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Vanni S, Vannucchi P, Pecci R, Pepe G, Paciaroni M, Pavellini A, Ronchetti M, Pelagatti L, Bartolucci M, Konze A, Castellucci A, Manfrin M, Fabbri A, de Iaco F, Casani AP. Consensus paper on the management of acute isolated vertigo in the emergency department. Intern Emerg Med 2024:10.1007/s11739-024-03664-x. [PMID: 39001977 DOI: 10.1007/s11739-024-03664-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/28/2024] [Indexed: 07/15/2024]
Abstract
Acute vertigo is defined as the perception of movement of oneself or the surroundings in the absence of actual motion and it is a frequent cause for emergency department admissions. The utilization of medical resources and the duration of hospital stay for this kind of symptom is high. Furthermore, the efficiency of brain imaging in the acute phase is low, considering the limited sensitivity of both CT and MRI for diagnosing diseases that are the causes of central type of vertigo. Relying on imaging tests can provide false reassurance in the event of negative results or prolong the in-hospital work-up improperly. On the other hand, clinical examinations, notably the assessment of nystagmus' features, have proven to be highly accurate and efficient when performed by experts. Literature data point out that emergency physicians often do not employ these skills or use them incorrectly. Several clinical algorithms have been introduced in recent years with the aim of enhancing the diagnostic accuracy of emergency physicians when evaluating this specific pathology. Both the 'HINTS and 'STANDING' algorithms have undergone external validation in emergency physician hands, showing good diagnostic accuracy. The objective of this consensus document is to provide scientific evidence supporting the clinical decisions made by physicians assessing adult patients with acute vertigo in the emergency department, particularly in cases without clear associated neurological signs. The document aims to offer a straightforward and multidisciplinary approach. At the same time, it tries to delineate benchmarks for the formulation of local diagnostic and therapeutic pathways, as well as provide a base for the development of training and research initiatives.
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Affiliation(s)
- Simone Vanni
- Dipartimento di Medicina Sperimentale e Clinica, Università degli studi di Firenze, Largo Brambilla 3, 50134, Florence, Italy.
| | | | - Rudi Pecci
- Audiologia, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Giuseppe Pepe
- Medicina Emergenza Urgenza e Pronto Soccorso, Azienda USL Toscana Nord Ovest, Ospedale Versilia, Viareggio, Italy
| | - Maurizio Paciaroni
- Medicina Interna e Cardiovascolare, Stroke Unit, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Andrea Pavellini
- Medicina e Chirurgia d'Urgenza e Accettazione, AOU-Careggi, Florence, Italy
| | - Mattia Ronchetti
- Medicina e Chirurgia d'Urgenza e Accettazione, AOU-Careggi, Florence, Italy
| | - Lorenzo Pelagatti
- Medicina e Chirurgia d'Urgenza e Accettazione, AOU-Careggi, Florence, Italy
| | - Maurizio Bartolucci
- Dipartimento di Diagnostica per Immagini, Azienda Usl Toscana Centro, Prato, Italy
| | - Angela Konze
- Neuroradiologia, Azienda USL Toscana Centro, Florence, Italy
| | - Andrea Castellucci
- Otorinolaringoiatria, Arcispedale Santa Maria Nuova, IRCCS, Reggio Emilia, Italy
| | - Marco Manfrin
- Otorinolaringoiatria, Libero Professionista, Milan, Italy
| | - Andrea Fabbri
- Pronto Soccorso e Medicina d'Urgenza, AUSL della Romagna, Ospedale Morgagni-Pierantoni, Forlì, Italy
| | - Fabio de Iaco
- Medicina d'Urgenza, Ospedale Maria Vittoria, Turin, Italy
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Martinez C, Wang Z, Zalazar G, Carmona S, Kattah J, Tarnutzer AA. Systematic Review and Meta-Analysis of the Diagnostic Accuracy of a Graded Gait and Truncal Instability Rating in Acutely Dizzy and Ataxic Patients. CEREBELLUM (LONDON, ENGLAND) 2024:10.1007/s12311-024-01718-6. [PMID: 38990511 DOI: 10.1007/s12311-024-01718-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/02/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND In patients presenting with acute prolonged vertigo and/or gait imbalance, the HINTS [Head-Impulse, Nystagmus, Test-of-Skew] are very valuable. However, their application may be limited by lack of training and absence of vertigo/nystagmus. Alternatively, a graded gait/truncal-instability (GTI, grade 0-3) rating may be applied. METHODS We performed a systematic search (MEDLINE/Embase) to identify studies reporting on the diagnostic accuracy of bedside examinations in adults with acute vestibular syndrome. Diagnostic test properties were calculated for findings using a random-effects model. Results were stratified by GTI-rating used. RESULTS We identified 6515 articles and included 18 studies (n = 1025 patients). Ischemic strokes (n = 665) and acute unilateral vestibulopathy (n = 306) were most frequent. Grade 2/3 GTI had moderate sensitivity (70.8% [95% confidence-interval (CI) = 59.3-82.3%]) and specificity (82.7 [71.6-93.8%]) for predicting a central cause, whereas grade 3 GTI had a lower sensitivity (44.0% [34.3-53.7%] and higher specificity (99.1% [98.0-100.0%]). In comparison, diagnostic accuracy of HINTS (sensitivity = 96.8% [94.8-98.8%]; specificity = 97.6% [95.3-99.9%]) was higher. When combining central nystagmus-patterns and grade 2/3 GTI, sensitivity was increased to 76.4% [71.3-81.6%] and specificity to 90.3% [84.3-96.3%], however, no random effects model could be used. Sensitivity was higher in studies using the GTI rating (grade 2/3) by Lee (2006) compared to the approach by Moon (2009) (73.8% [69.0-78.0%] vs. 57.4% [49.5-64.9%], p = 0.001). CONCLUSIONS In comparison to HINTS, the diagnostic accuracy of GTI is inferior. When combined with central nystagmus-patterns, diagnostic accuracy could be improved based on preliminary findings. GTI can be readily applied in the ED-setting and also in patients with acute imbalance syndrome.
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Affiliation(s)
| | - Zheyu Wang
- Division of Quantitative Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Guillermo Zalazar
- Hospital de San Luis, Fundación San Lucas Para La Neurociencia, Rosario, Argentina
| | - Sergio Carmona
- Fundación San Lucas Para La Neurosciencia, Rosario, Argentina
| | - Jorge Kattah
- University of Illinois College of Medicine, Peoria, IL, USA
| | - Alexander Andrea Tarnutzer
- Faculty of Medicine, University of Zurich, Zurich, Switzerland.
- Neurology, Cantonal Hospital of Baden, Baden, Switzerland.
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Jasinska-Nowacka A, Niemczyk K. Application of a Video Head Impulse Test in the Diagnosis of Vestibular Neuritis. Life (Basel) 2024; 14:757. [PMID: 38929740 PMCID: PMC11204878 DOI: 10.3390/life14060757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/08/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
In patients presenting in the emergency department with acute vertigo, a rapid and accurate differential diagnosis is crucial, as posterior circulation strokes can mimic acute vestibular losses, leading to inappropriate treatment. The diagnosis of vestibular neuritis is made based on the clinical manifestation and a bedside otoneurological assessment. In the clinical examination, an evaluation of the vestibulo-ocular reflex is the key element; however, the accuracy of the bedside head impulse test depends on the clinician's experience. Thus, new diagnostic methods are needed to objectify and facilitate such rapid vestibular evaluations. The aim of our paper is to provide a comprehensive review of the video head impulse test's application in the diagnosis of vestibular neuritis. Numerous studies have reported advantages that make this method helpful in detailed otoneurological evaluations; in contrast to the bedside head impulse test, it enables an analysis of all six semicircular canals function and records the covert corrective saccades, which are invisible to the naked eye. As a portable and easy diagnostic tool, it is known to improve the diagnostic accuracy in patients with acute vertigo presenting in the emergency department. Moreover, as it evaluates the vestibulo-ocular reflex across different frequencies, as compared to caloric tests, it can be used as an additional test that is complementary to videonystagmography. Recently, several papers have described the application of the video head impulse test in follow-up and recovery evaluations in patients with vestibular neuritis.
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Affiliation(s)
- Agnieszka Jasinska-Nowacka
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical University of Warsaw, 02-091 Warszawa, Poland;
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Hac NEF, Gold DR. Advances in diagnosis and treatment of vestibular migraine and the vestibular disorders it mimics. Neurotherapeutics 2024; 21:e00381. [PMID: 38845250 DOI: 10.1016/j.neurot.2024.e00381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 05/26/2024] [Accepted: 05/27/2024] [Indexed: 07/15/2024] Open
Abstract
Dizziness is one of the most common chief complaints in both the ambulatory care setting and the emergency department. These symptoms may be representative of a broad range of entities. Therefore, any attempt at treatment must first start with determining the etiology. In this current perspective, we focus specifically on the diagnosis of and treatment of vestibular migraine, which is common and overlaps clinically with a variety of other diagnoses. We discuss the traditional treatments for vestibular migraine in addition to the recent explosion of novel migraine therapeutics. Because vestibular migraine can mimic, or co-exist with, a variety of other vestibular diseases, we discuss several of these disorders including persistent postural-perceptual dizziness, benign paroxysmal positional vertigo, post-concussive syndrome, Ménière's disease, and cerebrovascular etiologies. We discuss the diagnosis of each, as well as overlapping and distinguishing clinical features of which the reader should be aware. Finally, we conclude with evidence based as well as expert commentary on management, with a particular emphasis on vestibular migraine.
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Wang LL, Thompson TA, Shih RY, Ajam AA, Bulsara K, Burns J, Davis MA, Ivanidze J, Kalnins A, Kuo PH, Ledbetter LN, Pannell JS, Pollock JM, Shakkottai VG, Shih RD, Soares BP, Soderlund KA, Utukuri PS, Woolsey S, Policeni B. ACR Appropriateness Criteria® Dizziness and Ataxia: 2023 Update. J Am Coll Radiol 2024; 21:S100-S125. [PMID: 38823940 DOI: 10.1016/j.jacr.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
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.
