前庭神經(jīng)炎的頸-眼誘發(fā)肌源電位臨床研究

陳 哲，饒任東，孫 勍，彭 新，劉金梅，梁旭暉，單希征

論 著

前庭神經(jīng)炎的頸-眼誘發(fā)肌源電位臨床研究

陳 哲，饒任東，孫 勍，彭 新，劉金梅，梁旭暉，單希征

目的 評(píng)估前庭神經(jīng)炎(vestibular neuritis,VN)的臨床分類及前庭上神經(jīng)(superior vestibular nerve,SVN)和下神經(jīng)(inferior vestibular nerve,IVN)的受累情況。方法 選擇本院60例診斷為前庭神經(jīng)炎的患者(前庭神經(jīng)炎組)和30例健康人(健康對(duì)照組)行頸肌前庭誘發(fā)肌源電位(ervical vestibular evoked myogenic potential,cVEMP)、眼肌前庭誘發(fā)肌源電位(ocular vestibular evoked myogenic potential,oVEMP)、前庭雙溫試驗(yàn)檢查。雙溫試驗(yàn)用于評(píng)估水平半規(guī)管，oVEMP用于評(píng)估橢圓囊及前庭上神經(jīng)功能，cVEMP用于評(píng)估球囊及前庭下神經(jīng)功能。結(jié)果 前庭神經(jīng)炎組中，前庭上神經(jīng)炎46例，前庭下神經(jīng)炎12例，全前庭神經(jīng)炎2例，VEMPs異常率較對(duì)照組明顯增高，兩組相比異常率差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。前庭上神經(jīng)患者患側(cè)oVEMP潛伏期與健康對(duì)照組比較，差異無(wú)統(tǒng)計(jì)學(xué)意義，振幅及不對(duì)稱比差異有統(tǒng)計(jì)學(xué)意義，而健側(cè)與健康對(duì)照組比較，差異無(wú)統(tǒng)計(jì)學(xué)意義，雙溫試驗(yàn)與健康對(duì)照組差異有統(tǒng)計(jì)學(xué)意義；前庭下神經(jīng)炎患者oVEMP潛伏期及振幅與健康對(duì)照組差異均無(wú)統(tǒng)計(jì)學(xué)意義；前庭下神經(jīng)炎患者oVEMP振幅及不對(duì)稱比與對(duì)照組比較，差異無(wú)統(tǒng)計(jì)學(xué)意義。前庭雙溫試驗(yàn)CP值與前庭神經(jīng)無(wú)明顯相關(guān)。前庭雙溫試驗(yàn)前庭cVEMP異常的患者oVEMP及前庭雙溫試驗(yàn)結(jié)果正常時(shí)代表前庭下神經(jīng)。結(jié)論 前庭神經(jīng)炎主要表現(xiàn)前庭上神經(jīng)炎，部分可累及前庭下神經(jīng)，cVEMP和oVEMP及雙溫試驗(yàn)提供更詳細(xì)的前庭神經(jīng)損傷定位。

前庭神經(jīng)炎；頸肌前庭誘發(fā)肌源電位；雙溫試驗(yàn)；眼肌前庭誘發(fā)肌源電位

前庭神經(jīng)炎是一種常見(jiàn)的外周性眩暈疾病，臨床表現(xiàn)為突發(fā)的眩暈，伴惡心、嘔吐等自主神經(jīng)反射，持續(xù)數(shù)天，無(wú)耳蝸及中樞神經(jīng)系統(tǒng)癥狀和體征[1]。目前，頸肌前庭誘發(fā)肌源電位(cVEMP)臨床上在胸鎖乳突肌上記錄的肌電活動(dòng)，已經(jīng)用于前庭-丘反射(vestibulo-collic reflex)通路，尤其是球囊-前庭下神經(jīng)傳入通路[2]。近年來(lái)，眼肌前庭誘發(fā)肌源性電位(oVEMP)通過(guò)耳ACS及BCV刺激[2-4]，于對(duì)側(cè)收縮的眼外肌記錄到短潛伏期的肌電反應(yīng)，oVEMP主要反映的是前庭-眼動(dòng)反射(vestibulo-oscular reflex)通路，尤其是橢圓囊-前庭上神經(jīng)反射通路。本研究旨在通過(guò)cVEMP和oVEMP檢查評(píng)估前庭神經(jīng)受累情況，為臨床治療提供依據(jù)。

