A New Diagnostic Approach to the Adult Patient with Acute Dizziness

ACR Appropriateness Criteria® Dizziness and Ataxia: 2023 Update

Diagnostic evaluation of a patient with dizziness or vertigo is complicated by a lack of standardized nomenclature, significant overlap in symptom descriptions, and the subjective nature of the patient's symptoms. Although dizziness is an imprecise term often used by patients to describe a feeling of being off-balance, in many cases dizziness can be subcategorized based on symptomatology as vertigo (false sense of motion or spinning), disequilibrium (imbalance with gait instability), presyncope (nearly fainting or blacking out), or lightheadedness (nonspecific). As such, current diagnostic paradigms focus on timing, triggers, and associated symptoms rather than subjective descriptions of dizziness type. Regardless, these factors complicate the selection of appropriate diagnostic imaging in patients presenting with dizziness or vertigo. This document serves to aid providers in this selection by using a framework of definable clinical variants. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Diagnosing Emergencies in Undifferentiated Acute Vertigo

Background: Patients with undifferentiated acute dizziness usually report with rapid onset of severe, often disabling illusion of movement with many other features. This accounts for roughly 50 to 100 million visits globally in emergencies annually. The causes may be numerous. Thus, the perplexed clinician needs to pursue advanced diagnostic imaging and unnecessary hospital admission in these patients. Aims and objectives: This study aims to assess the validity of HINTS Plus (head impulse test-nystagmus-test of skew + hearing assessment) test in diagnosing central causes of vertigo in patients with acute undifferentiated vertigo presenting within 72 h of onset of symptoms. The other objectives are to understand epidemiology and describe the assessment and management of these patients. Method: The data of 82 patients who visited the clinic within 72 h of the onset of symptoms as mentioned earlier during two years from August 2021 to 2023 at Ankush Hospital was stratified and analyzed. The outcome is reported here. Results: Among 82 patients, peripheral vestibular cause accounts for 84%. 12% were due to ischemic stroke and cardiovascular reasons. The sensitivity of HINTS Plus in isolating central acute vestibular vertigo was 100%, and the specificity was 95.6%. Conclusion: The risk for central and cerebrovascular causes of dizziness increases in the elderly with the presence of neurological signs and other comorbidities. The sensitivity and specificity of HINTS plus (4 Components) is very high in identifying central causes of undifferentiated acute vestibular in the first 72 h of onset of symptoms when undertaken by a trained clinician.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-024-04493-2.

Characteristics and risk of stroke in emergency department patients with acute dizziness

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.

Recognizing Posterior Circulation Transient Ischemic Attacks Presenting as Episodic Isolated Dizziness

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.

Similarities between explaining dizziness and explaining pain? Exploring common patient experiences, theoretical models, treatment approaches and potential therapeutic narratives for persistent dizziness or pain

Pain and dizziness are common experiences throughout the lifespan. However, nearly a quarter of those with acute pain or dizziness experience persistence, which is associated with disability, social isolation, psychological distress, decreased independence, and poorer quality of life. Thus, persistent pain or dizziness impacts peoples' lives in similarly negative ways. Conceptual models of pain and dizziness also have many similarities. Many of these models are more expansive than explaining mere symptoms; rather they describe pain or dizziness as holistic experiences that are influenced by biopsychosocial and contextual factors. These experiences also appear to be associated with multi-modal bodily responses related to evaluation of safety, threat detection and anticipation, as influenced by expectations, and predictions anticipation, not simply a reflection of tissue injury or pathology. Conceptual models also characterize the body as adaptable and therefore capable of recovery. These concepts may provide useful therapeutic narratives to facilitate understanding, dethreaten the experience, and provide hope for patients. In addition, therapeutic alliance, promoting an active movement-based approach, building self-efficacy, and condition-specific approaches can help optimize outcomes. In conclusion, there are significant overlaps in the patient experience, theoretical models and potential therapeutic narratives that guide care for people suffering with persistent pain or dizziness.

Neurotological emergencies: a narrative review

INTRODUCTION

Vestibular symptoms, including vertigo, dizziness, and gait unsteadiness, are a frequent reason of urgent medical assistance. Their causes are numerous and diverse, including neurological, otorhinolaryngological, and systemic diseases. Therefore, following a systematic approach is essential to differentiate striking but benign conditions from others that can compromise the patient's life. This study is intended to review vestibular disorders from a practical perspective and provide guidance to physicians involved in the emergency care of patients with vestibular symptoms.

MATERIALS AND METHODS

A narrative review was performed, revisiting the main causes of vestibular disorders.

RESULTS

Based on the speed of onset, duration, and history of similar episodes in the past, vestibular disorders can be categorized into three syndromic entities (acute, recurrent, and chronic vestibular syndromes). The most representative conditions pertaining to each group were reviewed (including their diagnosis and treatment) and a practical algorithm was proposed for their correct management in the acute care setting.

CONCLUSIONS

Carrying out a correct categorization of the vestibular disorders is essential to avoid diagnostic pitfalls. This review provides useful tools for clinicians to approach their patients with vestibular symptoms at the emergency room.

Pearls for the Emergency Clinician: Posterior Circulation Stroke

BACKGROUND

Posterior circulation (PC) stroke in adults is a rare, frequently misdiagnosed, serious condition that carries a high rate of morbidity.

OBJECTIVE OF THE REVIEW

This review evaluates the presentation, diagnosis, and management of PC stroke in the emergency department (ED) based on current evidence.

DISCUSSION

PC stroke presents most commonly with dizziness or vertigo and must be distinguished from more benign diagnoses. Emergency clinicians should consider this condition in patients with dizziness, even in younger patients and those who do not have traditional stroke risk factors. Neurologic examination for focal neurologic deficit, dysmetria, dysarthria, ataxia, and truncal ataxia is essential, as is the differentiation of acute vestibular syndrome vs. spontaneous episodic vestibular syndrome vs. triggered episodic vestibular syndrome. The HINTS (head impulse, nystagmus, and test of skew) examination can be useful for identifying dizziness presentations concerning for stroke when performed by those with appropriate training. However, it should only be used in patients with continuous dizziness who have ongoing nystagmus. Contrast tomography (CT), CT angiography, and CT perfusion have limited sensitivity for identifying PC strokes, and although magnetic resonance imaging is the gold standard, it may miss some PC strokes early in their course. Thrombolysis is recommended in patients presenting within the appropriate time window for thrombolytic therapy, and although some data suggest endovascular therapy for basilar artery and posterior cerebral artery infarcts is beneficial, its applicability for all PC strokes remains to be determined.

CONCLUSIONS

An understanding of PC stroke can assist emergency clinicians in diagnosing and managing this disease.

How a Subclinical Unilateral Vestibular Signal Improves Binocular Vision

The present study aimed to determine if an infra-liminal asymmetric vestibular signal could account for some of the visual complaints commonly encountered in chronic vestibular patients. We used infra-liminal galvanic vestibular stimulation (GVS) to investigate its potential effects on visuo-oculomotor behavior. A total of 78 healthy volunteers, 34 aged from 20 to 25 years old and 44 aged from 40 to 60 years old, were included in a crossover study to assess the impact of infra-liminal stimulation on convergence, divergence, proximal convergence point, and stereopsis. Under GVS stimulation, a repeated measures ANOVA showed a significant variation in near convergence (p < 0.001), far convergence (p < 0.001), and far divergence (p = 0.052). We also observed an unexpected effect of instantaneous blocking of the retest effect on the far divergence measurement. Further investigations are necessary to establish causal relationships, but GVS could be considered a behavioral modulator in non-pharmacological vestibular therapies.

