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Lima Neto AC, Bittar RSM. Vascular vertigo and dizziness: managing and treating outpatients. Braz J Otorhinolaryngol 2024; 90:101453. [PMID: 38991403 PMCID: PMC11295563 DOI: 10.1016/j.bjorl.2024.101453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 02/14/2024] [Accepted: 05/23/2024] [Indexed: 07/13/2024] Open
Abstract
OBJECTIVE Due the lack of data on the treatment of Vascular Vertigo and Dizziness, this study aimed to report how we managed and treated those outpatients according to the recently introduced American Heart Association and Stroke Association guidelines. METHODS We conducted a longitudinal case series from May 2022 to February 2023. We included patients who met the Bárány Society's Vascular Vertigo and Dizziness classification and were eligible for therapy in accordance with the American Heart Association and Stroke Association guidelines, featuring aspects of the stroke group and transient attack group. RESULTS Overall, 41 patients (51.2% female; median age 72 years) were enrolled; 10 (24.3%) had ischemic strokes, 30 (73.1%) had transient ischemic attack, and 1 (2.4%) had a probable isolated labyrinthine infarction. The patients received dual antiplatelet (48.7%), single antiplatelet therapy (48.7%), and anticoagulant therapy (2.4%). No new crises occurred in 95.2% of the patients, and the transient ischemic attack group showed a significant decrease in discomfort from imbalance on the visual analog scale. CONCLUSIONS Antiplatelets and anticoagulants are safe and effective in treating Vascular Vertigo and Dizziness as they prevent new ischemic events and increase the flow of the posterior circulation, reducing vertigo/dizziness attacks and imbalance complaints. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Arlindo Cardoso Lima Neto
- Setor de Otoneurologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - FMUSP, Brazil.
| | - Roseli Saraiva Moreira Bittar
- Setor de Otoneurologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo - FMUSP, Brazil
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2
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Vanni S, Vannucchi P, Pecci R, Pepe G, Paciaroni M, Pavellini A, Ronchetti M, Pelagatti L, Bartolucci M, Konze A, Castellucci A, Manfrin M, Fabbri A, de Iaco F, Casani AP. Consensus paper on the management of acute isolated vertigo in the emergency department. Intern Emerg Med 2024; 19:1181-1202. [PMID: 39001977 PMCID: PMC11364714 DOI: 10.1007/s11739-024-03664-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/28/2024] [Indexed: 07/15/2024]
Abstract
Acute vertigo is defined as the perception of movement of oneself or the surroundings in the absence of actual motion and it is a frequent cause for emergency department admissions. The utilization of medical resources and the duration of hospital stay for this kind of symptom is high. Furthermore, the efficiency of brain imaging in the acute phase is low, considering the limited sensitivity of both CT and MRI for diagnosing diseases that are the causes of central type of vertigo. Relying on imaging tests can provide false reassurance in the event of negative results or prolong the in-hospital work-up improperly. On the other hand, clinical examinations, notably the assessment of nystagmus' features, have proven to be highly accurate and efficient when performed by experts. Literature data point out that emergency physicians often do not employ these skills or use them incorrectly. Several clinical algorithms have been introduced in recent years with the aim of enhancing the diagnostic accuracy of emergency physicians when evaluating this specific pathology. Both the 'HINTS and 'STANDING' algorithms have undergone external validation in emergency physician hands, showing good diagnostic accuracy. The objective of this consensus document is to provide scientific evidence supporting the clinical decisions made by physicians assessing adult patients with acute vertigo in the emergency department, particularly in cases without clear associated neurological signs. The document aims to offer a straightforward and multidisciplinary approach. At the same time, it tries to delineate benchmarks for the formulation of local diagnostic and therapeutic pathways, as well as provide a base for the development of training and research initiatives.
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Affiliation(s)
- Simone Vanni
- Dipartimento di Medicina Sperimentale e Clinica, Università degli studi di Firenze, Largo Brambilla 3, 50134, Florence, Italy.
| | | | - Rudi Pecci
- Audiologia, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Giuseppe Pepe
- Medicina Emergenza Urgenza e Pronto Soccorso, Azienda USL Toscana Nord Ovest, Ospedale Versilia, Viareggio, Italy
| | - Maurizio Paciaroni
- Medicina Interna e Cardiovascolare, Stroke Unit, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Andrea Pavellini
- Medicina e Chirurgia d'Urgenza e Accettazione, AOU-Careggi, Florence, Italy
| | - Mattia Ronchetti
- Medicina e Chirurgia d'Urgenza e Accettazione, AOU-Careggi, Florence, Italy
| | - Lorenzo Pelagatti
- Medicina e Chirurgia d'Urgenza e Accettazione, AOU-Careggi, Florence, Italy
| | - Maurizio Bartolucci
- Dipartimento di Diagnostica per Immagini, Azienda Usl Toscana Centro, Prato, Italy
| | - Angela Konze
- Neuroradiologia, Azienda USL Toscana Centro, Florence, Italy
| | - Andrea Castellucci
- Otorinolaringoiatria, Arcispedale Santa Maria Nuova, IRCCS, Reggio Emilia, Italy
| | - Marco Manfrin
- Otorinolaringoiatria, Libero Professionista, Milan, Italy
| | - Andrea Fabbri
- Pronto Soccorso e Medicina d'Urgenza, AUSL della Romagna, Ospedale Morgagni-Pierantoni, Forlì, Italy
| | - Fabio de Iaco
- Medicina d'Urgenza, Ospedale Maria Vittoria, Turin, Italy
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3
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Ohle R, Savage DW, Roy D, McIsaac S, Singh R, Lelli D, Tse D, Johns P, Yadav K, Perry JJ. Development of a Clinical Risk Score to Risk Stratify for a Serious Cause of Vertigo in Patients Presenting to the Emergency Department. Ann Emerg Med 2024:S0196-0644(24)00326-3. [PMID: 39093245 DOI: 10.1016/j.annemergmed.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 05/14/2024] [Accepted: 06/03/2024] [Indexed: 08/04/2024]
Abstract
STUDY OBJECTIVE Identify high-risk clinical characteristics for a serious cause of vertigo in patients presenting to the emergency department (ED). METHODS Multicentre prospective cohort study over 3 years at three university-affiliated tertiary care EDs. Participants were patients presenting with vertigo, dizziness or imbalance. Main outcome measurement was an adjudicated serious diagnosis defined as stroke, transient ischemic attack, vertebral artery dissection or brain tumour. RESULTS A total of 2,078 of 2,618 potentially eligible patients (79.4%) were enrolled (mean age 77.1 years; 59% women). Serious events occurred in 111 (5.3%) patients. We used logistic regression to create a 7-item prediction model: male, age over 65, hypertension, diabetes, motor/sensory deficits, cerebellar signs/symptoms and benign paroxysmal positional vertigo diagnosis (C-statistic 0.96, 95% confidence interval [CI] 0.92 to 0.98). The risk of a serious diagnosis ranged from 0% for a score of <5, 2.1% for a score of 5 to 8, and 41% for a score >8. Sensitivity for a serious diagnosis was 100% (95% CI, 97.1% to 100%) and specificity 72.1% (95% CI, 70.1% to 74%) for a score <5. CONCLUSION The Sudbury Vertigo Risk Score identifies the risk of a serious diagnosis as a cause of a patient's vertigo and if validated could assist physicians in guiding further investigation, consultation, and treatment decisions, improving resource utilization and reducing missed diagnoses.
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Affiliation(s)
- Robert Ohle
- Department of Emergency Medicine, Health Sciences North, Health Sciences North Research Institute, Northern Ontario School of Medicine, Sudbury, ON, Canada.
| | - David W Savage
- Department of Emergency Medicine, Northern Ontario School of Medicine, Thunder Bay, ON, Canada
| | - Danielle Roy
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sarah McIsaac
- Department of Critical Care, Department of Anesthesia, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Ravinder Singh
- Department of Neurology, Health Sciences North, Health Sciences North Research Institute, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Daniel Lelli
- Department of Neurology and Otolaryngology, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Darren Tse
- Department of Neurology and Otolaryngology, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Peter Johns
- Department of Emergency Medicine University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Krishan Yadav
- Department of Emergency Medicine University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
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4
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Kerber KA. Dizziness in Primary Care. Prim Care 2024; 51:195-209. [PMID: 38692770 DOI: 10.1016/j.pop.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Dizziness is a prevalent symptom in the general population and is among the most common reasons patients present for medical evaluations. This article focuses on high yield information to support primary clinicians in the efficient and effective evaluation and management of dizziness. Key points are as follows: do not anchor on the type of dizziness symptom, do use symptom timing and prior medical history to inform diagnostics probabilities, do evaluate for hallmark examination findings of vestibular disorders, and seek out opportunities to deliver evidence-based interventions particularly the canalith repositioning maneuver and gaze stabilization exercises.
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Affiliation(s)
- Kevin A Kerber
- Department of Neurology, Ohio State University, 395 West 12th Avenue, 7th Floor, Columbus, OH 43210, USA.
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5
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Radecki RP. Where Do We Go Wrong?: June 2024 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2024; 83:621-623. [PMID: 38777504 DOI: 10.1016/j.annemergmed.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Affiliation(s)
- Ryan P Radecki
- Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
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6
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Chang YS, Tsai MJ, Hsieh CY, Sung SF. Characteristics and risk of stroke in emergency department patients with acute dizziness. Heliyon 2024; 10:e30953. [PMID: 38770312 PMCID: PMC11103531 DOI: 10.1016/j.heliyon.2024.e30953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 05/03/2024] [Accepted: 05/08/2024] [Indexed: 05/22/2024] Open
Abstract
Background Acute dizziness is a common symptom in the emergency department (ED), with strokes accounting for 3 %-5 % of cases. We investigated the risk of stroke in ED patients with acute dizziness and compared stroke characteristics diagnosed during and after the ED visit. Methods We identified adult patients with acute dizziness, vertigo, or imbalance using a hospital research-based database. Patients with abdominal or flank pain were used as the comparison group. Patients with dizziness were 1:1 matched to comparison patients. Each patient was traced for up to one year until being hospitalized for a stroke. Results Out of the 24,266 eligible patients, 589 (2.4 %) were hospitalized for stroke during the ED visit. For the remaining 23,677 patients, the risk of stroke at 7, 30, 90, and 365 days after ED discharge was 0.40 %, 0.52 %, 0.71 %, and 1.25 % respectively. Patients with dizziness had a higher risk of stroke compared to the comparison group at 7, 30, 90, and 365 days. The risk ratios decreased from 5.69 (95 % confidence interval [CI], 3.34-9.68) to 2.03 (95 % CI, 1.65-2.49). Compared to patients hospitalized for stroke during the ED visit, those hospitalized for stroke after the ED visit had greater stroke severity despite a lower initial triage acuity. Patients with early stroke (≤7 days) after ED discharge were less likely to have hypertension, diabetes, hyperlipidemia, and atrial fibrillation. They mostly experienced posterior circulation stroke. Patients with late stroke (>7 days) were older and less likely to have hypertension and hyperlipidemia but more likely to have a history of prior stroke and ischemic heart disease. Their strokes were mainly located in the anterior circulation territory. Conclusions The risk of stroke after ED discharge was higher in patients with dizziness than in the comparison group, with gradually decreasing risk ratios in the following year. Patients hospitalized for stroke during and after the ED visit had different profiles of vascular risk factors and clinical characteristics.
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Affiliation(s)
- Yu-Sung Chang
- Department of Otolaryngology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan
| | - Ming-Jen Tsai
- Department of Emergency Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan
| | - Cheng-Yang Hsieh
- Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan
- Department of Beauty & Health Care, Min-Hwei Junior College of Health Care Management, Tainan, Taiwan
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7
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Edlow JA, Bellolio F. Recognizing Posterior Circulation Transient Ischemic Attacks Presenting as Episodic Isolated Dizziness. Ann Emerg Med 2024:S0196-0644(24)00214-2. [PMID: 38795083 DOI: 10.1016/j.annemergmed.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 03/26/2024] [Accepted: 04/05/2024] [Indexed: 05/27/2024]
Abstract
Diagnosing patients presenting to the emergency department with self-limited episodes of isolated dizziness (the episodic vestibular syndrome) requires a broad differential diagnosis that includes posterior circulation transient ischemic attack. Because these patients are, by definition, asymptomatic without new neurologic findings on examination, the diagnosis, largely based on history and epidemiologic context, can be challenging. We review literature that addresses the frequency of posterior circulation transient ischemic attack in this group of patients compared with other potential causes of episodic vestibular syndrome. We present ways of distinguishing posterior circulation transient ischemic attack from vestibular migraine, the most common cause of episodic vestibular syndrome. We also present a diagnostic algorithm that may help clinicians to work their way through the differential diagnosis.
