Study On Risk Factors And Early Identification Of Isolated Vertigo Associated With Ischemic Stroke

Background and objective:In recent years,with the wide application of neuroimaging,more and more isolated vertigo associated with ischemic stroke have been identified.Due to the lack of specific neurological deficit symptoms,high field MRI can not be completed in time or the existence of early false negative,it is difficult to distinguish ischemic stroke-related isolated vertigo from peripheral vertigo in the early stage.In view of the different treatment,prognosis and prevention of peripheral vertigo and isolated vertigo associated with ischemic stroke,misdiagnosis and missed diagnosis will increase the rate of disability and mortality,so it is very important to establish a convenient and rapid clinical differentiation strategy.Previous studies have shown that HINTS bedside three-step examination and ABCD~2 score have certain predictive value for stroke in patients with vertigo,but some patients with isolated vertigo have varying degrees of symptom relief,HINTS bedside three-step examination may not be completely detected,while ABCD~2 score is not sensitive to posterior circulation stroke.Therefore,there are some defects in using the two to distinguish isolated vertigo associated with ischemic stroke.The purpose of this study is to explore the clinical risk factors of isolated vertigo associated with ischemic stroke,and to improve the ABCD~2 score,and to quickly identify isolated vertigo associated with ischemic stroke by combining HINTS bedside three-step examination and modified ABCD~2 score,in order to form a clinical strategy for early identification of isolated vertigo associated with ischemic stroke,and provide a guarantee for timely diagnosis and treatment of isolated vertigo associated with ischemic stroke.Methods:In this study,163 patients who complained of acute persistent(more than 24 hours)isolated vertigo in the Department of Neurology of Henan Provincial People’s Hospital from September 2020 to September2021 were studied.All subjects underwent detailed nervous system physical examination and vertigo-related physical examination.Basic clinical data of all subjects were recorded,including age,sex,history of vertigo(onset time,duration of symptoms,characteristics,aggravating factors and previous seizures),past history(hyperlipidemia,hypertension,diabetes,cardiovascular disease,stroke,smoking,drinking history),blood indicators(white blood cell count,neutrophils,lymphocyte count,platelet count,C-reactive protein,creatine kinase,Serum albumin,homocysteine,D-dimer,inorganic phosphorus,prothrombin time,etc.),HINTS bedside test results(head pulse,nystagmus,test of skew).All patients completed cranial CT examination on admission.3-5 days after admission,the patients completed magnetic resonance plain scan MRI-DWI and angiography MRA or CTA,recorded the location of infarction and vertebrobasilar artery stenosis,and completed vestibular function examination according to the condition.Due to the lack of clinical neurological deficit symptoms in isolated vertigo,the"C"(clinical symptom of limb weakness or poor speech)in ABCD~2 score was modified to be complicated with cardiovascular disease.IBM SPSS25.0software was used to analyze the data to find out the clinical and laboratory risk factors of isolated vertigo associated with ischemic stroke.Patients with isolated vertigo were graded with modified ABCD~2 score to evaluate the ability of modified ABCD~2score to identify isolated vertigo associated with ischemic stroke,and the ability to identify isolated vertigo associated with ischemic stroke by combining HINTS bedside three-step examination and modified ABCD~2 score.Results:(1)163 patients were included in the study.There were 85 males(52.1%)and 78 females(47.9%).63patients with isolated vertigo associated with ischemic stroke were diagnosed by transcranial DWI,and 100patients with peripheral vertigo were diagnosed by vestibular function examination.The main causes of isolated vertigo associated with ischemic stroke were cerebellar infarction.There were 41 cases(65.1%)of cerebellar infarction,10 cases of pontine infarction(15.9%),8 cases of medulla oblongata infarction(12.7%),4 cases of brainstem combined with cerebellar infarction(6.3%).In the stroke group,there were 24 cases