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Affiliation(s)
- Lily L Wang
- University of Cincinnati Medical Center, Cincinnati, Ohio.
| | - Trevor A Thompson
- Research Author, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Robert Y Shih
- Panel Chair, Uniformed Services University, Bethesda, Maryland
| | | | - Ketan Bulsara
- UCONN Health, University of Connecticut, Farmington, Connecticut, Neurosurgery expert
| | | | - Melissa A Davis
- Yale University School of Medicine, New Haven, Connecticut; Committee on Emergency Radiology-GSER
| | | | | | - Phillip H Kuo
- University of Arizona, Tucson, Arizona; Commission on Nuclear Medicine and Molecular Imaging
| | | | | | | | - Vikram G Shakkottai
- University of Texas Southwestern Medical Center, Dallas, Texas; American Academy of Neurology
| | - Richard D Shih
- Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida; American College of Emergency Physicians
| | - Bruno P Soares
- The University of Vermont Medical Center, Burlington, Vermont
| | | | | | - Sarah Woolsey
- Association for Utah Community Health, Salt Lake City, Utah; American Academy of Family Physicians
| | - Bruno Policeni
- Specialty Chair, University of Iowa Hospitals and Clinics, Iowa City, Iowa
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Mittal M. Diagnosing Emergencies in Undifferentiated Acute Vertigo. Indian J Otolaryngol Head Neck Surg 2024; 76:2314-2319. [PMID: 38883510 PMCID: PMC11169370 DOI: 10.1007/s12070-024-04493-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 12/31/2023] [Indexed: 06/18/2024] Open
Abstract
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.
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Affiliation(s)
- Mudit Mittal
- Director and ENT and Head Neck Surgeon, Ankush Medicare and Health Sciences, 2/1 Avantika parisar, lalghati, Bhopal, M.P. 462010 India
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Chang YS, Tsai MJ, Hsieh CY, Sung SF. Characteristics and risk of stroke in emergency department patients with acute dizziness. Heliyon 2024; 10:e30953. [PMID: 38770312 PMCID: PMC11103531 DOI: 10.1016/j.heliyon.2024.e30953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 05/03/2024] [Accepted: 05/08/2024] [Indexed: 05/22/2024] Open
Abstract
Background Acute dizziness is a common symptom in the emergency department (ED), with strokes accounting for 3 %-5 % of cases. We investigated the risk of stroke in ED patients with acute dizziness and compared stroke characteristics diagnosed during and after the ED visit. Methods We identified adult patients with acute dizziness, vertigo, or imbalance using a hospital research-based database. Patients with abdominal or flank pain were used as the comparison group. Patients with dizziness were 1:1 matched to comparison patients. Each patient was traced for up to one year until being hospitalized for a stroke. Results Out of the 24,266 eligible patients, 589 (2.4 %) were hospitalized for stroke during the ED visit. For the remaining 23,677 patients, the risk of stroke at 7, 30, 90, and 365 days after ED discharge was 0.40 %, 0.52 %, 0.71 %, and 1.25 % respectively. Patients with dizziness had a higher risk of stroke compared to the comparison group at 7, 30, 90, and 365 days. The risk ratios decreased from 5.69 (95 % confidence interval [CI], 3.34-9.68) to 2.03 (95 % CI, 1.65-2.49). Compared to patients hospitalized for stroke during the ED visit, those hospitalized for stroke after the ED visit had greater stroke severity despite a lower initial triage acuity. Patients with early stroke (≤7 days) after ED discharge were less likely to have hypertension, diabetes, hyperlipidemia, and atrial fibrillation. They mostly experienced posterior circulation stroke. Patients with late stroke (>7 days) were older and less likely to have hypertension and hyperlipidemia but more likely to have a history of prior stroke and ischemic heart disease. Their strokes were mainly located in the anterior circulation territory. Conclusions The risk of stroke after ED discharge was higher in patients with dizziness than in the comparison group, with gradually decreasing risk ratios in the following year. Patients hospitalized for stroke during and after the ED visit had different profiles of vascular risk factors and clinical characteristics.
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Affiliation(s)
- Yu-Sung Chang
- Department of Otolaryngology, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan
| | - Ming-Jen Tsai
- Department of Emergency Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan
| | - Cheng-Yang Hsieh
- Department of Neurology, Tainan Sin Lau Hospital, Tainan, Taiwan
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Sheng-Feng Sung
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chiayi City, Taiwan
- Department of Beauty & Health Care, Min-Hwei Junior College of Health Care Management, Tainan, Taiwan
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Xia S, Lai Y, Dong L, Yu D, Li Z, Xing Y. Assessments of Subjective Visual Gravity and Spontaneous Nystagmus in Patients With Vestibular Neuritis. Otolaryngol Head Neck Surg 2024. [PMID: 38699944 DOI: 10.1002/ohn.798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 02/05/2024] [Accepted: 04/13/2024] [Indexed: 05/05/2024]
Abstract
OBJECTIVE This study aimed to assess the correlation between the spontaneous nystagmus (SN) and the subjective visual vertical/horizontal (SVV/SVH) among patients with vestibular neuritis (VN) at the different head positions. STUDY DESIGN Case-control study. SETTING Affiliated Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine. METHODS This study evaluated the SVV/SVH in both healthy subjects and patients with VN. These evaluations were performed in 5 different head positions: upright, 45° tilt to the left, 90° tilt to the left, 45° tilt to the right, and 90° tilt to the right. Additionally, the intensity of SN, as measured by slow-phase velocity, was recorded. RESULTS In patients with VN, a significant correlation was observed between SN and SVV/SVH in an upright position. The intensity of SN was higher when the head was tilted 90° toward the affected side compared to other positions. The SVV/SVH displayed an ipsiversive shift, when the head was tilted toward both the lesion and unaffected sides, exhibiting a contraversive direction. Furthermore, the changes in position-induced SN were consistent with the displacements of SVV and SVH caused by head tilt. CONCLUSION The presence of SN in patients with VN was observed to vary across different head position. These variations could potentially be attributed to the diverse activation patterns of the mechanical properties of otolith organs that are induced by head tilts.
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Affiliation(s)
- Shan Xia
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Otolaryngology, Shanghai University of Medicine & Health Sciences Affiliated Zhoupu Hospital, Shanghai, China
| | - Yajing Lai
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
- School of Medical Technology and Information Engineering, Zhejiang Chinese Medical University, Hangzhou, China
| | - Lingkang Dong
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dongzhen Yu
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhuangzhuang Li
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yazhi Xing
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Ross A, Leemeyer AMR, Bruintjes TD, Cals JWL, Bronstein A, van Leeuwen RB, Lissenberg-Witte B, van Vugt VA, Rutgers S, Maarsingh OR. Prospective diagnostic accuracy study of history taking and physical examination for adults with vertigo in general practice: study protocol. BMJ Open 2024; 14:e085715. [PMID: 38569697 PMCID: PMC10989125 DOI: 10.1136/bmjopen-2024-085715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 03/18/2024] [Indexed: 04/05/2024] Open
Abstract
INTRODUCTION Vertigo is a prevalent and burdensome symptom. More than 80% of patients with vertigo are primarily treated by their general practitioner (GP) and are never referred to a medical specialist. Despite this therapeutic responsibility, the GP's diagnostic toolkit has serious limitations. All recommended tests lack empirical evidence, because a diagnostic accuracy study on vestibular disorders ('How well does test x discriminate between patients with or without target condition y?') has never been performed in general practice. The VERtigo DIagnosis study aims to fill this gap. METHODS AND ANALYSIS We will perform a diagnostic accuracy study on vertigo of primary vestibular origin in general practice to assess the discriminative ability of history taking and physical examination. We will compare all index tests with a respective reference standard. We will focus on five target conditions that account for more than 95% of vertigo diagnoses in general practice: (1) benign paroxysmal positional vertigo, (2) vestibular neuritis, (3) Ménière's disease, (4) vestibular migraine (VM) and (5) central causes other than VM. As these five target conditions have a different pathophysiology and lack one generally accepted gold standard, we will use consensus diagnosis as a construct reference standard. Data for each patient, including history, physical examination and additional tests as recommended by experts in an international Delphi procedure, will be recorded on a standardised form and independently reviewed by a neurologist and otorhinolaryngologist. For each patient, the reviewers have to decide about the presence/absence of each target condition. We will calculate sensitivity, specificity, predictive values, likelihood ratios and diagnostic ORs, followed by decision rules for each target condition. ETHICS AND DISSEMINATION The study obtained approval from the Vrije Universiteit Medical Center Medical Ethical Review Committee (reference: 2022.0817-NL83111.029.22). We will publish our findings in peer-reviewed international journals. TRIAL REGISTRATION NUMBER ISRCTN97250704.
