复位无效且磁共振成像阴性的位置性眩晕临床特点初探

Preliminary analysis of diagnosis and treatment for positional vertigo with invalid maneuver and negative MRI

目的对手法复位无效且MRI阴性的位置性眩晕患者的眼震类型和特点进行分析,并探讨药物治疗及预防方案。方法选择2016年6月至2017年9月共43例位置性眼震患者,随机(随机数字表法)接受氯硝西泮和盐酸氟桂利嗪治疗,通过比较治疗前后最大慢相角速度评价急性期药物疗效;另选择其中21例近2个月发作频繁患者,分为盐酸氟桂利嗪预防治疗组和对照组,随访并记录每月眩晕平均发作天数(单次发作时间×发作次数),分析盐酸氟桂利嗪对眼震发作的预防作用。结果 43例患者中有29例符合确定的和很可能的前庭性偏头痛,其眼震类型分别为水平背地性(23例,53.49%)、水平向地性(3例,6.98%)、垂直下跳性(4例,9.30%)和混合性(13例,30.23%),眼震持续时间长并缺乏渐强渐弱特点。治疗3 d后,氯硝西泮组患者最大慢相角速度[2.40(0.00,17.15)°/s]显著降低,急性期疗效优于氟桂利嗪组[18.85(1.58,35.75)°/s;Z=-2.284,P=0.022)];2个月后预防治疗组患者每月眩晕平均发作天数[1(0,2)d]缩短,与对照组[3.50(1.50,6.50)d]相比差异具有统计学意义(Z=-2.096,P=0.036)。结论手法复位无效且MRI阴性的位置性眩晕可能与中枢功能异常有关,排除相关禁忌证后,急性期予以氯硝西泮治疗具有缓解眩晕和眼震作用,尤以前庭性偏头痛患者疗效更佳;频繁发作者可预防性应用盐酸氟桂利嗪。

Objective To analyze the types and characteristics of nystagmus in patients with positional vertigo who were ineffective by particle repositioning maneuver(PRM) and had negative findings in MRI, and try to explore drug treatment and prevention programme. Methods A total of 43 patients with positional nystagmus were randomly treated with clonazepam or flunarizine hydrochloride. The therapeutic effect at acute phase was evaluated by comparing maximum slow phase velocity(SPV) before and after treatment. Among all patients, 21 patients with frequent attacks in recent 2 months were randomly divided into flunarizine hydrochloride prophylaxis treatment group(prophylaxis group) and blank control group(control group), followed up and recorded the average attack days of vertigo per month(days of single attack × number of attacks). The preventive effect of flunarizine hydrochloride was analyzed.Among 43 patients, 29 cases met the diagnostic criteria of definite and probable vestibular migraine. The main types of nystagmus were horizontal apogeotropic nystagmus(23 cases, 53.49%),horizontal geotropic nystagmus(3 cases, 6.98%), downbeat nystagmus(4 cases, 9.30%) and mixed nystagmus(13 cases, 30.23%). Nystagmus lasted a longer time and lacked the characteristics of crescendodecrescendo. After 3 d of treatment, the maximum SPV [2.40(0.00, 17.15) °/s] of clonazepam group was significantly reduced, and the therapeutic effect at acute phase was better compared with flunarizine hydrochloride group [18.85(1.58, 35.75) °/s;Z =-2.284, P = 0.022]. After 2 months, the average attack days of vertigo per month in prophylaxis group [1(0, 2) d] was significantly reduced in comparison with control group [3.50(1.50, 6.50) d;Z =-2.096, P = 0.036). Conclusions Positional vertigo with ineffective PRM and negative findings in MRI may be related to abnormal central function. After excluding the relevant contraindications, clonazepam can relieve vertigo and nystagmus in the acute phase, especially in vestibular migraine patients. For patients with frequent attacks, flunarizine hydrochloride maybe an available preventive treatment.