Vascular vertigo and dizziness: Diagnostic criteria 血管性眩晕和头晕：诊断标准
Consensus document of the committee for the classification of vestibular disorders of the Bárány society 巴朗尼学会前庭障碍分类委员会共识文件
Ji-Soo Kim , David E. Newman-Toker , Kevin A. Kerber , Klaus Jahn , Pierre Bertholon , 金智秀 ，大卫·E·纽曼-托克 ，凯文·A·科伯 ，克劳斯·扬 ，皮埃尔·贝尔托隆 ，John Waterston , Hyung Lee , Alexandre Bisdorff and Michael Strupp 约翰·沃特斯顿 ，李亨 ，亚历山大·比斯多夫 和迈克尔·斯特鲁普 Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang 首尔国立大学医学院神经科学系，首尔国立大学分院Hospital, Seongnam, Korea 韩国城南医院 Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, USA 美国巴尔的摩约翰斯·霍普金斯大学医学院神经科 Department of Neurology, University of Michigan Health System, Ann Arbor, USA 密歇根大学健康系统神经科 部，美国安娜堡 Department of Neurology Schoen Clinic Bad Aibling and German Center for Vertigo and Balance Disorders, 神经科 Schoen Clinic Bad Aibling 和德国眩晕与平衡障碍中心,Ludwig Maximilians University, Munich, Germany 德国慕尼黑路德维希·马克西米利安大学 Department of Otorhinolaryngology, CHU de Saint Étienne, France 法国圣艾蒂安大学医院耳鼻喉科 Monash Department of Neuroscience, Alfred Hospital, Melbourne, Australia 澳大利亚墨尔本阿尔弗雷德医院莫纳什神经科学系 Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea 韩国大邱庆明大学医学院脑研究所神经科 Department of Neurology, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg 卢森堡埃施-苏尔-阿尔泽特市埃米尔·迈里什中央医院神经科 Department of Neurology and German Center for Vertigo and Balance Disorders, Ludwig Maximilians 神经科和德国眩晕与平衡障碍中心，路德维希-马克西米连大学University, Munich, Germany 德国慕尼黑大学
Received 1 October 2021 2021 年 10 月 1 日收到
Accepted 1 March 2022 2022 年 3 月 1 日接受
Abstract 摘要
This paper presents diagnostic criteria for vascular vertigo and dizziness as formulated by the Committee for the Classification of Vestibular Disorders of the Bárány Society. The classification includes vertigo/dizziness due to stroke or transient ischemic attack as well as isolated labyrinthine infarction/hemorrhage, and vertebral artery compression syndrome. Vertigo and dizziness are among the most common symptoms of posterior circulation strokes. Vascular vertigo/dizziness may be acute and prolonged ( hours) or transient (minutes to hours). Vascular vertigo/dizziness should be considered in patients who present with acute vestibular symptoms and additional central neurological symptoms and signs, including central HINTS signs (normal head-impulse test, direction-changing gaze-evoked nystagmus, or pronounced skew deviation), particularly in the presence of vascular risk factors. Isolated labyrinthine infarction does not have a confirmatory test, but should be considered in individuals at increased risk of stroke and can be presumed in cases of acute unilateral vestibular loss if accompanied or followed within 30 days by an ischemic stroke in the anterior inferior cerebellar artery territory. For diagnosis of vertebral artery compression syndrome, typical symptoms and signs in combination with imaging or sonographic documentation of vascular compromise are required. 本文介绍了由 Bárány 学会前庭障碍分类委员会制定的血管性眩晕和头晕的诊断标准。该分类包括由于中风或短暂性缺血发作引起的眩晕/头晕，以及孤立性前庭迷路梗死/出血和椎动脉压迫综合征。眩晕和头晕是后循环中风最常见的症状之一。血管性眩晕/头晕可能是急性和持续的（ 小时）或短暂的（几分钟至 小时）。在出现急性前庭症状和额外的中枢神经症状和体征的患者中，应考虑血管性眩晕/头晕，尤其是在存在血管风险因素的情况下，包括中枢 HINTS 征（头部冲动试验正常，方向改变的凝视诱发性眼球震颤，或明显的斜视偏移）。 孤立性迷路梗死没有确诊测试，但应考虑在中风风险增加的个体中，并且在伴随或在 30 天内随后出现前庭神经丧失的急性病例中可以推测为前庭下动脉领域的缺血性中风。对于椎动脉压迫综合征的诊断，需要结合典型症状和体征以及血管受损的影像学或超声学证明。
The Bárány Society, representing the international community of basic scientists, otolaryngologists, and neurologists committed to vestibular research, mandated a Committee for an International Classification of Vestibular Disorders (ICVD) [12]. Bárány 学会代表着致力于前庭研究的国际基础科学家、耳鼻喉科医生和神经学家社区，成立了一个国际前庭障碍分类委员会（ICVD）[12]。
Vertigo/dizziness is one of the most common symptoms of posterior circulation stroke [29, 53, 106]. Its onset is typically acute and may be prolonged ( hours, acute prolonged vertigo/dizziness) or transient hours, transient vertigo/dizziness) [109, 131]. Transient vertigo/dizziness may recur in episodes (recurrent spontaneous vertigo/ dizziness). An isolated positional vestibular syndrome (or recurrent positional vertigo/dizziness) due to vascular vertigo/dizziness is rare. Vertigo/dizziness in cerebrovascular disorders is usually accompanied by other neurological symptoms and signs [49, 74, 95, 157]. Recent advances in clinical neuro-otology/ neuro-ophthalmology and neuroimaging have led to a consensus that strokes involving the brainstem or cerebellum can also present with isolated vertigo/dizziness or imbalance [106]. Finally, transient vertigo/dizziness is also one of the most common manifestations of vertebrobasilar ischemia and is occasionally isolated [22, 54, 55, 83]. 眩晕/头晕是后循环中风最常见的症状之一[29, 53, 106]。其发作通常是急性的，可能是持续的（ 小时，急性持续性眩晕/头晕）或短暂的 小时，短暂性眩晕/头晕）[109, 131]。短暂性眩晕/头晕可能会以发作的形式再次出现（反复发作性自发性眩晕/头晕）。由于血管性眩晕，孤立的姿势性前庭综合征（或反复性姿势性眩晕/头晕）是罕见的。脑血管疾病中的眩晕/头晕通常伴随其他神经症状和体征[49, 74, 95, 157]。临床神经耳鼻喉学/神经眼科学和神经影像学的最新进展已经形成共识，涉及脑干或小脑的中风也可能表现为孤立的眩晕/头晕或失衡[106]。最后，短暂性眩晕/头晕也是椎基底动脉缺血的最常见表现之一，有时是孤立的[22, 54, 55, 83]。
It is important to differentiate isolated vertigo/ dizziness of a vascular cause from non-vascular disorders, e.g., acute unilateral vestibulopathy (AUVP)/ vestibular neuritis, involving the labyrinth or vestibular nerve since therapeutic strategies and prognosis differ in these two conditions [109]. Misdiagnosis of acute stroke may result in loss of effective treatment opportunities, which may increase morbidity and mortality, while over-diagnosis of vascular vertigo/dizziness would lead to unnecessary costly work-ups and medication [30, 152-154]. Depending on the underlying etiology, more aggressive treatments including thrombolysis or endovascular intervention as well as dual antiplatelet therapy or anticoagulation may be indicated to treat a stroke and prevent recurrences of stroke in vascular vertigo/dizziness [39, 40, 122]. Finally, from a scientific point of view, detailed evaluation of patients with infarctions restricted to specific vestibular structures also allows a better understanding of the function of each vestibular structure and definition of various ischemic vestibular syndromes [92, 93]. 重要的是区分血管性单纯性眩晕/头晕与非血管性疾病，例如急性单侧前庭病（AUVP）/前庭神经炎，涉及迷路或前庭神经，因为这两种情况的治疗策略和预后不同。误诊急性中风可能导致失去有效的治疗机会，这可能增加发病率和死亡率，而过度诊断血管性眩晕/头晕会导致不必要的昂贵检查和药物治疗。根据潜在病因，可能需要更积极的治疗，包括溶栓或血管内介入以及双抗血小板治疗或抗凝治疗，以治疗中风并预防血管性眩晕/头晕的中风复发。最后，从科学角度来看，对于仅限于特定前庭结构的梗死患者进行详细评估还可以更好地了解每个前庭结构的功能，并定义各种缺血性前庭综合征。
To develop the diagnostic criteria for vascular vertigo/dizziness, creation of the subcommittee was initiated by the members of the ICVD Committee of the Bárány Society in Uppsala, 2012. They selected a chairperson (JSK) to choose subcommittee members representing different subspecialities from three different continents. Diagnostic criteria were developed through discussions among the subcommittee members. Draft criteria were presented to the ICVD committee of the Barany Society in November 2020 and then modified based on comments. A revised draft became available for comments by the Bárány Society membership in July 2021. 为了制定血管性眩晕/头晕的诊断标准，2012 年，乌普萨拉的巴拉尼学会 ICVD 委员会成员发起了成立小组委员会的倡议。他们选定了一位主席（JSK）来选择代表来自三个不同洲的不同亚专业的小组委员会成员。通过小组委员会成员之间的讨论制定了诊断标准。初稿标准于 2020 年 11 月提交给巴拉尼学会 ICVD 委员会，然后根据意见进行修改。修订后的草案于 2021 年 7 月向巴拉尼学会会员征求意见。
2. Diagnosis of vascular vertigo/dizziness 2. 血管性眩晕/头晕的诊断
Patients with vascular vertigo/dizziness typically present with acute vestibular syndrome (AVS), which refers to the acute onset of vertigo or dizziness with nausea or vomiting, head-motion intolerance, and unsteadiness [11, 154]. Depending on the presentation, vascular vertigo/dizziness can be divided into acute prolonged vascular vertigo/dizziness and transient vascular vertigo/dizziness. Acute prolonged vascular vertigo/dizziness refers to symptoms lasting 24 hours or more. When a patient presents with a previous episode of vertigo/dizziness of less than 24 hours, the term transient vascular vertigo/dizziness may be used [155]. In addition, the term acute vascular vertigo/dizziness in evolution may be applied when a patient with acute vertigo/dizziness is being evaluated within 24 hours from symptom onset. 患有血管性眩晕/头晕的患者通常表现为急性前庭综合征（AVS），指的是眩晕或头晕急性发作伴有恶心或呕吐、头部运动不耐受和不稳定感[11, 154]。根据表现，血管性眩晕/头晕可分为急性持续性血管性眩晕/头晕和短暂性血管性眩晕/头晕。急性持续性血管性眩晕/头晕指持续 24 小时或更长时间的症状。当患者出现持续时间不足 24 小时的既往眩晕/头晕发作时，可使用短暂性血管性眩晕/头晕这一术语[155]。此外，当患有急性眩晕/头晕的患者在症状发作后 24 小时内接受评估时，可使用急性血管性眩晕/头晕演变这一术语。