Is Biofeedback for Vertigo Effective in Ordinary Medical Centers? A Controlled Trial in Northern Italy

The aim of this study was to assess the therapeutic effectiveness of biofeedback, in a medical center's routine for treating vestibular disorders, reducing emotional, functional, and physical disability at three-month follow-up. A total of 197 outpatients were recruited from a medical center to treat vestibular disorders. Patients in the control group received treatment as usual, consisting of one monthly visit with an otolaryngologist and pharmacological treatment specific for vertigo, while the experimental group attended biofeedback training. Patients in the experimental group received pharmacological therapy only in the phase before the start of biofeedback in order to stabilize the acute phase. During the three-month follow-up, the experimental group did not receive any booster sessions of biofeedback. At three-month follow-up there was a statistically significant difference between the groups, both in the mean total score of the dizziness handicap inventory and in the three subscales: physical, emotional, and functional. Moreover, the biofeedback group had reduced psycho-physiological parameters for all average values at three-month follow-up compared to the baseline. This is one of few studies assessing the effectiveness of biofeedback in a naturalistic setting for vestibular disorder treatment. The data confirmed that biofeedback can impact illness course, in terms of self-perceived disability reduction, assessed on emotional, functional, and physical aspects of daily living.

Lyrical Trends: An Analysis of Music's (Mis) Use of Vertigo

BACKGROUND

Popular culture and music have long served as windows into the common attitudes, trends, and issues of the time. The representation of vertigo in music has not been previously explored. The objective of this study was to analyze the portrayal of vertigo in music through content and sentiment analysis of song lyrics.

METHODS

A large song lyric database was queried to identify English language song titles containing the word "vertigo." A sentiment and content analysis of the lyrics was performed to delineate the most frequently used words, the accuracy of vertigo depictions, and emotional valence (i.e., the ratio of positive to negative references to vertigo).

RESULTS

Between 1969 and 2022, there were a total of 54 songs specifically titled "Vertigo." Most songs (73%) portrayed vertigo negatively, and the prevalence of negative sentiment within music increased with each decade. The three most common words being used in association with vertigo within music were "feel" (n = 97), "love" (n = 66), and "falling" (n = 57). In early decades, songs using the word vertigo misrepresented the condition and associated perceptions relative to common medical understanding. In more recent decades, vertigo was used in a way more representative of medical interpretations.

CONCLUSION

The depiction of vertigo in songs has changed over time, and more recently, usage has reflected Bárány Society definitions. Interestingly, the negative sentiment has also increased with time. This work provides a lyrical analysis of vertigo that may improve physician understanding of the cultural usage of this challenging symptom.

Triggered episodic vestibular syndrome and transient loss of consciousness due to a retrostyloidal vagal schwannoma: a case report

Background

Various conditions may trigger episodic vertigo or dizziness, with positional changes being the most frequently identified condition. In this study, we describe a rare case of triggered episodic vestibular syndrome (EVS) accompanied by transient loss of consciousness (TLOC) linked to retrostyloidal vagal schwannoma.

Case description

A 27-year woman with known vestibular migraine presented with a 19-month history of nausea, dysphagia, and odynophagia triggered by swallowing food and followed by recurrent TLOC. These symptoms occurred independently of her body position, resulting in a weight loss of 10 kg within 1 year and in an inability to work. An extensive cardiologic diagnostic work-up undertaken before she presented to the neurologic department was normal. On the fiberoptic endoscopic evaluation of swallowing, she showed a decreased sensitivity, a slight bulging of the right lateral pharyngeal wall, and a pathological pharyngeal squeeze maneuver without any further functional deficits. Quantitative vestibular testing revealed an intact peripheral-vestibular function, and electroencephalography was read as normal. On the brain MRI, a 16 x 15 x 12 mm lesion in the right retrostyloidal space suspicious of a vagal schwannoma was detected. Radiosurgery was preferred over surgical resection, as resection of tumors in the retrostyloid space bears the risk of intraoperative complications and may result in significant morbidity. A single radiosurgical procedure (stereotactic CyberKnife radiosurgery, 1 x 13Gy) accompanied by oral steroids was performed. On follow-up, a cessation of (pre)syncopes was noted 6 months after treatment. Only residual infrequent episodes of mild nausea were triggered by swallowing solid food remained. Brain MRI after 6 months demonstrated no progression of the lesion. In contrast, migraine headaches associated with dizziness remained frequent.

Discussion

Distinguishing triggered and spontaneous EVS is important, and identifying specific triggers by structured history-taking is essential. Episodes being elicited by swallowing solid foods and accompanied by (near) TLOC should initiate a thorough search for vagal schwannoma, as symptoms are often disabling, and targeted treatment is available. In the case presented here, cessation of (pre)syncopes and significant reduction of nausea triggered by swallowing was noted with a 6-month delay, illustrating the advantages (no surgical complications) and disadvantages (delayed treatment response) of first-line radiotherapy in vagal schwannoma treatment.

Major radiological outcomes of CTA head and neck performed for dizziness in a major academic Emergency Department

Purpose: Routine head and neck CTAs (CTAhead+neck) performed for dizziness in the Emergency Department (ED) has steadily increased, but its clinical utility is still poorly elucidated. Our purpose was to assess the radiologic outcomes of CTAhead+neck in ED dizziness patients.Methods: ED dizziness patients with CTAhead+neck from January 2010 through November 2019 were retrospectively identified and further stratified into central vertigo (CV), peripheral vertigo (PV), and non-specific dizziness (NSD) groups by final clinical diagnoses. Findings on CTAhead+neck (vessel stenosis >50%, occlusion, dissection, and infarct), and infarct on subsequent MRI if performed, were assessed. Differences in imaging findings were analyzed using chi-square or Fisher's exact tests.Results: Of 867 dizziness patients, 88 were diagnosed with CV, 383 with PV, and 396 with NSD. On CTAhead+neck, 11.4% of all patients had posterior CTA findings, including posterior occlusions (4.2%), dissections (1.2%), and infarcts (2.3%). CV patients had more posterior circulation findings (31.8%) versus PV (9.9%) and NSD (8.3%) patients (both p < 0.01). 21.6% of CV patients had acute infarcts on CT versus none for PV and 0.03% for NSD patients (both p < 0.01). On MRI, 46.6% of CV patients had acute posterior circulation infarcts versus none for PV and 0.3% for NSD patients (p < 0.01).Conclusion: Diagnostic yield for CTAhead+neck for dizziness patients is low except in central vertigo patients which constitute only 1/10th of CTAs performed. Our single institution results support that CTAhead+neck is likely low-yield in patients with high clinical suspicion for PV or NSD and further studies are needed to test this hypothesis.

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department

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").