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Affiliation(s)
- Jonathan A Edlow
- Emergency Medicine, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
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8
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Hung SH, Xirasagar S, Dang LH, Chen YC, Cheng YF, Lin HC, Chen CS. Trends in the incidence of peripheral vestibular disorders: a Nationwide population-based study. Front Neurol 2023; 14:1322199. [PMID: 38192578 PMCID: PMC10773773 DOI: 10.3389/fneur.2023.1322199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 11/28/2023] [Indexed: 01/10/2024] Open
Abstract
Purpose This study aimed to examines the long-term trend of incidence of peripheral vestibular disorders between 2010 and 2018 in Taiwan. Methods Study-eligible patients were identified from Taiwan's Longitudinal Health Insurance Database 2005 maintained by the Ministry of Health and Welfare in Taiwan. We retrieved 230,566 patients with a first-time diagnosis of peripheral vestibular disorders between 2010 and 2018. We calculated annual incidence rates of peripheral vestibular disorders per 100,000 population. We used the annual percent change (APC) to test the trend of peripheral vestibular disorders over time. Results The mean annual incidence rate of peripheral vestibular disorders during the study period was 1489.6 per 100,000 population. Incidence showed a statistically significant steady decrease from 2010 to 2018 with a mean APC of -6.15% (95% CI = -6.97% ~ -5.32%). The decline was led by Meniere's disease (APC = -9.83, 95% CI = -10.66% ~ -8.99%), followed by benign paroxysmal positional vertigo (APC = -3.69, 95% CI = -4.53% ~ -3.03%), vestibular neuritis (APC = -7.85, 95% CI = -8.96 ~ -6.73), and other peripheral vestibular dizziness (APC = -5.56, 95% CI = -6.69% ~ -4.43%). Conclusion The incidence of peripheral vestibular disorders, overall, and the four major subgroups, benign paroxysmal positional vertigo, Meniere's disease, vestibular neuritis, and other peripheral vestibular dizziness, all decreased substantially, year by year within the 2010-2018 period.
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Affiliation(s)
- Shih-Han Hung
- Department of Otolaryngology, School of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Otolaryngology, Wan Fang Hospital, Taipei, Taiwan
- International Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Sudha Xirasagar
- Department of Health Services Policy and Management, University of South Carolina, Arnold School of Public Health, Columbia, SC, United States
| | - Luong Huu Dang
- Department of Otolaryngology, Wan Fang Hospital, Taipei, Taiwan
- Department of Otolaryngology, Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Yen-Chun Chen
- Department of Otolaryngology, School of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yen-Fu Cheng
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Research Center of Data Science on Healthcare Industry, College of Management, Taipei Medical University, Taipei, Taiwan
| | - Herng-Ching Lin
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan
- Research Center of Sleep Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Chin-Shyan Chen
- Research Center of Data Science on Healthcare Industry, College of Management, Taipei Medical University, Taipei, Taiwan
- Department of Economics, National Taipei University, New Taipei City, Taiwan
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9
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Zhu Y, Wang Z, Newman-Toker D. Misdiagnosis-related harm quantification through mixture models and harm measures. Biometrics 2023; 79:2633-2648. [PMID: 36219626 PMCID: PMC10086076 DOI: 10.1111/biom.13759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 09/22/2022] [Indexed: 11/28/2022]
Abstract
Investigating and monitoring misdiagnosis-related harm is crucial for improving health care. However, this effort has traditionally focused on the chart review process, which is labor intensive, potentially unstable, and does not scale well. To monitor medical institutes' diagnostic performance and identify areas for improvement in a timely fashion, researchers proposed to leverage the relationship between symptoms and diseases based on electronic health records or claim data. Specifically, the elevated disease risk following a false-negative diagnosis can be used to signal potential harm. However, off-the-shelf statistical methods do not fully accommodate the data structure of a well-hypothesized risk pattern and thus fail to address the unique challenges adequately. To fill these gaps, we proposed a mixture regression model and its associated goodness-of-fit testing. We further proposed harm measures and profiling analysis procedures to quantify, evaluate, and compare misdiagnosis-related harm across institutes with potentially different patient population compositions. We studied the performance of the proposed methods through simulation studies. We then illustrated the methods through data analyses on stroke occurrence data from the Taiwan Longitudinal Health Insurance Database. From the analyses, we quantitatively evaluated risk factors for being harmed due to misdiagnosis, which unveiled some insights for health care quality research. We also compared general and special care hospitals in Taiwan and observed better diagnostic performance in special care hospitals using various new evaluation measures.
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Affiliation(s)
- Yuxin Zhu
- Armstrong Institute Center for Diagnostic Excellence, Johns Hopkins University, Baltimore, MD 21202, U.S.A
| | - Zheyu Wang
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD 21205, U.S.A
| | - David Newman-Toker
- Department of Neurology, Johns Hopkins University, Baltimore, MD 21205, U.S.A
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10
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Lo BM, Carpenter CR, Ducey S, Gottlieb M, Kaji A, Diercks DB, Diercks DB, Wolf SJ, Anderson JD, Byyny R, Carpenter CR, Friedman B, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Moran M, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Tomaszewski CA, Trent S, Valente JH, Wall SP, Westafer LM, Yu Y, Cantrill SV, Finnell JT, Schulz T, Vandertulip K. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Acute Ischemic Stroke. Ann Emerg Med 2023; 82:e17-e64. [PMID: 37479410 DOI: 10.1016/j.annemergmed.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
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11
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Liberman AL, Wang Z, Zhu Y, Hassoon A, Choi J, Austin JM, Johansen MC, Newman-Toker DE. Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic error (SPADE): comparison groups to maximize SPADE validity. Diagnosis (Berl) 2023; 10:225-234. [PMID: 37018487 PMCID: PMC10659025 DOI: 10.1515/dx-2022-0130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/06/2023] [Indexed: 04/07/2023]
Abstract
Diagnostic errors in medicine represent a significant public health problem but continue to be challenging to measure accurately, reliably, and efficiently. The recently developed Symptom-Disease Pair Analysis of Diagnostic Error (SPADE) approach measures misdiagnosis related harms using electronic health records or administrative claims data. The approach is clinically valid, methodologically sound, statistically robust, and operationally viable without the requirement for manual chart review. This paper clarifies aspects of the SPADE analysis to assure that researchers apply this method to yield valid results with a particular emphasis on defining appropriate comparator groups and analytical strategies for balancing differences between these groups. We discuss four distinct types of comparators (intra-group and inter-group for both look-back and look-forward analyses), detailing the rationale for choosing one over the other and inferences that can be drawn from these comparative analyses. Our aim is that these additional analytical practices will improve the validity of SPADE and related approaches to quantify diagnostic error in medicine.
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Affiliation(s)
- Ava L. Liberman
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine
| | - Zheyu Wang
- The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Division of Biostatistics and Bioinformatics
- The Johns Hopkins Bloomberg School of Public Health, Department of Biostatistics
| | - Yuxin Zhu
- The Johns Hopkins University School of Medicine, Sidney Kimmel Comprehensive Cancer Center, Division of Biostatistics and Bioinformatics
- The Johns Hopkins University School of Medicine, Department of Neurology and the Armstrong Institute Center for Diagnostic Excellence
| | - Ahmed Hassoon
- The Johns Hopkins Bloomberg School of Public Health, Department of Biostatistics
| | - Justin Choi
- Department of Internal Medicine, Weill Cornell Medicine
| | - J. Matthew Austin
- The Johns Hopkins University School of Medicine, Department of Anesthesiology and Critical Care Medicine and the Armstrong Institute Center for Diagnostic Excellence
| | - Michelle C. Johansen
- The Johns Hopkins University School of Medicine, Department of Neurology and the Armstrong Institute Center for Diagnostic Excellence
| | - David E. Newman-Toker
- The Johns Hopkins University School of Medicine, Department of Neurology and the Armstrong Institute Center for Diagnostic Excellence
- The Johns Hopkins Bloomberg School of Public Health, Departments of Epidemiology and Health Policy & Management
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12
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Buyurgan CS, Eray O, Yigit O, Yaprak N, Unal A, Senol U. Diagnostic Contribution of Magnetic Resonance Imaging and Computerized Tomography in Patients with Unidentified Vertigo and Normal Neurologic Examination in Emergency Medicine. Niger J Clin Pract 2023; 26:694-700. [PMID: 37470641 DOI: 10.4103/njcp.njcp_803_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Background Vertigo and dizziness are common symptoms in patients presenting to emergency medicine (ED) clinics. Vertigo may be caused by peripheral or central origin. Routine imaging is not indicated; however, neuroimaging is increasing, and published studies have revealed a small number of positive findings on imaging modalities. Aims The aim of this study was to investigate whether neurological imaging was necessary in patients classified as "unidentified vertigo," who were admitted to the emergency department with vertiginous complaints and not revealing typical peripheral vertigo findings and any neurological deficits. Materials and Methods All patients with "dizzy symptoms" were included in the study. For patients who met the definition of "unidentified vertigo," experimental neurological imaging studies were done. Head computerized tomography (CT), magnetic resonance imaging (MRI) with gradient-echo sequences (GRE), and diffusion weighted images (DWI) were used for imaging. Patients who underwent neuroimaging in the ED were followed up for 6 months in Neurology and ENT clinics. Results A total of 351 patients were included in the study. Experimental imaging was performed on 100 patients. CT detected a significant pathology associated with the vertigo complaint in only one patient. MRI results were similar to the CT results. MRI-GRE sequences showed some additional pathologies in 14 patients and 4 of them were thought to be related to vertiginous symptoms. None of the patients classified as "non-central causes of vertigo" in the neuroimaging group developed TIA or CVD during 6 months of follow-up. Conclusion Head CT can be adequate to exclude life-threatening central pathology in "undifferentiated vertigo patients" and the addition of MRI did not add any diagnostic accuracy in ED management. Using the physical examination findings effectively to make a specific diagnosis may reduce misdiagnosis and improve resource utilization.
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Affiliation(s)
- C S Buyurgan
- Department of Emergency Medicine, Faculty of Medicine, Mersin University, Turkey
| | - O Eray
- Department of Emergency Medicine, Faculty of Medicine, Bandirma Onyedi Eylul University, Turkey
| | - O Yigit
- Department of Emergency Medicine, Akdeniz University, Turkey
| | - N Yaprak
- Department of ENT, Faculty of Medicine, Akdeniz University, Turkey
| | - A Unal
- Department of Neurology, Akdeniz University, Turkey
| | - U Senol
- Department of Radiology, Faculty of Medicine, Akdeniz University, Turkey
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13
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Edlow JA, Carpenter C, Akhter M, Khoujah D, Marcolini E, Meurer WJ, Morrill D, Naples JG, Ohle R, Omron R, Sharif S, Siket M, Upadhye S, E Silva LOJ, Sundberg E, Tartt K, Vanni S, Newman-Toker DE, Bellolio F. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. Acad Emerg Med 2023; 30:442-486. [PMID: 37166022 DOI: 10.1111/acem.14728] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/14/2023] [Indexed: 05/12/2023]
Abstract
This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").
