急性失衡综合征与急性前庭综合征：临床与地形学鉴别

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中文摘要

背景与目的： 卒中是对急性眩晕/头晕或失衡患者进行鉴别诊断时的主要考虑。当前诊断算法如头脉冲试验、凝视诱发性眼震和斜偏试验，是针对伴有自发性眼震（SPN）的表现进行优化的，传统上称为急性前庭综合征（AVS）。然而，近期研究显示，相当一部分卒中相关眩晕/头晕患者没有SPN，而是表现为姿势或步态失衡，这一表型最近被称为急性失衡综合征（AIS）。我们旨在概述卒中相关AIS与AVS的病理解剖学差异及其临床意义。
方法： 在LMU医院急诊科（ED）前瞻性纳入MRI证实的卒中相关急性眩晕/头晕或失衡患者。记录前庭、眼动和姿势体征（包括通过视频眼动图记录SPN的存在/强度，通过姿势描记法记录姿势失衡）。根据SPN的存在将患者分类为AIS或AVS。在Montreal Neurological Institute空间描绘卒中病灶分布，并辅以基于病灶核心的结构性失连接组映射。基于支持向量回归的多变量病灶-症状映射和失连接组映射被应用于SPN强度和摇摆路径，作为AVS和AIS的替代标志物。
结果： 在75例患者中（年龄：65.7 ± 13.3岁，40%女性），58.7%被诊断为AIS，38.7%为AVS，2.7%为中枢性位置性眩晕。在AIS中，病灶核心位于小脑前叶和小脑深部核团（小脑上动脉/小脑后下动脉供血区），通过小脑上脚连接至双侧脑桥中脑被盖。AVS卒中病灶大多位于小脑后叶/绒球小结叶（小脑后下动脉/小脑前下动脉供血区），并通过小脑下脚连接至同侧前庭核（VN）和双侧内侧纵束（MLF）。SPN强度与小脑VI-IX小叶中连接至VN和MLF的体素相关。姿势摇摆与小脑Crus I中的一个小局部簇相关。
讨论： AIS占卒中相关眩晕/头晕或失衡患者的一半以上。AIS病灶位于小脑前叶，扰乱了用于姿势和步态控制的小脑-脑桥中脑网络。AVS病灶影响小脑后叶/绒球小结叶及相关的前庭眼反射网络。识别这两种临床表型对于在急诊环境中识别所有眩晕/头晕患者中的卒中至关重要。
试验注册信息： DRKS00008992；U1111-1172-8719。

英文摘要

BACKGROUND AND OBJECTIVES: Stroke is a major differential diagnosis in patients with acute vertigo/dizziness or imbalance. Current diagnostic algorithms such as head impulse test, gaze-evoked nystagmus, and test of skew are optimized for presentations with spontaneous nystagmus (SPN), traditionally called acute vestibular syndrome (AVS). However, in recent studies, a relevant proportion of patients with stroke-related vertigo/dizziness had no SPN, but rather postural or gait imbalance, a phenotype lately termed acute imbalance syndrome (AIS). We aimed to outline the pathoanatomical differences of stroke-related AIS vs AVS and its clinical implications.
METHODS: Patients with MRI-proven stroke-related acute vertigo/dizziness or imbalance were included in this emergency department (ED) cohort study at LMU Hospital prospectively. Vestibular, ocular motor, and postural signs were documented (including SPN presence/intensity by video oculography, postural imbalance by posturography). Patients were classified as suffering from AIS or AVS based on the presence of SPN. Stroke lesion distribution was depicted in Montreal Neurological Institute space and supplemented by structural disconnectome mapping from the lesion cores. Multivariate lesion symptom-mapping based on support-vector regression and disconnectome mapping was applied for SPN intensity and sway path as surrogate markers for AVS and AIS.
RESULTS: Of 75 patients (age: 65.7 ± 13.3 years, 40% female), 58.7% were diagnosed with AIS, 38.7% with AVS, and 2.7% with central positional vertigo. In AIS, the lesion core was located in the anterior cerebellar lobe and deep cerebellar nuclei (superior cerebellar artery/posterior inferior cerebellar artery territory) connecting to the bilateral pontomesencephalic tegmentum through the superior cerebellar peduncle. AVS stroke lesions were mostly located in the posterior cerebellar/flocculonodular lobe (posterior inferior cerebellar artery/anterior inferior cerebellar artery territory) and connected to the ipsilesional vestibular nucleus (VN) and bilateral medial longitudinal fascicle (MLF) through the inferior cerebellar peduncle. SPN intensity correlated with voxels in the cerebellar lobules VI-IX connecting to VN and MLF. Postural sway was associated with a small local cluster in the cerebellar Crus I.
DISCUSSION: AIS accounts for more than half of patients with stroke-related vertigo/dizziness or imbalance. AIS lesions were located in the anterior cerebellar lobe, disturbing cerebellar-pontomesencephalic networks for posture and gait control. AVS lesions affected the posterior cerebellar/flocculonodular lobe and associated vestibulo-ocular reflex networks. Recognition of both clinical phenotypes is essential to identify all strokes among patients with vertigo/dizziness in the emergency setting.
TRIAL REGISTRATION INFORMATION: DRKS00008992; U1111-1172-8719.