EVESTA: Emergency VESTibular Algorithm and its impact on the acute management of benign paroxysmal positional vertigo

OBJECTIVE

To synthesise evidence-based research concerning the assessment and management of acute dizziness via construction of a comprehensive clinical algorithm. Assess its clinical impact with an aim to improve the acute management of benign paroxysmal positional vertigo (BPPV) within Wyong Public Hospital ED in four key recommendations.

METHOD

Current best practice models of care were synthesised into a single clinical, district-based peer-reviewed algorithm by a specialist focus group. An observational pre- and post-implementation study was completed to assess the impact of the algorithm on the management of BPPV. A total of 162 notes (pre [control] n = 87 and post [intervention] n = 75) met the inclusion criteria. Adherence to the BPPV clinical practice guidelines statements 1a, 3a, 4a and 6 were analysed for statistical difference in practice between the two groups.

RESULTS

Following implementation of the Emergency VESTibular Algorithm (EVESTA), compliance showed a significant improvement in Hallpike-Dix performed by 27% (95% confidence interval [CI] 14-40%; defects pre-intervention 40%: post-intervention 13%) (P < 0.001), utilisation of neuroimaging reduced by 16% (95% CI 2-30%; 40%: 24%) (P < 0.05), repositioning techniques performed increased by 33% (95% CI 18-48%; 68%: 36%) (P < 0.001). Administration of vestibular suppressant medication reduced by 30% (95% CI 15-45%; 59%: 29%) (P < 0.001). An interrupted time series analysis confirmed significant change in BPPV admissions post-project -4.23% (95% CI -7.20, -1.27%) (P = 0.041).

CONCLUSION

Diagnosis and management of acute dizziness is challenging within the ED. Synthesis of best practice into a clinical algorithm has improved the diagnosis and evidence-based treatment of BPPV. There is continued opportunity to improve the efficiency and effectiveness in the management of both central and peripheral acute dizziness within the ED.

Vestibular syndromes, diagnosis and diagnostic errors in patients with dizziness presenting to the emergency department: a cross-sectional study

OBJECTIVES

We aimed to determine the frequency of vestibular syndromes, diagnoses, diagnostic errors and resources used in patients with dizziness in the emergency department (ED).

DESIGN

Retrospective cross-sectional study.

SETTING

Tertiary referral hospital.

PARTICIPANTS

Adult patients presenting with dizziness.

PRIMARY AND SECONDARY OUTCOME MEASURES

We collected clinical data from the initial ED report from July 2015 to August 2020 and compared them with the follow-up report if available. We calculated the prevalence of vestibular syndromes and stroke prevalence in patients with dizziness. Vestibular syndromes are differentiated in acute (AVS) (eg, stroke, vestibular neuritis), episodic (EVS) (eg, benign paroxysmal positional vertigo, transient ischaemic attack) and chronic (CVS) (eg, persistent postural-perceptual dizziness) vestibular syndrome. We reported the rate of diagnostic errors using the follow-up diagnosis as the reference standard.

RESULTS

We included 1535 patients with dizziness. 19.7% (303) of the patients presented with AVS, 34.7% (533) with EVS, 4.6% (71) with CVS and 40.9% (628) with no or unclassifiable vestibular syndrome. The three most frequent diagnoses were stroke/minor stroke (10.1%, 155), benign paroxysmal positional vertigo (9.8%, 150) and vestibular neuritis (9.6%, 148). Among patients with AVS, 25.4% (77) had stroke. The cause of the dizziness remained unknown in 45.0% (692) and 18.0% received a false diagnosis. There was a follow-up in 662 cases (43.1%) and 58.2% with an initially unknown diagnoses received a final diagnosis. Overall, 69.9% of all 1535 patients with dizziness received neuroimaging (MRI 58.2%, CT 11.6%) in the ED.

CONCLUSIONS

One-fourth of patients with dizziness in the ED presented with AVS with a high prevalence (10%) of vestibular strokes. EVS was more frequent; however, the rate of undiagnosed patients with dizziness and the number of patients receiving neuroimaging were high. Almost half of them still remained without diagnosis and among those diagnosed were often misclassified. Many unclear cases of vertigo could be diagnostically clarified after a follow-up visit.

The role of vestibular cold caloric tests in the presence of spontaneous nystagmus

Objective

The bithermal caloric test is commonly used to detect a canal paresis. However, in case of spontaneous nystagmus, this procedure can provide results of non-univocal interpretation. On the other hand, confirming the presence of a unilateral vestibular deficit can help to differentiate between central and a peripheral vestibular involvement.

Methods

We studied 78 patients suffering from acute vertigo and showing spontaneous horizontal unidirectional nystagmus. All patients were submitted to bithermal caloric tests, and the results were compared with those obtained using a monothermal (cold) caloric test.

Results

We demonstrate the congruence between the bithermal and monothermal (cold) caloric test through mathematical analysis of the results of both tests in patients with acute vertigo and spontaneous nystagmus.

Conclusions

We propose to perform the caloric test in the presence of a spontaneous nystagmus using a monothermal cold assuming that the prevalence of the response to the cold irrigation on the side towards which the nystagmus beats is a sign of the presence of pathological unilateral weakness and therefore more likely peripheral in its origin.

Diagnosis of dizziness in the emergency department: A 1-year prospective single-center study

BACKGROUND

The management of dizziness and vertigo can be challenging in the emergency department (ED). It is important to rapidly diagnose vertebrobasilar stroke (VBS), as therapeutic options such as thrombolysis and anticoagulation require prompt decisions.

OBJECTIVE

This study aims to assess the rate of misdiagnosis in patients with dizziness caused by VBS in the ED.

METHODS AND RESULTS

The cohort was comprised of 66 patients with a mean age 56 years; 48% were women and 52% men. Among dizzy patients, 14% had VBS. We used Cohen's kappa test to quantify the agreement between two raters -namely, emergency physicians and neurologists -regarding the causes of dizziness in the ED. The Kappa value was 0.27 regarding the final diagnosis of central vertigo disorders and VBS, thus showing the low agreement. We used the χi2 test to show the association between the presence of two or more cardiovascular risk factors and admission to the stroke unit (p = 0.015).

CONCLUSION

There is a substantial rate of misdiagnosis in patients with dizziness caused by VBS in the ED. To reduce the number of missing diagnoses of VBS in the future, there is a need to train emergency physicians in neurovestibular examinations, including the HINTS examination for acute vestibular syndrome (AVS) and the Dix-Hallpike (DH) maneuver for episodic vestibular syndrome. Using video head impulse test could help reduce the rate of misdiagnosis of VBS in the ED.

Diagnostic accuracy of the physical examination in emergency department patients with acute vertigo or dizziness: A systematic review and meta-analysis for GRACE-3

BACKGROUND

History and physical examination are key features to narrow the differential diagnosis of central versus peripheral causes in patients presenting with acute vertigo. We conducted a systematic review and meta-analysis of the diagnostic test accuracy of physical examination findings.

METHODS

This study involved a patient-intervention-control-outcome (PICO) question: (P) adult ED patients with vertigo/dizziness; (I) presence/absence of specific physical examination findings; and (O) central (ischemic stroke, hemorrhage, others) versus peripheral etiology. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) was assessed.

