Protocolo de vértigo de origen dudoso / Unclear origin vertigo protocol

ANTECEDENTES Y OBJETIVO: El diagnóstico diferencial de vértigo supone un reto diagnóstico en el ámbito de urgencias. En nuestro centro hemos creado un protocolo de vértigo para ayudar a distinguir las diferentes patologías y su manejo en urgencias. Nuestro objetivo es determinar la eficacia de nuestro protocolo hospitalario en la actitud diagnóstica y terapéutica ante un síndrome vestibular agudo. PACIENTES Y MÉTODOS: Estudio observacional, descriptivo, retrospectivo, sobre pacientes ingresados con diagnóstico de síndrome vestibular agudo en urgencias mediante nuestro protocolo de vértigo de origen dudoso. A todos los pacientes se les realizó una exploración que incluyera el protocolo HINTS y tuvieron un seguimiento mínimo durante seis meses. Se compararon los resultados del estudio de impresiones clínicas por parte de los especialistas, así como la exploración física con los diferentes diagnósticos finales clasificados en periférico, central y otro origen. RESULTADOS: Obtuvimos 97 pacientes con una edad media de 61,46 años. Los diagnósticos finales fueron de 26 pacientes en el grupo periférico (26,8%), 38 en otro origen (39,2%) y 33 en central (34%). En este último se objetivaron accidentes cerebrovasculares en 18 de ellos, siendo el motivo más frecuente de activación del protocolo una discordancia clínico-exploratoria. CONCLUSIONES: Nuestro protocolo ha demostrado ser una herramienta útil para poder diferenciar un posible síndrome vestibular agudo de origen central de uno periférico, evitando la realización de pruebas de imagen de manera innecesaria. La causa más frecuente de activación del protocolo fue la discordancia clínico-exploratoria vista por el otorrino de guardia

BACKGROUND AND OBJECTIVE: Differential diagnosis of vertigo is a diagnostic challenge in the emergency setting. In our centre we have created a vertigo protocol to distinguish the different pathologies and their management in the emergency department. Our goal is to determine the efficacy of our hospital protocol in the diagnostic and therapeutic approach to acute vestibular syndrome. PATIENTS AND METHODS: It is a retrospective descriptive observational study on patients with a diagnosis of acute vestibular syndrome in the emergency department using our unclear origin vertigo protocol. All patients underwent an examination that included the HINTS protocol and had a minimum follow-up of 6 months. The results of the clinical assessments by the specialists were compared, as well as the physical examination with the different final diagnoses classified as peripheral, central and other-origin. RESULTS: We obtained 97 patients, with a mean age of 61.46 years. The final diagnoses were 26 patients for the peripheral group (26.8%), 38 for the other-origin group (39.2%) and 33 for the central group (34%). Stroke was found in 18 of the latter group, clinical-exploratory disagreement being the most frequent reason for activation of the protocol. CONCLUSIONS: Our protocol has proven to be a useful tool to differentiate a possible acute vestibular syndrome of central origin from a peripheral one, avoiding unnecessary imaging tests. The most frequent cause of activation of the protocol was clinical-exploratory disagreement seen by the ENT doctor

Unclear origin vertigo protocol. / Protocolo de vértigo de origen dudoso.

BACKGROUND AND OBJECTIVE: Differential diagnosis of vertigo is a diagnostic challenge in the emergency setting. In our centre we have created a vertigo protocol to distinguish the different pathologies and their management in the emergency department. Our goal is to determine the efficacy of our hospital protocol in the diagnostic and therapeutic approach to acute vestibular syndrome. PATIENTS AND METHODS: It is a retrospective descriptive observational study on patients with a diagnosis of acute vestibular syndrome in the emergency department using our unclear origin vertigo protocol. All patients underwent an examination that included the HINTS protocol and had a minimum follow-up of 6 months. The results of the clinical assessments by the specialists were compared, as well as the physical examination with the different final diagnoses classified as peripheral, central and other-origin. RESULTS: We obtained 97 patients, with a mean age of 61.46 years. The final diagnoses were 26 patients for the peripheral group (26.8%), 38 for the other-origin group (39.2%) and 33 for the central group (34%). Stroke was found in 18 of the latter group, clinical-exploratory disagreement being the most frequent reason for activation of the protocol. CONCLUSIONS: Our protocol has proven to be a useful tool to differentiate a possible acute vestibular syndrome of central origin from a peripheral one, avoiding unnecessary imaging tests. The most frequent cause of activation of the protocol was clinical-exploratory disagreement seen by the ENT doctor.

Nistagmo vertical inferior: ¿es obligada la resonancia magnética? / Inferior vertical nystagmus: is magnetic resonance imaging mandatory?