of cerebellar hemisphere(38.1%),2 cases of cerebellar tonsil(3.2%),9 cases of cerebellar vermis(14.3%)and 2 cases of villous tubercle(3.2%),3 cases of cerebellar hemisphere complicated with vermis(4.7%),1case of cerebellar hemisphere complicated with tonsil(1.6%).In brain cadre position,8 cases of medulla oblongata(12.7%),10 cases of pons(15.9%),4 cases of brainstem combined with cerebellum(6.3%).The most common site of isolated vertigo associated with ischemic stroke is the cerebellar hemisphere.All the63 patients with ischemic stroke completed cranial vascular MRA examination.The analysis of vascular involvement included 31 cases of posterior inferior cerebellar artery(49.2%),2 cases of anterior inferior cerebellar artery(3.2%),20 cases of vertebral artery(31.7%),6 cases of basilar artery(9.5%)and 4 cases of mixed vessels(6.4%).Most of the involved vessels were found in the posterior inferior cerebellar artery.(2)There were significant differences in age,hypertension,diabetes,cardiovascular disease,stroke,abnormal vertebrobasilar artery,white blood cells,neutrophils,NLR,albumin,homocysteine,D-dimer,alkaline phosphatase,inorganic phosphorus and prothrombin time between ischemic stroke-related isolated vertigo and peripheral vertigo.The average age of patients with isolated vertigo associated with ischemic stroke was older than that of patients with peripheral vertigo.Multivariate logistic regression analysis showed that history of hypertension,abnormal vertebrobasilar artery and high homocysteine were independent risk factors for isolated vertigo associated with ischemic stroke.(3)On the basis of vascular risk factors,"cardiovascular disease"was included in item"C",with 1score for cardiovascular disease and 0 score for no cardiovascular disease,and the ABCD~2 score was improved.The modified ABCD~2 score of patients with ischemic stroke was higher than that of patients in the surrounding group.The areas under the ROC curve of the unimproved ABCD~2 score and the improved ABCD~2 score were 0.767 and 0.804 respectively(P<0.05).When the modified ABCD~2 score was less than 4,it was more likely to be diagnosed as ischemic stroke-related isolated vertigo,with a sensitivity of84.1%and a specificity of 67%.The probability of stroke(cerebral infarction)increased gradually between different risk levels.(4)The sensitivity of negative head pulse test for the diagnosis of ischemic stroke-related isolated vertigo was 85.7%(95%CI:74.1%92.9%),and the specificity was 88%(95%CI:79.6%～93.4%).The sensitivity of gaze-evoked nystagmus in the diagnosis of isolated vertigo associated with ischemic stroke was 34.9%(95%CI:23.6%～48.1%),and the specificity was 98%(95%CI:92.3%～99.7%).The sensitivity of torsion deviation test in the diagnosis of isolated vertigo associated with ischemic stroke was 20.6%(95%CI:11.9%～33.0%),and the specificity was 97%(95%CI:90.8%～99.2%).The sensitivity of HINTS bedside three-step examination for the identification and diagnosis of isolated vertigo associated with ischemic stroke was 87.3%(95%CI:76.0%～94.0%),the specificity was88%(95%CI:79.6%～93.4%),the positive predictive value was 82.1%(95%CI:70.4%～90.0%),the negative predictive value was 91.7%(95%CI:83.8%～96.1%).(5)The sensitivity of HINTS bedside three-step examination combined with modified ABCD~2 score for identifying isolated vertigo associated with ischemic stroke was 84.1%(95%CI:72.3%～91.7%),and the specificity was 95%(95%CI:88.2%～98.1%),and the negative predictive value was 90.5%(95%CI:82.8%～95.1%).Conclusions:1.The main cause of isolated vertigo associated with ischemic stroke is cerebellar infarction,and most of the vessels involved in are the posterior inferior cerebellar artery.2.History of hypertension,abnormal vertebrobasilar artery and high homocysteine are independent risk factors for isolated vertigo associated with ischemic stroke.3.The modified ABCD~2 score has a good diagnostic value for ischemic stroke-related isolated vertigo.When the modified ABCD~2 score is less than 4,the greater the probability of diagnosis of ischemic stroke-related isolated vertigo.4.The combined application of HINTS bedside three-step examination and the modified ABCD~2 score can improve the accuracy of diagnosis of ischemic stroke-related isolated vertigo and have good diagnostic value for ischemic stroke-related isolated vertigo.