1 對(duì)象與方法

1.1 對(duì)象 收集60例來(lái)自我院眩暈病研究所住院診斷為前庭神經(jīng)炎的患者，女31例，男29例，年齡19～57歲，平均(40.33±9.30)歲。納入標(biāo)準(zhǔn)：(1)符合前庭神經(jīng)炎的診斷標(biāo)準(zhǔn)；(2)發(fā)病在1周以內(nèi)；(3)能積極配合體格檢查、前庭雙溫試驗(yàn)、cVEMP、oVEMP檢查；(4)獲取患者及家屬知情同意。排除標(biāo)準(zhǔn)：排除其他嚴(yán)重顱內(nèi)疾病及其他耳源性眩暈疾病。60例診斷為前庭神經(jīng)炎的患者為前庭神經(jīng)炎組，選擇30名健康體檢者為健康對(duì)照組。

1.2 檢查方法 前庭神經(jīng)炎組及健康對(duì)照組均行純音測(cè)聽(tīng)、前庭雙溫試驗(yàn)和前庭誘發(fā)肌源電位(vestibular evoked myogenic potential,VEMPs)檢查。

1.2.1 前庭交替雙溫試驗(yàn) 患者平臥于暗室內(nèi)，頭抬高30°，分別用30 ℃及44 ℃水灌注檢測(cè)耳，每次灌注40 s，灌注后觀察眼震60 s，通過(guò)視頻眼罩記錄下患者的眼震。灌注設(shè)備為德國(guó)ATMOS Varioair型前庭雙溫試驗(yàn)儀器。眼震記錄分析采用美國(guó)智聽(tīng)公司紅外眼震記錄分析系統(tǒng)。半規(guī)管輕癱(canal paresis,CP)值≥25%被視為異常，提示同側(cè)水平半規(guī)管功能減弱。

1.2.2 oVEMP (1)操作方法： 采用GN OTOMETR ICS A/S公司生產(chǎn)的聽(tīng)覺(jué)誘發(fā)電位儀(ICS Charte EP型)進(jìn)行oVEMP測(cè)試。測(cè)試前先行電耳鏡、純音測(cè)聽(tīng)等檢查。測(cè)試于安靜的電屏蔽室內(nèi)進(jìn)行，受檢者取端正坐位，刺激聲為95 dBnHL、500 Hz短純音，記錄參數(shù)為：刺激重復(fù)率5.1次/s，累加次數(shù)200次，記錄時(shí)窗50 ms，帶通濾波10～1000 kHz。使用插入式耳機(jī)給聲刺激。電極安放位置: 清潔面部相應(yīng)部位皮膚后，參考電極置于下頦中央[5]；接地電極置于眉間，記錄電極交叉置于下眼瞼中央下方。囑受試者于給聲刺激時(shí)雙眼以30°的視角向上注視約2 m遠(yuǎn)的固定目標(biāo)點(diǎn)，盡量避免眨眼及閉眼，以維持穩(wěn)定的眼外肌張力。(2)參數(shù)分析：oVEMP波形可見(jiàn)在約10 ms出現(xiàn)的負(fù)波(N1)及約在15 ms出現(xiàn)的正波(P1),要求相同刺激下，波形重復(fù)性較好視為引出；無(wú)重復(fù)性或無(wú)有效波形引出視為oVEMP未引出(正常波形如圖1A，一側(cè)未引出波形如圖1B)。oVEMP記錄參數(shù)包括N1、P1潛伏期(ms)，P1-N1間期(ms)，P1-N1振幅(μV)及兩耳間振幅的不對(duì)稱比AR。N1、P1潛伏期為測(cè)試開(kāi)始至N1波谷、P1波峰之間的間隔時(shí)長(zhǎng)(ms)，P1-N1間期為N1波谷至P1波峰間隔時(shí)長(zhǎng)(ms)，P1-N1振幅為P1波峰至N1波谷間垂直距離(μV)；不對(duì)稱比為兩耳的振幅差絕對(duì)值比兩耳的振幅之和，記為：|右耳-左耳|/(右耳+左耳)×100%。oVEMP異常的判斷：根據(jù)解放軍總醫(yī)院實(shí)驗(yàn)室健康對(duì)照組得出數(shù)據(jù)，(1)采用雙側(cè)不對(duì)稱比>31%[6]；(2)未引出。

