以急性头晕和眩晕为表现的后循环缺血性卒中的诊断挑战。

文献信息

中文摘要

后循环卒中（PCS）是急性头晕和眩晕的常见且具有重要临床意义的病因，约占所有急性缺血性卒中的20-25%。由于PCS常表现为非特异性、波动性或孤立性前庭症状，其在急诊救治中最初被漏诊的可能性约为前循环卒中（ACS）的三倍，这对急性治疗、二级预防和患者结局具有重要影响。诊断评估进一步复杂化，原因包括院前卒中量表对后颅窝综合征的敏感性低、美国国立卫生研究院卒中量表（NIHSS）对PCS缺陷的代表性不足，以及非增强计算机断层扫描（NCCT）和弥散加权磁共振成像（DWI-MRI）在后颅窝的早期敏感性有限。相比之下，由受过培训的临床医生实施结构化床旁评估可提高识别率。然而，没有任何单一诊断路径能够覆盖所有以急性头晕和眩晕为表现的PCS患者：头脉冲、眼震和偏斜试验检查（HINTS）及其扩展的床旁听力评估（HINTS+）需要自发性或凝视诱发性眼震，基于步态和姿势的方法需要相关的姿势不稳，而一个具有临床相关性的亚组两者均不具备。本综述概述了诊疗路径中的主要诊断挑战，并强调了在表现为急性头晕和眩晕的患者中提高识别率和减少PCS漏诊的实用机会。

英文摘要

Posterior circulation stroke (PCS) is a common and clinically important cause of acute dizziness and vertigo, accounting for approximately 20-25% of all acute ischemic strokes. Because PCS frequently presents with non-specific, fluctuating, or isolated vestibular symptoms, it is about three times more likely to be initially missed in emergency care than anterior circulation stroke (ACS), with important consequences for acute treatment, secondary prevention, and patient outcomes. Diagnostic evaluation is further complicated by the low sensitivity of prehospital stroke scales for posterior fossa syndromes, the under-representation of PCS deficits on the National Institutes of Health Stroke Scale (NIHSS), and the limited early sensitivity of non-contrast computed tomography (NCCT) and diffusion-weighted magnetic resonance imaging (DWI-MRI) in the posterior fossa. In contrast, structured bedside assessment can improve recognition when applied by trained clinicians. However, no single diagnostic pathway covers all patients with PCS presenting with acute dizziness and vertigo: the Head Impulse, Nystagmus, and Test of Skew examination (HINTS) and its extension with bedside hearing assessment (HINTS+) require spontaneous or gaze-evoked nystagmus, gait and posture-based approaches require relevant postural instability, and a clinically relevant subgroup presents with neither. This review outlines the main diagnostic challenges along the care pathway and highlights practical opportunities to improve recognition and reduce missed PCS in patients presenting with acute dizziness and vertigo.