LA CLINICA E LA DIAGNOSI DELLA VERTIGINE VASCOLARE

Transcription

1 LA CLINICA E LA DIAGNOSI DELLA VERTIGINE VASCOLARE M. Mandalà Azienda Ospedaliera Universitaria Senese

2 WHY ARE WE SCARED? NEED TO BETTER UNDERSTAND PATHOPHYSIOLOGY WHAT IS KNOWN WHAT IS EFFECTIVE and SIMPLE IN DIAGNOSIS

3 20% of ischemic events occur in the territory of the posterior circulation Dizziness/vertigo is one of the most common symptoms of vertebrobasilar diseases. 11% of patients with an isolated cerebellar infarction present with isolated vertigo Lee, % of patients with vertebrobasilar insufficiency had at least one isolated episode of vertigo, and 19% developed vertigo as the initial symptom. Choit et al., 2013

4 Kim et al., 2011 RISK OF STROKE IN PATIENTS HOSPITALIZED FOR ISOLATED VERTIGO: - 3.6% (Keber et al., 2006) - 6.1% vs 1.9% control group (Lee et al. 2011) Risk of vascular events in patients discharged from Emergency for dizziness or vertigo

5 SCARY PAPERS

6 NON-PRO GOLFER SYNDROME

7 MISDIAGNOSING DIZZY PATIENTS: COMMON PITFALLS IN CLINICAL PRACTICE 1- overreliance on dizziness symptom type to drive diagnosis 2- underuse/misuse of timing and triggers to categorize pts 3- underuse, misuse, and misconceptions linked to hallmark eye examination findings 4- overweighting age, vascular risk factors, and neuroexam to screen for stroke 5- overuse/overreliance on head CT to rule out neurologic causes Kerber KA et Newman-Toker DE. Neurol Clin. 2015;33:565-75

8 CLINICAL SYMPTOMS & SIGNS ACUTE vs CHRONIC - Vertigo/dizziness/diplopia - Nausea and vomiting - Previous episodes - Pre-syncope episode - Auditory symptoms - Headache - Craniocervical pain (trauma) - Ataxia (inability to stand or walk) RISK FACTORS - Age - Hypertension - Cigarette smoking - Previous stroke - Ischaemic heart disease - Hypercholesterolaemia - Diabetes mellitus NEUROLOGICAL SIGNS - Hemiparesis - Speech disturbance - Sensory disturbance - Facial weakness - Cerebellar signs

9 DIAGNOSIS OF ISOLATED VASCULAR VERTIGO - MR - ABCD2 - HINTS(+) - INFARCT

10 Lee, 2015

11 ABCD2 61.1% sensitivity 62.3% specificity HINTS 99.2% 97% MRI (< 48h) 14.5% false negative 190 patients Vestibular neuritis (34.7%) Posterior fossa stroke (59.5%) Other SNC disease (5.8%)

12 HINTS plus (subjctive auditory test) vs early MRI 15 subjects Inferior cerebellar peduncle: 73% Lateral medulla: 60% Focal neurological signs: 27%. 100% vs 47% sensitivity MRI false negative (6 48 h): 53% vs 7.8% (small vs large strokes)

13 HI-N-TS HEAD IMPULSE TEST NYSTAGMUS TEST SKEW

14 101 patients AVS: 25 peripheral and 76 central (69 strokes, 4 hemorrhages, 3 other). HIT normal, direction-changing nystagmus in eccentric gaze, o skew deviation: 100% sensitivity and 96% specificity for stroke. HINTS to Diagnose Stroke in the Acute Vestibular Syndrome: Three-Step Bedside Oculomotor Examination More Sensitive Than Early MRI Diffusion-Weighted Imaging Jorge C. Kattah, Arun V. Talkad, David Z. Wang, Yu-Hsiang Hsieh and David E. Newman-Toker Skew: 17% of subjects - 4% peripheral, - 4% cerebellar, - 30% brainstem (lateral medulla e lateral pons, Int. Cajal n.). Only 3 pts symptomatic (vertical diplopia)!!! Stroke. 2009;40: ; originally published online September 17, 2009; doi: /STROKEAHA Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX Copyright 2009 American Heart Association, Inc. All rights reserved. Print ISSN: Online ISSN: The online version of this article, along with updated information and services, is located on the World Wide Web at: Data Supplement (unedited) at: Skew: correct prediction of lateral pontine stroke in 2 /3 subjects where HIT was false positive for peripheral lesion. Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Stroke can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: Subscriptions: Information about subscribing to Stroke is online at: Downloaded from by guest on January 20, 2014 Early MRI diffusion-weighted: false negativie in 12% (<48h after symptoms onset).

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17 Ocular Tilt Reaction (OTR) acute tone imbalance of static utricular righting reflexes Counterroll Skew Head tilt Michael Halmagyi Halmagyi, 1979

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19 Skew (OTR) in Wallenberg Syndrome

20 Wallenberg s Syndrome Posterior Inferior Cerebellar Artery distribution infarct involving the dorsolateral medulla Caudal vestibular nuclei Courtesy of D. Zee

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22 BIL. POS. APOGEOT NYSTAGMUS Video apogeo

23 THE BEST WAY TO DO D.D. in APOGEO NY!!! gufoni

24 Video geo

25 Cerebrovascular Disease: 5 subjects

26 Diagnosis of Stroke in the Acutely Vertiginous Patient HINTS (HI-N-TS) Head Impulse negative Nystagmus gaze evoked, bilateral Test for Skew (Vertical misalignment and vertical diplopia) INFARCT (IN-FA-RCT) Impulse Negative (But if positive does not exclude a central (AICA) lesion) Fast phase Alternating, Refixation on Cover Test (Skew) OTHER CLUES TO STROKE Loss of hearing (AICA) + Abnormal pattern of head-shaking induced nystagmus (usually PICA) o Early reversal o Perverted (vertical nystagmus with horizontal head-shaking) o Oppositely directed to spontaneous nystagmus Courtesy of D. Zee

27 PROGNOSIS Few data Risk of new events: needs treatment (Felgueiras et al., 2014) Progressive edema 40% mortality in case of initial incorrect diagnoses vs 5% (Savitz et al., 2007)

28 Cerebral small vessel disease is a significant contributor to the development of imbalance and falls in the elderly. The frequency of severe lesions (Fazekas 3) was significantly higher in the 'unexplained' group (22%) than in the 'explained' group (5%; p=0.003). Increased severity of WMH in cases of unexplained dizziness suggests that such abnormalities are likely contributory to the development of dizziness.

29 CONCLUSIONS Not to be scared! The most you can do is the better Most of cases has more than one sign of CNS involvement Bedside examination of eye movements is effective and simple not yet perfect in d.d. you will always find a unique case and it is interesting not only scaring!