1.2.3 cVEMP 雙側(cè)胸鎖乳突肌中點(diǎn)表面放置雙導(dǎo)盤形肌電記錄電極，胸骨上端放置參考電極，前額正中接地極。囑患者仰臥，測(cè)試時(shí)頭部抬高20°～30°以激活胸鎖乳突肌，使其保持一定時(shí)間的強(qiáng)直收縮狀態(tài)，記錄雙側(cè)短聲刺激條件下的cVEMP。刺激聲為0.1 ms短聲，刺激強(qiáng)度100 dBnHL，刺激率為5次/s，帶通濾波的范圍是10～1000 Hz,疊加100次。記錄到得波形按照Yoshie等[7]的建議分別命名為P13(在潛伏期13 ms左右出現(xiàn)的正波)和N23(在潛伏期23 ms左右出現(xiàn)的負(fù)波)(正常波形如圖2A,一側(cè)未引出波形如圖2B)。本研究采用聽(tīng)覺(jué)誘發(fā)電位測(cè)試儀(Chartr EP,Otometrics公司)。cVEMP異常的判斷：(1)雙側(cè)振幅比>1.60或雙側(cè)不對(duì)稱比>29%為一側(cè)低振幅[8]；(2)未引出。

1.3 分組標(biāo)準(zhǔn) 前庭上神經(jīng)炎評(píng)估標(biāo)準(zhǔn)包括：(1)急性發(fā)作性眩暈；(2)表現(xiàn)為水平扭轉(zhuǎn)混合眼震；(3)受累水平半規(guī)管雙溫試驗(yàn)反應(yīng)降低或消失；(4)cVEMP正常，oVEMP異常；(5)無(wú)聽(tīng)覺(jué)及神經(jīng)系統(tǒng)癥狀[9]。

前庭下神經(jīng)炎評(píng)估標(biāo)準(zhǔn)：(1)急性發(fā)作性眩暈；(2)表現(xiàn)為垂直或扭轉(zhuǎn)眼震；(3)受累水平半規(guī)管雙溫試驗(yàn)正常；(4)cVEMP異常，oVEMP正常；(5)無(wú)聽(tīng)覺(jué)及神經(jīng)系統(tǒng)癥狀。

前庭全神經(jīng)炎評(píng)估標(biāo)準(zhǔn)：(1)急性發(fā)作性眩暈；(2)表現(xiàn)為扭轉(zhuǎn)或水平混合眼震；(3)受累水平半規(guī)管雙溫試驗(yàn)正常、反應(yīng)降低或消失；(4)cVEMP異常，oVEMP異常；(5)無(wú)聽(tīng)覺(jué)及神經(jīng)系統(tǒng)癥狀。

圖1 oVEMP檢測(cè)結(jié)果

圖2 cVEMP檢測(cè)結(jié)果

2 結(jié) 果

根據(jù)cVEMP、oVEMP及前庭雙溫試驗(yàn)結(jié)果將60例單側(cè)前庭神經(jīng)炎患者分為前庭上神經(jīng)炎46例，前庭下神經(jīng)炎12例，全前庭神經(jīng)炎2例。

