u2itfa5mu.pdf

Vertigo and Dizziness in the Elderly

Vestibular dysfunction causes postural instability, which is prevalent in the elderly. We previously showed that an imperceptible level of noisy galvanic vestibular stimulation (nGVS) can improve postural stability in patients with bilateral vestibulopathy during the stimulus, presumably by enhancing vestibular information processing. In this study, we investigated the after-effects of an imperceptible long-duration nGVS on body balance in elderly adults. Thirty elderly participants underwent two nGVS sessions in a randomised order. In Session 1, participants received nGVS for 30 min twice with a 4-h interval. In Session 2, participants received nGVS for 3 h. Two-legged stance tasks were performed with eyes closed while participants stood on a foam rubber surface, with and without nGVS, and parameters related to postural stability were measured using posturography. In both sessions, the postural stability was markedly improved for more than 2 h after the cessation of the stimulus and tended to decrease thereafter. The second stimulation in Session 1 caused a moderate additional improvement in body balance and promoted the sustainability of the improvement. These results suggest that nGVS can lead to a postural stability improvement in elderly adults that lasts for several hours after the cessation of the stimulus, probably via vestibular neuroplasticity.

/pdf/noisy-galvanic-vestibular-stimulation-induces-a-sustained-33svu443xc.pdf

Noisy galvanic vestibular stimulation induces a sustained improvement in body balance in elderly adults.

The vestibular system is part of themultisensory balance sense, which is responsible for postural control, gaze stabilization, and spatial orientation. In particular, the vestibulo-ocular reflex (VOR) is responsible for generating compensatory eyemovements relative to headmovements while moving. In patients with a bilateral loss of vestibular function, the VOR is absent or very weak. As a consequence, such patients complain about oscillopsia, the illusory perception of movement of the visual surroundings in dynamic situations. The direct functional consequence of this is an abnormal decrease of visual acuity when in movement (Lambert et al., 2010; Guinand et al., 2012), which translates into difficulty in reading signs and recognizing faces while walking. This considerably contributes to a significant impairment of the quality of life of affected patients. Currently, there is no evidence of an effective treatment for these patients. The idea of electrically stimulating the vestibular system emerged about a decade ago and is based on a concept very similar to that of cochlear implants. Briefly, such a system would use inertial sensors (i.e. a gyroscope and/or accelerometer) to detect motion information. Such information is translated into a pattern of neural excitation code by an external signal processor. This pattern is wirelessly transmitted to an implanted stimulator which finally delivers the corresponding patterns of electrical stimulation via electrodes implanted near the vestibular structures in the neural system. The translation of the cochlear implant concept into a device suitable for stimulating the vestibular system requires two steps: (1) adaptation of the electrode topology to the neural target to be stimulated, and (2) transformation of the pertinent input signal (in this case motion) into a signal that can be processed by the audio processor of a standard cochlear implant. Today, both steps have been completed. A modified cochlear implant providing 1–3 extracochlear electrodes was developed in collaboration with MED-EL (Innsbruck, Austria). Our research group has developed the necessary interfaces to capture the signal coming from a gyroscope and use it to modulate the stimulation signals delivered by the cochlear implant stimulator (Geneva University Hospitals: Device and method for electrical stimulation of neural or muscular tissue; 2013-01-30; European Patent Application 13153300.2-1652). A number of studies have contributed to establish the feasibility of the idea of restoring semicircular canal function via electrical stimulation in animal models. At the same time, several important steps have been taken towards the development of a system allowing for the chronic stimulation of the vestibular system in human patients. For example, special extralabyrinthine (Kos et al., 2006) and intralabyrinthine (Van de Berg et al., 2012) surgical techniques have been developed and the feasibility of electrical stimulation of vestibular structures has been demonstrated both in acute (Guyot et al., 2011a) and chronic configurations (Guyot et al., 2011b). To date, seven volunteer patients with a profound bilateral vestibular loss have received a custom-modified cochlear implant in which one or three electrodes are in contact with the vestibular structures (see Table 1). In addition, since hearing loss due to the implantation of electrodes near the vestibular system remains an important concern, patients were also profoundly deaf in the implanted ear. Two patients (BVL1 and BVL2) were implanted using the intralabyrinthine approach (Van de Berg et al., 2012) in Maastricht (Ethics committee protocol NL36777.068.11/METC 11-2-031). Five patients (BVL3–BVL7) were implanted using the extralabyrinthine approach (Kos et al., 2006) in Geneva (Ethics Committee protocol NAC 11-080). Correspondence to: Marco Pelizzone, Department of Otorhinolaryngology, Head and Neck Surgery, Geneva University Hospital, Geneva, Switzerland. Email: marco.pelizzone@hcuge.ch