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Affiliation(s)
- Andrew Ross
- Department of General Practice, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Anna-Marie Rebecca Leemeyer
- Department of General Practice, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Tjasse D Bruintjes
- Department of Otorhinolaryngology-Head and Neck Surgery, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, Gelre Hospital, Apeldoorn, The Netherlands
| | - Jochen W L Cals
- Department of Family Medicine, Maastricht University Care and Public Health Research Institute, Maastricht, The Netherlands
| | - Adolfo Bronstein
- Neuro-otology Unit, Division of Brain Sciences, Imperial College London, London, UK
| | | | - Birgit Lissenberg-Witte
- Department of Epidemiology and Data Science, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - Vincent Alexander van Vugt
- Department of General Practice, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
| | - Sandra Rutgers
- Patient association Hoormij NVVS, Houten, The Netherlands
| | - Otto R Maarsingh
- Department of General Practice, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, The Netherlands
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von Werdt M, Korda A, Zamaro E, Wagner F, Kompis M, Caversaccio MD, Mantokoudis G. The acute vestibular syndrome: prevalence of new hearing loss and its diagnostic value. Eur Arch Otorhinolaryngol 2024; 281:1781-1787. [PMID: 37943315 PMCID: PMC10942940 DOI: 10.1007/s00405-023-08296-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 10/17/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVES To assess the prevalence of new hearing losses in patients with acute vestibular syndrome (AVS) and to start to evaluate its diagnostic value for the differentiation between peripheral and central causes. DESIGN We performed a cross-sectional prospective study in AVS patients presenting to our Emergency Department (ED) from February 2015 to November 2020. All patients received an MRI, Head-impulse test, Nystagmus test and Test of skew ('HINTS'), caloric testing and a pure-tone audiometry. RESULTS We assessed 71 AVS patients, 17 of whom had a central and 54 a peripheral cause of dizziness. 12.7% had an objective hearing loss. 'HINTS' had an accuracy of 78.9% to diagnose stroke, whereas 'HINTS' plus audiometry 73.2%. 'HINTS' sensitivity was 82.4% and specificity 77.8% compared to 'HINTS' plus audiometry showing a sensitivity of 82.4% and specificity of 70.4%. The four patients with stroke and minor stroke had all central 'HINTS'. 55% of the patients did not perceive their new unilateral hearing loss. CONCLUSIONS We found that almost one-eighth of the AVS patients had a new onset of hearing loss and only half had self-reported it. 'HINTS' plus audiometry proved to be less accurate to diagnose a central cause than 'HINTS' alone. Audiometry offered little diagnostic accuracy to detect strokes in the ED but might be useful to objectify a new hearing loss that was underestimated in the acute phase. Complete hearing loss should be considered a red flag, as three in four patients suffered from a central cause.
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Affiliation(s)
- Moritz von Werdt
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, 3010, Bern, Switzerland
| | - Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, 3010, Bern, Switzerland
| | - Ewa Zamaro
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, 3010, Bern, Switzerland
| | - Franca Wagner
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Martin Kompis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, 3010, Bern, Switzerland
| | - Marco D Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, 3010, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, 3010, Bern, Switzerland.
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Klokman VW, Koningstein FN, Dors JWW, Sanders MS, Koning SW, de Kleijn DPV, Jie KE. Blood biomarkers for the differentiation between central and peripheral vertigo in the emergency department: a systematic review and meta-analysis. Acad Emerg Med 2024; 31:371-385. [PMID: 38403938 DOI: 10.1111/acem.14864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/17/2023] [Accepted: 12/18/2023] [Indexed: 02/27/2024]
Abstract
BACKGROUND/INTRODUCTION In patients with acute vestibular syndrome (AVS), differentiating between stroke and nonstroke causes is challenging in the emergency department (ED). Correct diagnosis of vertigo etiology is essential for early optimum treatment and disposition. OBJECTIVES The aim of this systematic review and meta-analysis was to summarize the published evidence on the potential of blood biomarkers in the diagnosis and differentiation of peripheral from central causes of AVS. METHODS A literature search was conducted for studies published until January 1, 2023, in PubMed, Ovid Medline, and EMBASE databases analyzing biomarkers for the differentiation between central and peripheral AVS. The Quality Assessment of Diagnostic Accuracy Studies questionnaire 2 was used for quality assessment. Pooled standardized mean difference and 95% confidence intervals were calculated if a biomarker was reported in two or more studies. Heterogeneity among included studies was investigated using the I2 metric. RESULTS A total of 17 studies with 859 central and 4844 peripheral causes of acute dizziness or vertigo, and analysis of 61 biomarkers were included. The general laboratory markers creatinine, blood urea nitrogen, albumin, C-reactive protein, glucose, HbA1c, leukocyte counts, and neutrophil counts and the brain-derived biomarkers copeptin, S100 calcium-binding protein β (S100β), and neuron-specific enolase (NSE) significantly differentiated central from peripheral causes of AVS. CONCLUSIONS This systematic review and meta-analysis highlights the potential of generalized inflammatory markers and brain-specific blood protein markers of NSE and S100β as diagnostic biomarkers for central from peripheral differentiation in AVS. These results, as a complement to clinical characteristics, provide guidance for future large-scale diagnostic research, in this challenging ED patient population.
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Affiliation(s)
- Vincent W Klokman
- Department of Emergency Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Fiona N Koningstein
- Department of Emergency Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Job W W Dors
- Faculty of Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marieke S Sanders
- Department of Emergency Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Sam W Koning
- Department of Emergency Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | | | - Kim E Jie
- Department of Emergency Medicine, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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12
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Liu X, Li Z, Ju Y, Zhao X. Application of bedside HINTS, ABCD 2 score and truncal ataxia to differentiate cerebellar-brainstem stroke from vestibular neuritis in the emergency room. Stroke Vasc Neurol 2024:svn-2023-002779. [PMID: 38531544 DOI: 10.1136/svn-2023-002779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 02/17/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND AND PURPOSE Acute vestibular syndrome (AVS) typically manifests as isolated dizziness or vertigo with no apparent neurological impairments. However, distinguishing life-threatening stroke from innocuous peripheral vestibular lesions in the emergency room (ER) remains challenging. This study aimed to explore the ability of the head impulse-nystagmus-test of skew (HINTS) combined with truncal ataxia or ABCD2 score to differentiate stroke from peripheral vestibular disease in patients with AVS in the ER. METHODS We prospectively recruited 121 patients with AVS from December 2022 to June 2023, 69 of whom presented with vestibular neuritis (VN) and the remaining with posterior circulation stroke (PCS). We analysed the HINTS results, truncal ataxia and ABCD2 score and compared the sensitivity and specificity among HINTS, truncal ataxia, ABCD2 score and their combinations using the McNemar test for paired samples. RESULTS HINTS combined with grade 2-3 truncal ataxia achieved significantly higher sensitivity than that of isolated HINTS in differentiating PCS from VN (100% vs 88.5%, p=0.031). The specificity of HINTS plus grade 2-3 truncal ataxia did not significantly differ from that of isolated HINTS (p=0.125); however, the combination of ABCD2 score and HINTS did not improve the diagnostic accuracy. The sensitivity of ABCD2 score ≥4 plus grade 2-3 truncal ataxia was significantly higher than those of isolated ABCD2 score ≥4 or isolated grade 2-3 truncal ataxia (p=0.016 and p<0.001, respectively) and not significantly lower than that of isolated HINTS (p=0.508). CONCLUSION Compared with the ABCD2 score, the truncal ataxia is of more valuable assistance to HINTS in differentiating PCS. Although the combination of ABCD2 score and truncal ataxia has a significant implication, it is not a replacement for HINTS.
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Affiliation(s)
- Xinmin Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhaoxia Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Clinical Center for Vertigo and Balance Disturbance, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi Ju
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Clinical Center for Vertigo and Balance Disturbance, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Clinical Center for Vertigo and Balance Disturbance, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
- Beijing Institute of Brain Disorders, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
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Yu AHK, Leung LY, Leung TWH, Abrigo JM, Cheung KH, Cheng CH, Graham CA. The TriAGe + score for vertigo or dizziness: A validation study in a university hospital emergency department in Hong Kong. Am J Emerg Med 2024; 77:39-45. [PMID: 38096638 DOI: 10.1016/j.ajem.2023.10.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 10/13/2023] [Accepted: 10/28/2023] [Indexed: 02/16/2024] Open
Abstract
OBJECTIVE Patients with dizziness commonly present to Emergency Departments (ED) and 6% of these patients will be diagnosed with acute stroke. The TriAGe+ score comprises of eight clinical parameters and stratifies patients into four risk groups. The Japanese authors reported that the tool performed well, so our aim was to validate this diagnostic tool in our ED in Hong Kong. MATERIALS AND METHODS A single-center retrospective observational study was conducted in the ED of our university hospital in Hong Kong. The primary outcome was the diagnosis of an acute cerebrovascular event. Receiver operator characteristic (ROC) analysis was performed to determine the best cut-off score. Secondary outcomes included univariable and multivariable analyses of stroke predictors. RESULTS 455 patients aged 18 years or above with dizziness or vertigo at ED triage were recruited between 19 July and 30 September 2021. The overall prevalence of stroke was 11.9%. The median TriAGe+ score was 7 (IQR = 4-9). The AUC was 0.9. At a cut-off >5, sensitivity was 96.4% (95%CI: 87.3-99.5) and the negative likelihood ratio was 0.09 (95%CI: 0.02-0.3). At a cut-off >10, specificity was 99.8% (95%CI: 98.6-100.0), and the positive likelihood ratio was 237.6 (95%CI: 33.1-1704). On multivariable analyses, atrial fibrillation, blood pressure, gender, dizziness (not vertigo) and no history of dizziness, vertigo or labyrinth/vestibular disease were found to be positively associated with stroke outcomes significantly. CONCLUSION The TriAGe+ score is an efficient stroke prediction score for patients presenting to the ED with dizziness.
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Affiliation(s)
- Adrian Ho-Kun Yu
- Department of Accident and Emergency Medicine, Prince of Wales Hospital, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR.
| | - Ling Yan Leung
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR
| | - Thomas W H Leung
- Division of Neurology, Department of Medicine & Therapeutics, Chinese University of Hong Kong, Prince of Wales Hospital, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR.
| | - Jill M Abrigo
- Department of Imaging and Interventional Radiology, Chinese University of Hong Kong, Prince of Wales Hospital, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR.
| | - Koon Ho Cheung
- Department of Accident and Emergency Medicine, Prince of Wales Hospital, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR.
| | - Chi Hung Cheng
- Department of Accident and Emergency Medicine, Prince of Wales Hospital, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR.
| | - Colin A Graham
- Department of Accident and Emergency Medicine, Prince of Wales Hospital, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR; Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, Ngan Shing Street, Shatin, New Territories, Hong Kong SAR.
