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VERTIJUL CRONIC

VERTIJUL CRONIC. Conf. Dr. Cristina Panea UMF “Carol Davila” Spitalul Universitar de Urgenta Elias. Vertijul. Prevalenta: 17% - 39% (peste 80 ani) 2,8% consultatii MF (SUA, 1998) = Senzatie de ameteala + instabilitate posturala (ataxie) semne vegetative. Substrat fiziopatologic.

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VERTIJUL CRONIC

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  1. VERTIJUL CRONIC Conf. Dr. Cristina Panea UMF “Carol Davila” Spitalul Universitar de Urgenta Elias

  2. Vertijul • Prevalenta: 17% - 39% (peste 80 ani) • 2,8% consultatii MF (SUA, 1998) = Senzatie de ameteala + • instabilitate posturala (ataxie) • semne vegetative

  3. 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

  4. 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

  5. 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”

  6. Incadrare temporala • Acut = paroxistic / recurent < 4 sapt • periferic • Cronic = continuu / recurent > 4 sapt • central

  7. Vertijul periferic • Opinia ORL-ului: otologic • Opinia neurologului: ureche + n VIII • Caractere generale = sd vestibular periferic: lateralizat • durata scurta • fenomene auditive • fenomene vegetative

  8. 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

  9. 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

  10. Vertijul periferic (3) • Neuronita vestibulara • vertij intens + vegetativ • etiologie virala • fara fenomene audiologice • zile - sapt • recuperare: 2/3 cazuri - 2-12 sapt • hidratare, antiemetice

  11. 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

  12. 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

  13. 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

  14. Vertijul si boala vasculara cerebrala (3) • Tratament: • antitrombotic • statine, antiHTA • vasoactive: Betahistina, Egb 761, Nicergolina Nicergolina - studiu clinic Felisati 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

  15. Boala cerebrovasculara ischemicaNicergolina (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)

  16. 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

  17. 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

  18. 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

  19. 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

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