Introducción. La aparición de un nistagmo vertical inferior clásicamente obliga a descartar una patología vascular o de la unión craneocervical mediante resonancia magnética (RM). Estudios recientes demuestran una baja rentabilidad de esta prueba, ya que sugieren que este signo oculomotor puede tener una causa vestibular periférica, sobre todo cuando el paciente presenta un vértigo posicional paroxístico benigno (VPPB) del canal semicircular superior. Objetivo. Comprobar la rentabilidad de la RM en una población de pacientes con nistagmo de posición vertical inferior. Pacientes y métodos. Estudio retrospectivo de 42 pacientes consecutivos a los que se les realizó una historia clínica, exploración física, y pruebas vestibulares calóricas y rotatorias. A todos ellos se les practicó una RM craneal y cervical. Resultados. El 52% de los pacientes con nistagmo de posición vertical inferior presentaba una clínica y exploración física compatibles con VPPB del canal semicircular superior. La RM fue normal en un 67%, un 26% mostraba datos de espondilopatía y un 5% de microangiopatía cerebral no relacionados con la clínica del paciente. La prevalencia de malformación de Arnold-Chiari de tipo I fue de un 9% en la población estudiada, sin que nadie tuviera un antecedente reciente de VPPB. Los resultados obtenidos en las pruebas complementarias vestibulares no aportaron información adicional para llegar a un diagnóstico etiológico. Conclusión. En los pacientes con un VPPB, la RM craneal y las pruebas vestibulares tienen una baja rentabilidad diagnóstica, y se debe evaluar la necesidad real de esta prueba con el contexto clínico (AU)

Introduction. The presentation of a down-beating nystagmus force to discard vascular pathology of brain and cervical joint with magnetic resonance imagine (MRI). Recent studies support the low profitability of this study and is subjected that this oculomotor sign has a peripheral origin especially when the patient has a benign paroxysmal positional vertigo (BPPV) with affection of the superior semicircular canal. Aim. To evidence the profitability of MRI in a population of patients with positional down-beating nystagmus. Patients and methods. We present a retrospective study with 42 consecutive patients. A complete clinical history and physical examination was performed. All of them perform vestibular tests (caloric and rotatory), cranial and cervical MRI. Results. Fifty-two percent of patients present clinical manifestations and physical exploration compatible with BPPV. MRI was normal in 67%. We found spondylopathy in 26% and vascular cerebral pathology in 5%. Prevalence of type I ArnoldChiari malformation was 9% in our population. None of them was founded when the main symptom was suggestive of BPPV. Results obtained of vestibular tests didn’t contribute additional information to give an ethiologic diagnosis. Conclusion. The profitability of vestibular tests and MRI in our population with down beating nystagmus was very low. We must evaluate the real necessity of this test with the clinical context (AU)

[Inferior vertical nystagmus: is magnetic resonance imaging mandatory?]. / Nistagmo vertical inferior: ¿es obligada la resonancia magnética?

INTRODUCTION: The presentation of a down-beating nystagmus force to discard vascular pathology of brain and cervical joint with magnetic resonance imagine (MRI). Recent studies support the low profitability of this study and is subjected that this oculomotor sign has a peripheral origin especially when the patient has a benign paroxysmal positional vertigo (BPPV) with affection of the superior semicircular canal. AIM: To evidence the profitability of MRI in a population of patients with positional down-beating nystagmus. PATIENTS AND METHODS: We present a retrospective study with 42 consecutive patients. A complete clinical history and physical examination was performed. All of them perform vestibular tests (caloric and rotatory), cranial and cervical MRI. RESULTS: Fifty-two percent of patients present clinical manifestations and physical exploration compatible with BPPV. MRI was normal in 67%. We found spondylopathy in 26% and vascular cerebral pathology in 5%. Prevalence of type I Arnold-Chiari malformation was 9% in our population. None of them was founded when the main symptom was suggestive of BPPV. Results obtained of vestibular tests didn't contribute additional information to give an ethiologic diagnosis. CONCLUSION: The profitability of vestibular tests and MRI in our population with down beating nystagmus was very low. We must evaluate the real necessity of this test with the clinical context.