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14
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Jaganathan N, Mohamed MH, Md Pauzi AL, Mahayidin H, Hanapai AF, Wan Sulaiman WA, Basri H, Inche Mat L. Video head impulse test in stroke: a review of published studies. Front Neurol 2024; 15:1339039. [PMID: 38497038 PMCID: PMC10940455 DOI: 10.3389/fneur.2024.1339039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/19/2024] [Indexed: 03/19/2024] Open
Abstract
Accurate and timely diagnosis of posterior circulation stroke in patients with acute dizziness is a challenge that can lead to misdiagnosis and significant harm. The present review sought to identify and describe published research on the clinical application of vHIT in posterior circulation stroke. vHIT, a portable device, has gained prominence in evaluating peripheral vestibular disorders and offers potential applications in diagnosing neurological disorders, particularly posterior circulation stroke. Several studies have shown that vHIT can differentiate between stroke and vestibular neuritis based on VOR gain values, with high sensitivity and specificity. The manuscript also discusses vHIT's performance in differentiating between types of posterior circulation stroke, such as PICA, AICA, and SCA strokes. While vHIT has demonstrated promise, the review emphasizes the need for further research to validate its use as a tool to rule out stroke in acute dizziness patients in the emergency department. In conclusion, the manuscript underscores the potential of vHIT as a valuable addition to the diagnostic arsenal for acute dizziness, particularly in the context of posterior circulation stroke. It calls for further research and wider adoption of vHIT in clinical settings to improve patient care and reduce unnecessary costs associated with misdiagnoses.
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Affiliation(s)
- Niranjana Jaganathan
- Department of Neurology, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Selangor, Malaysia
| | - Mohd Hazmi Mohamed
- Department of Otorhinolaryngology, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Selangor, Malaysia
| | - Ahmad Luqman Md Pauzi
- Department of Emergency, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Selangor, Malaysia
| | - Hasni Mahayidin
- Department of Pathology, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Selangor, Malaysia
| | - Ahmad Firdaus Hanapai
- Department of Neurology, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Selangor, Malaysia
| | - Wan Aliaa Wan Sulaiman
- Department of Neurology, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Selangor, Malaysia
| | - Hamidon Basri
- Department of Neurology, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Selangor, Malaysia
| | - Liyana Inche Mat
- Department of Neurology, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Selangor, Malaysia
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Kogej M, Scherzberg J, Schacher S, Berger M, Seidel M, Gräff I. Clinical use of the manchester triage system in patients with dizziness - An observational study in the emergency department. Int Emerg Nurs 2024; 73:101403. [PMID: 38295743 DOI: 10.1016/j.ienj.2023.101403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 12/03/2023] [Accepted: 12/23/2023] [Indexed: 03/11/2024]
Abstract
INTRODUCTION Dizziness is a common symptom with diverse causes, including ear-nose-throat, internal, neurological, or psychiatric origins. While for most parts treatable in nonemergency settings, it can also signal time-critical conditions, like an unnoticed stroke, requiring prompt diagnosis and treatment to prevent lasting harm or death. The aim of this study was to evaluate the validity of the Manchester Triage System in classifying patients presenting with dizziness based on final diagnoses and patient outcomes, as no specific flow chart exists for this symptom in the MTS. METHODS Monocentric, retrospective observational study. To test the validity of the MTS in the triage of dizziness patients, the treatment level was used as a surrogate parameter. We grouped the patients into outpatient, normal ward and intermediate care/intensive care unit (IMC/ICU) patients. Furthermore, we analyzed the dizziness patients in subgroups based on the origin of their dizziness to identify potential improvements for the MTS. Patients with dizziness and stroke, who represent the most vulnerable group of dizziness patients, were also evaluated separately. RESULTS During the observation period, 2958 patients presented at the ED with the symptom dizziness and 52 017 without, who formed the reference group. When examining the relationship between triage level and subsequent treatment level, a larger deviation is observed compared to the reference group. The receiver operating characteristics (ROC) regarding hospital admission in general showed an area under the curve (AUC) in the subgroup with dizziness due to a central nervous system causes (n=838) of 0.69 (95% CI 0.65 - 0.72) and in the subgroup of dizziness by other organic cause (n=901), an AUC of 0.64 (95% CI 0.60 - 0.68). The reference group had an AUC 0.75 (95% CI 0.75 - 0.76) here. In relation to admission to IMC/ICU, the results were similar. The sensitivity of the MTS in terms of an adequate initial assessment of dizziness patients with stroke or transient ischemic attack (TIA) was 0.39, the specificity was 0.91 (reference group sensitivity 0.72, specificity 0.82). CONCLUSION In terms of construct validity, the present study revealed that the use of MTS as a priority triage assessment tool was found to be less accurate in emergency patients with dizziness, particularly those diagnosed with stroke/TIA, when compared to other emergency patients.
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Affiliation(s)
- Monika Kogej
- Department of Clinical Acute and Emergency Medicine, University Hospital Bonn, Bonn, Germany
| | - Julia Scherzberg
- Department of Anesthesiology and Critical Care, University Hospital Freiburg, Freiburg, Germany
| | - Sylvia Schacher
- Department of Clinical Emergency Medicine, Helios Hospital Siegburg, Siegburg, Germany
| | - Moritz Berger
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
| | - Matthias Seidel
- Department of Emergency Medicine, St. Antonius Hospital, Cologne, Germany
| | - Ingo Gräff
- Department of Clinical Acute and Emergency Medicine, University Hospital Bonn, Bonn, Germany.
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16
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Bastani PB, Rieiro H, Badihian S, Otero‐Millan J, Farrell N, Parker M, Newman‐Toker D, Zhu Y, Saber Tehrani A. Quantifying Induced Nystagmus Using a Smartphone Eye Tracking Application (EyePhone). J Am Heart Assoc 2024; 13:e030927. [PMID: 38226513 PMCID: PMC10926800 DOI: 10.1161/jaha.123.030927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 12/10/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND There are ≈5 million annual dizziness visits to US emergency departments, of which vestibular strokes account for over 250 000. The head impulse, nystagmus, and test of skew eye examination can accurately distinguish vestibular strokes from peripheral dizziness. However, the eye-movement signs are subtle, and lack of familiarity and difficulty with recognition of abnormal eye movements are significant barriers to widespread emergency department use. To break this barrier, we sought to assess the accuracy of EyePhone, our smartphone eye-tracking application, for quantifying nystagmus. METHODS AND RESULTS We prospectively enrolled healthy volunteers and recorded the velocity of induced nystagmus using a smartphone eye-tracking application (EyePhone) and then compared the results with video oculography (VOG). Following a calibration protocol, the participants viewed optokinetic stimuli with incremental velocities (2-12 degrees/s) in 4 directions. We extracted slow phase velocities from EyePhone data in each direction and compared them with the corresponding slow phase velocities obtained by the VOG. Furthermore, we calculated the area under the receiver operating characteristic curve for nystagmus detection by EyePhone. We enrolled 10 volunteers (90% men) with an average age of 30.2±6 years. EyePhone-recorded slow phase velocities highly correlated with the VOG recordings (r=0.98 for horizontal and r=0.94 for vertical). The calibration significantly increased the slope of linear regression for horizontal and vertical slow phase velocities. Evaluating the EyePhone's performance using VOG data with a 2 degrees/s threshold showed an area under the receiver operating characteristic curve of 0.87 for horizontal and vertical nystagmus detection. CONCLUSIONS We demonstrated that EyePhone could accurately detect and quantify optokinetic nystagmus, similar to the VOG goggles.
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Affiliation(s)
- Pouya B. Bastani
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMDUSA
- Armstrong Institute Center for Diagnostic ExcellenceBaltimoreMDUSA
| | - Hector Rieiro
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMDUSA
- Armstrong Institute Center for Diagnostic ExcellenceBaltimoreMDUSA
| | - Shervin Badihian
- Armstrong Institute Center for Diagnostic ExcellenceBaltimoreMDUSA
- Neurological Institute, Cleveland ClinicClevelandOHUSA
| | - Jorge Otero‐Millan
- Herbert Wertheim School of Optometry and Vision ScienceUniversity of CaliforniaBerkeleyCAUSA
| | - Nathan Farrell
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMDUSA
- Armstrong Institute Center for Diagnostic ExcellenceBaltimoreMDUSA
| | - Max Parker
- Department of Neurology, NYU Langone HealthNew YorkNYUSA
| | - David Newman‐Toker
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMDUSA
- Armstrong Institute Center for Diagnostic ExcellenceBaltimoreMDUSA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Yuxin Zhu
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMDUSA
- Armstrong Institute Center for Diagnostic ExcellenceBaltimoreMDUSA
- Department of BiostatisticsJohns Hopkins University Bloomberg School of Public HealthBaltimoreMDUSA
| | - Ali Saber Tehrani
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMDUSA
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Mantokoudis G, Zwergal A, Heg D, Kerkeni H, Diener S, Kalla R, Korda A, Candreia C, Welge-Lüssen A, Tarnutzer AA. What neuro-otology specialists need for better care of dizzy patients: a national survey. Front Neurol 2024; 14:1322471. [PMID: 38259654 PMCID: PMC10800397 DOI: 10.3389/fneur.2023.1322471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 12/12/2023] [Indexed: 01/24/2024] Open
Abstract
Background A substantial fraction of dizzy patients are assessed by neurologists and ear-nose-throat (ENT) physicians. With the differential diagnosis being broad and often different specialties involved, we aimed to assess the interaction with generalists from the specialists' perspective to identify limitations and needs and to define strategies for improvement in patient care and education by the specialist. Methods One hundred eleven board-certified neurologists (n = 62) and ENT physicians (n = 49) working in Switzerland participated in an online survey. Here, we focused on limitations faced in the diagnostic workup and treatment of the dizzy patient and potential strategies to improve the standard of care and the interaction between generalists and specialists. Descriptive statistical analyses were performed. We hypothesized that those specialists applying modern concepts in history-taking and bedside examination techniques reach a specific diagnosis more often and request fewer referrals. Results Specialists indicated higher confidence in reaching a specific diagnosis for patients presenting with acute dizziness than episodic/chronic dizziness (80% vs. 60%) at the first consultation. Knowledge of the timing-and-trigger concept [odds ratio (OR) = 0.81 (0.67-0.98), p = 0.034], as well as of subtle oculomotor/vestibular signs [OR = 0.80 (0.68-0.94), p = 0.007] was predictive of the self-reported probability of reaching a specific diagnosis in patients with episodic/chronic dizziness, while no such differences were observed in the care of acutely dizzy patients. Further referrals of acutely dizzy patients were significantly higher in neurologists than in ENT physicians (17% vs. 10%, p < 0.001) and in specialists located in the Latin part of Switzerland [OR = 2.84 (1.63-4.93), p < 0.001], while this was not the case for patients with episodic/chronic dizziness. Identified unmet needs included regular communication between physicians (27%/53%; always/often true) and sufficiently detailed information on the previous workup from the referrals (27%/53%). Specialists expressed most interest in hands-on courses/workshops, webinars, and practical guidelines for education. Conclusion In our survey, bedside state-of-the-art assessments were key in reducing the fraction of unclear dizzy cases. Several gaps were identified that should be addressed. Specifically, referring physicians should provide more comprehensive details regarding urgency, prior diagnostics, and treatment. Specifically, when promoting the knowledge of neurologists and ENT physicians, this should be preferentially done by offering a combination of hands-on courses and webinars.