2.1. Diagnostic criteria for acute prolonged vascular vertigo/dizziness 2.1. 急性延长型血管性眩晕/头晕的诊断标准
Criteria A-C should be fulfilled to make the diagnosis of acute prolonged vascular vertigo/dizziness. 诊断急性持续性血管性眩晕/头晕应满足 A-C 标准。
A) Acute vertigo, dizziness, or unsteadiness lasting for 24 hours or more A) 持续 24 小时或更长时间的急性眩晕、头晕或不稳定
B) Imaging evidence of ischemia or hemorrhage in the brain or inner ear, which corresponds to the symptoms, signs and findings B) 大脑或内耳中的缺血或出血的影像证据，与症状、体征和发现相符
C) Not better accounted for by another disease or disorder C) 不能更好地解释为另一种疾病或障碍
Criteria A-C should be fulfilled to make the diagnosis of probable acute prolonged vascular vertigo/ dizziness. 应满足 A-C 标准才能诊断为可能的急性持续性血管性眩晕/头晕。
A) Acute vertigo, dizziness or unsteadiness lasting for 24 hours or more A) 持续 24 小时或更长时间的急性眩晕、头晕或不稳定
B) At least one of the following: B) 至少满足以下条件之一：
Focal central neurological symptoms and signs, e.g., hemiparesis, sensory loss, dysarthria, dysphagia, or severe truncal ataxia/postural instability 局灶性中枢神经系统症状和体征，例如偏瘫、感觉丧失、言语障碍、吞咽困难或严重的躯干共济失调/姿势不稳。
At least one component of central HINTS [normal head impulse test, directionchanging gaze-evoked nystagmus, or pronounced skew deviation] 至少有一个中央 HINTS 组分[正常头部冲动测试，方向改变的凝视诱发性眼球震颤，或明显的斜视偏移]
Other central ocular motor abnormalities, e.g., central nystagmus, impaired saccades, or impaired smooth pursuit ) 其他中枢眼动异常，例如中枢性眼震、迟钝性眼球运动或平滑追踪受损。
Increased risk for vascular events (e.g., score of 4 or more, or atrial fibrillation 血管事件风险增加（例如，得分为 4 分或更高，或房颤）。
C) Not better accounted for by another disease or disorder C) 不能更好地解释为另一种疾病或障碍
2.1.3. Notes 2.1.3. 注意事项
An acute prolonged vestibular syndrome consists of continuous vertigo/dizziness, imbalance, oscillopsia, vegetative symptoms such as nausea and vomiting, or head motion intolerance lasting more than 24 hours . 急性持续性前庭综合征包括持续性眩晕/头晕、失衡、视动性错视、恶心和呕吐等植物神经症状，或头部运动不耐受，持续时间超过 24 小时。
Even though a diagnosis of acute stroke is primarily based on the findings of neuroimaging, initial MRIs, including diffusion-weighted images (DWI), are falsely negative in 12-50% within the first 48 hours [21, 73, 75, 154] in patients who are eventually determined to have had a stroke. This high false negative rate has two implications: First, if the initial MRI is normal, serial radiological evaluation is required to identify an acute lesion in these patients. Second, it increases the importance of a systematic clinical examination, which has a higher sensitivity during the acute phase than imaging. Further, as the internal auditory artery (IAA), usually a branch of the anterior inferior cerebellar artery (AICA), supplies the inner ear [125], acute vertigo and hearing loss also can be due to labyrinthine or very rarely eighth cranial nerve infarction [36, 81, 90]. As isolated labyrinthine damage may precede ponto-cerebellar involvement in AICA infarction, recognizing audio-vestibular loss may provide an opportunity to prevent progression to a more widespread infarction involving the posterior circulation, mainly in the AICA territory . 尽管急性中风的诊断主要基于神经影像学的发现，但最初的磁共振成像（MRI），包括扩散加权成像（DWI），在最初 48 小时内 12-50%的患者中出现假阴性[21, 73, 75, 154]，这些患者最终被确定为中风。这种高假阴性率有两个含义：首先，如果最初的 MRI 正常，需要进行连续的放射学评估，以确定这些患者是否存在急性病变。其次，这增加了系统性临床检查的重要性，在急性期比影像学具有更高的敏感性。此外，由于内听动脉（IAA）通常是前下小脑动脉（AICA）的一个分支，供应内耳[125]，急性眩晕和听力丧失也可能是由迷路或极少见的第八颅神经梗死引起[36, 81, 90]。由于孤立的迷路损伤可能先于 AICA 梗死中的桥小脑受累，识别听觉-前庭丧失可能有助于防止病变进展至更广泛涉及后循环的梗死，主要是在 AICA 领域。 。
A very rare entity is labyrinthine hemorrhage. It may occur spontaneously, but more frequently it occurs in association with head trauma or bleeding disorders [97, 175]. It shares with labyrinthine infarction the frequent association of vertigo and hearing loss but without brainstem involvement [175]. In labyrinthine hemorrhage, the vertigo is often severe and hearing loss is profound with a poor prognosis [175]. Labyrinthine hemorrhage may be identified by a hyperintense signal in the labyrinth on T1 or fluid-attenuated inversion recovery (FLAIR) MRIs, although this signal can also be caused by inflammatory disorders [175]. 迷路出血是一种非常罕见的情况。它可能会自发发生，但更常见的是与头部创伤或出血性疾病有关[97, 175]。它与迷路梗死共享频繁出现眩晕和听力丧失的特点，但没有脑干受累[175]。在迷路出血中，眩晕常常严重，听力丧失严重，预后不佳[175]。迷路出血可能通过 T1 或液体衰减反转（FLAIR）MRI 上的迷路高信号来识别，尽管这种信号也可能是由炎症性疾病引起的[175]。
Severe truncal ataxia or postural instability is defined by a patient being unable to maintain an upright sitting or standing posture without support [16, 106, 174]. In a 2016 study, none of the patients with AUPV/vestibular neuritis showed severe truncal ataxia or postural instability [16] However, mild to moderate truncal ataxia or postural instability does not necessarily exclude a central lesion [16]. Thus, evaluation of upright balance function enhances the detection of central lesions in acute prolonged vertigo/dizziness . For patients who are too symptomatic to walk, postural stability can be assessed by asking the patient to sit upright in a stretcher with their arms crossed [16]. 严重的躯干共济失调或姿势不稳定是指患者无法在没有支撑的情况下保持直坐或站立姿势[16, 106, 174]。在 2016 年的一项研究中，AUPV/前庭神经炎患者中没有人表现出严重的躯干共济失调或姿势不稳定[16]。然而，轻度至中度的躯干共济失调或姿势不稳定并不一定排除中枢病变[16]。因此，评估直立平衡功能有助于检测急性持续性眩晕/头晕的中枢病变 。对于行走症状过于严重的患者，可以要求患者交叉双臂直坐在担架上以评估姿势稳定性[16]。
In a study of 101 patients ( 69 ischemic strokes, 4 hemorrhages, and 28 non-strokes), a refined bedside examination protocol that incorporates HINTS performed by a clinical expert showed an up to [69/69 with ischemic strokes, confidence interval ] sensitivity and (24/25 with acute peripheral vestibulopathy, ) specificity, giving a positive likelihood ratio of 25 ( ) and a negative likelihood ratio of , compared with delayed MRI in identifying ischemic strokes in patients with acute prolonged vertigo of more than 24 hours and one vascular risk factor, whereas initial DWIs were normal in 12% (8/69 ischemic strokes) [73]. Another report on 20 patients with acute pure vestibular syndrome ( 10 with strokes and 10 with vestibular neuritis) also found diagnostic utility of the signs including normal horizontal head impulse tests (HIT), skew deviation (SD), abnormal vertical smooth pursuit, and central type nystagmus at the bedside [19]. Since a 在一项对 101 名患者（69 例缺血性卒中，4 例出血性卒中和 28 例非卒中）的研究中，一个由临床专家执行的细化床边检查方案，结合 HINTS，显示出对缺血性卒中的敏感性高达 [69/69，置信区间 ]，特异性 （25/25 急性外周前庭病变， ），阳性似然比为 25（ ），阴性似然比为 ，与延迟 MRI 相比，在急性持续性眩晕超过 24 小时且存在一种血管风险因素的患者中识别缺血性卒中，初步 DWI 正常的患者占 12%（69 例缺血性卒中中的 8 例）[73]。另一份关于 20 名急性纯前庭综合征患者（10 例卒中和 10 例前庭神经炎）的报告也发现，床边检查中包括正常水平头冲击试验（HIT），斜视偏离（SD），异常垂直平稳追踪和中央型眼球震颤等征象的诊断效用[19]。
mild degree of SD may go unnoticed during bedside examination and gaze-evoked nystagmus may be absent in cerebellar strokes [106], bedside HIT is a good tool for differentiating isolated vertigo due to cerebellar strokes from AUVP/vestibular neuritis. Indeed, of the three bedside signs of 'HINTS', the horizontal HIT had the greatest combined sensitivity , and specificity ) for central causes [166]. Since pathological HIT and SD can be seen in either peripheral or central lesions, these tests are complementary in diagnosing central vestibular disorders [37, 56, 73, 96, 98]. 轻度 SD 可能在床边检查中被忽略，而在小脑卒中中可能不存在凝视诱发性眼球震颤[106]，床边 HIT 是区分由小脑卒中引起的孤立性眩晕与 AUVP / 前庭神经炎的良好工具。事实上，在“HINTS”的三个床边体征中，水平 HIT 对中枢原因具有最大的综合敏感性 ， 和特异性 ）[166]。由于病理性 HIT 和 SD 可以在外周或中枢病变中看到，因此这些测试在诊断中枢前庭障碍方面是互补的[37, 56, 73, 96, 98]。
The HINTS may not be sufficiently robust to detect an AICA infarction since the HIT is mostly pathological in this disorder [67]. Patients with AICA territory infarction may develop isolated vertigo with negative HINTS (pathological HIT in the absence of gaze-evoked nystagmus and SD), mimicking AUPV/vestibular neuritis [105]. Since the AICA supplies the inner ear, the signs of an AUVP/vestibular neuritis may overshadow the central signs and HINTS may be negative in AICA territory infarctions [34]. Indeed, about of patients with AICA territory ischemic strokes presented acute prolonged vertigo and canal paresis without hearing loss, mimicking acute peripheral vestibular syndrome [105]. Another study also showed negative HINTS in 5 of 17 patients (29.4%) with AICA infarction [67]. In those with negative HINTS, the addition of horizontal head shaking, hearing test with finger rub (HINTS plus), and examination of stance and gait may aid in detecting a central lesion . HINTS 可能不足以检测 AICA 梗死，因为在这种疾病中 HIT 主要是病理性的。AICA 领域梗死的患者可能出现孤立性眩晕，HINTS 检查结果为阴性（在无注视诱发性眼球震颤和 SD 的情况下出现病理性 HIT），模拟 AUPV/前庭神经炎。由于 AICA 供应内耳，AUVP/前庭神经炎的表现可能掩盖中枢体征，而在 AICA 领域梗死中 HINTS 检查结果可能为阴性。事实上，约 的 AICA 领域缺血性卒中患者出现急性持续性眩晕和半规管麻痹，但无听力丧失，模拟急性外周前庭综合征。另一项研究还显示，在 17 名 AICA 梗死患者中，有 5 名（29.4%）的 HINTS 检查结果为阴性。对于 HINTS 检查结果为阴性的患者，加入水平头摇、听力测试（HINTS plus）以及姿势和步态检查可能有助于检测中枢病变。