2.1 引出情況及異常率 前庭神經(jīng)炎患者VEMPs引出情況如下，cVEMP和oVEMP均未引出的只有1例，均正常的有2例(表1)；健康對(duì)照組oVEMP異常率為6.67%,而前庭神經(jīng)炎組oVEMP異常率較之明顯升高，其異常率為76.67%(表2)。健康對(duì)照組cVEMP異常率為3.33%,而前庭神經(jīng)炎組cVEMP異常率也較之升高23.33%。兩者相比差異有統(tǒng)計(jì)學(xué)意義(χ2=39.375，P=0.000,χ2=6.053，P=0.014)。

表1 前庭神經(jīng)炎組oVEMP和cVEMP引出情況

表2 前庭神經(jīng)炎組和健康對(duì)照組oVEMP、cVEMP異常率比較

2.2 前庭上神經(jīng)炎

2.2.1 潛伏期 由表3可見(jiàn)，前庭上神經(jīng)炎患側(cè)與健側(cè)P1、N1 潛伏期及P1-N1間期均值差異均無(wú)統(tǒng)計(jì)學(xué)意義(t=0.959，P=0.348；t=0.610，P=0.588；t=-1.692,P=0.106)；前庭上神經(jīng)炎患側(cè)和健康對(duì)照組P1、N1 潛伏期及P1-N1間期均值差異均無(wú)統(tǒng)計(jì)學(xué)意義(t=0.206，P=0.838；t=0.205，P=0.839；t=-1.225,P=0.832)；前庭上神經(jīng)炎健側(cè)和健康對(duì)照組P1、N1 潛伏期及P1-N1間期均值差異均無(wú)統(tǒng)計(jì)學(xué)意義(t=-1.573，P=0.120；t=-681，P=0.498；t=-0.1.225,P=0.224)。

表3 前庭神經(jīng)炎組和健康對(duì)照組oVEMP各波潛伏期間期比較 (±s；ms)

2.2.2 振幅及其不對(duì)稱比 由表4可見(jiàn)，前庭上神經(jīng)炎患者cVEMP引出，而oVEMP可引不出，可振幅降低。為方便統(tǒng)計(jì)，未引出側(cè)振幅記為1 μV。前庭上神經(jīng)炎組患側(cè)與健側(cè)、健康對(duì)照組振幅均值差異有統(tǒng)計(jì)學(xué)意義(t=2.434 ，P=0.024；t=-2.105，P=0.039)；而健康對(duì)照組耳與健側(cè)均值差異均無(wú)統(tǒng)計(jì)學(xué)意義(t=-1.045，P=0.299)。患者兩耳不對(duì)稱比與健康對(duì)照組不對(duì)稱比，兩者相比差異有統(tǒng)計(jì)學(xué)意義(t=-7.834，P=0.000)。

表4 前庭神經(jīng)炎組和健康對(duì)照組oVEMP振幅及不對(duì)稱比比較 (±s)

2.2.3 前庭雙溫試驗(yàn) 2例oVEMP、cVEMP正常，而雙溫試驗(yàn)異常。健康對(duì)照組與前庭上神經(jīng)炎組的雙溫試驗(yàn)CP均值分別為(15.267±3.713)%，(63.345±25.862)%，對(duì)比差異有統(tǒng)計(jì)學(xué)意義(t=10.077，P=0.000)。

2.3 前庭下神經(jīng)炎 前庭神經(jīng)炎組中12例為前庭下神經(jīng)炎， 12例oVEMP均引出，振幅及不對(duì)稱比與健康對(duì)照組比較，無(wú)統(tǒng)計(jì)學(xué)差異(t=0.642，P=0.523，t=-1.545，P=0.132)，前庭雙溫試驗(yàn)均正常，而cVEMP均為異常(4例低振幅，8例未引出)。

2.4 全前庭神經(jīng)炎 前庭神經(jīng)炎組中2例為全前庭神經(jīng)炎,其中1例顯示oVEMP波形消失，1例波幅降低。結(jié)合前庭雙溫試驗(yàn)1例正常，1例異常。2例cVEMP波形均消失。