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Affiliation(s)
- Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Zwergal
- German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, Munich, Germany
- Department of Neurology, LMU University Hospital, Munich, Germany
| | - Dik Heg
- CTU Bern, University of Bern, Bern, Switzerland
| | - Hassen Kerkeni
- Department of Neurology, Lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Suzie Diener
- Practice Neurology St. Gallen, St. Gallen, Switzerland
| | - Roger Kalla
- Department of Neurology, Lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, Lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Claudia Candreia
- Department of Otorhinolaryngology, Head and Neck Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Antje Welge-Lüssen
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Basel, Basel, Switzerland
| | - Alexander Andrea Tarnutzer
- Neurology, Cantonal Hospital of Baden, Baden, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
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Ursat G, Corda M, Ryard J, Guillet C, Guigou C, Tissier C, Bozorg Grayeli A. Virtual-reality-enhanced mannequin to train emergency physicians to examine dizzy patients using the HINTS method. Front Neurol 2024; 14:1335121. [PMID: 38249749 PMCID: PMC10796789 DOI: 10.3389/fneur.2023.1335121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/05/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction Acute vertigo is a frequent chief complaint in the emergency departments, and its efficient management requires thorough training. The HINTS protocol is a valid method to screen patients in the emergency room, but its application in routine is hindered by the lack of training. This study aimed to evaluate the training of emergency physicians for the HINTS method based on a mannequin-based virtual reality simulator (MBVRS). Methods We conducted a monocenter, prospective, longitudinal, and randomized cohort study in an Emergency Department at a regional university hospital. We included 34 emergency physicians randomized into two equal groups matched by age and professional experience. The control group attended a theoretical lesson with video demonstrations and the test group received a simulation-based training in addition to the lecture. Results We showed that the test group had a higher diagnosis performance for the HINTS method compared to the control group as evaluated by the simulator at 1 month (89% sensitivity versus 45, and 100% specificity versus 86% respectively, p < 001, Fisher's exact test). Evaluation at 6 months showed a similar advantage to the test group. Discussion The MBVRS is a useful pedagogic tool for the HINTS protocol in the emergency department. The advantage of a unique training session can be measured up to 6 months after the lesson.
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Affiliation(s)
- Guillaume Ursat
- Emergency Department, Dijon University Hospital, Dijon, France
| | - Morgane Corda
- Otolaryngology Department, Dijon University Hospital, Dijon, France
| | - Julien Ryard
- Institut Image, Ecole Nationale d’Arts-et-Métiers, Chalon-sur-Saône, France
| | - Christophe Guillet
- Institut Image, Ecole Nationale d’Arts-et-Métiers, Chalon-sur-Saône, France
| | - Caroline Guigou
- Otolaryngology Department, Dijon University Hospital, Dijon, France
- ICMUB, CNRS, Université Bourgogne-Franche-Comté, Dijon, France
| | - Cindy Tissier
- Emergency Department, Dijon University Hospital, Dijon, France
| | - Alexis Bozorg Grayeli
- Otolaryngology Department, Dijon University Hospital, Dijon, France
- ICMUB, CNRS, Université Bourgogne-Franche-Comté, Dijon, France
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19
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Nikles F, Kerkeni H, Zamaro E, Korda A, Wagner F, Sauter TC, Kalla R, Morrison M, Mantokoudis G. Do monosymptomatic stroke patients with dizziness present a vestibular syndrome without nystagmus? An underestimated entity. Eur J Neurol 2024; 31:e16066. [PMID: 37738525 PMCID: PMC11235630 DOI: 10.1111/ene.16066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 09/04/2023] [Accepted: 09/04/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND AND PURPOSE Vestibular symptoms are common in emergency department (ED) patients and have various causes, including stroke. Accurate identification of stroke in patients with vestibular symptoms is crucial for timely management. We conducted a prospective cross-sectional study from 2015 to 2019 to determine stroke prevalence and associated symptoms in ED patients with vestibular symptoms, aiming to improve diagnosis and outcomes. METHODS As part of the DETECT project, we screened 1647 ED patients with acute vestibular symptoms. Following a retrospective analysis of 961 head and neck magnetic resonance imaging (MRI) scans, we included 122 confirmed stroke cases and assessed them for vestibular signs and symptoms. RESULTS Stroke prevalence in dizzy patients was 13% (122/961 MRI scans). Most patients (95%) presented with acute vestibular symptoms with or without nystagmus, whereas 5% had episodic vestibular syndrome (EVS). Nystagmus was present in 50% of stroke patients. Eighty percent had a purely posterior circulation stroke, and nystagmus was absent in 46% of these patients. Seven patients (6%) had lesions in both the anterior and posterior circulation. Vertigo was experienced by 52% regardless of territory. CONCLUSIONS A stroke was identified in 13% of ED patients presenting with acute vestibular symptoms. In 5%, it was EVS. Most strokes were in the posterior circulation territory; vertigo occurred with similar frequency in anterior and posterior circulation stroke, and absence of nystagmus was common in both.
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Affiliation(s)
- Florence Nikles
- Department of Otorhinolaryngology, Head and Neck Surgery, InselspitalUniversity Hospital Bern and University of BernBernSwitzerland
| | - Hassen Kerkeni
- Department of Neurology, InselspitalUniversity Hospital Bern and University of BernBernSwitzerland
| | - Ewa Zamaro
- Department of Otorhinolaryngology, Head and Neck Surgery, InselspitalUniversity Hospital Bern and University of BernBernSwitzerland
| | - Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, InselspitalUniversity Hospital Bern and University of BernBernSwitzerland
| | - Franca Wagner
- University Institute of Diagnostic and Interventional Neuroradiology, InselspitalUniversity Hospital Bern and University of BernBernSwitzerland
| | - Thomas C. Sauter
- Department of Emergency Medicine, InselspitalUniversity Hospital Bern and University of BernBernSwitzerland
| | - Roger Kalla
- Department of Neurology, InselspitalUniversity Hospital Bern and University of BernBernSwitzerland
| | - Miranda Morrison
- Department of Otorhinolaryngology, Head and Neck Surgery, InselspitalUniversity Hospital Bern and University of BernBernSwitzerland
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, InselspitalUniversity Hospital Bern and University of BernBernSwitzerland
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Zwergal A, Mantokoudis G, Heg D, Kerkeni H, Diener S, Kalla R, Korda A, Candreia C, Welge-Lüssen A, Tarnutzer AA. What is the current status of care by neuro-otology specialists in Switzerland-A national survey. Front Neurol 2023; 14:1322330. [PMID: 38130837 PMCID: PMC10733682 DOI: 10.3389/fneur.2023.1322330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/14/2023] [Indexed: 12/23/2023] Open
Abstract
Background Vertigo and dizziness are frequent presenting symptoms in the emergency department and in outpatient centers. While the majority of dizzy patients are evaluated by primary care physicians, specialists are often involved in the diagnostic workup. We aimed to gain more insights into the role of specialists in the care of dizzy patients. Materials and methods Board-certified neurologists and ear-nose-throat (ENT) physicians working in Switzerland were invited to participate in an online survey. Descriptive statistical analyses were performed, and prospectively defined hypotheses were assessed using correlation analyses. Results All 111 participating specialists (neurologists = 62; ENT specialists = 49) were familiar with testing for posterior canal benign paroxysmal positional vertigo (BPPV), and 66% regularly applied provocation maneuvers for suspected lateral canal BPPV. Reposition maneuvers for posterior (99%) and lateral (68%) canals were frequently performed. ENT physicians were familiar with lateral canal BPPV repositioning maneuvers significantly more often than neurologists (84 vs. 56%, p ≤ 0.012). Specialists strongly agreed that performing the head impulse test (86%) and looking for deficient eccentric gaze holding (82%) are important. Compared to neurologists, significantly fewer ENT physicians indicated ordering brain MRI in acutely dizzy patients (OR = 0.33 [0.16-0.067], p = 0.002) and physical therapy in patients with acute (50 vs. 20%, p = 0.005) or episodic/chronic dizziness (78 vs. 50%, p = 0.003). Conclusion We found substantial differences in the care of dizzy patients by neurologists and ENT physicians. This underlines the need for a standardized, guideline-oriented diagnostic workup and treatment across specialties. Dedicated training for performing lateral canal BPPV repositioning maneuvers should be prioritized for neurologists. Similarly, physical therapy should be considered more often by ENT physicians.