The score (age, blood pressure, clinical features, duration, and presence of diabetes) was originally developed to estimate the future risk of stroke in patients with a transient ischemic attack (TIA) [69]. However, the score may be used to predict stroke in patients presenting with acute vertigo/dizziness [177]. In a study on patients having visited emergency department with dizziness, vertigo or imbalance, either prolonged or transient, only (5/502) with an score of 3 or less had a stroke compared with in those with a score of 4 or more. Notably, (7/26) of the patients with a score of 6 or 7 suffered from strokes [130]. A prospective study of emergency department dizziness presentations from a single center found that the score as a continuous variable was an independent predictor of acute infarct on MRI [odd ratio (OR) adjusting for findings on the general neurologic and oculomotor examination [75]. 分数（年龄、血压、临床特征、持续时间和糖尿病存在）最初是为了估计短暂性缺血发作（TIA）患者未来中风风险而开发的[69]。然而， 分数可能用于预测急性眩晕/头晕患者的中风[177]。在一项关于前往急诊科就诊出现头晕、眩晕或失衡的患者的研究中，只有 （5/502）个 分数为 3 或更低的患者中有中风，而在那些分数为 4 或更高的患者中有 。值得注意的是， （7/26）个分数为 6 或 7 的患者中患中风[130]。一项关于急诊科就诊出现头晕症状的前瞻性研究发现， 分数作为连续变量是磁共振成像上急性梗死的独立预测因子[调整后的奇数比（OR） ，考虑到一般神经学和眼动检查结果][75]。
2.2. Diagnostic criteria for transient vascular vertigo/dizziness and acute vascular vertigo/dizziness in evolution 2.2. 短暂性血管性眩晕/头晕和急性血管性眩晕/头晕演变的诊断标准
2.2.1. Transient vascular vertigo/dizziness or acute vascular vertigo/dizziness in evolution 2.2.1. 短暂性血管性眩晕/头晕或急性血管性眩晕/头晕发展中
Criteria A-C should be fulfilled to make the diagnosis of transient vascular vertigo/dizziness or acute vascular vertigo/dizziness in evolution. 诊断为短暂性血管性眩晕/头晕或急性血管性眩晕/头晕发展中应满足 A-C 标准。
A) Acute spontaneous vertigo, dizziness, or unsteadiness lasting less than 24 hours 1) A) 急性自发性眩晕，头晕或不稳定持续时间不超过 24 小时 1)
B) Imaging evidence of ischemia or hemorrhage in the brain or inner ear, which corresponds to the symptoms, signs and findings B) 大脑或内耳中的缺血或出血的影像证据，与症状、体征和发现相符
C) Not better accounted for by another disease or disorder C) 不能更好地解释为另一种疾病或障碍
2.2.2. Probable acute vascular vertigo/dizziness in evolution 2.2.2. 可能的急性血管性眩晕/头晕在发展中
Criteria A-C should be fulfilled to make the diagnosis of probable acute vascular vertigo/dizziness in evolution. 应满足标准 A-C，才能确诊为可能的急性血管性眩晕/头晕。
A) Acute spontaneous vertigo, dizziness, or unsteadiness for more than 3 hours, but that has not yet lasted for at least 24 hours when seen. A) 患有急性自发性眩晕、头晕或不稳定感超过 3 小时，但在就诊时尚未持续至少 24 小时。
B) At least one of the following: B) 至少满足以下条件之一：
Focal central neurological symptoms and signs, or severe truncal ataxia/postural instability 局灶性中枢神经系统症状和体征，或严重的躯干共济失调/姿势不稳
At least one component of central HINTS (normal head impulse tests, directionchanging gaze-evoked nystagmus, or pronounced skew deviation 至少有一个中央 HINTS 组分（正常头部冲动测试，方向改变的凝视诱发性眼球震颤，或明显的斜视偏移
Other central ocular motor abnormalities, e.g., central nystagmus, impaired saccades or impaired smooth pursuit) 其他中枢眼动异常，例如中枢眼震、迟钝性眼球运动或迟钝性平滑追踪。
New onset of moderate to severe craniocervical pain 新发生的中度至重度颅颈疼痛
Increased risk for vascular events, e.g., score of 4 or more, or atrial fibrillation 增加血管事件的风险，例如 得分为 4 或更高，或房颤
Significant ( ) narrowing of an artery of the vertebrobasilar system 椎基底动脉系统 的动脉明显狭窄（ ）
C) Not better accounted for by another disease or disorder C) 未被其他疾病或紊乱更好地解释
Criteria A-C should be fulfilled to make the diagnosis of probable transient vascular vertigo/dizziness. 应满足标准 A-C 才能确诊为可能的短暂性血管性眩晕/头晕。
A) Acute spontaneous vertigo, dizziness, or unsteadiness lasting less than 24 hours 1) A) 急性自发性眩晕，头晕或不稳定持续时间不超过 24 小时 1)
B) At least one of the following: B) 至少满足以下条件之一：
Focal central neurological symptoms or severe postural instability during the attack 发作期间的局灶性中枢神经系统症状或严重的姿势不稳
New onset of moderate to severe craniocervical pain during the attack 发作期间出现中度至重度颅颈疼痛的新发病
Increased risk for vascular events, e.g., score of 4 or more, or atrial fibrillation 增加血管事件的风险，例如 得分为 4 或更高，或房颤
Significant ( ) narrowing of an artery of the vertebrobasilar system 椎基底动脉系统 的动脉明显狭窄（ ）
C) Not better accounted for by another disease or disorder C) 未被其他疾病或紊乱更好地解释
2.2.4. Notes 2.2.4. 注释
Many patients develop acute vertigo/dizziness or imbalance lasting less than a day, which may be termed transient vestibular syndrome [22], even though the National Institute of Neurological Disorders and Stroke (NINDS) III Classification and the European Stroke Organization (ESO) Executive Committee and the ESO Writing Committee do not embrace isolated vertigo as a symptom of TIA involving the vertebrobasilar territory (VB-TIA) [51]. The use of the previous terminology "vertebrobasilar insufficiency" is not recommended [18]. Transient vestibular syndrome frequently occurs in VB-TIA [55, 148]. Indeed, isolated episodic vertigo was the only manifestation in of patients with a presumptive diagnosis of VB-TIA [54], and (29/42) of the patients with vertigo due to VB-TIA and (12/42) of patients with vertebrobasilar infarction had a history of isolated episodic vertigo [55]. Other studies reported that preceding transient isolated brainstem symptoms are common in patients with a completed stroke in the vertebrobasilar territory [148]. The episodic vertigo is typically spontaneous in onset and lasts for minutes in VB-TIA [55, 64]. Despite detailed neuro-otologic examination and neuroimaging studies including MRIs with DWI and perfusion imaging, underlying etiologies remained unknown in more than half of the patients with transient vestibular syndrome [22]. Transient vestibular syndrome may be attributed to rapid resolution of some peripheral vestibular disorders such as benign paroxysmal positional vertigo (BPPV) or Menière's disease during their first attack. Transient brainstem hypoperfusion may be another possibility since perfusion imaging has limitations in detecting a small perfusion defect restricted to the brainstem. 许多患者出现持续不到一天的急性眩晕/头晕或不平衡，可能被称为短暂前庭综合征[22]，尽管美国国家神经疾病和中风研究所（NINDS）III 分类、欧洲中风组织（ESO）执行委员会和 ESO 撰写委员会不将孤立性眩晕视为涉及椎基底动脉领域（VB-TIA）的 TIA 症状[51]。不推荐使用先前的术语“椎基底动脉供血不足”[18]。短暂前庭综合征在 VB-TIA 中经常发生[55, 148]。事实上，孤立性阵发性眩晕是 VB-TIA 患者中唯一的表现[54]，而 （29/42）VB-TIA 患者和 （12/42）患有椎基底动脉梗死的患者中有眩晕症状的患者有阵发性孤立性眩晕的病史[55]。其他研究报告称，在患有椎基底动脉领域完全中风的患者中，先前的短暂孤立性脑干症状很常见[148]。VB-TIA 中的阵发性眩晕通常是自发性的，持续几分钟[55, 64]。 尽管进行了详细的神经-耳科检查和包括 MRI 与 DWI 和灌注成像在内的神经影像学研究，但在半数以上患有暂时性前庭综合征的患者中，潜在病因仍然未知。暂时性前庭综合征可能归因于某些外周前庭疾病（如良性阵发性位置性眩晕（BPPV）或美尼尔氏病）在首次发作期间的快速缓解。暂时性脑干灌注不足可能是另一种可能性，因为灌注成像在检测限于脑干的小灌注缺损方面存在局限性。
A study found stroke in [23/86, cerebral infarction in 15% (13/86) and cerebellar hypoperfusion in (10/86)] of patients referred to the emergency department with transient vestibular syndrome [22]. 一项研究发现，在前往急诊科就诊的暂时性前庭综合征患者中， [23/86，脑梗死占 15%（13/86），小脑灌注不足占 （10/86）] 患有中风。
Whereas application of HINTS has greatly enhanced the diagnosis of stroke in acute prolonged vascular vertigo, the diagnostic utility of HINTS/HINTS plus examination and MRIs was limited in transient vestibular syndrome. HINTS plus could not be applied to the majority of patients with transient vestibular syndrome since the vestibular symptoms or signs had already resolved by the time of evaluation in about (63/86) of the patients [22]. 在急性持续性血管性眩晕中，HINTS 的应用极大地提高了中风的诊断，但在短暂性前庭综合征中，HINTS/HINTS 加检查和 MRI 的诊断效用有限。由于大多数短暂性前庭综合征患者在评估时前庭症状或体征已经消失，因此 HINTS 加无法应用于大多数患者。【22】。
Even though headache is a common symptom, moderate to severe craniocervical pain is very rare in peripheral vestibular disorders. Thus, when patients experience the new onset of moderate to severe craniocervical pain along with acute vestibular symptoms, vascular dissection or posterior circulation strokes including hemorrhages should be suspected, especially when migraine or vestibular migraine is unlikely. Indeed, associated craniocervical pain was a clue for strokes with an OR of 15.2 ( , multivariate logistic regression analysis) in a study of 86 patients who were diagnosed with transient vestibular syndrome [22]. 尽管头痛是一种常见症状，但在外周前庭障碍中，中度至重度颅颈疼痛非常罕见。因此，当患者出现中度至重度颅颈疼痛的新发症状以及急性前庭症状时，应怀疑血管夹层或包括出血在内的后循环卒中，尤其是当偏头痛或前庭偏头痛不太可能时。事实上，相关的颅颈疼痛是一种卒中的线索，一项研究中，86 名被诊断为短暂前庭综合征的患者中，经多元逻辑回归分析，其卒中的 OR 为 15.2（ ）。