RESULTS

From 6309 titles, 460 articles were retrieved, and 43 met the inclusion criteria: general neurologic examination-five studies, 869 patients, pooled sensitivity 46.8% (95% confidence interval [CI] 32.3%-61.9%, moderate certainty) and specificity 92.8% (95% CI 75.7%-98.1%, low certainty); limb weakness/hemiparesis-four studies, 893 patients, sensitivity 11.4% (95% CI 5.1%-23.6%, high) and specificity 98.5% (95% CI 97.1%-99.2%, high); truncal/gait ataxia-10 studies, 1810 patients (increasing severity of truncal ataxia had an increasing sensitivity for central etiology, sensitivity 69.7% [43.3%-87.9%, low] and specificity 83.7% [95% CI 52.1%-96.0%, low]); dysmetria signs-four studies, 1135 patients, sensitivity 24.6% (95% CI 15.6%-36.5%, high) and specificity 97.8% (94.4%-99.2%, high); head impulse test (HIT)-17 studies, 1366 patients, sensitivity 76.8% (64.4%-85.8%, low) and specificity 89.1% (95% CI 75.8%-95.6%, moderate); spontaneous nystagmus-six studies, 621 patients, sensitivity 52.3% (29.8%-74.0%, moderate) and specificity 42.0% (95% CI 15.5%-74.1%, moderate); nystagmus type-16 studies, 1366 patients (bidirectional, vertical, direction changing, or pure torsional nystagmus are consistent with a central cause of vertigo, sensitivity 50.7% [95% CI 41.1%-60.2%, moderate] and specificity 98.5% [95% CI 91.7%-99.7%, moderate]); test of skew-15 studies, 1150 patients (skew deviation is abnormal and consistent with central etiology, sensitivity was 23.7% [95% CI 15%-35.4%, moderate] and specificity 97.6% [95% CI 96%-98.6%, moderate]); HINTS (head impulse, nystagmus, test of skew)-14 studies, 1781 patients, sensitivity 92.9% (95% CI 79.1%-97.9%, high) and specificity 83.4% (95% CI 69.6%-91.7%, moderate); and HINTS+ (HINTS with hearing component)-five studies, 342 patients, sensitivity 99.0% (95% CI 73.6%-100%, high) and specificity 84.8% (95% CI 70.1%-93.0%, high).

CONCLUSIONS

Most neurologic examination findings have low sensitivity and high specificity for a central cause in patients with acute vertigo or dizziness. In acute vestibular syndrome (monophasic, continuous, persistent dizziness), HINTS and HINTS+ have high sensitivity when performed by trained clinicians.

Prevalence of stroke in acute vertigo presentations: A UK tertiary stroke centre perspective

The reported prevalence of stroke amongst patients presenting to hospital with acute vertigo and/or imbalance is c. 5%, leading to the pervasive notion amongst emergency and stroke physicians, that stroke is uncommon in this cohort. To interrogate the veracity of this notion, we systematically and retrospectively screened the electronic care records in our institution of patients referred as suspected stroke, to a hyperacute stroke service at a large tertiary referral centre. We screened 24,310 consecutive patients' electronic case records presenting to our hospital as an emergency over a 4-month period, 332 of whom were referred as suspected stroke whose case records were assessed via structured review. Of these 332 cases, 61 presented with a vestibular syndrome, i.e. having at least one of imbalance, dizziness or vertigo. Of the 61 vestibular cases, 38 (62%) were diagnosed as stroke confirmed by imaging in 25/38 or upon clinical grounds only (13/38). None of the 38 vestibular stroke cases received thrombolysis or thrombectomy treatment. In a UK urban population (2.5mn), acute vestibular syndrome cases referred to stroke services have a 50% stroke prevalence. None of the vestibular stroke cases received hyperacute stroke treatment e.g., thrombolysis, due to delay in diagnosis. The high stroke prevalence in our cohort may indicate an excessively high threshold for referring acute vestibular cases for stroke, implying a high number of missed stroke cases. We suggest that early access to vestibular neurologists in acute vestibular cases should improve the proportion of vestibular stroke cases receiving definitive stroke treatment.

Role of incubitus truncal ataxia, and equivalent standing grade 3 ataxia in the diagnosis of central acute vestibular syndrome

INTRODUCTION AND OBJECTIVES

acute vestibular syndrome is a diagnostic challenge, requiring a rapid and precise diagnosis to take therapeutic actions. Truncal ataxia, inability to sit still, and Babinski flexor dysergy were evaluated. Material anf methods: 52 patients with central pathology (stroke in aica and pica territory) and vestibular neuritis were prospectively studied. MRI of the brain was used as the gold standard.

RESULTS

A combination of grade 2-3 ataxia to differentiate patients with vestibular neuritis from patients with stroke resulted in a 92% sensitivity (95% CI 79-100%), a 67% specificity (95% CI 47-86%). Flexion asynergy had a 70% sensitivity (95% CI 47-92%), and an 88% specificity (95% CI 69-100%). The inability to sit still correlated well with truncal ataxia.

CONCLUSIONS

vestibulospinal signs are useful in the differential diagnosis of acute vestibular syndromes, and the inability to sit is a good substitute for truncal ataxia when it cannot be evaluated.

A prospective study on the application of HINTS in distinguishing the localization of acute vestibular syndrome

BACKGROUND

Acute vestibular syndrome (AVS) is a common clinical syndrome in neurology clinics and emergency department. Canonical standard for AVS diagnosis requires the presence of persistent vertigo for more than 24 h. HINTS (head impulse-nystagmus-test of skew) is an emerging scheme in the diagnosis of AVS. In this prospective study, we evaluated the specificity and sensitivity of HINTS in distinguishing between central and peripheral AVS.

METHODS

A cohort of 239 cases with complete clinical record was recruited in the study. All patients completed emergency brain CT examination to exclude hemorrhagic stroke. HINTS examination was conducted to distinguish between central AVS and peripheral AVS, and all patients completed head MRI, BAEP and vestibular function examinations within one week. Patients diagnosed as central AVS were subject to angiography (CTA/MRA/DSA), and patients with peripheral AVS were considered for a 3-month follow-up to correct the initial diagnosis.

RESULTS

Patients with central AVS were associated with an elder age, higher incidences of hypertension, atrial fibrillation, family history of stroke and previous history of stroke. Posterior circulation cerebral infarction, vestibular migraine and cerebellitis were the dominant diseases associated with central AVS. The sensitivities of HIT, GE, and TS in the diagnosis of central AVS were 73.5%, 61.2%, and 26.5%, and the specificities were 97.9%, 92.6%, and 93.2% respectively.

CONCLUSIONS

The sensitivity of HINTS for central AVS diagnosis is 89.8% and the specificity is 84.2%. HINTS is an easy-to-operate, low-cost, high-sensitivity and specific examination technique, which is practical in neurology outpatient clinics and emergency departments.

Corticosteroids for patients with vestibular neuritis: an evidence synthesis for guidelines for reasonable and appropriate care in the emergency department

BACKGROUND

A short course of corticosteroids is among the management strategies considered by specialists for the treatment of vestibular neuritis (VN). We conducted an umbrella review (systematic review of systematic reviews) to summarize the evidence of corticosteroids use for the treatment of VN.

