| Backgrouds:As one of the most common disease in neurology,acute vestibular syndrome(AVS)may affect the daily life and work of patients when the syndrome is severe.It can be divided into two categories according to the etiology:peripheral and central.There are great differences in treatment and prognosis between them,and sometimes the differential diagnosis is difficult since infarction of cerebellum or brain stem may cause similar signs to that of peripheral vestibulopathy.It is easy to misdiagnose to cause serious clinical consequencesObjectives:Aim to find special clinical featues helpful to differentiate peripheral and central vestibular lesions.These features must be simple and feasible to practice.Methods:We retrospectively analyze clinical charaters(including name,sex,age,previous stroke or transient ischemic attack,diabetes,ischemic heart disease,hyperlipidemia,hypertension,vertigo history,history of smoking and alcohol use,family migraine history),neurological physical examinations and vestibular function examinations of inpatients with AVS attending to Shandong Qianfoshan Hospital.According to the clinical data of all the patients,the subjects were divided into central and peripheral vertigo groups(c-AVS and p-AVS).Then clinical features of the two goups were comparedand analyzed.Results:A total of 224 patients with acute vestibular syndrome were included in this study.The clinical features of the patients with central or peripheral lesions in 208 patients were analyzed statistically:(1)The age range was 33 to 83 years old,the median age was 62 years old,the peak age of onset was 50-79 years old,accounting for 79.2%of the total number of patients.Few patients younger than 40,or older than 80 years old were hospitalized.(3)A total of 26 cases(12.5%)with cerebellum/brainstem lesions were diagnosed,of which there were 14 cases of cerebellar infarction,2 cases of cerebellar hemorrhage,6 cases of medullary infarction,2 cases of pontine infarction and 2 cases of cerebellar&pontine infarction.A total of 182 cases with non-cerebellum/brainstem lesions were diagnosed,accounting for 87.5%,of which there were 2 cases of sudden deafness,28 cases of benign paroxysmal positional vertigo,16 cases of Meniere's disease,30 cases of migrainous vertigo,46 cases of vestibular neuritis,12 cases of vestibular paroxysmia,48 cases of unknown causes.(4)A total of 26 cases with c-AVS and 182 cases with p-AVS were diagnosed.Patients with more than 2 vascular risk factors take a larger proportion in c-AVS group(84.6%VS 31.3%,p=0.000),whreas patients with variable features of nystagmus take a smaller proportion.Patients with either previous vertigo history or positive head impulse test take a larger proportion in p-AVS group(39.6%vs 0%,p=0.000;28.2%vs 0%,p=0.004,respectively).Conclusions:(1)AVS of inpatients is mainly caused by peripheral vestibular lesions other than central lesions,especially by vestibular neuronitis and benign paroxysmal positional vertigo.Infarctions of cerebellum and brain stem are responsible for the majority of central lesions.Isolated vertigo is mainly caused by minor cerebellar infarction.(2)There was no significant difference in age between the patients with c-AVS and p-AVS.More patients with two or more vascular risk factors and fewer patients with previous vertigo history were foud in c-AVS group.(3)Fatures of nystagmus and head impulse test may be helpful to differentiate c-AVS from p-AVS,whreas no one single of them could help ideally with both high sensitivity and specificity.(4)It may be useful to take into account vascular risk factors,previous vertigo history,features of nystagmus,together with head impulse test to make differiential diagnosis in patients with AVS.Backgrouds:The incidence of acute vestibular syndrome(AVS)is high,of which misdiagnosis may do harm to health,even to life of the patients.There are some limits for only using brain imaging to determine etiology of AVS.It is necessary to find a bedside algorithm to help differientiate central lesions from peripheral ones in patients with AVS.Previous researches have showed that horizontal head impulse test,nystagmus,test of skew or vertigo history may work.Objectives:Prospectively analyze the role of three-step bedside algorithm(vertigo history-nystagmus-horizontal head impulse test)play in differientiating central lesions from peripheral ones in patients with AVS.Methods:Consecutive enrolled patients with AVS who admitted to Qianfoshan Hospitall of Shandong province from July 2015 to May 2016,of which clinical characters were recorded,including name,sex,age,previous stroke or transient ischemic attack,diabetes,ischemic heart disease,hyperlipidemia,hypertension,vertigo history,history of smoking and alcohol use,family migraine history.Two general experienced neurologists evaluated all the patients with three-step bedside algorithm,and make a clinical diagnosis when they reached an agreement.All patients underwent brain MRI examinations,then a final diagnosis was made according to patients' clinical manifestations and imaging findings.Comparative analysis of clinical diagnosis and final diagnosis was performed.Results:The study included 169 cases with AVS,of which 109 cases underwent both three-step bedside algorithm and brain MRI examinations.(1)There were 20 cases with c-AVS,of which male patients accounted for 80%,which was significantly higher than that of patients with p-AVS(80%vs 43.8%,p=0.003);Patients with more than 2 vascular risk factors take a larger proportion in c-AVS group(65%VS 270%,p=0.001),and there is a significant difference in smoking between c-AVS and p-AVS group(45%vs 19.1%,p=0.014).(2)Cerebellar infarction accounted for 70 percent of c-AVS,and 2 cases of medullary infarction,1 case of pontine hemorrhage,1 case of medullary demyelination and 1 case of temporal lobe infarction accounted for the left.(3)24.7%of the patients with p-AVS were failed to identify the cause.Vstibular neuronitis take the largest proportion in the left patients,followed by migrainous vertigo and Meynier's disease with 15 cases and 13 cases,respectively.(4)There are 50 patients with previous vertigo history,including 2 cases with final diagnosi of c-AVS and 48 cases with final diagnosis of p-AVS.(5)The clinical diagnosis by three-step bedside algorithm was consistent with final diagnosis in 97 cases,including 18 cases of c-AVS and 79 cases of p-AVS.The sensitivity of the three-step bedside algorithm for diagnosis of vertigo due to central lesions was 90%with a 95%CI:69.9%-97.2%,and the specificity was 88.8%with a 95%CI:80.5%-93.8%,and the negative predictive value was 97.5%.Conclusions:(1)Central isolated vertigo are mainly due to cerebeller infarction,especially minor infarction in the territory of the medial branch of the posterior inferior cerebellar artery.(2)Not all the AVS patients will present nystagmus.More attention must to be paid that central lesion occupies a considerable proportion in such patients.(3)Temporal lobe infarction or myocardial infarction is a rare cause of AVS.(4)Considering the false negative finding of brain DWI for diagnosing central lesions in AVS,multiple repeated brain DWI examinations may be needed occasionally.(5)With ideal sensitivity and specificity for diagnosing cental lesions in AVS,three-step bedside algorithm may help to reduce medical cost diminishing diagnosin accuracy. |
PDF Full Text Request