伴有严重、持续性眩晕患者不可过度信赖MRI


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伴有严重、持续性眩晕患者不可过度信赖MRI


伴有卒中风险和严重、持续性眩晕的患者应避免过度信赖早期MRI扫描。

大多数眩晕都是良性发作,但眩晕也可以作为卒中的唯一症状而出现。临床医师常依赖于磁共振成像(MRI)作为排除卒中的敏感性工具,但先前已有研究强调它对于小型脑干卒中发作后最初几天的灵敏度有限。目前研究人员已经进行了一项回顾性研究,以观察以眩晕为主要表现的卒中的特征,最初不应用MRI检查。

在转诊中心的13年期间,有105名患者的卒中特征表现为急性前庭综合征(几天到几周持续性眩晕或头晕,恶心或呕吐,头位改变不耐受,步态不稳,及眼球震颤)。那些临床上高度怀疑和早期成像阴性的患者在之后的成像中被证实。

15例患者(14%)伴有小面积梗死(≤10 mm)。这些小梗死最常累积小脑下脚和延髓外侧(60%)。早期MRI(症状发作后6-48小时进行)对小梗死的敏感度为47%,对>10mm梗死的敏感度为92%。详细的床边检测包括HINTS“加”一系列测试(头部冲击测试,眼震,倾斜测试以及通过搓手指进行床边听力检查)对小面积和大面积梗死的敏感度≥99%。

评论

过度依赖急性MRI评估严重眩晕可能会导致脑干小卒中漏诊。对于急性前庭综合征表现为部分头晕亚型的病例,以及无显著卒中风险因素的非特异性头晕(如轻度和不明症状的短暂发作)患者,卒中评估确实不必要面面俱到。然而,伴有严重、持续性眩晕和卒中风险因素的患者应该进行详细和重点神经系统检查,如HINTS“加”试验。有相关或可疑检测结果的患者应该仔细进行临床监测,重复行MRI检查以明确排除卒中。


Small strokes causing severevertigo: Frequency of false-negative MRIs and nonlacunar mechanisms

OBJECTIVE

Describe characteristics of small strokes causing acute vestibular syndrome (AVS).

METHODS:

Ambispective cross-sectional study of patients with AVS(acutevertigo or dizziness, nystagmus, nausea/vomiting, head-motion intolerance,unsteady gait) with at least one stroke risk factor from 1999 to 2011 at asingle stroke referral center. Patients underwent nonquantitative HINTS"plus" examination(head impulse, nystagmus, test-of-skew plushearing), neuroimaging to confirm diagnoses(97% by MRI), and repeat MRI inthose with initially normal imaging but clinical signs of a central lesion. We identified patients with diffusion-weighted imaging(DWI) strokes≤10 mm in axial diameter.

RESULTS:

Of 190 high-risk AVS presentations (105 strokes), we found small strokes in 15 patients(median age 64 years, range 41-85). The most common vestibular structure infarcted was the inferior cerebellar peduncle(73%); the most common stroke location was the lateral medulla(60%). Focal neurologic signs were present in only 27%. The HINTS "plus" battery identified small strokes with greater sensitivity than early MRI-DWI(100%vs47%, p

CONCLUSIONS:

Small strokes affecting central vestibular projections canpresent with isolated AVS. The HINTS "plus" hearing battery identifies these patients with greater accuracy than early MRI-DWI, which isfalsely negative in half, up to 48 hours after onset. We found nonlacunar mechanisms in half, suggesting greater risk than might otherwise be assumed for patients with such small infarctions.


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伴有严重、持续性眩晕患者不可过度信赖MRI

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