METHODS

We included systematic reviews of randomized controlled trials (RCTs) and observational studies that evaluated the effects of corticosteroids as compared to placebo or usual care in adult patients with acute VN. Titles, abstracts, and full texts were screened in duplicate. The quality of reviews was assessed with the A MeaSurement Tool to Assess systematic Reviews (AMSTAR-2) tool. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment was used to rate certainty of evidence. No meta-analysis was performed.

RESULTS

From 149 titles, 5 systematic reviews were selected for quality assessment, and 2 reviews were of higher methodological quality and were included. These 2 reviews included 12 individual studies and 660 patients with VN. In a meta-analysis of 2 RCTs including a total of 50 patients, the use of corticosteroids (as compared to placebo) was associated with higher complete caloric recovery (risk ratio 2.81, 95% CI 1.32 to 6.00, low certainty). It is very uncertain whether this translates into clinical improvement as shown by the imprecise effect estimates for outcomes such as patient-reported vertigo or patient-reported dizziness disability. There was a wide confidence interval for the outcome of dizziness handicap score (1 study, 30 patients, 20.9 points in corticosteroids group vs 15.8 points in placebo, mean difference +5.1, 95% CI -8.09 to +18.29, very low certainty). Higher rates of minor adverse effects for those receiving corticosteroids were reported, but the certainty in this evidence was very low.

CONCLUSIONS

There is limited evidence to support the use of corticosteroids for the treatment of vestibular neuritis in the emergency department.

Health Promotion Combined with Psychological Care Improves Vestibular Function in Patients with Vestibular Neuritis

This study aimed to explore the effect of health education combined with psychological care on patients with vestibular neuritis and the effect on their vestibular function. One hundred patients with vestibular neuritis admitted to our hospital from January 2019 to December 2020 were enrolled and divided into two groups by the random number: the control group (CG) (n= 53, health education) and the study group (SG) (n= 47, health education + psychological care). The Dizziness Handicap Inventory (DHI) scores, Berg Balance Scale (BBS) scores, depression scores (SDS), anxiety scores (SAS), satisfaction with care, compliance, incidence of falls, quality of life (QOF), and clinical symptom scores were compared between the two groups. Compared with the CG, the SG had a more significant reduction in DHI scores and SDS and SAS scores and a significant increase in BBS scores ( $P<0.05$ ). Compared with the CG, the SG had higher nursing satisfaction and compliance and a lower incidence of falls ( $P<0.05$ ). Nursing efficiency was higher in the SG than in the CG ( $P<0.05$ ). QOF scores were higher in the SG than in the CG ( $P<0.05$ ). Clinical symptom scores were lower in the SG than in the CG ( $P<0.05$ ). Health education combined with psychological care can improve vestibular function and bad mood, reduce the incidence of falls, improve the QOF, and result in high patient satisfaction and compliance, which should be widely promoted.

The finger-to-nose test improved diagnosis of cerebrovascular events in patients presenting with isolated dizziness in the emergency department

It is difficult to identify patients with isolated dizziness caused by cerebrovascular events. The estimated risk of cerebrovascular events in isolated dizziness patients is not completely understood. We aimed to evaluate the association of the finger-to-nose test (FNT) in diagnosing cerebrovascular events in isolated dizziness patients in emergency departments (EDs). We combined 2 datasets from a single center for consecutive isolated dizziness patients, with the same inclusion and exclusion criteria. Those who met any of the following criteria were excluded: no FNT data, age < 16 years, and psychological trauma. The primary outcome was cerebrovascular event, which was defined as cerebral stroke due to cerebral infarction, cerebral hemorrhage, vertebral artery dissection, or transient ischemic attack. In the combined dataset, there were 357 patients complaining of isolated dizziness and 31 cerebrovascular events. After adjusted by 5 previously reported risk factors for cerebrovascular event, (age, hypertension, hyperlipidemia, diabetes mellitus, nystagmus), a multivariable logistic model analysis showed that the existence of FNT abnormalities was significantly associated with cerebrovascular events (odds ratio, 25.3; 95% confidence interval, 7.3-88.2; p < 0.001). There was a significant increase in predictive accuracy, with an AUC increase of 0.116 in the in a ROC analysis (p = 0.023). The existence of FNT abnormalities is considered as a strong risk factor that could be useful for predicting cerebrovascular events in isolated dizziness patients. We recommend the FNT for screening isolated dizziness patients in EDs to judge whether they need to undergo further diagnostic evaluation.

Diagnostic accuracy of neuroimaging in emergency department patients with acute vertigo or dizziness: A systematic review and meta-analysis for the Guidelines for Reasonable and Appropriate Care in the Emergency Department

BACKGROUND

Patients presenting to the emergency department (ED) with acute vertigo or dizziness represent a diagnostic challenge. Neuroimaging has variable indications and yield. We aimed to conduct a systematic review and meta-analysis of the diagnostic test accuracy of neuroimaging for patients presenting with acute vertigo or dizziness.

METHODS

An electronic search was designed following patient-intervention-control-outcome (PICO) question, (P) adult patients with acute vertigo or dizziness presenting to the ED; (I) Neuroimaging including Computed tomography (CT), CT Angiogram (CTA), Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiogram (MRA), and Ultrasound (US); (C) MRI/clinical gold standard; (O) central causes (stroke, hemorrhage, tumor, others) versus peripheral causes of symptoms. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) was used to assess certainty of evidence in pooled estimates.

RESULTS

We included studies that reported diagnostic test accuracy. Articles were assessed in duplicated. From 6,309 titles, 460 articles were retrieved, and 12 included. Non-contrast CT scan: 6 studies, 771 patients, pooled sensitivity 28.5% (95%CI 14.4-48.5%, moderate certainty) and specificity 98.9% (95%CI 93.4-99.8%, moderate certainty). MRI: 5 studies, 943 patients, sensitivity 79.8% (CI 71.4-86.2%, high certainty) and specificity 98.8% (CI 96.2-100%, high certainty). CTA: 1 study, 153 patients, sensitivity 14.3% (CI 1.8-42.8%) and specificity 97.7% (CI 93.8-99.6%). CT had higher sensitivity than CTA (21.4% and 14.3%) for central etiology. MRA: 1 study, 24 patients, sensitivity 60.0% (CI 26.2-87.8%) and specificity 92.9% (CI 66.1-99.8%). US: 3 studies, 258 patients, sensitivity ranged from 30-53.6%, specificity from 94.9-100%.

CONCLUSION

Non-contrast CT has very low sensitivity and MRI will miss approximately one in five patients with stroke if imaging is obtained early after symptom onset. Neuroimaging should not be used as the only tool for ruling out stroke and other central causes in patients with acute dizziness or vertigo presenting to the ED.