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Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christopher Carpenter
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Emergency Medicine, Washington University, St. Louis, Missouri, USA
| | - Murtaza Akhter
- Department of Emergency Medicine, Penn State School of Medicine, State College, Pennsylvania, USA
- Hershey Medical Center, State College, Pennsylvania, USA
| | - Danya Khoujah
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Adventhealth Tampa, Tampa, Florida, USA
| | - Evie Marcolini
- Department of Emergency Medicine, Geisel School of Medicine, Dartmouth, Hanover, New Hampshire, USA
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - James G Naples
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Otolaryngology-Head & Neck Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Robert Ohle
- Department of Emergency Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
- Health Science North Research Institute, Sudbury, Ontario, Canada
- Department of Emergency Medicine, Health Sciences North, Sudbury, Ontario, Canada
| | - Rodney Omron
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sameer Sharif
- Division of Critical Care and Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Matt Siket
- Department of Emergency Medicine, Robert Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
- Department of Emergency Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Suneel Upadhye
- Emergency Medicine, Evidence and Impact (HEI), McMaster University, Burlington, Ontario, Canada
- Health Research Methods, Evidence and Impact (HEI), McMaster University, Burlington, Ontario, Canada
| | - Lucas Oliveira J E Silva
- Mayo Clinic, Rochester, Minnesota, USA
- Department of Emergency Medicine, Hospital de Clinicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Etta Sundberg
- COO Royal Oasis Pool and Spas, Las Vegas, Nevada, USA
| | - Karen Tartt
- Absinthe Brasserie & Bar, San Francisco, California, USA
- St. George Spirits, San Francisco, California, USA
| | - Simone Vanni
- Department of Emergency Medicine, University of Florence, Firenze, Italy
- Department of Emergency Medicine, University Hospital Careggi, Firenze, Italy
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fernanda Bellolio
- Mayo Clinic College of Medicine, Rochester, Minnesota, USA
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
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14
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Wu PL, Lin HC, Chien WC, Chung CH, Chen JW. Increased Risk of Injury in Ménière's Disease and Effects of Treatment: Population-Based Retrospective Cohort Study. Otolaryngol Head Neck Surg 2023; 168:443-452. [PMID: 35763347 DOI: 10.1177/01945998221106628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 05/25/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To investigate the risk of injury in patients with Ménière's disease (MD) and the effects of treatment. STUDY DESIGN Population-based retrospective cohort study. SETTING Data were collected from the Longitudinal Health Insurance Database 2005, containing the information of 2 million randomly selected individuals in Taiwan. METHODS We enrolled 90,481 patients with newly diagnosed MD between 2000 and 2017 and 361,924 matched individuals without MD. The study outcomes were diagnoses of all-cause injuries. The Kaplan-Meier method was used to determine the cumulative incidence rates of injury in the MD and non-MD cohorts, and a log-rank test was used to analyze the differences between the cohorts. Cox proportional hazards models were used to calculate the 18-year hazard ratios of each cohort. RESULTS A total of 80,151 patients were diagnosed with injuries during the follow-up period: 24,031 and 56,120 from the MD and non-MD cohorts, respectively. The adjusted hazard ratio (aHR) was 2.19 (95% CI, 2.16-2.35) after adjusting for demographic characteristics and comorbidities. Subgroup analysis revealed that MD was associated with an increased incidence of unintentional and intentional injuries (aHR, 2.24 [95% CI, 2.21-2.41] and 2.05 [95% CI, 2.01-2.19], respectively). Treatment with diuretics, antivertigo medications, or surgery did not reduce the risk of injury (aHR, 0.98 [95% CI, 0.59-1.54], 0.94 [95% CI, 0.58-1.50], and 0.99 [95% CI, 0.61-1.54]). CONCLUSION MD is independently associated with an increased risk of injuries. Medical or surgical treatment for MD does not reduce the risk of injury in patients with MD. Physicians should counsel patients with MD regarding preventive measures for avoiding subsequent injuries.
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Affiliation(s)
- Po-Ling Wu
- Department of Medical Education and Research, Cardinal Tien Hospital, New Taipei City
| | - Hung-Che Lin
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei
- Department of Otolaryngology-Head and Neck Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Wu-Chien Chien
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei
- School of Public Health, National Defense Medical Center, Taipei
- Taiwanese Injury Prevention and Safety Promotion Association, Taipei
| | - Chi-Hsiang Chung
- Department of Medical Research, Tri-Service General Hospital, National Defense Medical Center, Taipei
- School of Public Health, National Defense Medical Center, Taipei
- Taiwanese Injury Prevention and Safety Promotion Association, Taipei
| | - Jeng-Wen Chen
- Department of Medical Education and Research, Cardinal Tien Hospital, New Taipei City
- Department of Otolaryngology-Head and Neck Surgery, Cardinal Tien Hospital and School of Medicine, Fu Jen Catholic University, New Taipei City
- Master Program of Big Data in Biomedicine, School of Medicine, Fu Jen Catholic University, New Taipei City
- Cardinal Tien Junior College of Healthcare and Management, New Taipei City
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15
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Li N, Li C, Xie X, Liu G, Wang K, Zhang W, Fan J. Impairment of attention network function in posterior circulation ischemia-evidence from the Attention Network Test. Front Hum Neurosci 2023; 16:1001500. [PMID: 36684832 PMCID: PMC9853055 DOI: 10.3389/fnhum.2022.1001500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 12/19/2022] [Indexed: 01/09/2023] Open
Abstract
Objective This study aimed to investigate the effect of posterior circulation ischemia (PCI) on attention network function and to determine whether PCI is holistic or selective attention network deficit and which attention network is affected. Methods Thirty-six PCI patients aged 30 to 75 were assessed using the Attention Network Test and the Mini-Mental State Examination (MMSE). There were no significant differences in age, sex, and education between PCI group and the control group (n = 32). All data were statistically analyzed by SPSS 23.0 software. Result There were no significant difference in the MMSE scores between the two groups. Compared with the control group, the PCI group had significantly shorter response time for alerting and orienting network. The executive control network response time was significantly longer in PCI group than in the control group. The overall mean response time was also significantly longer in PCI group than in normal control group. There was no significant difference in mean accuracy between the two groups. Conclusion The alerting, orienting, and executive control networks were significantly less efficient in PCI group than in the control group (P < 0.01). This indicates impaired attention network in PCI patients. Since transient nerve seizures caused by vertebrobasilar ischemia may precede posterior circulation stroke, early assessment of cognitive function in patients with PCI is particularly important, and ANT is an excellent tool for this assessment.
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Affiliation(s)
- Na Li
- The Third Department of Encephalopathy, The Second Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, Anhui, China
| | - Chuanjin Li
- The First Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
| | - Xiaohui Xie
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Gang Liu
- The Third Department of Encephalopathy, The Second Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, Anhui, China
| | - Kai Wang
- Department of Neurology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Wendong Zhang
- Department of Encephalopathy, The Second Affiliated Hospital of Anhui University of Chinese Medicine, Hefei, China
| | - Jin Fan
- Department of Psychiatry and Neuroscience, Mount Sinai School of Medicine, New York, NY, United States
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16
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Rastall DP, Green K. Deep learning in acute vertigo diagnosis. J Neurol Sci 2022; 443:120454. [PMID: 36379134 DOI: 10.1016/j.jns.2022.120454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/24/2022] [Accepted: 10/05/2022] [Indexed: 11/13/2022]
Abstract
Recent advances in artificial intelligence are transforming healthcare and there are increasing efforts to apply these breakthroughs to the diagnosis of acute vertigo. Because the diagnosis of vertigo relies on the analysis of eye movements, there are several unique considerations that must be made when implementing deep learning approaches to vertigo. This review discusses the need for diagnostic aids for acute vertigo, the techniques used to preprocess eye movement data and adapt deep learning models to vertigo, and summarizes and analyzes all published models to date.
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Affiliation(s)
- David Pw Rastall
- The Johns Hopkins University School of Medicine, Department of Neurology, Division of Neuro-Visual & Vestibular Disorders, USA.
| | - Kemar Green
- The Johns Hopkins University School of Medicine, Department of Neurology, Division of Advanced Clinical Neurology, USA
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17
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Editorial regarding Byworth article on HINTS exam use by emergency physicians. CAN J EMERG MED 2022; 24:679-681. [DOI: 10.1007/s43678-022-00402-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 10/13/2022] [Indexed: 11/26/2022]
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18
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Liberman AL, Zhang C, Lipton RB, Kamel H, Parikh NS, Navi BB, Segal AZ, Razzak J, Newman-Toker DE, Merkler AE. Short-term stroke risk after emergency department treat-and-release headache visit. Headache 2022; 62:1198-1206. [PMID: 36073865 PMCID: PMC10041409 DOI: 10.1111/head.14387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/02/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate whether patients discharged to home after an emergency department (ED) visit for headache face a heightened short-term risk of stroke. BACKGROUND Stroke hospitalizations that occur soon after ED visits for headache complaints may reflect diagnostic error. METHODS We conducted a retrospective cohort study using statewide administrative claims data for all ED visits and admissions at nonfederal hospitals in Florida 2005-2018 and New York 2005-2016. Using standard International Classification of Diseases (ICD) codes, we identified adult patients discharged to home from the ED (treat-and-release visit) with a benign headache diagnosis (cohort of interest) as well as those with a diagnosis of renal colic or back pain (negative controls). The primary study outcome was hospitalization within 30 days for stroke (ischemic or hemorrhagic) defined using validated ICD codes. We assess the relationship between index ED visit discharge diagnosis and stroke hospitalization adjusting for patient demographics and vascular comorbidities. RESULTS We identified 1,502,831 patients with an ED treat-and-release headache visit; mean age was 41 (standard deviation: 17) years and 1,044,520 (70%) were female. A total of 2150 (0.14%) patients with headache were hospitalized for stroke within 30 days. In adjusted analysis, stroke risk was higher after headache compared to renal colic (hazard ratio [HR]: 2.69; 95% confidence interval [CI]: 2.29-3.16) or back pain (HR: 4.0; 95% CI: 3.74-4.3). In the subgroup of 26,714 (1.78%) patients with headache who received brain magnetic resonance imaging at index ED visit, stroke risk was only slightly elevated compared to renal colic (HR: 1.47; 95% CI: 1.22-1.78) or back pain (HR: 1.49; 95% CI: 1.24-1.80). CONCLUSION Approximately 1 in 700 patients discharged to home from the ED with a headache diagnosis had a stroke in the following month. Stroke risk was three to four times higher after an ED visit for headache compared to renal colic or back pain.
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Affiliation(s)
- Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Richard B Lipton
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Alan Z Segal
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Junaid Razzak
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
| | - David E Newman-Toker
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology and Health Policy & Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Otolaryngology and Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
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19
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Choi JY, Kim S, Boo D, Yoo S, Kim HJ, Kim JY, Lee KJ, Kang J, Kim BJ, Han MK, Bae HJ, Kim JS. Risk of Future Stroke in Patients with a Diagnosis of Peripheral Vertigo in the Emergency Department. Eur J Neurol 2022. [PMID: 36056876 DOI: 10.1111/ene.15543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 08/05/2022] [Accepted: 08/29/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND We evaluated the temporal characteristics of stroke risks in the emergency department patients who had a diagnosis of peripheral vertigo. We also attempted to reveal the stroke risk factor among those with peripheral vertigo. METHODS This is a parallel group cohort study in a tertiary referral hospital. After assigning each of matched 4367 patients to the comparative set of peripheral vertigo and appendicitis-ureterolithiasis groups and each of matched 4911 to the comparative set of peripheral vertigo and ischemic stroke groups, we evaluated the relative stroke risk. In addition, to predict the individual stroke risk in patients with peripheral vertigo, any association between the demographic factors and stroke events was evaluated in the peripheral vertigo group. RESULTS The peripheral vertigo group had a higher stroke risk than the appendicitis-ureterolithiasis group (HR=1.73, 95% CI=1.18-2.55) but a lower risk than the ischemic stroke group (HR=0.30, 95% CI=0.24-0.37). The stroke risk of the peripheral vertigo group was just below that of small vessel stroke. The stroke risk of the peripheral vertigo group differed markedly by time: higher within seven days, moderate between seven days and one year, and diminished thereafter. Old age (>65), male gender, and diabetes mellitus were the risk factors for stroke in the peripheral vertigo group. CONCLUSION Patients with a diagnosis of peripheral vertigo in the ED showed a moderate future stroke risk so that requires a stroke preventive strategy tailored to the timing of symptom onset and individual risk.