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Affiliation(s)
- Andreas Zwergal
- German Center for Vertigo and Balance Disorders, LMU University Hospital, LMU Munich, Munich, Germany
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dik Heg
- Clinical Trials Unit Bern, University of Bern, Bern, Switzerland
| | - Hassen Kerkeni
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Suzie Diener
- Practice Neurology St. Gallen, St. Gallen, Switzerland
| | - Roger Kalla
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Claudia Candreia
- Department of Otorhinolaryngology, Head and Neck Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Antje Welge-Lüssen
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Basel, Basel, Switzerland
| | - Alexander A. Tarnutzer
- Neurology, Cantonal Hospital of Baden, Baden, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
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21
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Wibble T, Pansell T. Translation and validation of a Swedish version of the Visual Vertigo Analogue Scale. Ann Med 2023; 55:572-577. [PMID: 36896483 PMCID: PMC10795583 DOI: 10.1080/07853890.2023.2177724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/01/2023] [Indexed: 03/11/2023] Open
Abstract
PURPOSE The present study aimed to construct and validate a Swedish translation (VVAS-S) of the Visual Vertigo Analogue Scale (VVAS). MATERIALS AND METHODS The original English VVAS was translated into Swedish by the two authors and back-translated by an independent professional translator. Pilot-tests were performed on two healthy participants and five patients suffering from Visually Induced Dizziness (VID). The translation was deemed understandable by all subjects. Twenty-one patients with VID were recruited to complete the VVAS-S, once in-lab and once at home after 2-3 weeks. Cronbach's alpha, inter-item consistency and internal consistency were calculated. RESULTS Test-retest values were reliably strong across all items. Cronbach's alpha was 0.843, which is considered to represent very-high reliability. The corrected-item total-correlation was above 0.3 for all items, meaning they were appropriately associated with one-another. Fourteen out of 36 inter-item correlation interactions were within the 0.2-0.4 range. CONCLUSIONS The VVAS-S was found to be comparable to the original VVAS in terms of internal reliability. The translation was perceived as easy to implement by all participants and can be considered ready for clinical use in a Swedish-speaking setting. Item-specific correlations may be valuable for developing future vertigo questionnaires.Key messagesThe Swedish version of the Visual Vertigo Analogue Scale is a questionnaire suitable for evaluating visually induced dizziness in a Swedish population. This study found that the Swedish questionnaire was comparable to the original in terms of internal consistency. The Swedish Visual vertigo Analogue Scale can be found as an appendix to this article.
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Affiliation(s)
- Tobias Wibble
- Department of Clinical Neuroscience, Division of Ophthalmology and Vision, Marianne Bernadotte Centre, Karolinska Institutet, Stockholm, Sweden
| | - Tony Pansell
- Department of Clinical Neuroscience, Division of Ophthalmology and Vision, Marianne Bernadotte Centre, Karolinska Institutet, Stockholm, Sweden
- St. Erik Eye Hospital, Stockholm, Sweden
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22
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Gottlieb M, Peksa GD, Carlson JN. Head impulse, nystagmus, and test of skew examination for diagnosing central causes of acute vestibular syndrome. Cochrane Database Syst Rev 2023; 11:CD015089. [PMID: 37916744 PMCID: PMC10620998 DOI: 10.1002/14651858.cd015089.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
BACKGROUND Dizziness is a common reason for people to seek medical care. Acute vestibular syndrome (AVS) is a specific type of dizziness, which can include severe vertigo, nausea and vomiting, nystagmus, or unsteadiness. Acute vestibular syndrome can be due to peripheral or central causes. It is important to determine the cause, as the intervention and outcomes differ if it is from a peripheral or central cause. Clinicians can assess for the cause using risk factors, patient history, examination findings, or advanced imaging, such as a magnetic resonance imaging (MRI). The head impulse, nystagmus, test of skew (HINTS) examination is a three-part examination performed by clinicians to determine if AVS is due to a peripheral or central cause. This includes assessing how the eyes move in response to rapidly turning a person's head (head impulse), assessing the direction of involuntary eye movements (nystagmus), and assessing whether the eyes are aligned or misaligned (test of skew). The HINTS Plus examination includes an additional assessment of auditory function. OBJECTIVES To assess the diagnostic accuracy of the HINTS and HINTS Plus examinations, with or without video assistance, for identifying a central etiology for AVS. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Google Scholar, the International HTA database, and two trials registers to September 2022. SELECTION CRITERIA We included all retrospective and prospective diagnostic test accuracy studies that evaluated the HINTS or HINTS Plus test used in a primary care clinic, an urgent care clinic, the emergency department, or during inpatient hospitalization against a final diagnosis of a central etiology of AVS, as defined by the reference standard of advanced imaging or final diagnosis by a neurologist. DATA COLLECTION AND ANALYSIS Two review authors independently determined eligibility of each study according to eligibility criteria, extracted data, assessed the risk of bias, and determined the certainty of evidence. Disagreements were adjudicated by consensus or a third review author if needed. The primary outcome was the diagnostic accuracy of the HINTS and HINTS Plus examinations for identifying a central etiology for AVS, conducted clinically (clinician visual assessment) or with video assistance (e.g. video recording with goggles); we independently assessed the clinical and video-assisted examinations. Subgroup analyses were performed by provider type (e.g. physicians, non-physicians), time from symptom onset to presentation (e.g. less than 24 hours, longer than 24 hours), reference standard (e.g. advanced imaging, discharge diagnosis), underlying etiology (e.g. ischemic stroke, alternative etiologies [hemorrhagic stroke, intracranial mass]), study setting (e.g. outpatient [outpatient clinic, urgent care clinic, emergency department], inpatient), physician level of training (e.g. resident, fellow/attending), physician specialty (e.g. otolaryngology, emergency medicine, neurology, and neurologic subspecialist [e.g. neuro-ophthalmology, neuro-otology]), and individual diagnostic accuracy of each component of the examination (e.g. head impulse, direction-changing nystagmus, test of skew). We created 2 x 2 tables of the true positives, true negatives, false positives, and false negatives and used these data to calculate the sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio with 95% confidence intervals (95% CI) for each outcome. MAIN RESULTS We included 16 studies with a total of 2024 participants (981 women and 1043 men) with a mean age of 60 years. Twelve studies assessed the HINTS examination; five assessed the HINTS Plus examination. Thirteen studies were performed in the emergency department; half were performed by neurologists. The clinical HINTS examination (12 studies, 1890 participants) was 94.0% (95% confidence interval [CI] 82.0% to 98.2%) sensitive, and 86.9% (95% CI 75.3% to 93.6%) specific (low-certainty evidence). The video-assisted HINTS examination (3 studies, 199 participants) was 85.0% to 100% sensitive (low-certainty evidence), and 38.9% to 100% specific (very low-certainty evidence). The clinical HINTS Plus examination (5 studies, 451 participants) was 95.3% (95% CI 78.4% to 99.1%) sensitive, and 72.9% (95% CI 44.4% to 90.1%) specific (low-certainty evidence). The video-assisted HINTS Plus examination (2 studies, 163 participants) was 85.0% to 93.8% sensitive, and 28.6% to 38.9% specific (moderate-certainty evidence). Subgroup analyses were limited, as most studies were conducted in the emergency department, by physicians, and with MRI as a reference standard. Time from symptom onset to presentation varied across studies. Three studies were at high risk of bias and three studies were at unclear risk of bias for participant selection. Three studies were at unclear risk of bias for the index test. Four studies were at unclear risk of bias for the reference standard. Two studies were at unclear risk of bias for flow and timing. One study had unclear applicability concerns for participant selection. Two studies had high applicability concerns for the index test and two studies had unclear applicability concerns for the index test. No studies had applicability concerns for the reference standard. AUTHORS' CONCLUSIONS The HINTS and HINTS Plus examinations had good sensitivity and reasonable specificity for diagnosing a central cause for AVS in the emergency department when performed by trained clinicians. Overall, the evidence was of low certainty. There were limited data for the role of video-assistance or specific subgroups. Future research should include more high-quality studies of the HINTS and HINTS Plus examination; assessment of inter-rater reliability across users; accuracy across different providers, specialties, and experience; and direct comparison with no HINTS or MRI to assess the effect on clinical care.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Gary D Peksa
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Jestin N Carlson
- Emergency Department, Allegheny Health Network, Erie, Pennsylvania, USA
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23
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Pelletier J, Koyfman A, Long B. Pearls for the Emergency Clinician: Posterior Circulation Stroke. J Emerg Med 2023; 65:e414-e426. [PMID: 37806810 DOI: 10.1016/j.jemermed.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/29/2023] [Accepted: 07/15/2023] [Indexed: 10/10/2023]
Abstract
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.
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Affiliation(s)
- Jessica Pelletier
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, Texas
| | - Brit Long
- San Antonio Uniformed Services Health Education Consortium, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas.