Benign Paroxysmal Positional Vertigo: A Practical Approach for Emergency Physicians

Benign paroxysmal positional vertigo (BPPV) is a very common condition in the population and an important cause of acute vertigo or dizziness in patients presenting to an emergency department (ED). Despite this, abundant evidence shows that current ED management of patients with BPPV is suboptimal. Common ED management processes include brain imaging and treatment with vestibular suppressant medications such as meclizine, neither of which is recommended by current guidelines. The most efficient management of BPPV is to perform a bedside test (Dix-Hallpike test) and then to treat the patients with a bedside positional (the Epley) maneuver. In this practical review we emphasize the efficient management for the most common form of BPPV-posterior canal BPPV. Using this management will reduce resource utilization (laboratory testing, brain imaging, specialist consultation), reduce ED length of stay, and reduce use of ineffective mediations that have side effects but little therapeutic effect. Application of these practices would improve important patient-centered outcomes such as symptom reduction, radiation exposure, side effects from medications, and less need for urgent follow-up with another health care provider. The article also discusses the approach to patients in whom the Dix-Hallpike and/or Epley maneuvers do not seem to work. This includes a discussion the second most common variant of BPPV (horizontal canal BPPV) and criteria for safe discharge of patients. Another important advantage of learning BPPV best practices is that it is enormously satisfying for the clinician, not unlike treating a child with a nursemaid's elbow.

The HINTS examination and STANDING algorithm in acute vestibular syndrome: A systematic review and meta-analysis involving frontline point-of-care emergency physicians

This systematic review aims to evaluate whether point-of-care emergency physicians, without special equipment, can perform the HINTS examination or STANDING algorithm to differentiate between central and non-central vertigo in acute vestibular syndrome with diagnostic accuracy and reliability comparable to more specialized physicians (neuro-ophthalmologists and neuro-otologists). Previous research has concluded that emergency physicians are unable to utilize the HINTS examination with sufficient accuracy, without providing any appropriate education or training. A comprehensive systematic search was performed using MEDLINE, Embase, the Cochrane CENTRAL register of controlled trials, Web of Science Core Collection, Scopus, Google Scholar, the World Health Organization International Clinical Trials Registry Platform, and conference programs and abstracts from six medical organizations. Of the 1,757 results, only 21 were eligible for full-text screening. Two further studies were identified by a manual search of references and an electronic search for any missed studies associated with the authors. Five studies were included in the qualitative synthesis. For the STANDING algorithm, there were two studies of 450 patients who were examined by 11 emergency physicians. Our meta-analysis showed that emergency physicians who had received prior education and training were able to utilize the STANDING algorithm with a sensitivity of 0.96 (95% confidence interval: 0.87–1.00) and a specificity of 0.88 (0.85–0.91). No data was available for the HINTS examination. When emergency physicians are educated and trained, they can use the STANDING algorithm with confidence. There is a lack of evidence regarding the HINTS examination; however, two ongoing studies seek to remedy this deficit.

Clinician's perspectives in using head impulse-nystagmus-test of skew (HINTS) for acute vestibular syndrome: UK experience

BACKGROUND

Acute vestibular syndrome (AVS) features continuous dizziness and may result from a benign inner ear disorder or stroke. The head impulse-nystagmus-test of skew (HINTS) bedside assessment is more sensitive than brain MRI in identifying stroke as the cause of AVS within the first 24 hours. Clinicians' perspectives of the test in UK secondary care remains unknown. Here, we explore front-line clinicians' perspectives of use of the HINTS for the diagnosis of AVS.

METHODS

Clinicians from two large UK hospitals who assess AVS patients completed a short online survey, newly designed with closed and open questions.

RESULTS

Almost half of 73 total responders reported limited (n=33), or no experience (n=19), reflected in low rates of use of HINTS (n=31). While recognising the potential utility of HINTS, many reported concerns about subjectivity, need for specialist skills and poor patient compliance. No clinicians reported high levels of confidence in performing HINTS, with 98% identifying training needs. A lack of formalised training was associated with onward specialist referrals and neuroimaging (p=0.044).

CONCLUSIONS

Although the low sample size in this study limits the generalisability of findings to wider sites, our preliminary data identified barriers to the application of the HINTS in AVS patients and training needs to improve rapid, cost-effective and accurate clinical diagnosis of stroke presenting with vertigo.

Identification of Stroke and TIA in Patients With Acute Dizziness, Vertigo or Imbalance in Emergency Departments of Primary Care Hospitals: Early Experiences With a Network-Based Telemedical Approach

Background

Acute dizziness, vertigo, and imbalance are frequent and difficult to interpret symptoms in the emergency department (ED). Primary care hospitals often lack the expertise to identify stroke or TIA as underlying causes. A telemedical approach based on telestroke networks may offer adequate diagnostics and treatment.

Aim

The aim of this study is to evaluate the accuracy of a novel ED algorithm in differentiating between peripheral and central vestibular causes.

Methods

Within the Telemedical Project for Integrative Stroke Care (TEMPiS), a telemedical application including a videooculography (VOG) system was introduced in 2018 in 19 primary care spoke hospitals. An ED triage algorithm was established for all patients with acute dizziness, vertigo, or imbalance of unknown cause (ADVIUC) as a leading complaint. In three predefined months, all ADVIUC cases were prospectively registered and discharge letters analyzed. Accuracy of the ED triage algorithm in differentiation between central and peripheral vestibular cases was analyzed by comparison of ED diagnoses to final discharge diagnoses. The rate of missed strokes was calculated in relation to all cases with a suitable brain imaging. Acceptance of teleconsultants and physicians in spoke hospitals was assessed by surveys.

Results

A total number of 388 ADVIUC cases were collected, with a median of 12 cases per months and hospital (IQR 8–14.5). The most frequent hospital discharge diagnoses are vestibular neuritis (22%), stroke/TIA (18%), benign paroxysmal positioning vertigo (18%), and dizziness due to internal medicine causes (15%). Detection of a central vestibular cause by the ED triage algorithm has a high sensitivity (98.6%), albeit poor specificity (45.9%). One stroke out of 32 verified by brain scan was missed (3.1%). User satisfaction, helpfulness of the project, improvement of care, personal competence, and satisfaction about handling of the VOG systems were rated consistently positive.

Discussion

The concept shows good acceptance for a telemedical and network-based approach to manage ADVIUC cases in the ED of primary care hospitals. Identification of stroke cases is accurate, while specificity needs further improvement. The concept could be a major step toward a broadly available state of the art diagnostics and therapy for patients with ADVIUC in primary care hospitals.