2.5 前庭雙溫試驗(yàn)CP值與前庭上、下神經(jīng)炎(VEMPs)相關(guān)性分析 對(duì)前庭神經(jīng)炎組行前庭雙溫試驗(yàn)，結(jié)果發(fā)現(xiàn)雙溫試驗(yàn)CP值與oVEMP、cVEMP患側(cè)振幅、不對(duì)稱比(asymmetry ratio,AR)無(wú)相關(guān)性，差異無(wú)統(tǒng)計(jì)學(xué)意義(表5)。

表5 雙溫試驗(yàn)CP值與前庭上、下神經(jīng)炎(VEMPs)相關(guān)性分析

3 討 論

前庭神經(jīng)炎主要表現(xiàn)為急性發(fā)作的嚴(yán)重眩暈和惡心持續(xù)數(shù)天至數(shù)周，不伴有耳部癥狀及中樞神經(jīng)系統(tǒng)癥狀，是一種臨床常見(jiàn)的前庭性外周性眩暈，被認(rèn)為是病毒選擇性地侵入前庭神經(jīng)，可分為前庭上神經(jīng)炎、前庭下神經(jīng)炎和全前庭神經(jīng)炎[10]。 本研究60例前庭神經(jīng)炎患者中前庭上神經(jīng)占46例，所占比例與以往的其他急性前庭神經(jīng)炎臨床研究結(jié)果一致[11,12]。不少研究者認(rèn)為,可能是由于前庭上、下神經(jīng)在解剖學(xué)上的差別，使得前庭上神經(jīng)容易被侵犯[13,14],解剖研究表明，前庭上神經(jīng)的骨性通道比前庭下神經(jīng)長(zhǎng)7倍以上，比單通道長(zhǎng)3倍以上[13]，在前庭神經(jīng)炎中由于受到病毒侵襲，前庭上神經(jīng)在骨室腫脹，更容易造成前庭功能損傷[9]。

近年來(lái),關(guān)于前庭下神經(jīng)的損害也開(kāi)始報(bào)道。在本研究中，和前庭上神經(jīng)相比，下神經(jīng)在這項(xiàng)研究中較少，僅為12例占所有病例數(shù)的20%，其他研究報(bào)告這種亞型構(gòu)成比高達(dá)51%[15,17]，可能由于本研究下神經(jīng)例數(shù)較少。一直以來(lái)前庭下神經(jīng)炎由雙溫試驗(yàn)正常和cVEMP異常判斷[15，18],現(xiàn)在隨著oVEMP研究深入，Chiarovano等[19]發(fā)現(xiàn)單側(cè)前庭上神經(jīng)功能障礙患者oVEMP異常，而前庭下神經(jīng)cVEMPs異常，提示臨床上前庭上神經(jīng)炎o(hù)VEMPs與cVEMPs兩種檢查是橢圓囊和球囊功能檢查的相互補(bǔ)充。前庭上神經(jīng)支配水平半規(guī)管、上半規(guī)管、橢圓囊和部分球囊，前庭下神經(jīng)支配大部分球囊及后半規(guī)管。

本研究發(fā)現(xiàn)，前庭上神經(jīng)炎患者患側(cè)oVEMP異常率升高，潛伏期延長(zhǎng)，振幅降低、兩耳間不對(duì)稱比值增大乃至波形消失，本研究的異常率為76.67%，與Shin等[9]報(bào)道的73.2%基本相同，稍低于Murofushi等[20]的研究。本研究所得引出率較先前報(bào)道相差不大。本研究雙溫試驗(yàn)患側(cè)大多減弱，雙側(cè)cVEMP正常。前庭下神經(jīng)炎o(hù)VEMP、雙溫試驗(yàn)均正常，而cVEMP未引出，或較對(duì)照組振幅降低、兩耳間不對(duì)稱比值增大，乃至波形消失。全前庭神經(jīng)炎即oVEMP、cVEMP均未引出。本研究表明，前庭上神經(jīng)炎患側(cè)oVEMP未引出而cVEMP正常；相反前庭下神經(jīng)元炎，患側(cè)oVEMP引出而cVEMP未引出，與以往的研究類似[15,16,21-25]。