/pdf/first-functional-rehabilitation-via-vestibular-implants-n8o3ebewnl.pdf

First functional rehabilitation via vestibular implants

CONCLUSION: The singular neurectomy as described by Gacek in 1974 is an efficient procedure to control symptoms in case of intractable benign paroxysmal positional vertigo (BPPV), with an acceptable risk of postoperative sensorineural hearing loss (SNHL). We postulate that this complication may not be a direct consequence of the surgical procedure but rather may be consecutive to the reactivation of the biological phenomenon that caused the BPPV. We also observed in one patient that BPPV may exist although no nystagmus can be elicited by provocative manoeuvres. OBJECTIVE: To report our experience of the surgery, and to analyse the rate and causes of complications. PATIENTS AND METHODS: The eight patients operated in the department between August 1997 and April 2006 were evaluated in June 2006. One had been operated because he had a typical history of BPPV, but no nystagmus could be elicited by the Hallpike's manoeuvre. RESULTS: All patients were free of vertigo and considered their quality of life improved. The Hallpike's manoeuvre was negative in all cases. A SNHL occurred in two patients, immediately after surgery in one and several months later in the second. The patient with a negative Hallpike's manoeuvre before surgery went back to work 3 weeks after surgery.

Benign paroxysmal positional vertigo: a series of eight singular neurectomies.

The sudden unilateral loss of vestibular function is a frequent cause of vertigo. This condition is called vestibular neuronitis or vestibular neuritis. Its cause remains unknown, but many authors consider it to be a sequel of vestibular viral infection. We report the history and clinical findings of 5 patients in whom a unilateral vestibular loss occurred after head trauma. None of these patients complained of hearing loss. In all cases, the vertigo gradually subsided over days or weeks. The follow-up showed the partial recovery of vestibular function in 2 cases, while vestibular areflexia persisted in 3. The clinical course and findings were similar in every respect to those in patients with classic idiopathic vestibular neuronitis.

Isolated vestibular areflexia after blunt head trauma.

Currently there is no efficient treatment for patients with severe bilateral vestibular function impairment Presence of oscillopsia is their main complaint It has a significant negative impact on their quality of life Recently it has been shown that angular vestibulo-ocular reflex can be partially restored in animals In humans it is possible to elicit a nystagmic response by electric stimulation of ampullary parts of the vestibular nerve Controlled eye movements can be generated by frequency and intensity modulation of the restored baseline firing rate of the vestibular nerve During adaptation phase to the electric stimulus, patients experience nystagmus with associated inconveniences By repetition of “on/off periods” the duration of the adaptation phase can be significantly decreased Results show that permanent electric stimulation is necessary to maintain this “optimal” adaptation state

Vestibular implants: The first steps in humans

Jugular and tympanic paragangliomas are the most frequent tumors of the middle ear. They appear as a reddish, pulsatile, retrotympanic mass. Patients complain from hearing loss and pulsatile tinnitus. Tumors are most often benign. Secretory forms are rare. Angio-MRI and CT-scan are gold standard. MIBG or octreotid scintigraphies are helpful to rule out multiple lesions. The treatment consists in surgery alone, radiotherapy alone or association of both. Often, embolisation prior to surgery decreases hemorrhagic risks. Vital prognosis is good. The functional outcome is critical in extensive tumors.

Jugular and tympanic paragangliomas

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