In a previous study on transient vestibular syndrome [22], eight of the 10 patients with unilateral cerebellar hypoperfusion only on perfusion images without an infarction on DWI showed a focal stenosis or hypoplasia of the corresponding vertebral artery (VA). The results of multivariate logistic regression analysis showed 在先前对暂时性前庭综合征的研究中[22]，10 名患有单侧小脑灌注不足但在灌注图像上没有梗死的患者中，有 8 名显示出相应椎动脉（VA）的局部狭窄或发育不全。多元逻辑回归分析的结果显示
that VA stenosis or hypoplasia ( ) is a risk factor for strokes in patients with transient vertigo/dizziness [22]. Besides atherosclerotic stenosis or occlusion, hypoplasia of the VA may be a predisposing factor for posterior circulation stroke especially when vascular risk factors coexist . Vascular investigations may reveal reversal of flow in one VA [149], or other kinds of steal phenomena [172]. Reversal of VA flow is often asymptomatic or may be associated with carotid territory symptoms as it is with vertebrobasilar territory symptoms [7]. For this reason, subclavian steal syndrome is not included in this classification as a distinct entity for vascular vertigo/dizziness . VA 狭窄或发育不全（ ）是患有暂时性眩晕/头晕的患者中中风的危险因素[22]。除了动脉粥样硬化性狭窄或闭塞外，VA 的发育不全可能是后循环中风的易感因素，尤其是在血管风险因素共存时 。血管检查可能会显示一侧 VA 的血流逆转[149]，或其他类型的窃流现象[172]。VA 血流逆转通常是无症状的，或者可能与颈动脉供血区症状相关，就像与椎基底动脉供血区症状相关一样[7]。因此，锁骨下窃血综合征不作为血管性眩晕/头晕的独立实体包括在此分类中 。
Even though a vascular origin is a serious concern in patients with new onset transient vertigo/dizziness and vascular risk factors, other diagnoses such as vestibular migraine or Menière's disease are more likely in patients with episodes of vertigo/dizziness that have been occurring for many months or years . 尽管血管起源是新发短暂性眩晕/头晕和血管风险因素患者的严重关注焦点，但对于眩晕/头晕发作已持续数月或数年的患者，更可能是前庭偏头痛或梅尼埃病等其他诊断。
Criteria A-D should be fulfilled to make the diagnosis of VACS. 诊断 VACS 应满足标准 A-D。
A) Vertigo with or without tinnitus provoked by a sustained eccentric neck position, especially in an upright body position A) 由持续的偏心颈部位置引起的眩晕，伴有或不伴有耳鸣，尤其是在直立体位
B) Presence of nystagmus with the symptoms during an attack B) 发作期间症状伴有眼球震颤的存在
C) Either 1) or 2) during the provoking head motion C) 在引发头部运动 期间，选择 1)或 2)
Documentation of VA compression using dynamic angiography 使用动态血管造影记录 VA 压迫情况
Demonstration of decreased blood flow in the posterior circulation using transcranial Doppler 通过经颅多普勒显示后循环血流减少的演示
D) Not better accounted for by another disease or disorder D) 不能被其他疾病或紊乱更好地解释
2.3.2. Previously used terms 2.3.2. 以前使用过的术语
Bow hunter's syndrome, rotational VA syndrome, rotational VA compression syndrome, rotational VA occlusion syndrome. 弓手综合征，旋转 VA 综合征，旋转 VA 压迫综合征，旋转 VA 闭塞综合征。
2.3.3. Notes 2.3.3. 注释
Episodic vertigo, nystagmus, and syncope rarely may occur due to mechanical compression of the VA induced by horizontal or diagonal neck rotation, tilt or extension [99, 171, 187]. Tinnitus develops several seconds after the onset of vertigo and nystagmus, which suggests that the vestibule is more sensitive to ischemia than the cochlea . 由于椎动脉受到水平或对角颈部旋转、倾斜或伸展引起的机械压迫，可能偶发性出现眩晕、眼球震颤和晕厥，但这种情况很少发生[99, 171, 187]。耳鸣在眩晕和眼球震颤发作几秒钟后出现，这表明前庭对缺血的敏感性比耳蜗更高。
Oculographic analyses reveal various patterns of nystagmus during attacks in the VACS [32, 123, 164]: the initial nystagmus is mostly downbeat, with the horizontal and torsional components beating either toward the compressed VA side, indicating a transient excitation of the labyrinth [164], or directed away [32]. Patients may show spontaneous reversal of the nystagmus, or markedly diminished or absence of nystagmus when the provocative neck rotation is repeated [32]. 眼动分析揭示了 VACS 发作期间不同类型的眼球震颤模式：初始眼球震颤主要是向下的，水平和扭转分量要么向受压 VA 侧跳动，表明前庭暂时兴奋[164]，要么向远离方向跳动[32]。患者可能表现出眼球震颤的自发逆转，或在重复诱发性颈部旋转时明显减弱或消失[32]。
Patients with VACS usually have one hypoplastic or stenotic VA, or the VA terminating as the posterior inferior cerebellar artery (PICA), and a contralateral, dominant, VA compressed or occluded mostly at the atlantoaxial junction when the head is turned away from the compression side [ . VACS is confirmed if angiography documents compression of a dominant VA when vertigo occurs during head rotation or tilt [28], or by demonstrating a head rotation/tilt-induced decrease of blood flow in the posterior circulation using transcranial Doppler [156]. 患有 VACS 的患者通常有一侧发育不全或狭窄的 VA，或者 VA 终止为后下小脑动脉（PICA），以及在头部远离压迫侧时，对侧主导的 VA 在寰枢关节处受压或闭塞[ 。如果在头部旋转或倾斜时出现眩晕时，血管造影显示主导 VA 受压，则确认 VACS[28]，或通过经颅多普勒显示头部旋转/倾斜引起后循环血流减少[156]。
3. Lesion sites responsible for isolated vascular vertigo 3. 导致孤立性血管性眩晕的病变部位
In a study performed in the emergency department of a tertiary referral hospital, 47 (13.4%) of 351 patients with acute isolated vestibular or ocular motor symptoms of unclear etiology showed acute unilateral stroke on MRIs [189]. Volumetric analyses showed that medial cerebellar strokes are associated with vertigo, lateral cerebellar strokes with dizziness, and pontomesencephalic strokes with double vision [189]. In contrast, cerebral cortical lesions are rare and present with milder symptoms of shorter duration . 在三级转诊医院急诊科进行的一项研究中，351 名急性孤立性前庭或眼动症状不明原因患者中，有 47 人（13.4%）在 MRI 上显示急性单侧中风[189]。容积分析显示，中脑小脑中风与眩晕有关，侧脑小脑中风与头晕有关，桥脑中脑中风与复视有关[189]。相比之下，脑皮质病变罕见，表现为症状较轻、持续时间较短 。
3.1. Brainstem 3.1. 脑干
In brainstem lesions, vertigo/dizziness is commonly associated with other neurological symptoms 在脑干病变中，眩晕/头晕常常伴随其他神经症状
and signs, but some patients with an isolated vestibular syndrome show a small lesion confined to the vestibular nuclei or root entry zone of the eighth cranial nerve at the pontomedullary junction [50, 169], dorsolateral medulla , pontine or midbrain tegmentum , or cerebellar peduncles , 但一些患有孤立性前庭综合征的患者显示小的病变局限在桥延髓交界处第八颅神经的前庭核或根入区[50, 169]，背外侧延髓 ，桥脑或中脑腹侧 ，或小脑脚 ，
Patients with an infarction involving the caudal lateral medulla may present with isolated imbalance, probably due to interruption of the lateral vestibulospinal tract or dorsal spinocerebellar tract. In a study of 105 patients with AVS and at least one stroke risk factor from a single academic medical center, approximately (15/105) of the patients with a stroke had isolated AVS from a small ( ) infarction, and 11 of them showed a lesion involving the inferior cerebellar peduncle, mostly in the lateral medulla (9/11, 82%) [154]. Only one patient showed an isolated small infarction in the cerebellum [154], which is known as one of the most common sites causing AVS [21, 106]. The inferior cerebellar peduncle carries various input and output fibers to and from the cerebellum, which are mainly concerned with integrating proprioceptive sensory inputs with vestibular signals important for balance. Proprioceptive information from the body is carried to the cerebellum via the posterior spinocerebellar tract in the inferior cerebellar peduncle. The vestibulocerebellum also receives mossy fiber inputs from the vestibular nuclei and nerve, and projects efferent fibers to the vestibular nuclei via the inferior cerebellar peduncle. Thus, an infarction involving the inferior cerebellar peduncle may result in imbalance with vertigo and nystagmus [23]. Since the medial vestibular nucleus is more vulnerable to ischemia than other structures in the brainstem or cerebellum according to a animal study [107], ischemia of the dorsolateral medulla where the vestibular nuclei are located may be a mechanism of isolated vascular vertigo. Indeed, several studies described isolated vertigo from infarctions restricted to the vestibular nuclei [86]. Rarely, cerebral hemispheric infarctions involving the vestibular cortices can cause isolated vertigo with spontaneous nystagmus and subjective visual vertical (SVV) tilt , 176]. 涉及尾侧延髓的梗死患者可能表现为孤立的不平衡，可能是由于侧脑室旁脊髓束或背侧脊髓小脑径路的中断。在一项涉及 105 名 AVS 患者且至少有一个卒中风险因素的研究中，大约 （15/105）名中风患者中有孤立的 AVS，是由于小型（ ）梗死，其中 11 名患者 显示出涉及下小脑脚的病变，主要位于侧延髓（9/11，82%）[154]。只有一名患者显示出小型小脑梗死[154]，这被认为是引起 AVS 的最常见部位之一[21, 106]。下小脑脚携带各种输入和输出纤维到达小脑，主要涉及将身体的本体感觉输入与平衡重要的前庭信号整合。身体的本体感觉信息通过下小脑脚中的后侧脊髓小脑径路传递到小脑。 前庭小脑还接收来自前庭核和神经的苔藓纤维输入，并通过小脑下束向前庭核投射出运动纤维。因此，涉及小脑下束的梗死可能导致眩晕和眼球震颤的失衡。根据动物研究，前庭核所在的腹外侧延髓对缺血的脆弱性高于脑干或小脑的其他结构，因此，腹外侧延髓的缺血可能是独立血管性眩晕的机制。事实上，几项研究描述了由于仅限于前庭核的梗死而导致的孤立性眩晕。很少情况下，涉及前庭皮层的脑半球梗死可能导致伴有自发性眼球震颤和主观视觉垂直倾斜的孤立性眩晕。
However, since previous reports on isolated vestibular syndrome of vascular cause are mostly limited to anecdotal case reports, small case series from a single center, and specific subtypes of posterior circulation ischemia, the overall frequency and the structures involved remain to be determined in strokes presenting with isolated vestibular syndrome. 然而，由于先前关于血管原因孤立性前庭综合征的报告大多局限于轶事性个案报告、单一中心的小型病例系列以及后循环缺血的特定亚型，因此有待确定以孤立性前庭综合征呈现的中风中的总体频率和涉及的结构。