本研究觀察到，前庭上神經(jīng)炎患者健側(cè)oVEMP潛伏期與健康對(duì)照組比較，差異無(wú)統(tǒng)計(jì)學(xué)意義,此與Byoung等[9]研究結(jié)果一致。而患側(cè)振幅及不對(duì)稱比較健康對(duì)照組有明顯差異，而健側(cè)無(wú)明顯差異。AR在以往的研究中，單側(cè)前庭功能喪失的患者AR顯著大于健康對(duì)照組[ 26]。在本研究中，VN AR與以前的研究類似[27,28]。此外，本研究中發(fā)現(xiàn)雙溫試驗(yàn)與前庭神經(jīng)炎患側(cè)oVEMP、cVEMP振幅及不對(duì)稱比無(wú)明顯相關(guān)，與Shin等[9]研究結(jié)果相似。

總之，本研究通過(guò)對(duì)前庭神經(jīng)炎組及健康對(duì)照組oVEMP、cVEMP及分析，反映了前庭神經(jīng)炎組患側(cè)、健側(cè)的前庭神經(jīng)及橢圓囊、球囊受累情況，且oVEMP是一項(xiàng)無(wú)創(chuàng)性檢查技術(shù)，操作較為簡(jiǎn)便，患者較容易配合。因此，氣導(dǎo)oVEMP可用于評(píng)估前庭上神經(jīng)橢圓囊功能，能夠客觀反映前庭-眼反射通路，氣導(dǎo)cVEMP可用于評(píng)估前庭下神經(jīng)球囊功能，提供前庭-脊髓通路，進(jìn)一步明確前庭神經(jīng)受累部位情況。

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(2016-10-20收稿 2016-11-10修回)

(責(zé)任編輯 郭 青)

Cervical and ocular vestibular-evoked myogenic potentials in acute vestibular neuritis

CHEN Zhe, RAO Rendong, SUN Qing, PENG Xin, LIU Jinmei, LIANG Xuhui，and SHAN Xizheng.

Institute of Dizziness, General Hospital of Chinese People’s Armed Police Force, Beijing 100039，China

Objective To evaluate the classification of vestibular neuritis (VN) and involvement of the superior vestibular nerve (SVN)and inferior vestibular nerve (IVN).Methods Sixty patients diagnosed with vestibular neuritis in our department and 30 normal persons as healthy control group were included in our study. Ocular vestibular-evoked myogenic potential (oVEMP) test，cervical vestibular-evoked myogenic potential (cVEMP) test and caloric test were carried out in all the patients and healthy control group. Caloric test was used to measure the horizontal semicircular canal, oVEMPs were used to measure the function of the utricular and superior vestibular nerve, while cVEMPs were used to evaluate the function of the saccule and inferior vestibular nerve.Results VN selectively involved the superior vestibular nerve in 46 patients, affected the inferior vestibular nerve in twelve and damaged both superior and inferior vestibular nerve branches in two. The abnormal extraction rate of VEMPs of vestibular neuritis group was higher than in control group, and the difference was statistically significant. There was no significant difference in the latency of oVEMPs between patients in superior vestibular nerve group and healthy control group, whereas the amplitude and asymmetry ratio were significantly different. There was no significant difference between the healthy side and the healthy control group, but the difference was statistically significant in caloric test. However, there was no significant difference in the latency and amplitude of oVEMPs between patients in inferior vestibular nerve group and healthy control group. There was no correlation between the CP value of caloric test and the vestibular nerve. Patients with abnormal cVEMPs and normal oVEMPs and caloric test represented the inferior vestibular nerve.Conclusions Vestibular neuritis mostly involves the superior portion of the vestibular nerve. cVEMPs, oVEMPs and caloric test can provide more detailed localization of vestibular nerve damage.

vestibular neuritis; cervical vestibular evoked myogenic potential;caloric test;ocular vestibular evoked myogenic potential

陳 哲，碩士研究生。

100039 北京，武警總醫(yī)院眩暈病研究所

單希征，E-mail: sxzent@163.com

R276.1