HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging.
HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging.
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DOI：
10.1161/strokeaha.109.551234
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发表时间：
2009-11
期刊：
影响因子：
8.3
通讯作者：
Newman-Toker DE
中科院分区：
文献类型：
--
作者：
Kattah JC;Talkad AV;Wang DZ;Hsieh YH;Newman-Toker DE
急性前庭综合征(AVS)通常由前庭神经炎引起，但也可由椎基底动脉中风引起。在急诊环境中，后颅窝梗塞的误诊是很常见的。床边动眼神经检查结果可以可靠地确定脑动静脉综合征患者的卒中，但缺乏前瞻性研究。在一家学术医院进行的前瞻性横断面研究。对具有≥-1卒中危险因素的连续aVS患者(眩晕、眼球震颤、恶心/呕吐、头部运动不耐受、步态不稳)进行结构化检查，包括前庭-眼-反射功能的平头冲动试验(h-HIT)、不同注视位置的眼球震颤观察和眼球排列的棱镜交叉覆盖试验。所有患者均接受神经成像和入院(一般在症状出现72小时后)。卒中的诊断是通过MRI或CT。外周病变由正常MRI和临床随访确诊。101例高危AVS患者包括25个周围性病变和76个中心性病变(69个缺血性卒中，4个出血，3个其他)。偏心注视下出现正常的h击打、方向改变的眼球震颤，或斜视(眼球垂直错位)，对中风的敏感性为100%，特异性为96%。17%的患者伴有脑干病变(外周病变4%，单纯小脑病变4%，脑干病变30%，χ2p=0.003)。在3例异常h-HIT错误提示外周定位的病例中，有2例偏斜正确地预测了桥脑外侧卒中。最初的磁共振弥散加权成像假阴性的占12%(均在症状出现48小时后)。Skew可以预测AVS的脑干受累情况，当异常h-HIT错误地提示周围病变时，可以识别中风。床边三步眼球运动检查(H.I.N.T.S.：头部-脉冲-眼球震颤-斜视测试)对中风似乎比AVS的早期MRI更敏感。
Acute vestibular syndrome (AVS) is often due to vestibular neuritis but can result from vertebrobasilar strokes. Misdiagnosis of posterior fossa infarcts in emergency-care settings is frequent. Bedside oculomotor findings may reliably identify stroke in AVS, but prospective studies have been lacking. Prospective, cross-sectional study at an academic hospital. Consecutive AVS patients (vertigo, nystagmus, nausea/vomiting, head-motion intolerance, unsteady gait) with ≥1 stroke risk factor underwent structured examination including horizontal head impulse test (h-HIT) of vestibulo-ocular-reflex function, observation of nystagmus in different gaze positions, and prism cross-cover test of ocular alignment. All underwent neuroimaging and admission (generally <72 hours after symptom onset). Strokes were diagnosed by MRI or CT. Peripheral lesions were diagnosed by normal MRI and clinical follow-up. 101 high-risk AVS patients included 25 peripheral and 76 central lesions (69 ischemic strokes, 4 hemorrhages, 3 other). The presence of either normal h-HIT, direction-changing nystagmus in eccentric gaze, or skew deviation (vertical ocular misalignment) was 100% sensitive and 96% specific for stroke. Skew was present in 17% and associated with brainstem lesions (4% peripheral, 4% pure cerebellar, 30% brainstem involvement, χ2 p=0.003). Skew correctly predicted lateral pontine stroke in 2 of 3 cases where an abnormal h-HIT erroneously suggested peripheral localization. Initial MRI DWI was falsely negative in 12% (all <48hrs after symptom onset). Skew predicts brainstem involvement in AVS and can identify stroke when an abnormal h-HIT falsely suggests a peripheral lesion. A three-step bedside oculomotor exam (H.I.N.T.S.: Head-Impulse—Nystagmus—Test-of-Skew) appears more sensitive for stroke than early MRI in AVS.