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Kattah JC. Concordant GRADE-3 Truncal Ataxia and Ocular Laterodeviation in Acute Medullary Stroke. Audiol Res 2023; 13:767-778. [PMID: 37887849 PMCID: PMC10604033 DOI: 10.3390/audiolres13050068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/08/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023] Open
Abstract
Background: Severe truncal ataxia associated with an inability to sit up without assistance (STA grade 3) is frequent in patients with central acute vestibular syndrome (AVS) involving the brainstem or cerebellum. When these patients have nystagmus, central HINTS excludes peripheral lesions; however, additional localization and lateralization signs are helpful, not only to resolve the peripheral versus central vestibular lesion dilemma, but to zero in on a precise lesion localization/lateralization to the lateral medulla, the most common ischemic lesion localization associated with an initially false-negative stroke MRI. Methods: This is a study of AVS patients with additional inclusion criteria: grades 2 or 3 ataxia with an eventual diagnosis of medullary stroke (MS), either involving the lateral medulla (LMS) or the medial medulla (MMS), and horizontal (h) gaze paralysis was the main exclusion criteria. All patients sat on the side of the bed or stretcher, with assistance if needed. A general neurologic examination followed in the sitting position, the testing protocol included the head impulse, spontaneous nystagmus, and skew deviation (HINTS) tests, followed by observation of the effect of brief 3-5 sec eyelid closure on ocular position, and saccade and pursuit eye movement tests. If they could sit, the protocol included the ability to stand with a wide base, then a narrow base, the Romberg test, and tandem gait. Radiographic lesion localization and horizontal gaze deviation concluded the protocol. Results: A total of 34 patients met the entry criteria, 34 MS (13 in the lateral medulla, 12 previously described, and 1 new patient), and 1 new MMS. Among them, n = 10/12 had grade 3 ataxia, and 3 (1 new patient) had grade 2 ataxia. In addition, overt ocular laterodeviation (OLD) was present in thirteen of them (35.3%). All OLD patients had gaze deviation and ipsilateral saccade and truncal lateropulsion, 1 medial medulla stroke patient had grade 3 truncal contrapulsion and contralateral hemiparesis without OLD, n = 20/21 patients with LMS without OLD had grade 3 truncal ataxia, and 1 had grade 2 truncal ataxia. Discussion: AVS patients with severe truncal ataxia (inability to sit without assistance) potentially have brainstem, cerebellum, or subcortical lesions. All patients had central HINTS; however, simultaneous direction-concordant STA 3 and OLD provided greater lateral medulla localization specificity, affecting the ipsilateral medulla. Future work to explore a practical posterior circulation stroke scale that includes HINTS, STA, and OLD will potentially select cases for thrombolysis even in the event of initially false-negative imaging.
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Affiliation(s)
- Jorge C Kattah
- College of Medicine, Neurology University of Illinois, Peoria, IL 61637, USA
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25
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Noda M, Kuroda T, Nomura A, Ito M, Yoshizaki T, Fushiki H. Smartphone-Assisted Medical Care for Vestibular Dysfunction as a Telehealth Strategy for Digital Therapy Beyond COVID-19: Scoping Review. JMIR Mhealth Uhealth 2023; 11:e48638. [PMID: 37695671 PMCID: PMC10496931 DOI: 10.2196/48638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/13/2023] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Dizziness and vertigo can be caused by various factors, such as peripheral vestibular and central disorders. Although consultations with specialists are advisable when necessary, patients with severe vertigo symptoms may have limited mobility, which may interfere with hospital visits. The spread of COVID-19 has further limited the number of hospital visits for patients with dizziness; therefore, a method of medical care that enables more accurate treatment under time and geographical constraints is needed. Telemedicine has become widespread, owing to the popularity of smartphone and tablet devices in recent years, and the use of devices and systems has made it possible to provide efficient medical care. However, no previous scoping review has mapped existing studies on telemedicine for vertigo and dizziness, and no recommendations have been made regarding which devices and systems should be used for specific diseases. OBJECTIVE The aim of this review was to map and assess previous studies on the use of information communications technology, smartphones, and apps for treating patients with vertigo and discuss the added value of introducing telemedicine to improve the quality of medical care and create an environment that builds security and trust among patients. METHODS A scoping review was conducted with the methodological framework of Arksey and O'Malley and in accordance with the of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews) guidelines. The PubMed, MEDLINE, and Cochrane Library databases were searched to retrieve previous reports on smartphone-assisted telemedicine treatment for vertigo published between January 2000 and May 2023. Two authors independently assessed eligibility and extracted data. RESULTS This review included 20 papers that reported devices or systems for telemedicine for vestibular dysfunction. Among studies that reported the use of a device or app, 2 were related to anamnesis and subjective symptoms, 12 were related to objective examination, 7 were related to remote diagnosis, and 7 were related to treatment and rehabilitation. CONCLUSIONS With the advancement of technology, the use of telemedicine in patients with dizziness may be feasible. In the future, it will be necessary to consider how telemedicine can be used in dizziness treatment and develop an effective treatment system combining in-person medical care and the effective use of devices for the management of severe vertigo and related diseases. The smooth introduction of telemedicine in vertigo treatment is expected to improve the quality of treatment, increase opportunities for patients to receive medical care, and reduce time and travel costs, leading to a sense of security and trust among patients.
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Affiliation(s)
- Masao Noda
- Department of Otolaryngology, Jichi Medical University, Shimotsuke, Japan
- Mejiro University Ear Institute Clinic, Saitama, Japan
| | - Tatsuaki Kuroda
- Mejiro University Ear Institute Clinic, Saitama, Japan
- Kuroda Ear, Nose and Throat Clinic, Kumamoto, Japan
| | - Akihiro Nomura
- College of Transdisciplinary Sciences for Innovation, Kanazawa University, Kanazawa, Japan
| | - Makoto Ito
- Department of Otolaryngology, Jichi Medical University, Shimotsuke, Japan
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Zwergal A, Mantokoudis G, Heg D, Kerkeni H, Diener S, Kalla R, Korda A, Candreia C, Welge-Lüssen A, Tarnutzer AA. What is the current status of primary care in the diagnosis and treatment of patients with vertigo and dizziness in Switzerland? A national survey. Front Neurol 2023; 14:1254080. [PMID: 37745663 PMCID: PMC10513417 DOI: 10.3389/fneur.2023.1254080] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/14/2023] [Indexed: 09/26/2023] Open
Abstract
Background Vertigo and dizziness are among the most frequent presenting symptoms in the primary care physicians' (PCPs) office. With patients facing difficulties in describing their complaints and clinical findings often being subtle and transient, the diagnostic workup of the dizzy patient remains challenging. We aimed to gain more insights into the current state of practice in order to identify the limitations and needs of the PCPs and define strategies to continuously improve their knowledge in the care of the dizzy patient. Materials and methods Board-certified PCPs working in Switzerland were invited to participate in an online survey. A descriptive statistical analysis was performed, and prospectively defined hypotheses were assessed using regression analyses. Results A vast majority of participating PCPs (n = 152) were familiar with the key questions when taking the dizzy patient's history and with performing provocation/repositioning maneuvers when posterior-canal benign paroxysmal positional vertigo (BPPV) was suspected (91%). In contrast, strong agreement that performing the alternating cover test (21%), looking for a spontaneous nystagmus with fixation removed (42%), and performing the head-impulse test (47%) were important was considerably lower, and only 19% of PCPs were familiar with lateral-canal BPPV treatment. No specific diagnosis could be reached in substantial fractions of patients with acute (35% [25; 50%], median [inter-quartile range]) and episodic/chronic (50% [40; 65.8%]) dizziness/vertigo. Referral to specialists was higher in patients with episodic/chronic dizziness than in acutely dizzy patients (50% [20.3; 75] vs. 30% [20; 50]), with younger PCPs (aged 30-40 years) demonstrating significantly increased odds of referral to specialists (odds ratio = 2.20 [1.01-4.81], p = 0.048). Conclusion The assessment of dizzy patients takes longer than that of average patients in most primary care practices. Many dizzy patients remain undiagnosed even after a thorough examination, highlighting the challenges faced by PCPs and potentially leading to frequent referrals to specialists. To address this, it is crucial to promote state-of-the-art neuro-otological examination and treatment techniques that are currently neglected by most PCPs, such as "HINTS" and lateral-canal BPPV treatment. This can help reduce referral rates allowing more targeted treatment and referrals.
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Affiliation(s)
- Andreas Zwergal
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig Maximilian University Hospital, Munich, Germany
- Department of Neurology, Ludwig Maximilian University Hospital, Munich, Germany
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dierik Heg
- Clinical Trial Unit Bern, University of Bern, Bern, Switzerland
| | - Hassen Kerkeni
- Department of Neurology, Lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Suzie Diener
- Practice Neurology St. Gallen, St. Galen, Switzerland
| | - Roger Kalla
- Department of Neurology, Lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, Lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Claudia Candreia
- Department of Otorhinolaryngology, Head and Neck Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Antje Welge-Lüssen
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Basel, Basel, Switzerland
| | - Alexander A. Tarnutzer
- Neurology, Cantonal Hospital of Baden, Baden, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
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Buizza C, Franco E, Ghilardi A. Is Biofeedback for Vertigo Effective in Ordinary Medical Centers? A Controlled Trial in Northern Italy. Appl Psychophysiol Biofeedback 2023; 48:345-354. [PMID: 37231183 PMCID: PMC10412656 DOI: 10.1007/s10484-023-09588-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2023] [Indexed: 05/27/2023]
Abstract
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.
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Affiliation(s)
- Chiara Buizza
- Department of Clinical and Experimental Sciences, University of Brescia, Viale Europa 11, Brescia, Italy.
| | - Elena Franco
- Medical Center San Francesco, Via Zadei 16, Brescia, Italy
| | - Alberto Ghilardi
- Department of Clinical and Experimental Sciences, University of Brescia, Viale Europa 11, Brescia, Italy
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Tarnutzer AA, Edlow JA. Bedside Testing in Acute Vestibular Syndrome-Evaluating HINTS Plus and Beyond-A Critical Review. Audiol Res 2023; 13:670-685. [PMID: 37736940 PMCID: PMC10514811 DOI: 10.3390/audiolres13050059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/16/2023] [Accepted: 08/28/2023] [Indexed: 09/23/2023] Open
Abstract
Acute vertigo and dizziness are frequent presenting symptoms in patients in the emergency department. These symptoms, which can be subtle and transient, present diagnostic challenges because they can be caused by a broad range of conditions that cut across many specialties and organ systems. Previous work has emphasized the value of combining structured history taking and a targeted examination focusing on subtle oculomotor signs. In this review, we discuss various diagnostic bedside algorithms proposed for the acutely dizzy patient. We analyzed these different approaches by calculating their area-under-the-curve (ROC) characteristics and sensitivity/specificity. We found that the algorithms that incorporated structured history taking and the use of subtle oculomotor signs had the highest diagnostic accuracy. In fact, both the HINTS+ bedside exam and the STANDING algorithm can more accurately diagnose acute strokes than early (<24 to 48 h after symptom onset) MRI with diffusion-weighted imaging (DWI). An important caveat is that HINTS and STANDING require moderate training to achieve this accuracy. Therefore, for physicians who have not undergone adequate training, other approaches are needed. These other approaches (e.g., ABCD2 score, PCI score, and TriAGe+ score) rely on vascular risk factors, clinical symptoms, and focal neurologic findings. While these other scores are easier for frontline providers to use, their diagnostic accuracy is far lower than HINTS+ or STANDING. Therefore, a focus on providing dedicated training in HINTS+ or STANDING techniques to frontline clinicians will be key to improving diagnostic accuracy and avoiding unnecessary brain imaging.
