Akutes zentrales vestibuläres Syndrom

ZUSAMMENFASSUNG

Einem akuten Schwindelsyndrom liegt in 4–15 % der Fälle ein akutes zentrales vestibuläres Syndrom in Folge eines Schlaganfalls im Bereich des Hirnstamms und/oder Kleinhirns zugrunde. Bei der differenzialdiagnostischen Einordnung helfen insbesondere die gezielte Anamnese, klinische und apparative Untersuchung der vestibulären und okulomotorischen Systeme und der bedarfsweise Einsatz geeigneter zerebraler Bildgebung weiter. Die Anamnese sollte folgende Aspekte umfassen: Akuität des Symptombeginns, schwindelspezifische Trigger, Begleitsymptome und Vorgeschichte von Schwindelattacken. Die Schwindelqualität, -intensität und -dauer helfen hingegen nicht bei der Differenzierung zu peripher-vestibulären Ursachen. Die zielgerichtete klinische vestibuläre und okulomotorische Untersuchung umfasst 4 Tests: Untersuchung auf Spontan-/Provokations-/Blickrichtungs-/Lagerungs-/Lagenystagmus, Kopfimpulstest, Abdecktest zur Erfassung einer Vertikaldeviation und Romberg-Stehversuch mit Frage nach posturaler Instabilität. Eine videookulografiegestützte Testung des Kopfimpulstests (vHIT) erhöht die Genauigkeit für die Erfassung einer zentralen Ursache (Schwellenwert für Verstärkungsfaktor: 0,7). Bildgebende Diagnostik sollte bei klinischem Verdacht auf eine zentrale Ursache durchgeführt werden. Der MRT-basierte Nachweis eines Schlaganfalls gelingt am besten 3–5 Tage nach Symptombeginn, während Diffusionsstörungen < 10 mm in der Akutphase nur in ca. 50 % der Fälle erfasst werden. Für die Therapie des akuten zentralen vestibulären Syndroms mittels intravenöser Thrombolyse gibt es keine hochwertigen und kontrollierten Untersuchungen. Die Nachbehandlung des akuten zentralen vestibulären Syndroms umfasst ein multimodales Gleichgewichtstraining zur Förderung der vestibulären Kompensation. Die Prognose ist in der Regel günstig. Einflussfaktoren sind die Symptomintensität im Akutstadium, die Infarktgröße, weibliches Geschlecht in Kombination mit einer Ängstlichkeit der Patienten und das Vorhandensein einer Extremitäten- oder Gangataxie.

ABSTRACT

An acute central vestibular syndrome accounts for 4–15 % of cases of acute vertigo and dizziness and is mostly caused by strokes in the brainstem and cerebellum. Differential diagnosis is based on structured history taking, clinical and device-based investigations of the vestibular and ocular motor systems and the tailored application of appropriate cerebral imaging. History taking should include four major aspects: acuity of symptom onset, vertigo-specific trigger factors, accompanying symptoms, and a previous history of vertigo attacks. Symptom quality, intensity and duration in contrast do not contribute to the differentiation of peripheral and central etiologies. Structured clinical vestibular and ocular motor examination includes four aspects: 1) Assessment of spontaneous, provocation, gaze-evoked and positional nystagmus, 2) head impulse test, 3) cover test to detect a skew deviation, 4) Romberg’s test for postural imbalance. Videooculography-based testing of the head impulse test (vHIT) improves the diagnostic accuracy for a central vestibular syndrome markedly (gain cut-off: 0.7). Imaging diagnostics should be guided by the clinical suspicion of a central etiology. Vestibular stroke is depicted best by MRI within 3–5 days after symptom onset, while diffusion restrictions < 10 mm remain undetected in 50 % of cases in the acute stage of vestibular stroke. Evidence from high-quality controlled trials for the application of intravenous thrombolysis is missing. The therapy of vestibular stroke includes multimodal balance training to foster vestibular compensation. Prognosis is favorable in most cases. Negative prognostic factors are the symptom intensity during the acute stage, the infarct volume, female gender combined with a high anxiety state of the patients, and the presence of limb or gait ataxia.

Schlüsselwörter

Akuter Schwindel - vestibulärer Schlaganfall - akutes vestibuläres Syndrom - Kopfimpulstest - Videookulografie

Key words

Acute vertigo - vestibular stroke - acute vestibular syndrome - head impulse test - video oculography

Publikationsverlauf

Artikel online veröffentlicht:
13. Februar 2023

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