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Affiliation(s)
- Jeong-Yoon Choi
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Seok Kim
- Office of eHealth Research and Business, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Dachung Boo
- Office of eHealth Research and Business, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Sooyoung Yoo
- Office of eHealth Research and Business, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hyo-Jung Kim
- Research Administration Team, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jun Yup Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Keon-Joo Lee
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Jihoon Kang
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Neurology, Seoul National University College of Medicine, Seoul, South Korea
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20
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Agarwal K, Harnett J, Mehta N, Humphries F, Kaski D. Acute vertigo: getting the diagnosis right. BMJ 2022; 378:e069850. [PMID: 35961676 DOI: 10.1136/bmj-2021-069850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
| | - James Harnett
- Emergency Department, University College London Hospitals NHS Foundation Trust, London, UK
| | - Nishchay Mehta
- University College London Hospitals Biomedical Research Centre, National Institute for Health Research, London, UK
| | - Fiona Humphries
- Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
| | - Diego Kaski
- Department of Clinical and Movement Neurosciences, University College London, UK
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21
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Filippopulos FM, Strobl R, Belanovic B, Dunker K, Grill E, Brandt T, Zwergal A, Huppert D. Validation of a comprehensive diagnostic algorithm for patients with acute vertigo and dizziness. Eur J Neurol 2022; 29:3092-3101. [PMID: 35708513 DOI: 10.1111/ene.15448] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/24/2022] [Accepted: 06/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Vertigo and dizziness are common complaints in emergency departments and primary care, which pose major diagnostic challenges due to various underlying etiologies. Most supportive diagnostic algorithms concentrate on either identifying cerebrovascular events or diagnosing specific vestibular disorders or are restricted to specific patient subgroups. METHODS The study was conducted in the scope of the 'PoiSe' project (prevention, online feedback, and interdisciplinary therapy of acute vestibular syndromes by e-health). A three-level algorithm was developed according to international guidelines and scientific evidence addressing both, the detection of cerebrovascular events and the classification to non-vascular vestibular disorders (unilateral vestibulopathy, benign paroxysmal positional vertigo, vestibular paroxysmia, Menière's disease, vestibular migraine, functional dizziness). The algorithm was validated on a prospectively collected dataset of 407 patients with acute vertigo and dizziness presenting to the emergency department at LMU Munich. RESULTS The algorithm assigned 287 of 407 patients to the correct diagnosis, corresponding to an overall accuracy of 71%. Cerebrovascular events were identified with high sensitivity of 94%. The six most common vestibular disorders were classified with high specificity above 95%. Random forest identified the presence of a paresis, sensory loss, central ocular motor and vestibular signs (HINTS), and older age as the most important variables indicating a cerebrovascular event. CONCLUSIONS The proposed diagnostic algorithm can correctly classify the most common vestibular disorders based on a comprehensive set of key questions and clinical examinations. It is easily applied, not limited to subgroups, and might therefore be transferred to broad clinical settings such as primary health care.
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Affiliation(s)
- Filipp M Filippopulos
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany.,Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany
| | - Ralf Strobl
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany.,Institute for Medical Information Processing, Biometrics and Epidemiology, Ludwig-Maximilians-Universität München (LMU), Marchioninistr. 15, Munich, Germany
| | - Bozidar Belanovic
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany
| | - Konstanze Dunker
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany
| | - Eva Grill
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany.,Institute for Medical Information Processing, Biometrics and Epidemiology, Ludwig-Maximilians-Universität München (LMU), Marchioninistr. 15, Munich, Germany
| | - Thomas Brandt
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany
| | - Andreas Zwergal
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany.,Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany
| | - Doreen Huppert
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany.,Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany
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22
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Kim JS, Newman-Toker DE, Kerber KA, Jahn K, Bertholon P, Waterston J, Lee H, Bisdorff A, Strupp M. Vascular vertigo and dizziness: Diagnostic criteria. J Vestib Res 2022; 32:205-222. [PMID: 35367974 PMCID: PMC9249306 DOI: 10.3233/ves-210169] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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 (≥24 hours) or transient (minutes to < 24 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.
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Affiliation(s)
- Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Kevin A Kerber
- Department of Neurology, University of Michigan Health System, Ann Arbor, USA
| | - Klaus Jahn
- Department of Neurology Schoen Clinic Bad Aibling and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
| | | | - John Waterston
- Monash Department of Neuroscience, Alfred Hospital, Melbourne, Australia
| | - Hyung Lee
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
| | - Alexandre Bisdorff
- Department of Neurology, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg
| | - Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
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Edlow J. A negative non-contrast CT is insufficient to exclude a cerebellar infarct. Emerg Med J 2022; 39:564-565. [PMID: 35347061 DOI: 10.1136/emermed-2022-212404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/04/2022]
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Bi Y, Cao F. A Dynamic Nomogram to Predict the Risk of Stroke in Emergency Department Patients With Acute Dizziness. Front Neurol 2022; 13:839042. [PMID: 35250839 PMCID: PMC8896851 DOI: 10.3389/fneur.2022.839042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 01/17/2022] [Indexed: 11/25/2022] Open
Abstract
Objective To develop a risk prediction tool for acute ischemic stroke (AIS) for patients presenting to the emergency department (ED) with acute dizziness/vertigo or imbalance. Method A prospective, multicenter cohort study was designed, and adult patients presenting with dizziness/vertigo or imbalance within 14 days were consecutively enrolled from the EDs of 4 tertiary hospitals between August 10, 2020, and June 10, 2021. Stroke was diagnosed by CT or MRI performed within 14 days of symptom onset. Participants were followed-up for 30 days. The least absolute shrinkage and selection operator (LASSO) logistic regression analysis was conducted to extract predictive factors that best identified patients at high risk of stroke to establish a prediction model. Model discrimination and calibration were assessed and its prediction performance was compared with the age, blood pressure, clinical features, duration, and diabetes (ABCD2) score, nystagmus scheme, and finger to nose test. Results In this study, 790 out of 2,360 patients were enrolled {median age, 60.0 years [interquartile range (IQR), 51–68 years]; 354 (44.8%) men}, with complete follow-up data available. AIS was identified in 80 patients. An online web service tool (https://neuroby.shinyapps.io/dynnomapp/) was developed for stroke risk prediction, including the variables of sex, trigger, isolated symptom, nausea, history of brief dizziness, high blood pressure, finger to nose test, and tandem gait test. The model exhibited excellent discrimination with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.889 (95% CI: 0.855–0.923), compared with the ABCD2 score, nystagmus scheme, and finger to nose test [0.712 (95% CI, 0.652–0.771), 0.602 (95% CI, 0.556–0.648), and 61.7 (95% CI, 0.568–0.666) respectively]. Conclusion Our new prediction model exhibited good performance and could be useful for stroke identification in patients presenting with dizziness, vertigo, or imbalance. Further externally validation study is needed to increase the strength of our findings.
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Capturing vertigo in the emergency room: three tools to double the rate of diagnosis. J Neurol 2022; 269:294-306. [PMID: 34398269 DOI: 10.1007/s00415-021-10627-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 05/23/2021] [Accepted: 05/24/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Many patients attending the emergency room (ER) with vertigo, leave without a diagnosis. We assessed whether the three tools could improve ER diagnosis of vertigo. METHODS A prospective observational study was undertaken on 539 patients presenting to ER with vertigo. We used three tools: a structured-history and examination, nystagmus video-oculography (VOG) in all patients, additional video head-impulse testing (vHIT) for acute-vestibular-syndrome (AVS). RESULTS In the intervention-group (n = 424), case-history classified AVS in 34.9%, episodic spontaneous-vertigo (ESV 32.1%), and episodic positional-vertigo (EPV 22.6%). In AVS, we employed "Quantitative-HINTS plus" (Head-Impulse, Nystagmus and Test-of-Skew quantified by vHIT and VOG, audiometry) to identify vestibular-neuritis (VN) and stroke (41.2 and 31.1%). vHIT gain ≤ 0.72, catch-up saccade amplitude > 1.4○, saccade-frequency > 154%, and unidirectional horizontal-nystagmus, separated stroke from VN with 93.1% sensitivity and 88.5% specificity. In ESV, 66.2 and 14% were diagnosed with vestibular migraine and Meniere's Disease by using history and audiometry. Horizontal-nystagmus velocity was lower in migraine 0.4 ± 1.6○/s than Meniere's 5.7 ± 5.5○/s (p < 0.01). In EPV, benign positional vertigo (BPV) was identified in 82.3% using VOG. Paroxysmal positional-nystagmus lasting < 60 s separated BPV from non-BPV with 90% sensitivity and 100% specificity. In the control group of ER patients undergoing management-as-usual (n = 115), diagnoses included BPV (38.3%) and non-specific vertigo (41.7%). Unblinded assessors reached a final diagnosis in 90.6 and 30.4% of the intervention and control groups. Blinded assessors provided with the data gathered from each group reached a diagnosis in 86.3 and 41.1%. CONCLUSION Three tools: a structured-assessment, vHIT and VOG doubled the rate of diagnosis in the ER.
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Gerlier C, Hoarau M, Fels A, Vitaux H, Mousset C, Farhat W, Firmin M, Pouyet V, Paoli A, Chatellier G, Ganansia O. Differentiating central from peripheral causes of acute vertigo in an emergency setting with the HINTS, STANDING, and ABCD2 tests: A diagnostic cohort study. Acad Emerg Med 2021; 28:1368-1378. [PMID: 34245635 DOI: 10.1111/acem.14337] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Diagnosing stroke in dizzy patients remains a challenge in emergency medicine. The accuracy of the neuroophthalmologic examination HINTS performed by emergency physicians (EPs) is unknown. Our objective was to determine the accuracy of the HINTS examination performed by trained EPs for diagnosing central cause of acute vertigo and unsteadiness and to compare it with another bedside clinical tool, STANDING, and with the history-based score ABCD2. METHODS This was a prospective diagnostic cohort study among patients with isolated vertigo and unsteadiness seen in a single emergency department (ED). Trained EPs performed HINTS and STANDING tests blinded to attending physicians. ABCD2 ≥ 4 was used as the threshold and was calculated retrospectively. The criterion standard was diffusion-weighted brain magnetic resonance imaging (MRI). Peripheral diagnoses were established by a normal MRI, and etiologies were further refined by an otologic examination. RESULTS We included 300 patients of whom 62 had a central lesion on neuroimaging including 49 strokes (79%). Of the 238 peripheral diagnoses, 159 were vestibulopathies, mainly benign paroxysmal positional vertigo (40%). HINTS and STANDING tests reached high sensitivities at 97% and 94% and NPVs at 99% and 98%, respectively. The ABCD2 score failed to predict half of central vertigo cases and had a sensitivity of 55% and a NPV of 87%. The STANDING test was more specific and had a better positive predictive value (PPV; 75% and 49%, respectively; positive likelihood ratio [LR+] = 3.71, negative likelihood ratio [LR-] = 0.09) than the HINTS test (67% and 44%, respectively; LR+ = 2.96, LR- = 0.04). The ABCD2 score was specific (82%, LR+ = 3.04, LR- = 0.56) but had a very low PPV (44%). CONCLUSIONS In the hands of EPs, HINTS and STANDING tests outperformed ABCD2 in identifying central causes of vertigo. For diagnosing peripheral disorders, the STANDING algorithm is more specific than the HINTS test. HINTS and STANDING could be useful tools saving both time and costs related to unnecessary neuroimaging use.