Sintomas vestibulares encaminhados ao otorrinolaringologista pela atenção primária da cidade do Recife

Introdução: A Atenção Primária é a “porta de entrada” do usuário ao Sistema Único de Saúde. Caso o médico tenha dificuldade em conduzir o caso, ele encaminha-o a um especialista. A otorrinolaringologia é uma das especialidades que mais recebe referências, com longo tempo de espera em nosso meio. Objetivo: Estimar a frequência das queixas de tontura e suspeita de doença vestibular nos encaminhamentos dos pacientes que aguardam consulta com otorrinolaringologista. Há poucos estudos semelhantes na literatura, e esse levantamento é importante para traçar o perfil desses pacientes e planejar ações de saúde pública. Métodos: Estudo observacional, longitudinal, descritivo, baseado na coleta de dados secundários do Sistema de Regulação da Secretaria de Saúde da Prefeitura do Recife. Foram incluídas as solicitações dos médicos da Estratégia Saúde da Família para o serviço de otorrinolaringologia em outubro-novembro de 2019, que estavam na fila de espera desde junho–julho de 2018. Resultados: A frequência dos encaminhamentos por tontura e suspeita de doença vestibular foi 22,5% de todas as solicitações para otorrinolaringologia. O tempo de espera foi um ano e quatro meses. A maioria era de mulheres (74,7%) e idosos acima de 60 anos (48,3%). Os motivos dos encaminhamentos foram: zumbido (43,2%), labirintite (20%), múltiplos sintomas (17,3%), tontura (11,6%), vertigem (3,9%), labirintopatia (3,6%) e vertigem posicional paroxística benigna (0,6%). Os sintomas aumentam com a idade. Conclusão: A taxa de encaminhamento foi compatível com a literatura. O zumbido é um sintoma muito incômodo, comum tanto nas doenças do labirinto quanto em outras patologias, por isso a alta frequência de solicitação. O termo labirintite nem sempre se refere à neuronite vestibular, mas erroneamente pode ser usado para qualquer síndrome vertiginosa, o que pode justificar a alta taxa de encaminhamento em detrimento de outras vestibulopatias. A educação continuada na Atenção Primária é importante tanto para o diagnóstico correto quanto para a solicitação apropriada da interconsulta. É preciso novas estratégias para diminuir o tempo de espera, como o aumento da oferta de serviços de especialistas, a qualificação da demanda e a otimização do sistema de regulação.

Differentiating central from peripheral causes of acute vertigo in an emergency setting with the HINTS, STANDING, and ABCD2 tests: A diagnostic cohort study

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.

Pitfalls in the Diagnosis of Posterior Circulation Stroke in the Emergency Setting

Posterior circulation stroke (PCS), caused by infarction within the vertebrobasilar arterial system, is a potentially life-threatening condition and accounts for about 20–25% of all ischemic strokes. Diagnosing PCS can be challenging due to the vast area of brain tissue supplied by the posterior circulation and, as a consequence, the wide range of—frequently non-specific—symptoms. Commonly used prehospital stroke scales and triage systems do not adequately represent signs and symptoms of PCS, which may also escape detection by cerebral imaging. All these factors may contribute to causing delay in recognition and diagnosis of PCS in the emergency context. This narrative review approaches the issue of diagnostic error in PCS from different perspectives, including anatomical and demographic considerations as well as pitfalls and problems associated with various stages of prehospital and emergency department assessment. Strategies and approaches to improve speed and accuracy of recognition and early management of PCS are outlined.

Perspectives: Evaluation of Older Adult Cochlear Implant Candidates for Fall Risk in a Developing Country Setting

Dizziness, vertigo, and falls are common in older adults. Data suggest that cochlear implant candidates are no different and could be argued to be at elevated risk due to the presence of hearing loss and likely vestibular involvement. Perspectives contextualizes current testing and screening paradigms for vestibular deficits and fall risk and suggests a protocol suitable for use in developing country settings.

Clinical Diagnosis of Central Vertigo in Patients With Dizziness in Emergency Practice

BACKGROUND

Life-threatening diseases should be promptly identified to provide appropriate medical care for emergency outpatients experiencing dizziness. However, dizziness is associated with various medical conditions; thus, a definitive diagnosis is challenging. To accurately diagnose vertigo in an emergency outpatient, we conducted a survey on the need to identify vertigo patients in the current outpatient departments.

MATERIALS AND METHODS

The participants included 509 patients who visited the outpatient department at our hospital from February 2014 to May 2017. Overall, 12 characteristics were retrospectively extracted from the patients' medical records: age, sex, visit method, medical history (diabetes, hypertension, cardiac, or cerebrovascular disease), dizziness history, vertigo characteristics, concomitant symptoms, systolic blood pressure, nystagmus, imaging history, diagnosis, and hospitalization department. Univariate and multivariate analyses were performed to identify factors related to central vertigo.

RESULTS

The diagnosis of central vertigo was confirmed when intracranial lesions were detected through imaging. In multivariate analysis, the presence/absence of a history of headache and cardiovascular disease were significantly correlated with central vertigo (P=0.002 and 0.006, respectively), with odds ratios of 5.18 and 4.38, respectively.

CONCLUSIONS

To avoid missing central dizziness in a patient, diagnostic abilities should be improved by including careful interviews and confirmation of the presence/absence of accompanying symptoms. Furthermore, collaboration with neurology and neurosurgery departments is important for improving the diagnosis in suspected cases.

Value of copeptin and S100B protein in the differential diagnosis of central vertigo and peripheral vertigo

OBJECTIVE

To investigate the usefulness of copeptin and S100B levels in the differentiation of central and peripheral vertigo.

METHODS

Ninety patients were included in the study. Copeptin and S100B levels were measured using the enzyme-linked immunosorbent assay method.

RESULTS

The time between symptom onset and presentation to the emergency department was longer in the patients diagnosed with central vertigo. S100B and copeptin levels were significantly higher in central vertigo patients. The confirmed cut-off value was 17 for the S100B level and 1.65 for the copeptin level.

CONCLUSION

Quick and reliable differentiation between central and peripheral vertigo is important to reduce the length of hospital stay of patients in the emergency department, and for patient comfort. S100B and copeptin levels are potential biomarkers in the differential diagnosis of central vertigo and peripheral vertigo for patients whose aetiology of vertigo cannot be differentially diagnosed with history-taking and physical examination.

Diagnostic Accuracy of the HINTS Exam in an Emergency Department: A Retrospective Chart Review

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.

Approach to the History and Evaluation of Vertigo and Dizziness

PURPOSE OF REVIEW

This article reviews a method of obtaining the medical history of patients presenting with dizziness, vertigo, and imbalance. By combining elements of the history with examination, the goal is to identify patterns and an effective differential diagnosis for this group of patients to help lead to an accurate diagnosis.

RECENT FINDINGS

Studies over the past dozen years have changed the historical approach to patients with dizziness from one based primarily on how the patient describes the sensation of dizziness. This older approach can lead to misdiagnosis, so a preferred method puts greater emphasis on whether the dizziness is acute or chronic, episodic or continuous, or evoked by or brought on by an event or circumstance so that a pattern may be derived that better narrows the differential diagnosis and focused examination can further narrow to a cause or causes.

SUMMARY

Dizziness is a common symptom of many possible causes. This article will help clinicians navigate gathering the history and examination to formulate a working diagnosis in patients affected by dizziness.

Episodic Spontaneous Dizziness

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.

Patient Harm Due to Diagnostic Error of Neuro-Ophthalmologic Conditions

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.

Limited usefulness of routine head and neck CT angiogram in the imaging assessment of dizziness in the emergency department

OBJECTIVE

To assess the usefulness of head and neck computed tomography angiogram for the investigation of isolated dizziness in the emergency department in detecting significant acute findings leading to a change in management in comparison to non-contrast computed tomography scan of the head.

METHODS

Patients presenting with isolated dizziness in the emergency department investigated with non-contrast computed tomography and computed tomography angiogram over the span of 36 months were included. Findings on non-contrast computed tomography were classified as related to the emergency department presentation versus unrelated/no significant abnormality. Similarly, computed tomography angiogram scans were classified as positive or negative posterior circulation findings.

