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

• Literatur

• 1 Newman-Toker DE, Hsieh YH, Camargo Jr CA. et al Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample. Mayo Clin Proc 2008; 83: 765-775
• 2 Kerber KA, Meurer WJ. et al Dizziness presentations in U. S. emergency departments. Acad Emerg Med 2008; 15: 744-750
• 3 Royl G, Ploner CJ, Leithner C. Dizziness in the emergency room: diagnoses and misdiagnoses. Eur Neurol 2011; 66: 256-263
• 4 Zwergal A, Dieterich M. Vertigo and dizziness in the emergency room. Curr Opin Neurol 2020; 33 (01) 117-125
• 5 Zwergal A, Möhwald K, Salazar López E. et al A Prospective Analysis of Lesion-Symptom Relationships in Acute Vestibular and Ocular Motor Stroke. Front Neurol 2020; 11: 822
• 6 Lee H, Sohn SI, Cho YW. et al Cerebellar infarction presenting isola-ted vertigo: frequency and vascular topographical patterns. Neurology 2006; 67: 1178-1183
• 7 Dieterich M, Brandt T. Why acute unilateral vestibular cortex lesions mostly manifest without vertigo. Neurology 2015; 84: 1680-1684
• 8 Tarnutzer AA, Lee SH, Robinson KA. et al ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: a meta-analysis. Neurology 2017; 88: 1468-1477
• 9 Kuruvilla A, Bhattacharya P, Rajamani K. et al Factors associated with misdiagnosis of acute stroke in young adults. J Stroke Cerebrovasc Dis 2011; 20 (06) 523-527
• 10 Newman-Toker DE, Moy E, Valente E. et al Missed diagnosis of stroke in the emergency department: a cross-sectional analysis of a large population-based sample. Diagnosis 2014; 01 (02) 155-166
• 11 Atzema CL, Grewal K, Lu H. et al Outcomes among patients discharged from the emergency department with a diagnosis of peripheral vertigo. Ann Neurol 2016; 79: 32-41
• 12 Saber Tehrani AS, Kattah JC, Mantokoudis G. et al Small strokes causing severe vertigo: frequency of false-negative MRIs and nonlacunar mechanisms. Neurology 2014; 83 (02) 169-173
• 13 Eagles D, Stiell IG, Clement CM. et al International survey of emergency physicians’ priorities for clinical decision rules. Acad Emerg Med 2008; 15 (02) 177-182
• 14 Choi DC, Kim JS. Vascular vertigo: updates. J Neurol 2019; 266 (08) 1835-1843
• 15 Newman-Toker DE, Edlow JA. TiTrATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo. Neurol Clin 2015; 33 (03) 577-599
• 16 Filippopulos FM, Strobl R, Belanovic B. et al Validation of a comprehensive diagnostic algorithm for patients with acute vertigo and dizziness. Eur J Neurol. 2022
• 17 Ahmadi SA, Vivar G, Navab N. et al Modern machine-learning can support diagnostic differentiation of central and peripheral acute vestibular disorders. J Neurol 2020; 267 (Suppl. 01) 143-152
• 18 Kerber KA, Callaghan BC, Telian SA. et al Dizziness symptom type prevalence and overlap: a US nationally representative survey. Am J Med 2017; 130: 1461-1465
• 19 Möhwald K, Hadzhikolev H, Bardins S. et al Health-related quality of life and functional impairment in acute vestibular disorders. Eur J Neurol 2020; 27 (10) 2089-2098
• 20 Kim JS, Newman-Toker DE, Kerber KA. et al Vascular vertigo and dizziness: Diagnostic criteria. J Vestib Res 2022; 32 (03) 205-222
• 21 Strupp M, Bisdorff A, Furman J. et al Acute unilateral vestibulopathy/vestibular neuritis: Diagnostic criteria. J Vestib Res 2022; 32 (05) 389-406
• 22 Lopez-Escamez JA, Carey J, Chung WH. et al Diagnostic criteria for Menière’s disease. J Vestib Res 2015; 25 (01) 1-7
• 23 Kuroda R, Nakada T, Ojima T. et al The TriAGe + score for vertigo or dizziness: a diagnostic model for stroke in the emergency department. J Stroke Cerebrovasc Dis 2017; 26: 1144-1153
• 24 Lempert T, Olesen J, Furman J. et al Vestibular migraine: Diagnostic criteria1. J Vestib Res 2022; 32 (01) 1-6
• 25 Choi SY, Kim HJ, Kim JS. Chasing dizzy chimera: Diagnosis of combined peripheral and central vestibulopathy. J Neurol Sci 2016; 371: 69-78
• 26 Zwergal A, Kirsch V, Gerb J. et al [Neuro-otology: at the borders of ear and brain]. Nervenarzt 2018; 89 (10) 1106-1114
• 27 Paul NL, Simoni M, Rothwell PM. et al Transient isolated brainstem symptoms preceding posterior circulation stroke: a population-based study. Lancet Neurol 2013; 12 (01) 65-71
• 28 Hoshino T, Nagao T, Mizuno S. et al Transient neurological attack before vertebrobasilar stroke. J Neurol Sci 2013; 325 1–2 39-42
• 29 Strupp M, Brandt T, Dieterich M. Vertigo – Leitsymptom Schwindel. Heidelberg: Springer Medizin; 2022
• 30 Kattah JC, Talkad AV, Wang DZ. et al HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 2009; 40: 3504-3510
• 31 Newman-Toker DE, Kattah JC, Alvernia JE. et al Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology 2008; 70: 2378-2385