3.2. Cerebellum 3.2. 小脑
The frequency of acute isolated vascular vertigo and the structures involved were analyzed in 132 prospectively recruited consecutive patients with posterior circulation infarctions in a referral Stroke Center [21]. This study found that approximately (34/132) of patients with posterior circulation infarction present with isolated vestibular syndrome: cerebellar infarction ( ) was most frequent, mostly in the territory of medial PICA. These results are consistent with those of previous and recent studies that showed a high frequency of medial PICA infarction in patients presenting with acute isolated vascular vertigo, and frequent isolated vertigo in medial PICA infarction [106, 189]. Indeed, dysmetria, a major sign of cerebellar dysfunction, may be minimal or absent in cerebellar infarctions involving the territory of medial PICA, especially when the infarction is not large. In the cerebellum, the nodulus and ventral uvula may cause isolated vestibular syndrome when damaged [104, 127]. A study of eight patients from a single center also showed that isolated nodular infarction mostly presents with isolated vertigo and imbalance without other neurological deficits, mimicking AUVP/vestibular neuritis [127]. The flocculus and paraflocculus may be other neural structures leading to isolated vestibular syndrome [110, 145, 182]. They participate in the control of smooth tracking, gaze-holding, and eye movements induced by vestibular stimulation. Experimental lesions cause gaze-evoked nystagmus, downbeat nystagmus, post-saccadic drift, impaired smooth pursuit, and impaired cancellation of the vestibulo-ocular reflex (VOR) [188]. However, since the flocculus is supplied by a branch from the AICA, which also supplies the dorsolateral pons and inner ear, an infarction involving the flocculus usually accompanies other brainstem signs or hearing loss [4]. Studies have also suggested the inferior cerebellum as a lesion site responsible for isolated vascular vertigo. In AVS due to stroke, the lesions are mostly found in the cerebellum, usually in the territory of PICA [106]. In a retrospective study of 240 patients with a cerebellar infarction in a single center, isolated vestibular syndrome mimicking AUVP/vestibular neuritis was found in 10% (25/240) of patients [106]. 132 名前瞻性招募的后循环梗死连续患者中，分析了急性孤立性血管性眩晕的发生频率和涉及的结构。这项研究发现，大约 （34/132）的后循环梗死患者表现为孤立性前庭综合征：小脑梗死（ ）最为常见，主要位于后下脑动脉的中央后下脑动脉领域。这些结果与先前和最近的研究结果一致，显示出患急性孤立性血管性眩晕的患者中，中央后下脑动脉梗死的高发生率，以及中央后下脑动脉梗死中频繁出现的孤立性眩晕。事实上，小脑功能障碍的主要体征——运动失调，在涉及中央后下脑动脉领域的小脑梗死中可能很小或不存在，尤其是当梗死范围不大时。在小脑中，当 nodulus 和 ventral uvula 受损时，可能引起孤立性前庭综合征。 一项来自单一中心的八名患者的研究还显示，孤立性结节性梗死主要表现为孤立性眩晕和不平衡，没有其他神经功能缺陷，类似 AUVP / 前庭神经炎。小脑小叶和旁小叶可能是导致孤立性前庭综合征的其他神经结构。它们参与控制由前庭刺激引起的平滑跟踪、凝视保持和眼球运动。实验性损伤会导致凝视诱发性眼震、向下性眼震、后视动漂移、平滑追踪障碍以及前庭眼球反射的取消障碍。然而，由于小脑小叶由 AICA 的一个分支供应，AICA 还供应腹外侧脑桥和内耳，涉及小脑小叶的梗死通常伴随其他脑干体征或听力丧失。研究还表明，下小脑是导致孤立性血管性眩晕的病变部位。在因中风引起的 AVS 中，病变主要发现在小脑，通常在 PICA 领域。 在一项对 240 名单个中心的小脑梗死患者进行的回顾性研究中，发现有 10%（25/240）的患者出现了模拟 AUVP/前庭神经炎的孤立性前庭综合征。
3.3. Inner ear 3.3. 内耳
Ischemia of the inner ear may cause isolated vascular vertigo/dizziness due to its requirement for high-energy metabolism and absence of collateral 内耳缺血可能导致孤立的血管性眩晕/头晕，因为内耳需要高能量代谢且缺乏侧支
circulation . The labyrinth and its individual components appear to be vulnerable to ischemia because the IAA is an end artery with minimal collaterals from the otic capsule [125], such that blockage of the IAA leads most often to a severe peripheral vestibular deficit and loss of hearing (see above). By contrast, the vestibulocochlear nerve is less vulnerable to ischemia based on the arterial system of the internal auditory canal [125]. It is nearly impossible to document isolated labyrinthine infarction, labyrinthine component infarction, or vestibulocochlear nerve infarction without a pathologic study . 循环 。迷路及其各个组成部分似乎容易受缺血影响，因为内听动脉是一个末梢动脉，从耳囊几乎没有侧支[125]，因此内听动脉阻塞最常导致严重的外周前庭功能障碍和听力丧失（见上文）。相比之下，基于内听道的动脉系统，前庭蜗神经对缺血的脆弱性较小[125]。几乎不可能在没有病理研究的情况下记录到孤立的迷路梗死、迷路组分梗死或前庭蜗神经梗死 。
4. Epidemiology of vascular vertigo/dizziness 4. 血管性眩晕/头晕的流行病学
Approximately of ischemic events are known to involve the neural structures supplied by the posterior (vertebrobasilar) circulation, and vertigo/dizziness is one of the most common symptoms of vertebrobasilar diseases [148, 157]. Recent large database prospective studies also reported dizziness as a presenting symptom in of patients with posterior circulation stroke . In the USA, dizziness and vertigo account for to of visits to emergency departments [132], and stroke is responsible for of these presentations , 75, 132]. Furthermore, those patients hospitalized with isolated vertigo have a 3 times higher risk for stroke ; absolute risk, vertigo group vs comparison group) than a comparison group of patients hospitalized for appendectomy during the 4 -year follow-up [101]. Nearly all of the excess risk for stroke occurred in patients with vertigo who also had vascular risk factors. In particular, those patients with three or more risk factors had a 5.51 -fold higher risk for stroke ( CI, 3.10-9.79; ) than those without risk factors [101]. Overall, patients with vertigo/dizziness showed a 2 -fold higher risk of stroke or cardiovascular events ( CI, 1.35-2.96, ) than a non-dizziness comparison group during a follow-up of 3 years after adjusting for confounding and risk factors [100]. Thus, even if we accept that a proven cerebrovascular cause is rare in patients with isolated vertigo in unselected samples and the risk of future stroke is low, the future risk of stroke is considerably higher in those patients with vertigo/dizziness as compared with those patients with non-dizziness visits [5], especially when several vascular risk factors are present. Furthermore, there has been an accumulation of evidence indicating that posterior circulation ischemia can present with isolated vertigo without other focal signs [21, 106]. 大约 的缺血事件已知涉及由后（椎基底动脉）循环供应的神经结构，眩晕/头晕是椎基底动脉疾病最常见的症状之一[148, 157]。最近的大型数据库前瞻性研究还报告了眩晕作为 患者中后循环卒中的首发症状 。在美国，眩晕和头晕占急诊科就诊的 至 [132]，卒中负责 这些病例 ，75, 132]。此外，患有单纯性眩晕的住院患者中中风风险是对照组（4 年随访期间接受阑尾切除术的患者）的 3 倍 ；绝对风险， 眩晕组对照组 ）比对照组的患者在 4 年随访期间接受阑尾切除术的患者高。中风的多发风险几乎都发生在患有眩晕且具有血管风险因素的患者身上。特别是，那些具有三个或更多风险因素的患者中风风险高出 5.51 倍（ CI，3.10-9.79; ）比没有风险因素的患者高[101]。 总体而言，眩晕/头晕患者在经过 3 年的随访后，即使调整了混杂因素和风险因素，他们患中风或心血管事件的风险是非眩晕对照组的 2 倍（ CI，1.35-2.96, ）[100]。因此，即使我们接受在未经选择的样本中，孤立性眩晕患者中的已证实的脑血管原因很少，未来中风的风险很低，但与非眩晕就诊患者相比，眩晕/头晕患者未来中风的风险要高得多[5]，尤其是当存在多种血管风险因素时。此外，有证据表明，后循环缺血可以表现为孤立性眩晕，而无其他局灶体征[21, 106]。
Vertebrobasilar ischemia is also a serious concern when patients present with acute transient vertigo [49, 54, 55].Vertigo typically occurs abruptly and usually lasts several minutes to hours [22, 49]. In a study of 84 patients with vertigo due to vertebrobasilar ischemia, had at least one isolated episode of vertigo, and developed vertigo as the initial symptom [55]. In another study, of 29 patients with VB-TIA reported episodic vertigo as the only symptom for at least 4 weeks [54]. In a study of patients with posterior circulation stroke, reported subtle transient neurological symptoms in the 90 days preceding their stroke, most frequently vertigo [148]. Patients with infarction in the territory of the AICA can also experience recurrent vertigo in combination with fluctuating hearing loss and/or tinnitus as the initial symptoms 1-10 days prior to an infarction [103]. Thus, to prevent future strokes, it is crucial to identify those patients presenting with vertiginous episodes as a symptom of a TIA [83, 173]. 患者出现急性短暂性眩晕时，椎基底动脉缺血也是一个严重的关注点。眩晕通常突然发生，通常持续几分钟到几小时。在一项涉及 84 名因椎基底动脉缺血引起眩晕的患者的研究中， 至少有一次单独的眩晕发作， 作为初始症状出现。在另一项研究中，29 名 VB-TIA 患者中， 报告说至少有 4 周的时间只有周期性的眩晕作为唯一症状。在一项关于后循环中风患者的研究中， 报告说在中风前的 90 天内出现了轻微的短暂神经症状，其中最常见的是眩晕。在 AICA 领域梗死的患者中，也可能在梗死前 1-10 天出现反复的眩晕，伴随波动性听力丧失和/或耳鸣作为初始症状。因此，为了预防未来的中风，至关重要的是识别那些以眩晕发作作为 TIA 症状出现的患者。
5. Evaluation of vascular vertigo/dizziness 5. 血管性眩晕/头晕的评估