RESULTS

One hundred and fifty-three patients were imaged as a result of emergency department presentation with isolated dizziness. Fourteen cases were diagnosed clinically as of central aetiology. Non-contrast computed tomography was positive in three patients, all with central causes with sensitivity 21.4%, specificity 100%, positive predictive value 100%, negative predictive value 92.6% and accuracy 92.8%. Computed tomography angiogram was positive for angiographic posterior circulation abnormalities in five cases, and only two of them had a central cause of dizziness, with sensitivity 14.3%, specificity 97.7%, positive predictive value 40%, negative predictive value 91.46% and accuracy 92.1%.

CONCLUSION

Both non-contrast computed tomography and computed tomography angiogram of the head and neck have low diagnostic yield for the detection of central causes of dizziness, However, non-contrast computed tomography has higher sensitivity and positive predictive value than computed tomography angiogram, implying a lack of diagnostic advantage from the routine use of computed tomography angiogram in the emergency department for the investigation of isolated dizziness. Further studies are required to determine the role of computed tomography angiogram in the work-up of isolated dizziness in the emergency department.

Diagnosis of Patients with Acute Dizziness

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.

Experiences of patients and physiotherapists with blended internet-based vestibular rehabilitation: a qualitative interview study

Background

Internet-based vestibular rehabilitation (VR) with physiotherapy support, known as blended VR, was effective in reducing vestibular symptoms in a recent randomised controlled trial. Blended VR is a complex intervention comprised of physiotherapeutic visits, the vertigo training website, and VR exercises. Because of these interacting components, it is important to understand how blended VR works, for whom it works best, and how it should ideally be delivered.

Aim

To investigate the experiences of both patients and physiotherapists with blended internet-based VR.

Design & setting

A qualitative interview study was performed with patients who received blended internet-based VR with physiotherapy support, and physiotherapists who provided this support.

Method

Semi-structured interviews were conducted with 14 patients and eight physiotherapists after the 6-month follow-up of the randomised trial. All interviews were audio-recorded, transcribed, and thematically analysed.

Results

According to both patients and physiotherapists, the physiotherapist visits were useful in providing personal attention, helping patients safely execute exercises, and improving patients’ adherence to therapy. Some patients said they did not need physiotherapist support and, according to physiotherapists, both the necessity and the optimal way to deliver guidance differed greatly between patients. The Vertigo Training website and exercises provided patients with a sense of control over their symptoms. Patients reported that the VR exercises were easy to perform and most patients continued to use them long after the trial ended.

Conclusion

In blended VR, physiotherapeutic visits appear to offer benefits above the vertigo training website and VR exercises alone. Physiotherapy support may best be used when individually tailored.

Treatment success of internet-based vestibular rehabilitation in general practice: development and internal validation of a prediction model

OBJECTIVES

To develop and internally validate prediction models to assess treatment success of both stand-alone and blended online vestibular rehabilitation (VR) in patients with chronic vestibular syndrome.

DESIGN

Secondary analysis of a randomised controlled trial.

SETTING

59 general practices in The Netherlands.

PARTICIPANTS

202 adults, aged 50 years and older with a chronic vestibular syndrome who received either stand-alone VR (98) or blended VR (104). Stand-alone VR consisted of a 6-week, internet-based intervention with weekly online sessions and daily exercises. In blended VR, the same intervention was supplemented with physiotherapy support.

MAIN OUTCOME MEASURES

Successful treatment was defined as: clinically relevant improvement of (1) vestibular symptoms (≥3 points improvement Vertigo Symptom Scale-Short Form); (2) vestibular-related disability (>11 points improvement Dizziness Handicap Inventory); and (3) both vestibular symptoms and vestibular-related disability. We assessed performance of the predictive models by applying calibration plots, Hosmer-Lemeshow statistics, area under the receiver operating characteristic curves (AUC) and applied internal validation.

RESULTS

Improvement of vestibular symptoms, vestibular-related disability or both was seen in 121, 81 and 64 participants, respectively. We generated predictive models for each outcome, resulting in different predictors in the final models. Calibration for all models was adequate with non-significant Hosmer-Lemeshow statistics, but the discriminative ability of the final predictive models was poor (AUC 0.54 to 0.61). None of the identified models are therefore suitable for use in daily general practice to predict treatment success of online VR.

CONCLUSION

It is difficult to predict treatment success of internet-based VR and it remains unclear who should be treated with stand-alone VR or blended VR. Because we were unable to develop a useful prediction model, the decision to offer stand-alone or blended VR should for now be based on availability, cost effectiveness and patient preference.

TRIAL REGISTRATION NUMBER

The Netherlands Trial Register NTR5712.

Cost-effectiveness of internet-based vestibular rehabilitation with and without physiotherapy support for adults aged 50 and older with a chronic vestibular syndrome in general practice

OBJECTIVES

To evaluate the cost-effectiveness of stand-alone and blended internet-based vestibular rehabilitation (VR) in comparison with usual care (UC) for chronic vestibular syndromes in general practice.

DESIGN

Economic evaluation alongside a three-armed, individually randomised controlled trial.

SETTING

59 Dutch general practices.

PARTICIPANTS

322 adults, aged 50 years and older with a chronic vestibular syndrome.

INTERVENTIONS

Stand-alone VR consisted of a 6-week, internet-based intervention with weekly online sessions and daily exercises. In blended VR, this intervention was supplemented with face-to-face physiotherapy support. UC group participants received usual general practice care without restrictions.

MAIN OUTCOME MEASURES

Societal costs, quality-adjusted life years (QALYs), Vertigo Symptom Scale-Short Form (VSS-SF), clinically relevant response (≥3 points VSS-SF improvement).

RESULTS

Mean societal costs in both the stand-alone and blended VR groups were statistically non-significantly higher than in the UC group (mean difference (MD) €504, 95% CI -1082 to 2268; and €916, 95% CI -663 to 2596). Both stand-alone and blended VR groups reported non-significantly more QALYs than the UC group (MD 0.02, 95% CI -0.00 to 0.04; and 0.01, 95% CI -0.01 to 0.03), and significantly better VSS-SF Scores (MD 3.8 points, 95% CI 1.7 to 6.0; and 3.3 points, 95% CI 1.3 to 5.2). For stand-alone VR compared with UC, the probability of cost-effectiveness was 0.95 at a willingness-to-pay ratio of €24 161/QALY, €600/point improvement in VSS-SF and €8000/clinically relevant responder in VSS-SF. For blended VR versus UC, the probability of cost-effectiveness was 0.95 at a willingness-to-pay ratio of €123 335/QALY, €900/point improvement in VSS-SF and €24 000/clinically relevant responder in VSS-SF.

CONCLUSION

Stand-alone and blended internet-based VR non-significantly increased QALYs and significantly reduced vestibular symptoms compared with UC, while costs in both groups were non-significantly higher. Stand-alone VR has the highest probability to be cost-effective compared with UC.

TRIAL REGISTRATION NUMBER

The Netherlands Trial Register NTR5712.