Medical and Nonstroke Neurologic Causes of Acute, Continuous Vestibular Symptoms

The "Vestibular Eye Sign"-"VES": a new radiological sign of vestibular neuronitis can help to determine the affected vestibule and support the diagnosis

INTRODUCTION

Nystagmus is a valuable clinical finding. Although nystagmus is often described by the direction of its quick phases, it is the slow phase that reflects the underlying disorder. The aim of our study was to describe a new radiological diagnostic sign called "Vestibular Eye Sign"-VES. This sign is defined as an eye deviation that correlates with the slow phase of nystagmus (vestibule pathological side), which is seen in acute vestibular neuronitis and can be assessed on a CT head scan.

MATERIALS AND METHODS

A total of 1250 patients were diagnosed with vertigo in the Emergency Department at Ziv Medical Center (ED) in Safed, Israel. The data of 315 patients who arrived at the ED between January 2010 and January 2022 were collected, with criteria eligible for the study. Patients were divided into 4 groups: Group A, "pure VN", Group B, "non-VN aetiology", Group C, BPPV patients, and Group D, patients who had a diagnosis of vertigo with unknown aetiology. All groups underwent head CT examination while in the ED.

RESULTS

In Group 1, pure vestibular neuritis was diagnosed in 70 (22.2%) patients. Regarding accuracy, VES (Vestibular Eye Sign) was found in 65 patients in group 1 and 8 patients in group 2 and had a sensitivity of 89%, specificity of 75% and a negative predictive value of 99.4% in group 1-pure vestibular neuronitis.

CONCLUSION

VN is still a clinical diagnosis, but if the patient undergoes head CT, we suggest using the "Vestibular Eye Sign" as a complementary sign. As per our findings, this is a valuable sign on CT imaging for diagnosing the pathological side of isolated pure VN. It is sensitive to support a diagnosis with a high negative predictive value.

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").

Acute truncal ataxia without nystagmus in patients with acute vertigo

BACKGROUND AND PURPOSE

Differentiating between peripheral and central aetiologies can be challenging in patients with acute vertigo, given substantial symptom overlap. A detailed clinical history and focused physical eye movement examination such as the HINTS eye examination appear to be the most reliable approach to identify acute cerebellar/brainstem stroke, outperforming even acute brain imaging. We have observed, however, that isolated vertigo of central cause may be accompanied by acute truncal ataxia, in the absence of nystagmus.

METHODS

We explored the frequency of ataxia without concurrent nystagmus in a cross section of patients with acute vertigo who presented to the emergency department at two centres in Argentina (Group A) and the UK (Group B). Patients underwent detailed clinical neuro-otological assessments (Groups A and B), which included instrumented head impulse testing and oculography (Group B).

RESULTS

A total of 71 patients in Group A and 24 patients in Group B were included in this study. We found acute truncal ataxia-without nystagmus-in 15% (n = 14) of our overall cohort. Lesions involved stroke syndromes affecting the posterior inferior cerebellar artery, anterior inferior cerebellar artery, and superior cerebellar artery, thalamic stroke, cerebral hemisphere stroke, multiple sclerosis, and a cerebellar tumour. Additional oculomotor deficits did not reliably identify a central cause in these individuals, even with oculography.

CONCLUSIONS

We have identified a significant subpopulation of patients with acute vertigo in whom the current standard approaches such as the HINTS examination that focus on oculomotor assessment may not be applicable, highlighting the need for a formal assessment of gait in this setting.

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.

A Neurological Appearance of Celiac Disease: Is There Any Associated Factor?

OBJECTIVE

Celiac disease may present with one or more neurological signs and/or symptoms. We aimed to define the incidence of accompanying neurological manifestations in children diagnosed as having celiac disease.

METHODS

The prospective study included 146 children diagnosed as having celiac disease. The medical records (presentation symptoms, clinical findings, serological test, duodenal biopsy results, lack/deficiency of vitamin, tissue type, accompanying autoimmune disorders) and demographic data of all patients were also reviewed.

RESULTS

Thirty-five (23.9%) of the 146 celiac patients exhibited one or more neurological findings. Headache (11.6%) and dizziness (6.1%) were the most common symptoms among neurological manifestations. There was a significant difference between the patients with and without neurological manifestations in terms of sex, biopsy result, and tissue type (P < 0.05). Moreover, there was a statistically significant difference between tissue types of the patients with and without headache (P < 0.05). We found that grade 3a by Marsh classification was the most common type among the patients with and without neurological findings in celiac disease. On neuroimaging evaluation of patients, 1 patient with chronic focal ischemic lesion, 1 patient with Chiari type 1 malformation, and 1 patient with subcortical white matter changes were identified.