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Affiliation(s)
- Camille Gerlier
- Emergency Department Groupe Hospitalier Paris Saint‐Joseph Paris France
| | - Maëlle Hoarau
- Emergency Department Groupe Hospitalier Paris Saint‐Joseph Paris France
| | - Audrey Fels
- Clinical Research Center Groupe Hospitalier Paris Saint‐Joseph Paris France
| | - Hélène Vitaux
- Department of Otolaryngology Groupe Hospitalier Paris Saint‐Joseph Paris France
| | - Carole Mousset
- Department of Otolaryngology Groupe Hospitalier Paris Saint‐Joseph Paris France
| | - Wassim Farhat
- Departments of Neurology Groupe Hospitalier Paris Saint‐Joseph Paris France
| | - Marine Firmin
- Emergency Department Groupe Hospitalier Paris Saint‐Joseph Paris France
| | - Victorine Pouyet
- Emergency Department Groupe Hospitalier Paris Saint‐Joseph Paris France
| | - Audrey Paoli
- Emergency Department Groupe Hospitalier Paris Saint‐Joseph Paris France
| | - Gilles Chatellier
- Faculté de Paris INSERM CIC 14‐18Hôpital Européen Georges Pompidou Paris France
| | - Olivier Ganansia
- Emergency Department Groupe Hospitalier Paris Saint‐Joseph Paris France
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Pohl M, Hesszenberger D, Kapus K, Meszaros J, Feher A, Varadi I, Pusch G, Fejes E, Tibold A, Feher G. Ischemic stroke mimics: A comprehensive review. J Clin Neurosci 2021; 93:174-182. [PMID: 34656244 DOI: 10.1016/j.jocn.2021.09.025] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/01/2021] [Accepted: 09/12/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Ischemic stroke is the leading cause of disability and one of the leading causes of death. Ischemic stroke mimics (SMs) can account for a noteble number of diagnosed acute strokes and even can be thrombolyzed. METHODS The aim of our comprehensive review was to summarize the findings of different studies focusing on the prevalence, type, risk factors, presenting symptoms, and outcome of SMs in stroke/thrombolysis situations. RESULTS Overall, 61 studies were selected with 62.664 participants. Ischemic stroke mimic rate was 24.8% (15044/60703). Most common types included peripheral vestibular dysfunction in 23.2%, toxic/metabolic in 13.2%, seizure in 13%, functional disorder in 9.7% and migraine in 7.76%. Ischemic stroke mimic have less vascular risk factors, younger age, female predominance, lower (nearly normal) blood pressure, no or less severe symptoms compared to ischemic stroke patients (p < 0.05 in all cases). 61.7% of ischemic stroke patients were thrombolysed vs. 26.3% among SMs (p < 0.001). (p < 0.001). Overall intracranial hemorrhage was reported in 9.4% of stroke vs. 0.7% in SM patients (p < 0.001). Death occurred in 11.3% of stroke vs 1.9% of SM patients (p < 0.001). Excellent outcome was (mRS 0-1) was reported in 41.8% ischemic stroke patients vs. 68.9% SMs (p < 0.001). Apart from HINTS manouvre or Hoover sign there is no specific method in the identification of mimics. MRI DWI or perfusion imaging have a role in the setup of differential diagnosis, but merit further investigation. CONCLUSION Our article is among the first complex reviews focusing on ischemic stroke mimics. Although it underscores the safety of thrombolysis in this situation, but also draws attention to the need of patient evaluation by physicians experienced in the diagnosis of both ischemic stroke and SMs, especially in vertigo, headache, seizure and conversional disorders.
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Affiliation(s)
- Marietta Pohl
- Centre for Occupational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | | | - Krisztian Kapus
- Centre for Occupational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Janos Meszaros
- Centre for Occupational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | | | - Imre Varadi
- Centre for Occupational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | | | | | - Antal Tibold
- Centre for Occupational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Gergely Feher
- Centre for Occupational Medicine, Medical School, University of Pécs, Pécs, Hungary; Neurology Outpatient Clinic, EÜ-MED KFT, Komló, Hungary.
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Zhu Y, Wang Z, Liberman AL, Chang TP, Newman-Toker D. Statistical insights for crude-rate-based operational measures of misdiagnosis-related harms. Stat Med 2021; 40:4430-4441. [PMID: 34115418 PMCID: PMC8365112 DOI: 10.1002/sim.9039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 03/31/2021] [Accepted: 05/01/2021] [Indexed: 11/28/2022]
Abstract
In longitudinal event data, a crude rate is a simple quantification of the event rate, defined as the number of events during an evaluation window, divided by the at-risk population size at the beginning or mid-time point of that window. The crude rate recently received revitalizing interest from medical researchers who aimed to improve measurement of misdiagnosis-related harms using administrative or billing data by tracking unexpected adverse events following a "benign" diagnosis. The simplicity of these measures makes them attractive for implementation and routine operational monitoring at hospital or health system level. However, relevant statistical inference procedures have not been systematically summarized. Moreover, it is unclear to what extent the temporal changes of the at-risk population size would bias analyses and affect important conclusions concerning misdiagnosis-related harms. In this article, we present statistical inference tools for using crude-rate based harm measures, as well as formulas and simulation results that quantify the deviation of such measures from those based on the more sophisticated Nelson-Aalen estimator. Moreover, we present results for a generalized multibin version of the crude rate, for which the usual crude rate is a single-bin special case. The generalized multibin crude rate is more straightforward to compute than the Nelson-Aalen estimator and can reduce potential biases of the single-bin crude rate. For studies that seek to use multibin measures, we provide simulations to guide the choice regarding number of bins. We further bolster these results using a worked example of stroke after "benign" dizziness from a large data set.
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Affiliation(s)
- Yuxin Zhu
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Zheyu Wang
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ava L. Liberman
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Tzu-Pu Chang
- Department of Neurology/Neuro-Medical Scientific Center, Taichung Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Taichung, Taiwan
- Department of Neurology, School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - David Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, Maryland
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Lin HC, Xirasagar S, Wang CH, Cheng YF, Liu TC, Yang TH. A Nationwide Population-Based Study on the Association between Land Transport Accident and Peripheral Vestibular Disorders. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18126570. [PMID: 34207241 PMCID: PMC8296321 DOI: 10.3390/ijerph18126570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/02/2021] [Accepted: 06/10/2021] [Indexed: 12/14/2022]
Abstract
This case–control study aimed to investigate the association of peripheral vestibular disorders (PVD) with subsequent land transport accidents. Data for this study were obtained from Taiwan’s National Health Insurance (NHI) dataset. We retrieved 8704 subjects who were newly found to have land transport accidents as cases. Their diagnosis date was used as their index date. Controls were identified by propensity score matching (one per case, n = 8704 controls) from the NHI dataset with their index date being the date of their first health service claim in 2017. Multiple logistic regressions were performed to calculate the prior PVD odds ratio of cases vs. controls. We found that 2.36% of the sampled patients had been diagnosed with PVD before the index date, 3.37% among cases and 1.36% among controls. Chi-square test revealed that there was a significant association between land transport accident and PVD (p < 0.001). Furthermore, multiple logistic regression analysis suggested that cases were more likely to have had a prior PVD diagnosis when compared to controls (OR = 2.533; 95% CI = 2.041–3.143; p < 0.001). After adjusting for age, gender, hypertension, diabetes, coronary heart disease, and hyperlipidemia, cases had a greater tendency to have a prior diagnosis of PVD than controls (OR = 3.001, 95% CI = 2.410–3.741, p < 0.001). We conclude that patients with PVD are at twofold higher odds for land transport accidents.
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Affiliation(s)
- Herng-Ching Lin
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei 110, Taiwan;
- Sleep Research Center, Taipei Medical University Hospital, Taipei 110, Taiwan
| | - Sudha Xirasagar
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC 29210, USA;
| | - Chia-Hui Wang
- Department of Urban Development, University of Taipei, Taipei 110, Taiwan;
- Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan;
| | - Yen-Fu Cheng
- Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan;
- Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei 112, Taiwan
- Department of Speech, Language and Audiology, National Taipei University of Nursing and Health, Taipei 112, Taiwan
| | - Tsai-Ching Liu
- Department of Public Finance, Public Finance and Finance Research Center, National Taipei University, New Taipei City 237, Taiwan;
| | - Tzong-Hann Yang
- Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei 110, Taiwan;
- Department of Otorhinolaryngology, Taipei City Hospital, Taipei 110, Taiwan
- Correspondence:
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Wang Y, Zhou X, Luo Y. Predicting value of fibrinogen in identifying cerebrovascular ischemic events in patients with dizziness/vertigo. Neurol Sci 2021; 43:1105-1113. [PMID: 34131814 DOI: 10.1007/s10072-021-05363-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/28/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Dizziness and vertigo are caused by multiple etiologies, including cerebrovascular ischemic events. However, identifying cerebrovascular ischemic events as a cause of dizziness and vertigo remains a challenge. We tried to assess the value of fibrinogen (FIB) in identifying of cerebral ischemic event in patients with dizziness/vertigo. METHODS The study enrolled patients with dizziness/vertigo presented within 72 h in a tertiary hospital. The plasma FIB levels were measured in all participants. According to the final diagnosis, participants were divided into cerebral ischemic events group and non-cerebrovascular diseases group. Multivariate logistic regression was performed to explore the association between FIB and cerebral ischemic events. The receiver operating characteristic curve was performed, and the nomogram was constructed to evaluate the overall prediction ability of FIB in cerebral ischemic event. RESULTS A total of 298 participants were enrolled in our study, of 126 cerebral ischemic events patients. Multivariate logistic regression analysis showed that FIB was independently associated with cerebral ischemic event in patients with dizziness (OR = 1.84, 95%CI [1.15, 2.92], p = 0.010). The cut-off value of FIB in predicting cerebral ischemic event was 2.43 g/L (AUC = 0.658). The nomogram showed that higher FIB level was associated with a greater risk of cerebral ischemic event (C-index = 0.800). CONCLUSIONS Our study suggested that FIB may be a useful biochemical parameter for identifying cerebral ischemic event in patients with dizziness/vertigo.
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Affiliation(s)
- You Wang
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Yuzhong District, 1 Youyi Road, Chongqing, 400016, China
| | - Xueling Zhou
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Yuzhong District, 1 Youyi Road, Chongqing, 400016, China
| | - Yong Luo
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Yuzhong District, 1 Youyi Road, Chongqing, 400016, China.
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Zwergal A, Dieterich M. [Update on diagnosis and therapy in frequent vestibular and balance disorders]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2021; 89:211-220. [PMID: 33873210 DOI: 10.1055/a-1432-1849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The 8 most frequent vestibular disorders account for more than 70% of all presentations of vertigo, dizziness, and imbalance. In acute (and mostly non-repetitive) vestibular disorders acute unilateral vestibulopathy and vestibular stroke are most important, in episodic vestibulopathies benign paroxysmal positional vertigo (BPPV), Menière's disease and vestibular migraine, and in chronic vestibular disorders bilateral vestibulopathy/presbyvestibulopathy, functional dizziness and cerebellar dizziness. In the last decade, internationally consented diagnostic criteria and nomenclature were established for the most frequent vestibular disorders, which can be easily applied in clinical practice. The diagnostic guidelines are based on history taking (including onset, duration, course, triggers, accomanying symptoms), clinical examination, and only a few apparative tests (by videooculography and audiometry) for securing the diagnosis. Treatment of vestibular disorders includes physical training (repositioning maneuvers, multimodal balance training) and pharmacological approaches (e.g., corticosteroids, antiepileptics, antidepressants, potassium-canal-blockers, drugs enhancing neuroplasticity). For most drugs, high-level evidence from prospective controlled trials is lacking. In clinical practice, the most frequent vestibular disorders can be treated effectively, thus avoiding chronicity and secondary comorbidity (by immobility, falls or psychiatric disorders such as anxiety or depression).
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Affiliation(s)
- Andreas Zwergal
- LMU Klinikum, Neurologische Klinik und Deutsches Schwindel- und Gleichgewichtszentrum (DSGZ)
| | - Marianne Dieterich
- LMU Klinikum, Neurologische Klinik und Deutsches Schwindel- und Gleichgewichtszentrum (DSGZ)
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Steenerson KK. Acute Vestibular Syndrome. ACTA ACUST UNITED AC 2021; 27:402-419. [PMID: 34351112 DOI: 10.1212/con.0000000000000958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW This article provides a practical approach to acute vestibular syndrome while highlighting recent research advances. RECENT FINDINGS Acute vestibular syndrome is defined as sudden-onset, continuous vertigo lasting longer than 24 hours with associated nausea and vomiting, all of which are worsened with head movement. Acute vestibular syndrome is provoked by a variety of central and peripheral causes, the most common of which are vestibular neuritis and acute stroke (posterior circulation). A clinical approach focusing on timing, associated history, and ocular motor findings can improve diagnostic accuracy and is more sensitive and specific than early neuroimaging. Because of the shared neurovascular supply, both peripheral and central vestibular disorders can manifest overlapping signs previously considered solely peripheral or central, including vertical skew, nystagmus, abnormal vestibular ocular reflex, hearing loss, and gait instability. Although acute vestibular syndrome is typically benign, stroke should be considered in every person with acute vestibular syndrome because it can act as a harbinger of stroke or impending cerebellar herniation. Treatment is focused on physical therapy because the evidence is minimal for the long-term use of medication. SUMMARY The diagnosis of acute vestibular syndrome first requires the elimination of common medical causes for dizziness. Next, underlying pathology must be determined by distinguishing between the most common causes of acute vestibular syndrome: central and peripheral vestibular disorders. Central vestibular disorders are most often the result of ischemic stroke affecting the cerebellar arteries. Peripheral vestibular disorders are assumed to be caused mostly by inflammatory sources, but ischemia of the peripheral vestibular apparatus may be underappreciated. By using the HINTS Plus (Head Impulse test, Nystagmus, Test of Skew with Plus referring to hearing loss assessment) examination in addition to a comprehensive neurologic examination, strokes are unlikely to be missed. For nearly all acute vestibular disorders, vestibular physical therapy contributes to recovery.
