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Vestibular agnosia in traumatic brain injury and its link to imbalance.

创伤性脑损伤的前庭失认及其与失衡的联系。

  • 影响因子:7.52
  • DOI:10.1093/brain/awaa386
  • 作者列表:"Calzolari E","Chepisheva M","Smith RM","Mahmud M","Hellyer PJ","Tahtis V","Arshad Q","Jolly A","Wilson M","Rust H","Sharp DJ","Seemungal BM
  • 发表时间:2021-02-12
Abstract

:Vestibular dysfunction, causing dizziness and imbalance, is a common yet poorly understood feature in patients with TBI. Damage to the inner ear, nerve, brainstem, cerebellum and cerebral hemispheres may all affect vestibular functioning, hence, a multi-level assessment-from reflex to perception-is required. In a previous report, postural instability was the commonest neurological feature in ambulating acute patients with TBI. During ward assessment, we also frequently observe a loss of vertigo sensation in patients with acute TBI, common inner ear conditions and a related vigorous vestibular-ocular reflex nystagmus, suggesting a 'vestibular agnosia'. Patients with vestibular agnosia were also more unbalanced; however, the link between vestibular agnosia and imbalance was confounded by the presence of inner ear conditions. We investigated the brain mechanisms of imbalance in acute TBI, its link with vestibular agnosia, and potential clinical impact, by prospective laboratory assessment of vestibular function, from reflex to perception, in patients with preserved peripheral vestibular function. Assessment included: vestibular reflex function, vestibular perception by participants' report of their passive yaw rotations in the dark, objective balance via posturography, subjective symptoms via questionnaires, and structural neuroimaging. We prospectively screened 918 acute admissions, assessed 146 and recruited 37. Compared to 37 matched controls, patients showed elevated vestibular-perceptual thresholds (patients 12.92°/s versus 3.87°/s) but normal vestibular-ocular reflex thresholds (patients 2.52°/s versus 1.78°/s). Patients with elevated vestibular-perceptual thresholds [3 standard deviations (SD) above controls' average], were designated as having vestibular agnosia, and displayed worse posturography than non-vestibular-agnosia patients, despite no difference in vestibular symptom scores. Only in patients with impaired postural control (3 SD above controls' mean), whole brain diffusion tensor voxel-wise analysis showed elevated mean diffusivity (and trend lower fractional anisotropy) in the inferior longitudinal fasciculus in the right temporal lobe that correlated with vestibular agnosia severity. Thus, impaired balance and vestibular agnosia are co-localized to the inferior longitudinal fasciculus in the right temporal lobe. Finally, a clinical audit showed a sevenfold reduction in clinician recognition of a common peripheral vestibular condition (benign paroxysmal positional vertigo) in acute patients with clinically apparent vestibular agnosia. That vestibular agnosia patients show worse balance, but without increased dizziness symptoms, explains why clinicians may miss treatable vestibular diagnoses in these patients. In conclusion, vestibular agnosia mediates imbalance in traumatic brain injury both directly via white matter tract damage in the right temporal lobe, and indirectly via reduced clinical recognition of common, treatable vestibular diagnoses.

摘要

: 引起头晕和失衡的前庭功能障碍是TBI患者常见但知之甚少的特征。内耳,神经,脑干,小脑和大脑半球的损伤都可能影响前庭功能,因此,需要从反射到感知的多层次评估。在以前的报告中,姿势不稳定是急性TBI患者行走中最常见的神经特征。在病房评估期间,我们还经常观察到急性TBI患者的眩晕感觉丧失,常见的内耳状况和相关的强烈的前庭-眼反射性眼球震颤,提示 “前庭无痛症”。前庭性失认症也更不平衡; 然而,链接之间前庭失认症和不平衡混淆存在内耳条件.我们通过对保留外周前庭功能的患者进行前庭功能从反射到感知的前瞻性实验室评估,研究了急性TBI失衡的脑机制、与前庭失认的联系以及潜在的临床影响。评估包括: 前庭反射功能,参与者在黑暗中被动偏航旋转报告的前庭感知,通过姿势描记法的客观平衡,通过问卷调查的主观症状和结构神经成像。我们前瞻性筛查了918例急性入院,评估了146例,招募了37例。与37名匹配的对照相比,患者显示前庭知觉阈值升高 (患者12.92 °/s对3.87 °/s),但前庭-眼反射阈值正常 (患者2.52 °/s对1.78 °/s)。前庭知觉阈值升高的患者 [比对照组平均水平高3个标准差 (SD)] 被指定为前庭失认症,尽管前庭症状评分无差异,但其体位图显示比非前庭失认症患者差。仅在姿势控制受损 (高于控制均值3 SD) 的患者中,全脑扩散张量体素分析显示,与前庭失认严重程度相关的右颞叶下纵束的平均扩散率升高 (并有降低部分各向异性的趋势)。因此,平衡障碍和前庭失认共定位于右颞叶的下纵束。最后,临床审计显示,临床医生对临床上明显的前庭失认症的急性患者的常见外周前庭状况 (良性阵发性位置性眩晕) 的识别降低了7倍。前庭失认症患者表现出更差的平衡,但没有增加头晕症状,这解释了为什么临床医生可能会错过这些患者可治疗的前庭诊断。总之,前庭失认症介导了创伤性脑损伤的失衡,既直接通过右颞叶的白质束损伤,也间接通过降低临床对常见的、可治疗的前庭诊断的认识。

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