CONCLUSIONS

Pathophysiology of neurological involvement in celiac disease is liable for various neurological findings. This study contributes to data suggesting that female sex, mild histopathological form, and human leukocyte antigen DQ2 heterozygosity are related to neurological manifestations, and also human leukocyte antigen DQ2 heterozygosity is associated with headache in celiac disease.

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.

Inpatient Treatment of Patients Admitted for Dizziness: A Population-Based Healthcare Research Study on Epidemiology, Diagnosis, Treatment, and Outcome

OBJECTIVE

To determine inpatient treatment rates of patients with dizziness with focus on diagnostics, treatment and outcome.

STUDY DESIGN

Retrospective population-based study.

SETTING

Inpatients in the federal state Thuringia in 2014.

PATIENTS

All 1,262 inpatients (62% females, median age: 61 yr) treated for inpatient dizziness were included.

MAIN OUTCOME MEASURES

The association between analyzed parameters and probability of improvement and recovery was tested using univariable and multivariable statistics.

RESULTS

Final diagnosis at demission was peripheral vestibular disorder (PVD), central vestibular disorder (CVD), cardiovascular syndrome, somatoform syndrome, and unclassified disease in 75, 9, 3, 0.6, and 13%, respectively. The most frequent diseases were acute vestibular neuritis (28%) and benign paroxysmal positional vertigo (22%). The follow-up time was 38 ± 98 days. 88.5% of patients showed at least an improvement of complaints and 31.4% a complete recovery. The probability for no improvement from inpatient dizziness was higher if the patient had a history of ear/vestibular disease (hazard ratio [HR] = 1.506; 95% confidence interval [CI] = 1.301-1.742), and was taking more than two drugs for comorbidity (HR = 1.163; CI = 1.032-1.310). Compared with final diagnosis of cardiovascular syndrome, patients with PVD (HR = 1.715; CI = 1.219-2.415) and CVD (HR = 1.587; CI = 1.076-2.341) had a worse outcome.

CONCLUSIONS

Inpatient treatment of dizziness was highly variable in daily practice. The population-based recovery rate was worse than reported in clinical trials. We need better ways to implement clinical trial findings for inpatients with dizziness.

Reexpression of Prior Stroke Symptoms in Adults: When is a Mimic a Mimic?

A "stroke mimic" refers to any clinical condition that causes neurological symptoms clinically indistinguishable from a cerebral lesion that affects a vascular distribution, but is not caused by ischemia. One subtype of stroke mimic, termed stroke reexpression, is a form of mimicry in which previously recovered or improved stroke symptoms recur in the setting of a neurological disturbance (seizure, hypoperfusion state) or a systemic disturbance (toxic, metabolic, infectious). Many reports of stroke reexpression exist in the literature and are well known to clinicians, but there has been no consensus regarding terminology that has been published to date. The purpose of this review is to summarize several examples of stroke reexpression and propose simple, useful criteria for this clinical condition.

A New Diagnostic Approach to the Adult Patient with Acute Dizziness

BACKGROUND

Dizziness, a common chief complaint, has an extensive differential diagnosis that includes both benign and serious conditions. Emergency physicians must distinguish the majority of patients with self-limiting conditions from those with serious illnesses that require acute treatment.

OBJECTIVE OF THE REVIEW

This article presents a new approach to diagnosis of the acutely dizzy patient that emphasizes different aspects of the history to guide a focused physical examination with the goal of differentiating benign peripheral vestibular conditions from dangerous posterior circulation strokes in the emergency department.

DISCUSSION

Currently, misdiagnoses are frequent and diagnostic testing costs are high. This relates in part to use of an outdated, prevalent, diagnostic paradigm. The traditional approach, which relies on dizziness symptom quality or type (i.e., vertigo, presyncope, or disequilibrium) to guide inquiry, does not distinguish benign from dangerous causes, and is inconsistent with current best evidence. A new approach divides patients into three key categories using timing and triggers, guiding a differential diagnosis and targeted bedside examination protocol: 1) acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke; 2) spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack; and 3) triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions.

CONCLUSIONS

The timing and triggers diagnostic approach for the acutely dizzy patient derives from current best evidence and offers the potential to reduce misdiagnosis while simultaneously decreases diagnostic test overuse, unnecessary hospitalization, and incorrect treatments.