When acute vertigo/dizziness accompanies other neurological symptoms and signs, diagnosis of central, most often vascular vertigo is straightforward in most cases even without documentation of a stroke with neuroimaging. Even though introduction of DWI has greatly enhanced detection of infarctions in patients with vascular vertigo/dizziness, especially due to compromised posterior circulation or atrial fibrillation, bedside neuro-otologic evaluation by experts has been more sensitive than acute MRI including DWI in detecting acute small infarctions seen on a delayed MRI as the cause of spontaneous vertigo lasting more than 24 hours, especially during the first 48 hours [21, 73, 134, 154]. 当急性眩晕/头晕伴随其他神经症状和体征时，在大多数情况下，即使没有神经影像学证明中风，中枢性眩晕的诊断通常也是直截了当的。尽管 DWI 的引入极大地增强了对患有血管性眩晕/头晕的患者中梗死的检测，尤其是由于后循环或心房颤动受损，但专家进行的床边神经-耳科评估比包括 DWI 在内的急性 MRI 更敏感，能够检测出在延迟 MRI 上看到的急性小梗死，这些梗死是持续超过 24 小时的自发性眩晕的原因，尤其是在最初的 48 小时内。
Thus, vascular vertigo should be strongly suspected in patients with an AVS and vascular risk factors even though confirmation of a stroke is mostly based on the findings of the neurotological examination and imaging of the brain and cerebral vasculature [178]. Vascular causes should also be suspected in non-positional episodic vestibular syndrome, especially when the dizzy spells last only minutes in patients with risk factors for stroke [55]. Brain imaging assists in determining the involved territories and stroke etiology. 因此，即使中风的确认主要基于神经耳科检查和脑部及脑血管成像的结果，但在具有 AVS 和血管危险因素的患者中，应强烈怀疑血管性眩晕。在具有中风风险因素的患者中，尤其是在眩晕发作仅持续几分钟的非位置性周期性前庭综合征中，也应怀疑血管性原因。脑部成像有助于确定受累领域和中风病因。
5.1. Clinical evaluation 5.1. 临床评估
Despite the marked progress in laboratory medicine and neuroimaging, systematic history taking and bedside examination provide the foundation for accurate diagnosis of vestibular disorders [41, 66, 75, 174]. Patients with vascular vertigo/dizziness invariably present with acute vestibular symptoms, either transient or prolonged [55]. Patients often have vascular risk factors or atrial fibrillation and, in most cases, present with other neurological symptoms and signs. History may disclose preceding attacks of vertigo/dizziness suggestive of VB-TIA [49, 55]. Patients with vertigo/dizziness should undergo a bedside evaluation for ocular misalignment including as a component of the ocular tilt reaction (OTR), spontaneous and gaze-evoked nystagmus, HIT, and gait and balance function [37, 43, 66]. Positional testing and examination of head-shaking nystagmus (HSN), saccades, and smooth pursuit may provide additional support in discriminating a central from a peripheral vestibular lesion [26, 37, 67]. 尽管实验室医学和神经影像学取得了显著进展，但系统性病史采集和床边检查为准确诊断前庭障碍提供了基础。患有血管性眩晕/头晕的患者通常表现为急性前庭症状，短暂或持续。患者常伴有血管性危险因素或心房颤动，并且在大多数情况下伴有其他神经症状和体征。病史可能揭示出现眩晕/头晕的前兆性发作，提示可能为 VB-TIA。眩晕/头晕患者应接受床边评估，包括眼球错位，作为眼球倾斜反应（OTR）的一个组成部分，自发性和凝视诱发性眼球震颤，头部冲击试验（HIT），以及步态和平衡功能。姿势测试和头部摇晃性眼球震颤（HSN），快速眼球运动（saccades）和平稳追踪的检查可能提供额外支持，有助于区分中枢性和外周性前庭病变。
5.1.1. Ocular tilt reaction (OTR) and tilt of the subjective visual vertical (SVV) 5.1.1. 眼倾斜反应（OTR）和主观视觉垂直线的倾斜（SVV）
The OTR refers to the triad of head tilt, SD, and ocular torsion . The OTR and SVV tilt may be attributed to unilateral lesions involving the pathways from the otolithic organs or semicircular canals . SD indicates vertical misalignment of the eyes in the absence of an extraocular muscle palsy or strabismus. The presence of SD or other ocular misalignment should be determined with the alternating cover test. In OTR, the head tilt and ocular torsion occur toward the lower eye. Even though a small SD is also observed in peripheral vestibular disorders [56, 80, 96] (e.g., in according to a study on 53 patients with acute unilateral vestibulopathy [96]), it has been included as a part of an ocular motor assessment to discriminate central from peripheral causes of AVS [37, 73]. Pronounced SD may be specific ( ) for stroke detection when larger than [96], but is not very sensitive since SD is found in only about one third of patients with acute unilateral brainstem infarctions [14]. Pathological SVV tilts and ocular torsion are the most sensitive signs of vestibular imbalance in the roll plane in patients with acute unilateral brainstem infarction [14], but these signs do not discriminate between a peripheral and central lesion [190]. SVV can be measured easily in the emergency department by the bucket test [190]. The measurement of ocular torsion requires magnified fundoscopy, fundus photography or a scanning laser ophthalmoscope [14, 44, 60, 190]. OTR 指的是头部倾斜、SD 和眼球扭转的三联症 。OTR 和 SVV 倾斜可能归因于涉及耳石器官或半规管通路的单侧病变 。SD 表示眼睛在没有外眼肌麻痹或斜视的情况下垂直错位。应通过交替遮盖试验确定 SD 或其他眼球错位的存在。在 OTR 中，头部倾斜和眼球扭转朝向下眼发生。即使在外周前庭障碍中也观察到小的 SD[56, 80, 96]（例如，根据一项关于 53 例急性单侧前庭病变患者的研究[96]），它已被纳入眼动评估的一部分，以区分 AVS 的中心和外周原因[37, 73]。当 SD 大于 [96]时，明显的 SD 可能是中风检测的特异性 ，但并不是非常敏感，因为 SD 仅在约三分之一的急性单侧脑干梗死患者中发现 [14]。 病理性 SVV 倾斜 和眼球扭转 是急性单侧脑干梗死患者滚动平面前庭失衡最敏感的体征[14]，但这些体征不能区分外周和中枢病变[190]。在急诊科可以通过桶试验轻松测量 SVV[190]。眼球扭转的测量需要放大的眼底镜检查、眼底摄影或扫描激光眼底镜[14, 44, 60, 190]。
5.1.2. Spontaneous, gaze-evoked, head-shaking and positional nystagmus 5.1.2. 自发性、凝视诱发性、头晕和位置性眼球震颤
Spontaneous nystagmus: Patients with AUVP/ vestibular neuritis show spontaneous horizontaltorsional nystagmus that beats away from the lesion side [43]. The nystagmus is unidirectional and maximal when looking in the direction of the fast phases of nystagmus (Alexander's law). In contrast, pure downbeat, upbeat, or torsional nystagmus is well recognized in central vestibular lesions [114]. Marked suppression by visual fixation has been considered a hallmark of peripheral nystagmus [61]. The effects of visual fixation on spontaneous nystagmus are variable in central lesions [63, 121]. Failure of fixation suppression is observed in about of patients with cerebellar infarctions, especially when the nodulus and flocculus are affected [84]. Thus, proper observation of nystagmus requires the use of Frenzel's goggles or M glasses [163]. Fixation may evoke nystagmus or augment spontaneous nystagmus in central lesions . 自发性眼球震颤：患有 AUVP/前庭神经炎的患者表现出远离病变侧的自发性水平扭转性眼球震颤[43]。眼球震颤是单向的，在眼球震颤快相方向注视时达到最大（亚历山大定律）。相比之下，纯下视、上视或扭转性眼球震颤在中枢前庭病变中被广泛认可[114]。视觉固定明显抑制被认为是外周眼球震颤的特征[61]。视觉固定对自发性眼球震颤的影响在中枢病变中是多变的[63, 121]。大约 的小脑梗死患者观察到固定抑制失败，尤其是当小结节和小叶受到影响时[84]。因此，正确观察眼球震颤需要使用弗伦泽尔眼镜或 M 型眼镜[163]。固定可能会引发眼球震颤或增强中枢病变的自发性眼球震颤 。
Gaze-evoked nystagmus: Integrity of the central neural network can be evaluated by inducing eccentric gaze [114]. Direction-changing gaze-evoked or gaze-holding nystagmus in the horizontal or vertical plane is generally considered a sign of impaired neural integration from lesions involving the brainstem and cerebellum [43]. However, with a peripheral lesion, a reversal of the nystagmus direction can occur with gaze in the direction opposite to the spontaneous slow phase possibly based on a leaky neural integrator induced by an acute peripheral vestibular asymmetry . 凝视性眼球震颤：通过诱发偏心凝视可以评估中枢神经网络的完整性。水平或垂直平面上出现方向改变的凝视性眼球震颤或凝视保持性眼球震颤通常被认为是脑干和小脑损伤引起的神经整合受损的迹象。然而，对于外周损伤，眼球震颤方向可能会在凝视朝向与自发慢相反方向时发生逆转，这可能是由于急性外周前庭不对称引起的漏电神经整合器。
Head-shaking nystagmus (HSN) and positional nystagmus: Both HSN and positional nystagmus may give additional information. HSN may be ipsi- or contralesional according to the location and extent of central lesions [31, 65, 67]. However, vigorous HSN ( ) or HSN with cross-coupling (mostly downbeat after horizontal head shaking) should be considered a central sign [184]. Vigorous horizontal HSN is typically observed in patients with lateral medullary infarction [31]. HSN with cross-coupling has been reported in strokes involving the cerebellum or brainstem [ , and has been explained by enhanced responses of the anterior semi- 头部摇晃性眼震（HSN）和姿势性眼震：HSN 和姿势性眼震可能提供额外信息。根据中央病变的位置和范围，HSN 可能是同侧或对侧的[31, 65, 67]。然而，有力的 HSN（ ）或具有交叉耦合的 HSN（水平头部摇晃后主要是下视性）应被视为中央征象[184]。水平方向有力的 HSN 通常观察到于侧脑干梗死患者[31]。已报道涉及小脑或脑干的中风患者出现具有交叉耦合的 HSN[ ]，并已通过前半半椎体反应增强来解释。
circular canal pathway due to cerebellar dysfunction [25]. 由于小脑功能障碍引起的环形管道通路【25】。
