VERTIJUL CRONIC
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Transcript of VERTIJUL CRONIC
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VERTIJUL CRONIC
Conf. Dr. Cristina Panea
UMF “Carol Davila”
Spitalul Universitar de Urgenta Elias
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Vertijul
• Prevalenta: 17% - 39% (peste 80 ani)– 2,8% consultatii MF (SUA, 1998)
= Senzatie de ameteala +– instabilitate posturala (ataxie)– semne vegetative
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Substrat fiziopatologic
• Alterarea sistemelor de asigurare a echilibrului si posturii:– ureche interna vertij periferic– nerv vestibular– trunchi cerebral, cerebel– talamus vertij– cortex central /– cai vizuale ameteala– sistem proprioceptiv
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Substrat fiziopatologic
• Informatiile din:– sistemul vestibular, auditiv– sistemul vizual, tactil– sistemul proprioceptiv (articular, muscular, nn
periferici)
integrare corticala perceptie corecta a posturii ajustare controlata
• mismatch (incongruenta) vertij ameteala
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Vertij / ameteala
• Vertij = senzatie de rotatie a obiectelor sau a
subiectului periferica
• Ameteala: centrala– Ameteala = senzatie de instabilitate, balans – Presincopa = senzatie de cadere iminenta / dezechilibru /
pierdere a constientei– Senzatie de dezechilibru = cap greu, tulbure, “ca de betie,
mahmureala”
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Incadrare temporala
• Acut = paroxistic / recurent < 4 sapt– periferic
• Cronic = continuu / recurent > 4 sapt– central
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Vertijul periferic
• Opinia ORL-ului: otologic
• Opinia neurologului: ureche + n VIII
• Caractere generale = sd vestibular periferic: lateralizat– durata scurta– fenomene auditive– fenomene vegetative
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Vertijul periferic (1)
• Sd Meniere– paroxism vertij rotator, fenomen audiologic (tinitus,
diplacuzie, hipoacuzie), vegetativ
– hidrops endolimfatic idiopatic / alergic, genetic, inflamator; 30-50 ani
– recurente < 24 ore, ani
– vasodilatatoare (betahistina 24 - 48 mg/zi x 90 zile), antiemetice, diazepinice,
– ototoxice: instilatii gentamicina, lidocaina
– chirurgical
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Vertijul periferic (2)
• Vertijul pozitional benign– 1921 Barany– vertij la schimbarea pozitiei capului/rotatie,
supinatie– litiaza canale semicirculare, traumatisme, infectii,
idiopatic– fara fen audiologic, vegetativ– sapt., luni– reeducare, chirurgie
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Vertijul periferic (3)
• Neuronita vestibulara– vertij intens + vegetativ– etiologie virala– fara fenomene audiologice– zile - sapt– recuperare: 2/3 cazuri - 2-12
sapt– hidratare, antiemetice
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Vertijul central
• Sd. Vestibular central ameteala– deviatie nesistematizata, instabilitate, ataxie + alte
semne SNC– durata lunga (sapt, luni)– fenomene vegetative ocaz– ischemice, tumorale,
infectioase, traumatice– ex neurologic + imagistica
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Vertijul si boala vasculara cerebrala (1)
• Vertij cronic - “insuficienta circulatorie cr”
• Suferinta vasculara:
– AVC / AIT - vertij izolat = 0,7% (1668 subiecti)
vertij dominant = 3,2%
Morgenstern LB, Stroke 2006;37:2482-2487
– sechela AVC nerecuperata - dificultate de compensare = 15% din AVC vertebro-bazilare
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Vertijul si boala vasculara cerebrala (2)
– Vertijul din suferinta hemodinamica• “presincopa neurogena”• ! Leziuni aterosclerotice in sistemul aa
cerebrale, teren vascular
– hipotensiune, boala cardiaca severa hipoglicemie
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Vertijul si boala vasculara cerebrala (3)
• Tratament:– antitrombotic– statine, antiHTA– vasoactive: Betahistina, Egb 761, Nicergolina
Nicergolina - studiu clinicFelisati et al, 2002: studiu dublu-orb, randomizat, placebo-controlat, nicergolina
30 mg x2/zi, 3 luni
- 89 pacienti, 50 - 85 ani, cu tulburari echilibru de cauza centrala
- evaluare standardizata (scale, posturografie)
Concluzii: - ameliorare semnificativa a tulb echilibru 57%
- cresterea calitatii vietii
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Boala cerebrovasculara ischemica
Nicergolina (Sermion)
= Derivat semisintetic de ergot, initial vasodilatator - blocaj adrenergic
• Neuroprotectie: antioxidant & cresterea metabolismului- antioxidant: previne formarea radicalilor hidroxil - prin inhibitia productiei superoxid din neutrofile (Tanaka, 1998)
- reducerea peroxidarii lipidelor & cresterea activitatii catalazei - protectie impotriva toxicitatii peroxidului (Iwata, 1998)
- conserva metabolismul cerebral in conditii de hipoxie / ischemie (Le Poncin-Lafite, 1984; Groo, 1988; Shintomi, 1991)
- creste captarea si utilizarea glucozei (Benzi, 1971; Le Poncin-Lafite, 1984)
- creste utilizarea oxigenului (Benzi, 1971)
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Boala cerebrovasculara ischemica
• Neuroplasticitate - stimuleaza plasticitatea neuronala si sinaptica- reface nivelele de neurotransmitatori - creste transmisia dopaminergica (McArthur, 1997; Winblad, 2000)
- stimuleaza transmisia intraneuronala (Carfagnas, 1996; Winblad, 2000)
- stimuleaza factorul de crestere neuronala NGF (Nishio, 1998)
- creste sinteza de acizi nucleici si proteine (Paul & Chandra, 1979)
Faciliteaza recuperarea dupa sindromul vestibular central / periferic
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Vertijul cronic la pacientul varstnic
• Incapacitate de procesare a informatiilor discordante provenite de la:
• analizator vizual: prezbitie, cataracta• analizatorul auditiv: prezbiacuzie • sistemele proprioceptive: ataxie• medicatie: sedative, diuretice ansa
PREZBIATAXIE
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Vertijul cronic la pacientul tanar
• Intoxicatii cofeina,
alcool, nicotina• vertij paroxistic antecedente
• Tulburare afectiva– senzatie de ameteala, buimaceala– fara corespondent obiectiv / test hiperventilatie– psiholog + psihiatru
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Concluzii
Vertijul cronic– cvasicontinuu / recurent > 4 saptamani
– tulburare de integrare a sistemelor de mentinere a echilibrului: examen clinic complet
– cauze diferite la varstnic / tanar
– cronicizare - reactie anxioasa supraadaugata
– terapie individualizata + pluridisciplinara