前庭卒中(2):表现形式与鉴别要点 这4种表现形式分别为触发性EVS(t-EVS), 自发性EVS(s-EVS), 创伤/毒性AVS(t-AVS) , 自发性AVS(s-AVS) [24]。EVS由ICVD定义为持续数秒至数小时的一过性眩晕头晕或不稳的临床综合征,偶尔持续数天,通常具有一过性短暂性前庭系统功能障碍的特征。临床常可表现为触发性和自发性两种特点的形式。AVS由ICVD定义为持续数天至数周的急性发作性连续性眩晕头晕或不稳的临床综合征,通常具有新发持续存在前庭系统功能障碍的特征。临床常可因创伤毒性损害造成或病因不很明确的自发性形式存在。 急诊最常见的t-EVS依次是直立性低血压、BPPV、CPPV。直立性低血压可经站立和卧位血压检查确定(请参阅血液动力性眩晕头晕诊断标准)。BPPV可经变位实验出现典型位置性眼震确定(请参阅BPPV诊断标准)。CPPV可来自良性中枢性病因例如酒精中毒或前庭偏头痛,也可来自后颅凹结构性病变。脑血管病引起的t-EVS虽不常见,但有两种情况需要注意:1)第四脑室附近的小卒中(缺血或出血)可引起CPPV,眼震与BPPV的经典性位置性眼震不同;2)旋转椎动脉综合征(Rotational Vertebral Artery Syndrome,RVAS)可因侧方转颈导致一侧或双侧椎动脉闭塞,引发短暂性眩晕和眼震。 多项研究显示,即使是孤立性眩晕或头晕,也可能是后循环卒中前数天至数周最常见的前驱性椎基底动脉TIA症状。一个较大人群的研究发现,51%(n = 23/45)前驱性椎基底动脉TIA症状表现为孤立性眩晕,其中52%持续时间超过1小时,非常不典型,与现代TIA定义不符。当TIA累及AICA灌注区时可产生听觉症状,看起来很像梅尼埃病(MD),感音性听力丧失伴周围型眼震可能来自迷路缺血,此时诊断需谨慎。一些s-EVS可能经MRI-DWI显示有很小的梗死。头晕是椎动脉夹层的最常见症状(58%),可累及年轻患者,看起来很像前庭偏头痛,容易误诊。椎动脉夹层可能与颈部损伤关联,但是不到一半的病人有这种病史。不过,突然严重持续的头痛和颈痛是重要的指向线索。若伴有畏光畏声则指向前庭偏头痛可能性。 此类患者的主要脑血管顾虑是重叠综合征问题:原发性疾病例如来自钝性颅脑损伤的直接性迷路震荡或伴有跌倒的酒精中毒,可能掩盖了继发性疾病例如引起小脑梗死的椎动脉夹层。
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