Positional maneuvers can evoke nystagmus or modulate a spontaneous nystagmus in central as well as peripheral vestibular disorders. Central positional vertigo and nystagmus may be paroxysmal ( minute in duration) or persistent . Since the paroxysmal and persistent forms of central positional nystagmus may mimic the positional nystagmus of BPPV [15, 91], a central lesion should be suspected in patients with positional nystagmus atypical for BPPV, mimicking multi-canal BPPV, or positional dizziness and nystagmus refractory to repeated treatment maneuvers [91, 129]. Vascular causes are very rare in pure positional vertigo/dizziness, and there have been no convincing cases of a central lesion causing a nystagmus pattern typical of posterior canal BPPV: upward/torsional nystagmus with a transient crescendo-decrescendo pattern, elicited on the Dix-Hallpike/diagnostic Sémont maneuver to the affected side. Geotropic or apogeotropic central positional nystagmus can also be differentiated from BPPV involving the horizontal semicircular canal by the temporal profile of the positional nystagmus, associated central symptoms and signs, and no response to repeated canalith repositioning maneuvers 位置性操作可以引起中枢和外周前庭障碍的眼震或调节自发性眼震。中枢性位置性眩晕和眼震可能是阵发性（ 分钟持续时间）或持续性 。由于中枢性位置性眼震的阵发性和持续性形式可能模仿 BPPV 的位置性眼震[15, 91]，在位置性眼震不典型于 BPPV、模仿多半规管 BPPV 的位置性眩晕和眼震、或对重复治疗操作无效的患者中应怀疑中枢性病变[91, 129]。在纯位置性眩晕/眩晕中，血管原因非常罕见，并且没有令人信服的中枢性病变引起典型的后半规管 BPPV 眼震模式的案例：向上/扭转性眼震，具有短暂的渐强渐弱模式，在 Dix-Hallpike/diagnostic Sémont 操作中朝受影响的一侧引发。地性或远地性中央位置性眼震也可通过位置性眼震的时间特征、相关的中央症状和体征以及对重复的半规管颗粒重定位操作的无反应与涉及水平半规管的 BPPV 进行区分
5.1.3. Head impulse test (HIT) 5.1.3. 头部冲动试验（HIT）
The bedside HIT is a useful tool for differentiating central vascular vertigo from disorders of peripheral vestibular structures , but it has a low sensitivity and specificity to diagnose a vestibular deficit [186]. Therefore, whenever possible, the video-HIT should be used (see below) [118, 136]. Pathological HIT with corrective catch-up saccades due to a reduced gain of the VOR is generally considered as localizing to peripheral vestibular structures, particularly the vestibular nerve or labyrinth [59]. In contrast, a bilaterally normal HIT indicates that the peripheral vestibular function is intact, and therefore is suggestive of a central lesion in patients with AVS [73]. Indeed, bedside HIT was normal in 24 patients with isolated vertigo from cerebellar infarction involving the medial PICA territory [106]. However, the HIT may also be pathological in patients with cerebellar or brainstem strokes [133]. Several studies documented pathological HIT in patients with lesions involving central vestibular structures such as the root entry zone of the vestibular nerve, vestibular nucleus [86], flocculus [145], and nucleus prepositus hypoglossi (NPH) [94]. In unilateral lesions involv- ing the flocculus or NPH, pathological HIT may be more prominent when the head is turned to the intact side. Bedside HIT was also positive during contralesional head rotation in about of patients with PICA or superior cerebellar artery territory infarction (4 of 20) [20]. Thus, while normal HIT is a strong indicator of central vestibular dysfunction in patients with AVS, pathological HIT does not necessarily indicate a peripheral lesion. Furthermore, bedside HIT may be normal (false negative), especially when the vestibular deficits are partial, e.g., in Menière's disease with a low-frequency hearing deficit during an attack, or when the corrective saccades occur during the head impulse (covert saccades) . Up to of patients with AUPV/vestibular neuritis may have an isolated inferior divisional involvement and thus show normal horizontal HIT. [6, 89, 108]. 床边 HIT 是一个有用的工具，用于区分中央血管性眩晕与外周前庭结构紊乱，但其对诊断前庭功能缺陷的敏感性和特异性较低。因此，尽可能应使用视频-HIT。由于 VOR 增益降低而出现矫正性追赶性快速眼动的病理性 HIT 通常被认为是定位于外周前庭结构，特别是前庭神经或迷路。相反，双侧正常的 HIT 表明外周前庭功能完好，因此在 AVS 患者中提示中央病变。事实上，24 名患有单纯眩晕的患者的床边 HIT 在涉及中央 PICA 领域的小脑梗死中是正常的。然而，HIT 在小脑或脑干卒中患者中也可能是病理性的。几项研究记录了患有涉及中央前庭结构的病变的患者的病理性 HIT，如前庭神经根入区、前庭核、小叶、前视下核。 在涉及小叶或 NPH 的单侧损害中，当头部转向未受损一侧时，病理性 HIT 可能更突出。在 PICA 或上小脑动脉领域梗死患者中，大约 的患者（20 中的 4）在逆侧头部旋转期间床边 HIT 也呈阳性[20]。因此，虽然正常 HIT 是 AVS 患者中中枢前庭功能障碍的强有力指标，但病理性 HIT 并不一定表示外周损伤。此外，床边 HIT 可能正常（假阴性），特别是当前庭功能缺陷是部分的时候，例如，在梅尼埃病发作期间伴有低频听力缺陷，或者在头部冲动期间发生矫正性快速眼运动（隐性快速眼运动） 。高达 的 AUPV/前庭神经炎患者可能有单独的下部分受累，因此显示正常的水平 HIT。[6, 89, 108]。
The video-HIT can provide objective measurements of VOR gains and also document isolated vertical canal involvement. [8, 117]. The sensitivity of clinical HIT for identifying vestibular hypofunction at the bedside ranges widely between and depending on the test technique and the extent of vestibular loss . Examiner skill plays an important role in detecting an abnormal result [70], raising questions about whether inexperienced examiners should use the clinical HIT to make high-stakes triage decisions about stroke in acute dizziness in the emergency department [38, 143]. Eye and head movements can be recorded at the bedside using lightweight portable video goggles with an integrated high-speed infrared camera . The video-HIT (see below) can assist clinicians to correctly perform a standardized HIT and facilitate interpretation of the test results [128]. Portable VOG can be used in the emergency department in real time to help differentiate brain infarction from AUVP/vestibular neuritis in patients with AVS [120, 135]. 视频头部摇动试验（video-HIT）可以提供视觉迷走神经反射增益的客观测量，并记录孤立的垂直半规管受累【8, 117】。临床头部摇动试验（HIT）对于在床边识别前庭功能减退的敏感性在 和 之间变化很大，这取决于测试技术和前庭功能丧失的程度 。检查者的技能在检测异常结果中起着重要作用[70]，这引发了一个问题，即是否应该让经验不足的检查者在急诊科使用临床头部摇动试验做出关于急性眩晕中中风的高风险分流决策[38, 143]。可以使用集成高速红外摄像头的轻便便携式视频护目镜在床边记录眼部和头部运动 。视频头部摇动试验（见下文）可以帮助临床医生正确执行标准化的头部摇动试验，并促进对测试结果的解释[128]。便携式视觉眼动仪（VOG）可以实时在急诊科使用，帮助区分脑梗死和 AUVP/前庭神经炎在患有 AVS 的患者中的情况[120, 135]。
5.1.4. Central ocular motor signs 5.1.4. 中枢眼动征象
Saccades: Abnormal saccades may be a feature of central lesions. Slow vertical saccades in association with or without a gaze palsy indicate a lesion in the midbrain affecting the rostral interstitial nucleus of the medial longitudinal fasciculus and slow horizontal saccades indicate a lesion involving the paramedian pontine reticular formation [114]. Hypermetric saccades suggest lesions involving the cerebellum (fastigial nucleus) or lateral medulla, and hypometric saccades imply lesions involving the dorsal ocular motor vermis [114]. 扫视：异常的扫视可能是中枢病变的特征。伴随或不伴随凝视麻痹的缓慢垂直扫视表明中脑的病变影响了纵行束的前间核，而缓慢水平扫视表明病变涉及桥脑网状结构的副中线部[114]。过度扫视暗示涉及小脑（桥小叶核）或外侧延髓的病变，而不足扫视暗示涉及眼球运动蚓部的病变[114]。
Smooth pursuit: Impaired smooth pursuit is also considered a central sign and is considered a hallmark of cerebellar disorders though it is not specific for cerebellar dysfunction. Smooth pursuit is typically less relevant in identifying acute vascular vertigo and should be interpreted with caution since it could be affected by various factors including an underlying spontaneous nystagmus, medications, and cognition. 平稳追踪：受损的平稳追踪也被视为中枢征象，被认为是小脑疾病的标志，尽管它并非小脑功能障碍的特异性表现。平稳追踪通常在识别急性血管性眩晕时不太相关，应谨慎解释，因为它可能受到各种因素的影响，包括潜在的自发性眼球震颤、药物和认知。
5.1.5. Posture and gait 5.1.5. 姿势和步态
Patients with vascular vertigo should have an evaluation of balance while standing and balance during gait. Severe postural instability is a predictor of a central lesion [57, 106, 174, 183]. 患有血管性眩晕的患者应在站立时评估平衡和步行时的平衡。严重的姿势不稳是中枢病变的预测因子[57, 106, 174, 183]。
5.2. Laboratory tests 5.2. 实验室检查
5.2.1. Examination of the vestibular, ocular motor, and auditory systems 5.2.1. 对前庭、眼动和听觉系统的检查
VOG may aid in documenting and characterizing SD, spontaneous and triggered nystagmus, and other ocular motor function including saccades and smooth pursuit . Caloric tests are mostly normal and are of limited value in assessing the horizontal VOR in central vestibular disorders. Ocular and cervical vestibular evoked myogenic potentials (o/cVEMPs) have been used to evaluate the function of the otolithic pathways in central as well as peripheral vestibular disorders [140]. In patients with isolated vestibular nucleus infarction, o/cVEMPs were diminished or absent during stimulation of the ipsilesional ear [86]. Above the vestibular nucleus level, oVEMPs are impaired in lesions involving the medial longitudinal fasciculus [85, 141]. In unilateral cerebellar infarction, o/cVEMPs are frequently impaired [35]. Thus, abnormalities of VEMPs are not helpful in differentiating peripheral from central vestibular disorders [47]. VOG 可能有助于记录和描述 SD，自发性和触发性眼球震颤，以及其他眼球运动功能，包括快速眼球运动和平稳追踪。 火热试验大多数情况下正常，并且在评估中枢前庭障碍中的水平 VOR 方面价值有限。 眼球和颈部前庭诱发肌源性电位（o/cVEMPs）已被用于评估中枢和外周前庭障碍中耳石通路的功能。 在孤立性前庭核梗死患者中，刺激同侧耳朵时，o/cVEMPs 减弱或消失。 在前庭核水平以上，涉及中脑纵行束的病变会导致 oVEMPs 受损。 在单侧小脑梗死中，o/cVEMPs 经常受损。 因此，VEMPs 的异常对于区分外周和中枢前庭障碍并不有帮助。
Ocular torsion can be measured with magnified fundoscopy, fundus photography or scanning laser ophthalmoscope [44, 60]. Patients may have quantitative evaluation of the SVV, for instance using the Bucket Test or more specialized equipment. A deviation of SVV is found acutely in more than (48/51) of patients with unilateral vestibular lesions [80], but it does not discriminate between a peripheral and central lesion [190]. 眼球扭转可以通过放大的眼底镜检查、眼底摄影或扫描激光眼底镜来测量[44, 60]。患者可以通过量化 SVV 进行评估，例如使用桶试验或更专业的设备。在单侧前庭损伤的患者中，超过 （48/51）的患者会出现 SVV 的偏移[80]，但它不能区分外周和中枢损伤[190]。