• 32 Newman-Toker DE, Saber Tehrani AS. et al Quantitative video-oculography to help diagnose stroke in acute vertigo and dizziness: toward an ECG for the eyes. Stroke 2013; 44 (04) 1158-1161
• 33 Machner B, Erber K, Choi JH. et al Usability of the head impulse test in routine clinical practice in the emergency department to differentiate vestibular neuritis from stroke. Eur J Neurol 2021; 28 (05) 1737-1744
• 34 Mantokoudis G, Korda A, Zee DS. et al Bruns’ nystagmus revisited: A sign of stroke in patients with the acute vestibular syndrome. Eur J Neurol 2021; 28 (09) 2971-2979
• 35 Korda A, Zamaro E, Wagner F. et al Acute vestibular syndrome: is skew deviation a central sign?. J Neurol 2022; 269 (03) 1396-1403
• 36 Korda A, Wimmer W, Zamaro E. et al Videooculography „HINTS“ in Acute Vestibular Syndrome: A Prospective Study. Front Neurol 2022; 13: 920357
• 37 Mantokoudis G, Wyss T, Zamaro E. et al Stroke Prediction Based on the Spontaneous Nystagmus Suppression Test in Dizzy Patients: A Diagnostic Accuracy Study. Neurology 2021; 97 (01) e42-e51
• 38 Machner B, Choi JH, Trillenberg P. et al Risk of acute brain lesions in dizzy patients presenting to the emergency room: who needs imaging and who does not?. J Neurol 2020; 267 (Suppl. 01) 126-135
• 39 Lemos J, Strupp M. Central positional nystagmus: an update. J Neurol 2022; 269 (04) 1851-1860
• 40 von Brevern M, Zeise D, Neuhauser H. et al Acute migrainous vertigo: clinical and oculographic findings. Brain 2005; 128 Pt 2 365-374
• 41 Mantokoudis G, Otero-Millan J, Gold DR. Current concepts in acute vestibular syndrome and video-oculography. Curr Opin Neurol 2022; 35 (01) 75-83
• 42 Nham B, Reid N, Bein K. et al Capturing vertigo in the emergency room: three tools to double the rate of diagnosis. J Neurol 2022; 269 (01) 294-306
• 43 Machner B, Erber K, Choi JH. et al A Simple Gain-Based Evaluation of the Video Head Impulse Test Reliably Detects Normal Vestibulo-Ocular Reflex Indicative of Stroke in Patients With Acute Vestibular Syndrome. Front Neurol 2021; 12: 741859
• 44 Nham B, Akdal G, Young AS. et al Capturing nystagmus in the emergency room: posterior circulation stroke versus acute vestibular neuritis. J Neurol. 2022
• 45 Morrison M, Kerkeni H, Korda A. et al Automated alternate cover test for ‘HINTS’ assessment: a validation study. Eur Arch Otorhinolaryngol 2022; 279 (06) 2873-2879
• 46 Navi BB, Kamel H, Shah MP. et al The use of neuroimaging studies and neurological consultation to evaluate dizzy patients in the emergency department. Neurohospitalist 2013; 03 (01) 7-14
• 47 Ojala M, Ketonen L, Palo J. The value of CT and very low field MRI in the etiological diagnosis of dizziness. Acta Neurol Scand 1988; 78: 26-29
• 48 Zwergal A, Möhwald K, Dieterich M. Vertigo and dizziness in the emergency room. Nervenarzt 2017; 88 (06) 587-596
• 49 Kerber KA, Meurer WJ, Brown DL. et al Stroke risk stratification in acute dizziness presentations: A prospective imaging-based study. Neurology 2015; 85 (21) 1869-1878
• 50 Navi BB, Kamel H, Shah MP. et al Application of the ABCD2 score to identify cerebrovascular causes of dizziness in the emergency department. Stroke 2012; 43 (06) 1484-1489
• 51 Sarraj A, Medrek S, Albright K. et al Posterior circulation stroke is associated with prolonged door-to-needle time. Int J Stroke 2015; 10: 672-678
• 52 Sand KM, Naess H, Nilsen RM. et al Less thrombolysis in posterior circulation infarction—a necessary evil?. Acta Neurol Scand 2017; 135: 546-552
• 53 Kim M, Park SY, Lee SE. et al Significance of Vertigo, Imbalance, and Other Minor Symptoms in Hyperacute Treatment of Posterior Circulation Stroke. Front Neurol 2022; 13: 845707
• 54 Cnyrim CD, Rettinger N, Mansmann U. et al Central compensation of deviated subjective visual vertical in Wallenberg’s syndrome. J Neurol Neurosurg Psychiatry 2007; 78 (05) 527-528
• 55 Schuhbeck F, Strobl R, Conrad J. et al Determinants of functioning and health-related quality of life after vestibular stroke. Front Neurol 2022; 13: 957283
• 56 Machner B, Choi JH, Neumann A. et al What guides decision-making on intravenous thrombolysis in acute vestibular syndrome and suspected ischemic stroke in the posterior circulation?. J Neurol 2021; 268 (01) 249-264
• 57 Balci BD, Akdal G, Yaka E. et al Vestibular rehabilitation in acute central vestibulopathy: a randomized controlled trial. J Vestib Res 2013; 23 4–5 259-67
• 58 Zhang S, Liu D, Tian E. et al Central vestibular dysfunction: don’t forget vestibular rehabilitation. Expert Rev Neurother. 2022: 1-12