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Dmitriew C, Regis A, Bodunde O, Lepage R, Turgeon Z, McIsaac S, Ohle R. Diagnostic Accuracy of the HINTS Exam in an Emergency Department: A Retrospective Chart Review. Acad Emerg Med 2021; 28:387-393. [PMID: 33171003 DOI: 10.1111/acem.14171] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The HINTS exam is a series of bedside ocular motor tests designed to distinguish between central and peripheral causes of dizziness in patients with continuous dizziness, nystagmus, and gait unsteadiness. Previous studies, where the HINTS exam was performed by trained specialists, have shown excellent diagnostic accuracy. Our objective was to assess the diagnostic accuracy of the HINTS exam as performed by emergency physicians on patients presenting to the emergency department (ED) with a primary complaint of vertigo or dizziness. METHODS A retrospective cohort study was performed using data from patients who presented to a tertiary care ED between September 2014 and March 2018 with a primary complaint of vertigo or dizziness. Patient characteristics of those who received the HINTS exam were assessed along with sensitivity and specificity of the test to rule out a central cause of stroke. RESULTS A total of 2,309 patients met criteria for inclusion in the study. Physician uptake of the HINTS exam was high, with 450 (19.5%) dizzy patients receiving all or part of the HINTS. A large majority of patients (96.9%) did not meet criteria for receiving the test as described in validation studies; most often this was because patients lacked documentation of nystagmus or described their symptoms as intermittent. In addition, many patients received both HINTS and Dix-Hallpike exams, which are intended for use in mutually exclusive patient populations. In no case was dizziness due to a central cause identified using the HINTS exam. CONCLUSIONS Our results suggest that despite widespread use of the HINTS exam in our ED, its diagnostic value in that setting was limited. The test was frequently used in patients who did not meet criteria to receive the HINTS exam (i.e., continuous vertigo, nystagmus, and unsteady gait). Additional training of emergency physicians may be required to improve test sensitivity and specificity.
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Affiliation(s)
- Cait Dmitriew
- From the Department of Undergraduate Medicine Northern Ontario School of Medicine Sudbury Ontario Canada
| | - Aaron Regis
- From the Department of Undergraduate Medicine Northern Ontario School of Medicine Sudbury Ontario Canada
| | - Oluwadamilola Bodunde
- From the Department of Undergraduate Medicine Northern Ontario School of Medicine Sudbury Ontario Canada
| | - Rory Lepage
- From the Department of Undergraduate Medicine Northern Ontario School of Medicine Sudbury Ontario Canada
| | - Zachary Turgeon
- From the Department of Undergraduate Medicine Northern Ontario School of Medicine Sudbury Ontario Canada
| | - Sarah McIsaac
- the Department of Critical Care Department of Anesthesia Northern Ontario School of Medicine Sudbury OntarioCanada
| | - Robert Ohle
- and the Department of Emergency Medicine Health Science North Research InstituteNorthern Ontario School of Medicine Sudbury Ontario Canada
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Abstract
PURPOSE OF REVIEW Conditions causing recurrent spontaneous episodes of dizziness or vertigo span several medical specialties, making it challenging for clinicians to gain confidence in evaluating and managing the spectrum of episodic vestibular disorders. Patients are often asymptomatic and have normal examinations at the time of evaluation. Thus, diagnosis depends heavily on eliciting key features from the history. Overreliance on symptom quality descriptions commonly leads to misdiagnosis. The goal of this article is to provide the reader with a straightforward approach to the diagnosis and management of conditions that cause episodic spontaneous dizziness. RECENT FINDINGS Consensus diagnostic criteria have been established for vestibular migraine, Ménière disease, vestibular paroxysmia, and hemodynamic orthostatic dizziness/vertigo. Vertigo has been recognized as a common symptom in vertebrobasilar ischemia, cardiogenic dizziness, and orthostatic hypotension. Treatment recommendations for vestibular migraine still lack high-quality evidence, but controlled trials are occurring. SUMMARY The evaluation should start with a detailed description of the episodes from the patient and any observers. Rather than focusing first on whether the symptom quality is most consistent with vertigo, dizziness, lightheadedness, or unsteadiness, the clinician should clarify the timing (episode frequency and duration), possible triggers or circumstances (eg, position changes, upright posture), and accompanying symptoms. History should identify any auditory symptoms, migraine features, posterior circulation ischemic symptoms, vascular risk factors, clues for anxiety, and potentially relevant medications. Carefully selected testing can help secure the diagnosis, but excessive and indiscriminate testing can lead to more confusion. Treatments for these conditions are vastly different, so an accurate diagnosis is critical.
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Yang TH, Xirasagar S, Cheng YF, Wang CH, Lin HC. Increased Risk of Injury Following a Diagnosis of Vertigo: A Population-based Study. Laryngoscope 2021; 131:1633-1638. [PMID: 33734445 DOI: 10.1002/lary.29519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 02/17/2021] [Accepted: 03/03/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND This study aimed to evaluate whether peripheral vestibular disorders (PVD) are associated with subsequent injury. METHODS Data for this follow-up study were retrieved from the Taiwan's National Health Insurance (NHI) Dataset. A total of 251,355 patients with newly diagnosed PVD during January 2015 to December 2016 was identified as the study cohort, the diagnosis date being their index date. Comparison patients were identified by propensity score-matching (one per case, n = 251,355 controls) from the remaining NHI beneficiaries in 2015 with their index date being the date of their first health service claim in 2015. We tracked each subject's claims history for 1 year from the index date to identify those who suffered an injury. Cox proportional hazards regressions were performed to calculate the injury hazard ratio of cases versus controls. RESULTS The incidence of injury during 1-year follow-up was 128.6 (95% CI = 127.6-129.5) per 1,000 person-years, 158.2 (95% CI = 156.8-159.6) and 97.5 (95% CI = 96.3-98.7) among the study and comparison cohorts, respectively. After adjusting for demographic variables, the hazard ratio (HR) for injury during 1-year was 1.663 (95% CI: 1.636-1.690) for cases relative to controls. CONCLUSIONS Patients with PVD were at a higher risk for a wide range of injuries, most of all, joint dislocation and sprain. LEVEL OF EVIDENCE 3 Laryngoscope, 131:1633-1638, 2021.
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Affiliation(s)
- Tzong-Hann Yang
- Department of Otorhinolaryngology, Taipei City Hospital, Taipei, Taiwan
- Department of Speech, Language and Audiology, National Taipei University of Nursing and Health, Taipei, Taiwan
- Department of Otorhinolaryngology, National Yang-Ming University, School of Medicine, Taipei, Taiwan
- University of Taipei, Taipei, Taiwan
- Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Sudha Xirasagar
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, U.S.A
| | - Yen-Fu Cheng
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, National Yang-Ming University, Taipei, Taiwan
- Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chia-Hui Wang
- Research Center of Sleep Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Department of Urban Development, University of Taipei, Taipei, Taiwan
| | - Herng-Ching Lin
- Sleep Research Center, Taipei Medical University Hospital, Taipei, Taiwan
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan
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Stunkel L, Sharma RA, Mackay DD, Wilson B, Van Stavern GP, Newman NJ, Biousse V. Patient Harm Due to Diagnostic Error of Neuro-Ophthalmologic Conditions. Ophthalmology 2021; 128:1356-1362. [PMID: 33713783 DOI: 10.1016/j.ophtha.2021.03.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/04/2021] [Accepted: 03/05/2021] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To prospectively examine diagnostic error of neuro-ophthalmic conditions and resultant harm at multiple sites. DESIGN Prospective, cross-sectional study. PARTICIPANTS A total of 496 consecutive adult new patients seen at 3 university-based neuro-ophthalmology clinics in the United States in 2019 to 2020. METHODS Collected data regarding demographics, prior care, referral diagnosis, final diagnosis, diagnostic testing, treatment, patient disposition, and impact of the neuro-ophthalmologic encounter. For misdiagnosed patients, we identified the cause of error using the Diagnosis Error Evaluation and Research (DEER) taxonomy tool and whether the patient experienced harm due to the misdiagnosis. MAIN OUTCOME MEASURES The primary outcome was whether patients who were misdiagnosed before neuro-ophthalmology referral experienced harm as a result of the misdiagnosis. Secondary outcomes included appropriateness of referrals, misdiagnosis rate, interventions undergone before referral, and the primary type of diagnostic error. RESULTS Referral diagnosis was incorrect in 49% of cases. A total of 26% of misdiagnosed patients experienced harm, which could have been prevented by earlier referral to neuro-ophthalmology in 97%. Patients experienced inappropriate laboratory testing, diagnostic imaging, or treatment before referral in 23%, with higher rates for patients misdiagnosed before referral (34% of patients vs. 13% with a correct referral diagnosis, P < 0.0001). Seventy-six percent of inappropriate referrals were misdiagnosed, compared with 45% of appropriate referrals (P < 0.0001). The most common reasons for referral were optic neuritis or optic neuropathy (21%), papilledema (18%), diplopia or cranial nerve palsies (16%), and unspecified vision loss (11%). The most common sources of diagnostic error were the physical examination (36%), generation of a complete differential diagnosis (24%), history taking (24%), and use or interpretation of diagnostic testing (13%). In 489 of 496 patients (99%), neuro-ophthalmology consultation (NOC) affected patient care. In 2% of cases, neuro-ophthalmology directly saved the patient's life or vision; in an additional 10%, harmful treatment was avoided or appropriate urgent referral was provided; and in an additional 48%, neuro-ophthalmology provided a diagnosis and direction to the patient's care. CONCLUSIONS Misdiagnosis of neuro-ophthalmic conditions, mismanagement before referral, and preventable harm are common. Early appropriate referral to neuro-ophthalmology may prevent patient harm.
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Affiliation(s)
- Leanne Stunkel
- Department of Ophthalmology and Visual Sciences, Washington University in St. Louis School of Medicine, St. Louis, Missouri; Department of Neurology, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | | | - Devin D Mackay
- Departments of Neurology, Ophthalmology, and Neurosurgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Bradley Wilson
- Department of Ophthalmology and Visual Sciences, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Gregory P Van Stavern
- Department of Ophthalmology and Visual Sciences, Washington University in St. Louis School of Medicine, St. Louis, Missouri; Department of Neurology, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Nancy J Newman
- Department of Ophthalmology, Emory University, Atlanta, Georgia; Department of Neurology, Emory University, Atlanta, Georgia; Department of Neurological Surgery, Emory University, Atlanta, Georgia
| | - Valérie Biousse
- Department of Ophthalmology, Emory University, Atlanta, Georgia; Department of Neurology, Emory University, Atlanta, Georgia.
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Dmitriew C, Bodunde O, Regis A, Lepage R, Turgeon Z, Johns P, McIsaac S, Ohle R. The use and misuse of the Dix-Hallpike test in the emergency department. CAN J EMERG MED 2021; 23:613-616. [PMID: 33677822 DOI: 10.1007/s43678-021-00110-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 02/12/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVES A simple bedside test, the Dix-Hallpike test (DHT), can reliably diagnose benign paroxysmal positional vertigo (BPPV) in patients with acute onset dizziness or vertigo. We evaluated patterns of DHT use by emergency physicians in patients presenting with dizziness and vertigo. Our objective was to assess the frequency and clinically appropriate use of the DHT in an emergency department. METHODS A health records review was performed using data from patients who presented to a tertiary care emergency department between September 2014 and March 2018 with a primary complaint of vertigo or dizziness. Patient records were reviewed for documentation of symptoms consistent with BPPV and DHT usage. RESULTS A total of 2309 patients met inclusion criteria. Of all dizzy patients who had complete documentation of signs and symptoms consistent with BPPV, 53% were assessed with a DHT. Of 469 patients who received a DHT, 134 (29%) of tests were done on patients who had documentation of at least one characteristic that was inconsistent with a diagnosis of BPPV. Eight patients who received a DHT were ultimately diagnosed with a central cause for their vertigo. CONCLUSIONS The DHT is both underutilized and frequently applied to patients whose symptoms are not consistent with BPPV. This may result in prolonged patient discomfort and increased resource utilization, as well as increasing the risk of misdiagnosing central vertigo.