In patients with acute auditory symptoms, pure tone and speech audiometry can aid in documenting hearing loss, in particular if an AICA-infarction or Menière's disease are suspected [105]. 在急性听觉症状患者中，纯音和语音听力测定可以帮助记录听力损失，特别是在怀疑 AICA 梗死或梅尼埃病的情况下。
5.2.2. Blood tests 5.2.2. 血液检查
In general, routine laboratory studies including complete blood counts, electrolytes, and thyroid function tests have a very low yield in diagnosing a cause of dizziness. In a meta-analysis, only 26 of patients ( had laboratory abnormalities that could explain their dizziness [62]. The ischemic stroke guidelines also recommend a limited number of hematologic, coagulation, and biochemistry tests during the initial emergency evaluation, and only the assessment of blood glucose must precede the initiation of intravenous recombinant tissue plasminogen activator [68]. If giant cell arteritis is a concern, inflammatory markers should be checked. The diagnostic value of serum biomarkers in differentiating central from peripheral causes remains to be elucidated . 通常情况下，包括完整血细胞计数、电解质和甲状腺功能检测在内的常规实验室研究在诊断头晕原因方面的收益非常低。在一项荟萃分析中，只有 名患者中的 26 名（ 有实验室异常可以解释他们的头晕[62]。缺血性中风指南还建议在急诊初期评估期间进行有限数量的血液学、凝血学和生化检测，只有血糖评估必须在静脉重组组织型纤溶酶原活化剂开始前进行[68]。如果担心巨细胞动脉炎，应检查炎症标志物。血清生物标志物在区分中枢和外周原因方面的诊断价值有待阐明 。
5.2.3. Cardiovascular work-up 5.2.3. 心血管检查
Extra- and transcranial Doppler/duplex sonography, ECG monitoring, and echocardiography are recommended in patients with acute ischemic stroke [68]. 急性缺血性中风患者建议进行颅内和经颅多普勒/双重超声检查、心电监护和心脏超声检查[68]。
5.3. Imaging 5.3. 影像学
Neuroimaging studies are essential in the evaluation of stroke. CT has a limited value in detecting acute posterior circulation infarction, and is only recommended to detect hemorrhages or other pathologies [17, 42]. Introduction of DWI has greatly enhanced detection of infarctions in patients with isolated vascular vertigo. However, even DWI may miss up to one in five strokes occurring in the posterior fossa when performed during the first 24-48 hours, though this may relate in part to the MRI protocol of slice thickness and gaps [21, 45, 73, 142]. False negative initial MRIs (6-48 hours) were more common with small ) strokes than larger ones ( vs ) [154]. Furthermore, current imaging technique cannot detect isolated labyrinthine infarction that may progress to involve the portions of the brainstem and cerebellum supplied by the AICA . Thus, serial evaluation should be considered in patients with suspected vascular vertigo when the initial DWIs are normal [21,73]. 神经影像学研究在中风评估中至关重要。CT 在检测急性后循环梗死方面价值有限，仅建议用于检测出血或其他病理[17, 42]。引入 DWI 大大增强了对患有孤立性血管性眩晕的患者梗死的检测。然而，即使进行首次 24-48 小时的 DWI，也可能错过后颅窝中发生的五分之一中风，尽管这可能部分与 MRI 切片厚度和间隙的协议有关[21, 45, 73, 142]。初步 MRI 的假阴性（6-48 小时）在小中风中比较常见（ vs vs ）[154]。此外，当前的影像技术无法检测孤立的前庭迷路梗死，可能会发展到由 AICA 供应的脑干和小脑部分。因此，在初步 DWI 正常的疑似血管性眩晕患者中应考虑进行连续评估[21,73]。
It is challenging to visualize an image correlate of acute isolated vascular vertigo/dizziness when MRI, including DWI, does not show any evidence of acute infarction. Since perfusion CT or MRI can detect hypoperfusion and potentially reversible injury to the brain, they may aid in detection of stroke in patients with isolated 当 MRI，包括 DWI，没有显示任何急性梗死的证据时，很难将急性孤立性血管性眩晕/头晕的影像相关性可视化。由于灌注 CT 或 MRI 可以检测脑部低灌注和潜在可逆的损伤，它们可能有助于检测孤立性中风患者的中风。
vascular vertigo/dizziness especially when MRI, including DWI, is normal [79, 161, 167]. Perfusion imaging mostly has been used to assess the risks or benefits of stroke intervention or to predict the outcome of an infarction [167]. However, perfusion imaging does not readily detect small perfusion reductions in the brainstem, and thus, the diagnostic yield of perfusion imaging still needs to be validated in isolated vascular vertigo/dizziness [124]. 血管性眩晕/头晕，尤其是在 MRI（包括 DWI）正常的情况下[79, 161, 167]。灌注成像主要用于评估中风干预的风险或益处，或者预测梗死的结果[167]。然而，灌注成像不容易检测脑干中的小灌注减少，因此，灌注成像的诊断效果仍需要在孤立的血管性眩晕/头晕中得到验证[124]。
Imaging of the cerebral vasculature using CT/CT-angiography or MRI/MR-angiography can be considered in patients with suspected vascular vertigo/dizziness. However, the evidence base for vascular interventions in the posterior circulation is substantially less than that for interventions in the anterior circulation [109]. Unilateral cerebellar hypoperfusion mostly is caused by stenosis or occlusion of the ipsilesional VA or proximal PICA. In one study, (8/10) of patients with cerebellar hypoperfusion on perfusion CT or MRI showed a luminal irregularity or hypoplasia of the corresponding VA [22]. VA hypoplasia may be a risk factor for posterior circulation ischemia, especially when other vascular risk factors coexist . A study using perfusion CT revealed that VA hypoplasia can lead to a relative regional hypoperfusion in the territory of PICA [168]. In one study, patients with vertigo/dizziness of unknown etiology had a higher prevalence of VA hypoplasia than that in a control group [144]. A unilateral hypoplastic VA may rarely cause recurrent isolated vertigo and subsequent cerebellar infarction [2]. In patients with cerebellar hypoperfusion on perfusion CT or MRI in the presence of a normal VA on the corresponding side, focal atherosclerosis or dissection of the PICA should be suspected, which may require conventional digital subtraction angiography for documentation [79, 147]. 使用 CT/CT-血管造影术或 MRI/MR-血管造影术成像脑血管可以考虑用于疑似血管性眩晕/头晕的患者。然而，与前循环干预相比，后循环血管干预的证据基础要少得多。单侧小脑灌注不足主要是由同侧 VA 或近端 PICA 的狭窄或闭塞引起的。一项研究发现，表现为小脑灌注不足的患者中， （8/10）显示相应 VA 的腔内不规则或发育不全。VA 发育不全可能是后循环缺血的危险因素，尤其是当存在其他血管危险因素时。一项使用灌注 CT 的研究显示，VA 发育不全可能导致 PICA 领域的相对区域性灌注不足。一项研究发现，原因不明的眩晕/头晕患者中 VA 发育不全的患病率高于对照组。单侧发育不全的 VA 可能很少引起反复的孤立性眩晕和随后的小脑梗死。 在脑灌注 CT 或 MRI 上出现小脑灌注不足的患者，且对应侧 VA 正常时，应怀疑 PICA 的局灶性动脉粥样硬化或夹层，可能需要常规数字减影血管造影进行确认。
Although current imaging cannot detect isolated labyrinthine infarction, observation of a hypersignal in the labyrinth on pre-enhanced T1 or FLAIR MRIs suggests the rare diagnosis of labyrinthine hemorrhage [78, 160, 180]. Vascular imaging of the neck can be used to diagnose VA dissection, in particular in the setting of neck pain or trauma [58]. 尽管目前的影像学无法检测孤立的前庭迷路梗死，但在预增强 T1 或 FLAIR MRI 中观察到迷路的高信号暗示罕见的前庭迷路出血[78, 160, 180]。颈部血管影像学可用于诊断 VA 夹层，特别是在颈部疼痛或外伤的情况下[58]。
Overall, the rate of false negative imaging in vascular vertigo/dizziness further supports the relevance of a systematic patient history and bedside as well as laboratory evaluation of vestibular and ocular motor function to look for central signs, which permits a differentiation of acute vascular vertigo/dizziness from AUVP/vestibular neuritis with a sensitivity and a specificity of about . 总的来说，血管性眩晕/头晕的假阴性成像率进一步支持系统性患者病史和床边以及实验室评估前庭和眼动功能的相关性，以寻找中枢体征，从而区分急性血管性眩晕/头晕和 AUVP/前庭神经炎，其敏感性和特异性约为 。
6. Conclusion 6. 结论
Determining the characteristics of vestibular symptoms, associated central symptoms, and vascular risk factors should be the first step in establishing a diagnosis of vascular vertigo/dizziness. A systematic examination focused on central vestibular and ocular motor signs, especially HINTS and evaluating postural instability provides more accurate diagnostic information than early ( .) imaging in patients with vascular vertigo/dizziness. Video-HIT and video-oculographic recording of eye movements may help to increase diagnostic accuracy. Identifying the underlying etiology of vascular vertigo/dizziness is essential for guiding the selection of appropriate management options, including both acute treatment and secondary prevention of future stroke. 确定前庭症状的特征、相关的中枢症状和血管危险因素应是建立血管性眩晕/头晕诊断的第一步。针对中枢前庭和眼动症状的系统检查，特别是 HINTS 和评估姿势不稳定性，提供比早期（ .）影像更准确的诊断信息，适用于患有血管性眩晕/头晕的患者。视频头部防护帽试验（Video-HIT）和视频眼动图记录眼动可能有助于提高诊断准确性。确定血管性眩晕/头晕的潜在病因对指导选择适当的治疗方案至关重要，包括急性治疗和未来卒中的二级预防。
Acknowledgments 致谢
The authors are thankful for the comments and suggestions received from the vestibular community. The authors also thank to Joseph Furman for his advice and editorial help. 作者们感谢从前庭社区收到的评论和建议。作者们还感谢 Joseph Furman 提供的建议和编辑帮助。
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*Corresponding author: Ji-Soo Kim, MD, PhD., Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 173-82 Gumi-ro, 通讯作者：金智秀，医学博士，首尔国立大学医学院神经内科，首尔国立大学分院医院，173-82 号，九美路。