[Not Available]

Zusammenfassung. Schwindel ist nach Kopfschmerzen eines der häufigsten Symptome, die zu einem Arztbesuch führen. Ausgehend von dieser Tatsache stellen sich ca. 25 % der Patienten mit akuten Schwindelbeschwerden in einer Notfallaufnahme vor. Die Herausforderung der betreuenden Kollegen besteht darin, ein akut zentral-vestibuläres Syndrom nicht zu übersehen, was verheerende Folgen mit sich bringen könnte. Eine sorgfältige und strukturierte Anamneseerhebung zusammen mit der klinischen Untersuchung trägt bereits zu ca. 90 % zur Diagnosestellung bei und ist sensitiver als die diffusionsgewichtete Kernspintomografie. Der Fokus der Anamnese liegt bei der Dauer der Symptome und deren Triggerfaktoren. Ein Bedside-Test, bestehend aus Kopfimpulstest, Nystagmusprüfung, Test auf Skew und zusätzliche Hörprüfung mittels Fingerreiben, hilft bei der differenzialdiagnostischen Eingrenzung im Hinblick auf die Differenzierung zwischen akutem zentralen und peripheren Schwindelsyndrom.

A New Approach to the Diagnosis of Acute Dizziness in Adult Patients

Dizziness is a common chief complaint in emergency medicine. The differential diagnosis is broad and includes serious conditions, such as stroke, cardiac arrhythmia, hypovolemic states, and acute toxic and metabolic disturbances. Emergency physicians must distinguish the majority of patients who suffer from benign self-limiting conditions from those with serious illnesses that require acute treatment. Misdiagnoses are frequent and diagnostic test costs high. The traditional approach does not distinguish benign from dangerous causes and is not consistent with best current evidence. This article presents a new approach to the diagnosis of acutely dizzy patients that highly leverages the history and the physical examination.

Using the Physical Examination to Diagnose Patients with Acute Dizziness and Vertigo

BACKGROUND

Emergency department (ED) patients who present with acute dizziness or vertigo can be challenging to diagnose. Roughly half have general medical disorders that are usually apparent from the context, associated symptoms, or initial laboratory tests. The rest include a mix of common inner ear disorders and uncommon neurologic ones, particularly vertebrobasilar strokes or posterior fossa mass lesions. In these latter cases, misdiagnosis can lead to serious adverse consequences for patients.

OBJECTIVE

Our aim was to assist emergency physicians to use the physical examination effectively to make a specific diagnosis in patients with acute dizziness or vertigo.

DISCUSSION

Recent evidence indicates that the physical examination can help physicians accurately discriminate between benign inner ear conditions and dangerous central ones, enabling correct management of peripheral vestibular disease and avoiding dangerous misdiagnoses of central ones. Patients with the acute vestibular syndrome mostly have vestibular neuritis, but some have stroke. Data suggest that focused eye movement examinations, at least when performed by specialists, are more sensitive for detecting early stroke than brain imaging, including diffusion-weighted magnetic resonance imaging. Patients with the triggered episodic vestibular syndrome mostly have benign paroxysmal positional vertigo (BPPV), but some have posterior fossa mass lesions. Specific positional tests to provoke nystagmus can confirm a BPPV diagnosis at the bedside, enabling immediate curative therapy, or indicate the need for imaging.

CONCLUSIONS

Emergency physicians can effectively use the physical examination to make a specific diagnosis in patients with acute dizziness or vertigo. They must understand the limitations of brain imaging. This may reduce misdiagnosis of serious central causes of dizziness, including posterior circulation stroke and posterior fossa mass lesions, and improve resource utilization.

Vertigo and hearing loss

Symptoms referable to disorders affecting the inner ear and vestibulocochlear nerve (eighth cranial nerve) include dizziness, vertigo, tinnitus, and hearing loss, in various combinations. Similar symptoms may occur with involvement of the central nervous system, principally the brainstem and cerebellum, to which the vestibular and auditory systems are connected. Imaging choices should be tailored to patient symptoms and the clinical context. Computed tomography (CT) should be used primarily to assess bony structures. Magnetic resonance imaging (MRI) should be used primarily to assess soft-tissue structures. Vascular imaging by angiography or venography should be obtained when vascular lesions are suspected. No imaging should be obtained in patients with typical presentations of common peripheral vestibular or auditory disorders. In current clinical practice, neuroimaging is often overused, especially CT in the assessment of acute dizziness and vertigo in the emergency department. Despite low sensitivity for ischemic strokes, CT is often used to rule out neurologic causes. When ischemic stroke is the principal concern in acute vestibular presentations, imaging should almost always be by MRI with diffusion-weighted images, rather than CT. In this chapter, we describe recommended strategies for audiovestibular imaging based on patient symptoms and signs.