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Affiliation(s)
- Cait Dmitriew
- Department of Undergraduate Medicine, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Oluwadamilola Bodunde
- Department of Undergraduate Medicine, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Aaron Regis
- Department of Undergraduate Medicine, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Rory Lepage
- Department of Undergraduate Medicine, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Zachary Turgeon
- Department of Undergraduate Medicine, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Peter Johns
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sarah McIsaac
- Department of Critical Care, Northern Ontario School of Medicine, Sudbury, ON, Canada.,Department of Anesthesia, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Robert Ohle
- The Department of Emergency Medicine, Health Science North Research Institute, Northern Ontario School of Medicine, 41 Ramsey Lake Rd, Sudbury, ON, P3E 5J1, Canada.
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Stunkel L, Newman-Toker DE, Newman NJ, Biousse V. Diagnostic Error of Neuro-ophthalmologic Conditions: State of the Science. J Neuroophthalmol 2021; 41:98-113. [PMID: 32826712 DOI: 10.1097/wno.0000000000001031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Diagnostic error is prevalent and costly, occurring in up to 15% of US medical encounters and affecting up to 5% of the US population. One-third of malpractice payments are related to diagnostic error. A complex and specialized diagnostic process makes neuro-ophthalmologic conditions particularly vulnerable to diagnostic error. EVIDENCE ACQUISITION English-language literature on diagnostic errors in neuro-ophthalmology and neurology was identified through electronic search of PubMed and Google Scholar and hand search. RESULTS Studies investigating diagnostic error of neuro-ophthalmologic conditions have revealed misdiagnosis rates as high as 60%-70% before evaluation by a neuro-ophthalmology specialist, resulting in unnecessary tests and treatments. Correct performance and interpretation of the physical examination, appropriate ordering and interpretation of neuroimaging tests, and generation of a differential diagnosis were identified as pitfalls in the diagnostic process. Most studies did not directly assess patient harms or financial costs of diagnostic error. CONCLUSIONS As an emerging field, diagnostic error in neuro-ophthalmology offers rich opportunities for further research and improvement of quality of care.
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Affiliation(s)
- Leanne Stunkel
- Departments of Ophthalmology and Visual Sciences (LS) and Neurology (LS), Washington University in St. Louis School of Medicine, St. Louis, Missouri; Department of Neurology (DEN-T), The Johns Hopkins University School of Medicine, Baltimore, Maryland; and Departments of Ophthalmology (NJN, VB), Neurology (NJN, VB), and Neurological Surgery (NJN), Emory University School of Medicine, Atlanta, Georgia
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Abstract
PURPOSE OF REVIEW To provide an update on diagnostic algorithms for differential diagnosis of acute vertigo and dizziness and swift identification of potentially harmful causes. RECENT FINDINGS About 25% of patients with acute vertigo and dizziness have a potentially life-threatening diagnosis, including stroke in 4-15%. Diagnostic work-up relies on the combination of symptom features (triggers, duration, history of vertigo/dizziness, accompanying symptoms) and a comprehensive vestibular, ocular motor, and balance exam. The latter includes head impulse, head-shaking nystagmus, positional nystagmus, gaze-holding, smooth pursuit, skew deviation, and Romberg's test. Recent standardized diagnostic algorithms (e.g., HINTS, TriAGe+) suggest the combination of several elements to achieve a good diagnostic accuracy in differentiation of central and peripheral vestibular causes. Neuroimaging with MRI must be applied and interpreted with caution, as small strokes are frequently overlooked, especially in the acute setting (false-negative rate of up to 50%). SUMMARY Diagnostic differentiation of acute vertigo and dizziness remains a complex task, which can be tackled by a structured clinical assessment focusing on symptom characteristics and constellations of ocular motor and vestibular findings. Specific challenges arise in cases of transient or atypical vestibular syndromes.
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Ahmadi SA, Vivar G, Navab N, Möhwald K, Maier A, Hadzhikolev H, Brandt T, Grill E, Dieterich M, Jahn K, Zwergal A. Modern machine-learning can support diagnostic differentiation of central and peripheral acute vestibular disorders. J Neurol 2020; 267:143-152. [PMID: 32529578 PMCID: PMC7718180 DOI: 10.1007/s00415-020-09931-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Diagnostic classification of central vs. peripheral etiologies in acute vestibular disorders remains a challenge in the emergency setting. Novel machine-learning methods may help to support diagnostic decisions. In the current study, we tested the performance of standard and machine-learning approaches in the classification of consecutive patients with acute central or peripheral vestibular disorders. METHODS 40 Patients with vestibular stroke (19 with and 21 without acute vestibular syndrome (AVS), defined by the presence of spontaneous nystagmus) and 68 patients with peripheral AVS due to vestibular neuritis were recruited in the emergency department, in the context of the prospective EMVERT trial (EMergency VERTigo). All patients received a standardized neuro-otological examination including videooculography and posturography in the acute symptomatic stage and an MRI within 7 days after symptom onset. Diagnostic performance of state-of-the-art scores, such as HINTS (Head Impulse, gaze-evoked Nystagmus, Test of Skew) and ABCD2 (Age, Blood, Clinical features, Duration, Diabetes), for the differentiation of vestibular stroke vs. peripheral AVS was compared to various machine-learning approaches: (i) linear logistic regression (LR), (ii) non-linear random forest (RF), (iii) artificial neural network, and (iv) geometric deep learning (Single/MultiGMC). A prospective classification was simulated by ten-fold cross-validation. We analyzed whether machine-estimated feature importances correlate with clinical experience. RESULTS Machine-learning methods (e.g., MultiGMC) outperform univariate scores, such as HINTS or ABCD2, for differentiation of all vestibular strokes vs. peripheral AVS (MultiGMC area-under-the-curve (AUC): 0.96 vs. HINTS/ABCD2 AUC: 0.71/0.58). HINTS performed similarly to MultiGMC for vestibular stroke with AVS (AUC: 0.86), but more poorly for vestibular stroke without AVS (AUC: 0.54). Machine-learning models learn to put different weights on particular features, each of which is relevant from a clinical viewpoint. Established non-linear machine-learning methods like RF and linear methods like LR are less powerful classification models (AUC: 0.89 vs. 0.62). CONCLUSIONS Established clinical scores (such as HINTS) provide a valuable baseline assessment for stroke detection in acute vestibular syndromes. In addition, machine-learning methods may have the potential to increase sensitivity and selectivity in the establishment of a correct diagnosis.
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Affiliation(s)
- Seyed-Ahmad Ahmadi
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany
- Computer Aided Medical Procedures, Technical University, Munich, Germany
| | - Gerome Vivar
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany
- Computer Aided Medical Procedures, Technical University, Munich, Germany
| | - Nassir Navab
- Computer Aided Medical Procedures, Technical University, Munich, Germany
| | - Ken Möhwald
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany
- Department of Neurology, Ludwig-Maximilians-University, Marchioninistrasse 15, 81377, Munich, Germany
| | - Andreas Maier
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany
- Department of Neurology, Ludwig-Maximilians-University, Marchioninistrasse 15, 81377, Munich, Germany
| | - Hristo Hadzhikolev
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany
- Department of Neurology, Ludwig-Maximilians-University, Marchioninistrasse 15, 81377, Munich, Germany
| | - Thomas Brandt
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany
- Clinical Neurosciences, Ludwig-Maximilians-University, Munich, Germany
| | - Eva Grill
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany
- Institute for Medical Information Processing, Ludwig-Maximilians-University, Biometry, and Epidemiology, Munich, Germany
| | - Marianne Dieterich
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany
- Department of Neurology, Ludwig-Maximilians-University, Marchioninistrasse 15, 81377, Munich, Germany
- Munich Cluster of Systems Neurology, SyNergy, Munich, Germany
| | - Klaus Jahn
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany
- Department of Neurology, Schön Klinik Bad Aibling, Munich, Germany
| | - Andreas Zwergal
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany.
- Department of Neurology, Ludwig-Maximilians-University, Marchioninistrasse 15, 81377, Munich, Germany.
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Abstract
Using an algorithmic approach to acutely dizzy patients, physicians can often confidently make a specific diagnosis that leads to correct treatment and should reduce the misdiagnosis of cerebrovascular events. Emergency clinicians should try to become familiar with an approach that exploits timing and triggers as well as some basic "rules" of nystagmus. The gait should always be tested in all patients who might be discharged. Computed tomographic scans are unreliable to exclude posterior circulation stroke presenting as dizziness, and early MRI (within the first 72 hours) also misses 10% to 20% of these cases.
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Affiliation(s)
- Kiersten L Gurley
- Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Anna Jaques Hospital, Newburyport, MA, USA.
| | - Jonathan A Edlow
- Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Kim H, Lee S, Kim J. Risk of injury after emergency department visit for acute peripheral vertigo: a matched-cohort study. Clin Exp Emerg Med 2020; 7:176-182. [PMID: 33028060 PMCID: PMC7550811 DOI: 10.15441/ceem.19.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 10/01/2019] [Indexed: 11/25/2022] Open
Abstract
Objective Peripheral vertigo is one of the most common causes of the emergency department (ED) visits. It can impair balance and might predispose patients to injuries after discharge. The purpose of this study was to determine whether peripheral vertigo is associated with an increased risk of trauma. Methods This matched-cohort study used the nationally representative dataset of de-identified claim information of 1 million randomly sampled individuals from a real Korean population, from 2002 to 2013. The exposure cohort included patients who visited EDs for new-onset peripheral vertigo without prior or concurrent injury. Each patient was randomly matched to five unexposed individuals (also without previous injury) by incidence density sampling. The primary outcome was a new injury within 1 year. The secondary outcomes were various injury subtypes. The time-dependent effect of the exposure was modeled using the extended Cox model. Age, sex, comorbidities, and household income level were included as covariates. Results A total of 776 and 3,880 individuals were included as the exposure and comparison cohorts, respectively. The risks of trunk injury and upper extremity injury were significantly higher in the exposure cohort. Extended Cox models with multivariable adjustment showed significantly increased risk for up to 1 year, with the first 1-month; 1 month to 3 months; and 3 months to 1 year hazard ratios of 5.23 (95% confidence interval [CI], 2.83–9.64); 1.50 (95% CI, 1.02–2.20); and 1.37 (95% CI, 1.11–1.68), respectively. Conclusion Patients visiting EDs for acute peripheral vertigo are at a higher risk of a new injury for up to a year.
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Affiliation(s)
- Hayoung Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sihyoung Lee
- Department of Emergency Medicine, Sejong Hospital, Bucheon, Korea
| | - Joonghee Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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43
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Li BX, Li C, Du YZ, Meng XG. Efficacy and safety of acupuncture for posterior circulation ischemic vertigo: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2020; 99:e22132. [PMID: 32925764 PMCID: PMC7489707 DOI: 10.1097/md.0000000000022132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 08/11/2020] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Posterior circulation ischemic vertigo (PCIV) is one of the most complaint symptoms in clinical, and is associated with high risk of recurrence. Current studies show that acupuncture has therapeutic effect on releasing symptom as well as improving the blood flow of posterior circulation. In this review, we aim to assess the efficacy and safety of acupuncture for PCIV. METHODS Literature of clinical randomized control trials regarding acupuncture for PCIV published before August of 2020 will be searched in databases, including 5 English databases and 4 Chinese databases. For the included studies, methodological quality will be assessed according to Cochrane Risk of Bias Tool, and evidence quality will be evaluated with Grading of Recommendations Assessment, Development and Evaluation guidelines. Data analysis will be performed using Review Manager Software. RESULTS The primary outcomes involve changes of PCIV symptoms and blood flow velocity of vertebrobasilar. The secondary outcomes include Barthel Index, National Institute of Health Stroke Scale, clinical effectiveness, and adverse reactions. CONCLUSION Based on current clinical studies, this systematic review and meta-analysis will provide evidence-based basis for the efficacy and safety of acupuncture in treating PCIV. TRIAL REGISTRATION The protocol for this review has been registered in the INPLASY network (Registration number: INPLASY202070116).