TITLE: Nistagmo vertical inferior: es obligada la resonancia magnetica?Introduccion. La aparicion de un nistagmo vertical inferior clasicamente obliga a descartar una patologia vascular o de la union craneocervical mediante resonancia magnetica (RM). Estudios recientes demuestran una baja rentabilidad de esta prueba, ya que sugieren que este signo oculomotor puede tener una causa vestibular periferica, sobre todo cuando el paciente presenta un vertigo posicional paroxistico benigno (VPPB) del canal semicircular superior. Objetivo. Comprobar la rentabilidad de la RM en una poblacion de pacientes con nistagmo de posicion vertical inferior. Pacientes y metodos. Estudio retrospectivo de 42 pacientes consecutivos a los que se les realizo una historia clinica, exploracion fisica, y pruebas vestibulares caloricas y rotatorias. A todos ellos se les practico una RM craneal y cervical. Resultados. El 52% de los pacientes con nistagmo de posicion vertical inferior presentaba una clinica y exploracion fisica compatibles con VPPB del canal semicircular superior. La RM fue normal en un 67%, un 26% mostraba datos de espondilopatia y un 5% de microangiopatia cerebral no relacionados con la clinica del paciente. La prevalencia de malformacion de Arnold-Chiari de tipo I fue de un 9% en la poblacion estudiada, sin que nadie tuviera un antecedente reciente de VPPB. Los resultados obtenidos en las pruebas complementarias vestibulares no aportaron informacion adicional para llegar a un diagnostico etiologico. Conclusion. En los pacientes con un VPPB, la RM craneal y las pruebas vestibulares tienen una baja rentabilidad diagnostica, y se debe evaluar la necesidad real de esta prueba con el contexto clinico.

Executive function and memory in patients with relapsing-remitting multiple sclerosis / Función ejecutiva y memoria en pacientes con esclerosis múltiple recurrente-remitente

Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system very heterogeneous in its characteristics. In contrast to the well known sensitive/motor deficits, the cognitive dysfunction has only been analyzed in the last few decades. Attention, executive function, and memory were assessed in 28 patients with recurrent-remittent MS (RRMS) (duration, median 7 years; EDSS median 2) by means of a specific neuropsychological battery. Depression (BDI), anxiety (STAI) and fatigue (FSS) were also assessed. Twenty-five of these patients were selected for statistical study because they presented deficits in some cognitive areas. Twenty-four percent of the patients displayed memory deficits and 80% showed attention and executive function deficits related to prefrontal lobe function. No global memory difficulties were found, except for immediate visual memory of complex elements (immediate recall of the Rey figure), although the visual reproduction I subtest of the WMSR was unaffected. In RRMS patients with a relatively short duration and low level of incapacity, cognitive impairments mainly affected prefrontal functions. The difficulties in immediate visual memory of complex elements could also be explained by a failure in these areas, due to the alteration of the organization and strategic use of the material to be encoded (AU)

La esclerosis múltiple (EM) es una enfermedad inflamatoria crónica del sistema nervioso central muy heterogénea en sus manifestaciones. A diferencia de los déficits sensitivos-motores, muy bien estudiados, los aspectos cognitivos están siendo analizados sólo en las últimas décadas. A 28 pacientes con EM recurrente-remitente (EMRR) (tiempo de evolución, mediana 7 años; EDSS, mediana 2) se les realizó una evaluación de atención, función ejecutiva y memoria mediante una batería neuropsicológica específica.Se evaluaron también el grado de depresión (BDI), ansiedad (STAI) y fatiga (EGF). Veinticinco fueron seleccionados para el estudio por presentar alteración en algún aspecto cognitivo. El 24% mostraba disminución en memoria y el 80% en atención y funciones ejecutivas relacionadas con regiones prefrontales. No se observaron dificultades globales de memoria, salvo en memoria inmediata visual de elementos complejos (Figura de Rey reproducción inmediata), sin afectarse la prueba de reproducción visual I de la WMS-R. En pacientes con EMRR con un tiempo medio de evolución y bajo nivel de incapacidad, las alteraciones cognitivas afectan fundamentalmente a funciones atribuidas a regiones prefrontales. Las dificultades en memoria inmediata visual de elementos complejos se explicarían también por un fallo de estas áreas al alterarse la organización y uso estratégico del material a codificar (AU)

Executive function and memory in patients with relapsing-remitting multiple sclerosis.

Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system very heterogeneous in its characteristics. In contrast to the well known sensitive/motor deficits, the cognitive dysfunction has only been analyzed in the last few decades. Attention, executive function, and memory were assessed in 28 patients with recurrent-remittent MS (RRMS) (duration, median 7 years; EDSS median 2) by means of a specific neuropsychological battery. Depression (BDI), anxiety (STAI) and fatigue (FSS) were also assessed. Twenty-five of these patients were selected for statistical study because they presented deficits in some cognitive areas. Twenty-four percent of the patients displayed memory deficits and 80% showed attention and executive function deficits related to prefrontal lobe function. No global memory difficulties were found, except for immediate visual memory of complex elements (immediate recall of the Rey figure), although the visual reproduction I subtest of the WMS-R was unaffected. In RRMS patients with a relatively short duration and low level of incapacity, cognitive impairments mainly affected prefrontal functions. The difficulties in immediate visual memory of complex elements could also be explained by a failure in these areas, due to the alteration of the organization and strategic use of the material to be encoded.