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Salehi Omran S, Parikh NS, Poisson S, Armstrong J, Merkler AE, Prabhu M, Navi BB, Riley LE, Fink ME, Kamel H. Association between Pregnancy and Cervical Artery Dissection. Ann Neurol 2020; 88:596-602. [PMID: 32525238 PMCID: PMC10001425 DOI: 10.1002/ana.25813] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 06/09/2020] [Accepted: 06/09/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE We wanted to determine whether pregnancy is associated with cervical artery dissection. METHODS We performed a case-control study using claims data from all nonfederal emergency departments and acute care hospitals in New York and Florida between 2005 and 2015. Cases were women 12-42 years of age hospitalized with cervical artery dissection, defined using validated diagnosis codes for carotid/vertebral artery dissection. Controls were women 12-42 years of age with a primary diagnosis of renal colic. Cases and controls were matched 1:1 on age, race, insurance, income, state, and visit year. The exposure variable was pregnancy, defined as labor and delivery within 90 days before or 6 months after the index visit. Logistic regression was used to compare the odds of pregnancy between cases and controls. We performed a secondary cohort-crossover study comparing the risk of cervical artery dissection during pregnancy versus the same time period 1 year later. RESULTS Pregnancy was twice as common among 826 women with cervical artery dissection compared with the 826 matched controls with renal colic (odds ratio, 2.5; 95% confidence interval [CI], 1.3-4.7). In our secondary analysis, pregnancy was associated with a higher risk of cervical artery dissection (incidence rate ratio [IRR], 2.2; 95% CI, 1.3-3.5), with the heightened risk limited to the postpartum period (IRR, 5.5; 95% CI, 2.6-11.7). INTERPRETATION Pregnancy, specifically the postpartum period, was associated with hospitalization for cervical artery dissection. Although these findings might in part reflect ascertainment bias, our results suggest that arterial dissection is one mechanism by which pregnancy can lead to stroke. ANN NEUROL 2020;88:596-602.
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Affiliation(s)
- Setareh Salehi Omran
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA.,Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Sharon Poisson
- Department of Neurology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jennifer Armstrong
- Department of Pediatrics (Neurology) and Obstetrics and Gynecology, University of Colorado Anschutz School of Medicine & Children's Hospital Colorado, Denver, CO, USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Malavika Prabhu
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Laura E Riley
- Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY, USA
| | - Matthew E Fink
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
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Zwergal A, Möhwald K, Salazar López E, Hadzhikolev H, Brandt T, Jahn K, Dieterich M. A Prospective Analysis of Lesion-Symptom Relationships in Acute Vestibular and Ocular Motor Stroke. Front Neurol 2020; 11:822. [PMID: 32849250 PMCID: PMC7424024 DOI: 10.3389/fneur.2020.00822] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/30/2020] [Indexed: 12/17/2022] Open
Abstract
Background: Diagnosing stroke as a cause of acute vertigo, dizziness, or double vision remains a challenge, because symptom characteristics can be variable. The purpose of this study was to prospectively investigate lesion-symptom relationships in patients with acute vestibular or ocular motor stroke. Methods: Three hundred and fifty one patients with acute and isolated vestibular or ocular motor symptoms of unclear etiology were enrolled in the EMVERT lesion trial. Symptom quality was assessed by the chief complaint (vertigo, dizziness, double vision), symptom intensity by the visual analog scale, functional impairment by EQ-5D-5L, and symptom duration by daily rating. Acute vestibular and ocular motor signs were registered by videooculography. A standardized MRI (DWI-/FLAIR-/T2-/T2*-/3D-T1-weighted sequences) was recorded within 7 days of symptom onset. MRIs with DWI lesions were further processed for voxel-based lesion-symptom mapping (VLSM). Results: In 47 patients, MRI depicted an acute unilateral stroke (13.4%). The chief complaints were dizziness (42.5%), vertigo (40.4%) and double vision (17.0%). Lesions in patients with vertigo or dizziness showed a large overlap in the cerebellar hemisphere. VLSM indicated that strokes in the medial cerebellar layers 7b, 8, 9 were associated with vertigo, strokes in the lateral cerebellar layer 8, crus 1, 2 with dizziness, and pontomesencephalic strokes with double vision. Symptom intensity and duration varied largely between patients. Higher symptom intensity and longer duration were associated with medial cerebellar lesions. Hemispheric lesions of the cortex were rare and presented with milder symptoms of shorter duration. Conclusions: Prospective evaluation of patients with acute vestibular or ocular motor stroke revealed that symptom quality, intensity and duration were not suited to differentiating peripheral from central etiologies. Lesions in the lateral cerebellum, thalamus, or cortex presented with unspecific, mild and transient symptoms prone to being misdiagnosed.
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Affiliation(s)
- Andreas Zwergal
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany.,German Center for Vertigo and Balance Disorders, DSGZ, LMU Munich, Munich, Germany
| | - Ken Möhwald
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany.,German Center for Vertigo and Balance Disorders, DSGZ, LMU Munich, Munich, Germany
| | - Elvira Salazar López
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany.,German Center for Vertigo and Balance Disorders, DSGZ, LMU Munich, Munich, Germany.,Department of Human Movement Science, Technical University of Munich, Munich, Germany
| | - Hristo Hadzhikolev
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany.,German Center for Vertigo and Balance Disorders, DSGZ, LMU Munich, Munich, Germany
| | - Thomas Brandt
- German Center for Vertigo and Balance Disorders, DSGZ, LMU Munich, Munich, Germany.,Clinical Neurosciences, LMU Munich, Munich, Germany
| | - Klaus Jahn
- German Center for Vertigo and Balance Disorders, DSGZ, LMU Munich, Munich, Germany.,Department of Neurology, Schön Klinik Bad Aibling, Bad Aibling, Germany
| | - Marianne Dieterich
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany.,German Center for Vertigo and Balance Disorders, DSGZ, LMU Munich, Munich, Germany.,Munich Cluster of Systems Neurology, SyNergy, Munich, Germany
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Abstract
PURPOSE OF REVIEW The current review covers recent advances in vascular vertigo in terms of diagnostic strategies, clinical/laboratory features, pathophysiology, and differential diagnosis. RECENT FINDINGS Acute strokes presenting with isolated dizziness/vertigo without other obvious symptoms or signs of central nervous system involvements may be easily mistaken as peripheral vestibulopathy. For correct diagnosis of vascular vertigo, the importance of clinical history (timing and triggers) and targeted bedside examination cannot be overemphasized. In addition to Head Impulse-Nystagmus-Test of Skew, several differential strategies have been advanced by adopting a combination of clinical history, bedside or laboratory examination, and imaging for diagnosis of vascular vertigo. Circumscribed cerebellar and brainstem lesions may cause isolated central vestibular syndromes with characteristic vestibular and ocular motor manifestations. Recognition of these findings would aid in localizing the lesions and understanding the function of each central vestibular structure. Central positional nystagmus (CPN) may mimic benign paroxysmal positional vertigo (BPPV), but additional oculomotor or neurological findings mostly permit differentiation of CPN from BPPV. SUMMARY In acute vestibular syndrome, discriminating vascular causes is still challenging especially when other central symptoms and signs are not evident. An integrated approach based on understanding of clinical features, laboratory findings, speculated mechanisms, and limitations of current diagnostic tests will lead to better clinical practice.
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Dubosh NM, Edlow JA, Goto T, Camargo CA, Hasegawa K. Missed Serious Neurologic Conditions in Emergency Department Patients Discharged With Nonspecific Diagnoses of Headache or Back Pain. Ann Emerg Med 2019; 74:549-561. [DOI: 10.1016/j.annemergmed.2019.01.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 12/08/2018] [Accepted: 01/04/2019] [Indexed: 12/30/2022]
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Kummer BR, Diaz I, Wu X, Aaroe AE, Chen ML, Iadecola C, Kamel H, Navi BB. Associations between cerebrovascular risk factors and parkinson disease. Ann Neurol 2019; 86:572-581. [PMID: 31464350 DOI: 10.1002/ana.25564] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 07/22/2019] [Accepted: 07/28/2019] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To determine whether cerebrovascular risk factors are associated with subsequent diagnoses of Parkinson disease, and whether these associations are similar in magnitude to those with subsequent diagnoses of Alzheimer disease. METHODS This was a retrospective cohort study using claims data from a 5% random sample of Medicare beneficiaries from 2008 to 2015. The exposures were stroke, atrial fibrillation, coronary disease, hyperlipidemia, hypertension, sleep apnea, diabetes mellitus, heart failure, peripheral vascular disease, chronic kidney disease, chronic obstructive pulmonary disease, valvular heart disease, tobacco use, and alcohol abuse. The primary outcome was a new diagnosis of idiopathic Parkinson disease. The secondary outcome was a new diagnosis of Alzheimer disease. Marginal structural Cox models adjusting for time-dependent confounding were used to characterize the association between exposures and outcomes. We also evaluated the association between cerebrovascular risk factors and subsequent renal colic (negative control). RESULTS Among 1,035,536 Medicare beneficiaries followed for a mean of 5.2 years, 15,531 (1.5%) participants were diagnosed with Parkinson disease and 81,974 (7.9%) were diagnosed with Alzheimer disease. Most evaluated cerebrovascular risk factors, including prior stroke (hazard ratio = 1.55; 95% confidence interval = 1.39-1.72), were associated with the subsequent diagnosis of Parkinson disease. The magnitudes of these associations were similar, but attenuated, to the associations between cerebrovascular risk factors and Alzheimer disease. Confirming the validity of our analytical model, most cerebrovascular risk factors were not associated with the subsequent diagnosis of renal colic. INTERPRETATION Cerebrovascular risk factors are associated with Parkinson disease, an effect comparable to their association with Alzheimer disease. ANN NEUROL 2019;86:572-581.
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Affiliation(s)
- Benjamin R Kummer
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Iván Diaz
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY
| | - Xian Wu
- Division of Biostatistics and Epidemiology, Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY
| | - Ashley E Aaroe
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Monica L Chen
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, and Department of Neurology, Weill Cornell Medicine, New York, NY
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49
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Abstract
PURPOSE OF REVIEW This review summarizes the recent literature on diagnostic error relevant to the practice of neuro-ophthalmology, and evaluates the potential for increased access to neuro-ophthalmology to decrease rates of diagnostic error, thereby reducing medical harm and spending on unnecessary tests and treatments. RECENT FINDINGS Despite medical advances, current research continues to show alarmingly high rates of diagnostic error. Research into diagnostic error shows that many of these errors can be traced to cognitive errors. Recent studies on diagnostic problems relevant to neuro-ophthalmology, including studies of misdiagnosis of posterior communicating artery aneurysms, idiopathic intracranial hypertension, optic neuritis, and optic nerve sheath meningiomas, have identified major causes of diagnostic error in these conditions. SUMMARY Studies on diagnostic error in neuro-ophthalmologic conditions show that prior to evaluation by a neuro-ophthalmologist, patients may undergo unnecessary tests and treatments that are costly and potentially harmful. Further research on diagnostic error will inform better utilization of neuro-ophthalmologists as a resource to decrease diagnostic error.
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Menger R, Kelly P, Fernando S, Wolf ME, Martino A. Rear Admiral (Astronaut) Alan Shepard: Ménière's disease and the race to the moon. J Neurosurg 2019; 131:304-310. [PMID: 30771763 DOI: 10.3171/2018.9.jns182522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 09/28/2018] [Indexed: 11/06/2022]
Abstract
On May 5, 1961, Alan B. Shepard Jr. piloted the Freedom 7 craft into a suborbital flight to become the first American man in space. His promising astronautical career was soon scuttled by spells of dizziness and tinnitus later diagnosed as Ménière's disease, until William F. House-considered the father of neurotology and a pioneer in surgery for vestibular schwannomas-intervened. In 1968 House implanted an endolymphatic-subarachnoid shunt, which at the time was a virtually experimental procedure. Shepard's debilitating Ménière's disease was cured, but not quite in time for him to pilot the doomed Apollo 13 mission; he was reassigned to Apollo 14 and as a result would step foot on the moon on February 5, 1971. This historical vignette depicts the tale of how the career trajectories of Shepard and House-two notable figures in their respective fields-fatefully intersected.
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Affiliation(s)
- Richard Menger
- 1Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | | | - Shanik Fernando
- 3Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael E Wolf
- 4Department of Occupational and Environmental Medicine, Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- 5US Navy, Airborne Command, Control, and Logistics Wing, Point Mugu, California; and
| | - Anthony Martino
- 6Department of Neurosurgery, University of South Alabama, Mobile, Alabama
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