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Affiliation(s)
- Alexander A. Tarnutzer
- Department of Neurology, Cantonal Hospital of Baden, 5404 Baden, Switzerland
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
| | - Jonathan A. Edlow
- Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA;
- Emergency Medicine, Harvard Medical School, Boston, MA 02115, USA
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Tarnutzer AA, Gold D, Wang Z, Robinson KA, Kattah JC, Mantokoudis G, Tehrani ASS, Zee DS, Edlow JA, Newman-Toker DE. Impact of Clinician Training Background and Stroke Location on Bedside Diagnostic Test Accuracy in the Acute Vestibular Syndrome - A Meta-Analysis. Ann Neurol 2023; 94:295-308. [PMID: 37038843 PMCID: PMC10524166 DOI: 10.1002/ana.26661] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/24/2023] [Accepted: 03/30/2023] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Acute dizziness/vertigo is usually due to benign inner-ear causes but is occasionally due to dangerous neurologic ones, particularly stroke. Because symptoms and signs overlap, misdiagnosis is frequent and overuse of neuroimaging is common. We assessed the accuracy of bedside findings to differentiate peripheral vestibular from central neurologic causes. METHODS We performed a systematic search (MEDLINE and Embase) to identify studies reporting on diagnostic accuracy of physical examination in adults with acute, prolonged dizziness/vertigo ("acute vestibular syndrome" [AVS]). Diagnostic test properties were calculated for findings. Results were stratified by examiner type and stroke location. RESULTS We identified 6,089 citations and included 14 articles representing 10 study cohorts (n = 800). The Head Impulse, Nystagmus, Test of Skew (HINTS) eye movement battery had high sensitivity 95.3% (95% confidence interval [CI] = 92.5-98.1) and specificity 92.6% (95% CI = 88.6-96.5). Sensitivity was similar by examiner type (subspecialists 94.3% [95% CI = 88.2-100.0] vs non-subspecialists 95.0% [95% CI = 91.2-98.9], p = 0.55), but specificity was higher among subspecialists (97.6% [95% CI = 94.9-100.0] vs 89.1% [95% CI = 83.0-95.2], p = 0.007). HINTS sensitivity was lower in anterior cerebellar artery (AICA) than posterior inferior cerebellar artery (PICA) strokes (84.0% [95% CI = 65.3-93.6] vs 97.7% [95% CI = 93.3-99.2], p = 0.014) but was "rescued" by the addition of bedside hearing tests (HINTS+). Severe (grade 3) gait/truncal instability had high specificity 99.2% (95% CI = 97.8-100.0) but low sensitivity 35.8% (95% CI = 5.2-66.5). Early magnetic resonance imaging (MRI)-diffusion-weighted imaging (DWI; within 24-48 hours) was falsely negative in 15% of strokes (sensitivity 85.1% [95% CI = 79.2-91.0]). INTERPRETATION In AVS, HINTS examination by appropriately trained clinicians can differentiate peripheral from central causes and has higher diagnostic accuracy for stroke than MRI-DWI in the first 24-48 hours. These techniques should be disseminated to all clinicians evaluating dizziness/vertigo. ANN NEUROL 2023;94:295-308.
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Affiliation(s)
- Alexander A. Tarnutzer
- Neurology, Cantonal Hospital of Baden, Baden, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Daniel Gold
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD
| | - Zheyu Wang
- Division of Biostatistics and Bioinformatics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine
- Johns Hopkins Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD
| | - Karen A. Robinson
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD
| | | | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ali S. Saber Tehrani
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD
| | - David S. Zee
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD
| | - Jonathan A. Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
- Harvard Medical School, Boston, MA
| | - David E. Newman-Toker
- Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD
- Johns Hopkins Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD
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Wüthrich M, Wang Z, Martinez CM, Carmona S, Mantokoudis G, Tarnutzer AA. Systematic review and meta-analysis of the diagnostic accuracy of spontaneous nystagmus patterns in acute vestibular syndrome. Front Neurol 2023; 14:1208902. [PMID: 37396773 PMCID: PMC10312004 DOI: 10.3389/fneur.2023.1208902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 06/05/2023] [Indexed: 07/04/2023] Open
Abstract
Objectives For the assessment of patients presenting with acute prolonged vertigo meeting diagnostic criteria for acute vestibular syndrome (AVS), bedside oculomotor examinations are essential to distinguish peripheral from central causes. Here we assessed patterns of spontaneous nystagmus (SN) observed in AVS and its diagnostic accuracy at the bedside. Methods MEDLINE and Embase were searched for studies (1980-2022) reporting on the bedside diagnostic accuracy of SN-patterns in AVS patients. Two independent reviewers determined inclusion. We identified 4,186 unique citations, examined 219 full manuscripts, and analyzed 39 studies. Studies were rated on risk of bias (QUADAS-2). Diagnostic data were extracted and SN beating-direction patterns were correlated with lesion locations and lateralization. Results Included studies reported on 1,599 patients, with ischemic strokes (n = 747) and acute unilateral vestibulopathy (n = 743) being most frequent. While a horizontal or horizontal-torsional SN was significantly more often found in peripheral AVS (pAVS) than in central AVS (cAVS) patients (672/709 [94.8%] vs. 294/677 [43.4%], p < 0.001), torsional and/or vertical SN-patterns were more prevalent in cAVS than in pAVS (15.1 vs. 2.6%, p < 0.001). For an (isolated) vertical/vertical-torsional SN or an isolated torsional SN specificity (97.7% [95% CI = 95.1-100.0%]) for a central origin etiology was high, whereas sensitivity (19.1% [10.5-27.7%]) was low. Absence of any horizontal SN was more frequently observed in cAVS than in pAVS (55.2 vs. 7.0%, p < 0.001). Ipsilesional and contralesional beating directions of horizontal SN in cAVS were found at similar frequency (28.0 vs. 21.7%, p = 0.052), whereas for pAVS a contralesional SN was significantly more frequent (95.2 vs. 2.5%, p < 0.001). For PICA strokes presenting with horizontal SN, beating direction was ipsilesional more often than contralesional (23.9 vs. 6.4%, p = 0.006), while the opposite was observed for AICA strokes (2.2 vs. 63.0%, p < 0.001). Conclusions (Isolated) vertical and/or torsional SN is found in a minority (15.1%) of cAVS patients only. When present, it is highly predictive for a central cause. A combined torsional-downbeating SN-pattern may be observed in pAVS also in cases with isolated lesions of the inferior branch of the vestibular nerve. Furthermore, in cAVS patients the SN beating direction itself does not allow a prediction on the lesion side.
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Affiliation(s)
| | - Zheyu Wang
- Division of Quantitative Sciences, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | | | - Sergio Carmona
- Fundación San Lucas para la Neurosciencia, Rosario, Argentina
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander Andrea Tarnutzer
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
- Department of Neurology, Cantonal Hospital of Baden, Baden, Switzerland
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Du EHY, Tenenbaum MN, Bhadelia RA, Sotman TE, Edlow JA, Selim MH, Chang YM. Major radiological outcomes of CTA head and neck performed for dizziness in a major academic Emergency Department. Neuroradiol J 2023; 36:259-266. [PMID: 36045600 PMCID: PMC10268097 DOI: 10.1177/19714009221124304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Elizabeth HY Du
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mary N Tenenbaum
- Department of Radiology, Baystate Medical Center, Springfield, MA, USA
| | - Rafeeque A Bhadelia
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Timothy E Sotman
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Magdy H Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Yu-Ming Chang
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Edlow JA, Carpenter C, Akhter M, Khoujah D, Marcolini E, Meurer WJ, Morrill D, Naples JG, Ohle R, Omron R, Sharif S, Siket M, Upadhye S, E Silva LOJ, Sundberg E, Tartt K, Vanni S, Newman-Toker DE, Bellolio F. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. Acad Emerg Med 2023; 30:442-486. [PMID: 37166022 DOI: 10.1111/acem.14728] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/14/2023] [Indexed: 05/12/2023]
Abstract
This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").
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Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christopher Carpenter
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Emergency Medicine, Washington University, St. Louis, Missouri, USA
| | - Murtaza Akhter
- Department of Emergency Medicine, Penn State School of Medicine, State College, Pennsylvania, USA
- Hershey Medical Center, State College, Pennsylvania, USA
| | - Danya Khoujah
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Adventhealth Tampa, Tampa, Florida, USA
| | - Evie Marcolini
- Department of Emergency Medicine, Geisel School of Medicine, Dartmouth, Hanover, New Hampshire, USA
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - James G Naples
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Otolaryngology-Head & Neck Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Robert Ohle
- Department of Emergency Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
- Health Science North Research Institute, Sudbury, Ontario, Canada
- Department of Emergency Medicine, Health Sciences North, Sudbury, Ontario, Canada
| | - Rodney Omron
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sameer Sharif
- Division of Critical Care and Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Matt Siket
- Department of Emergency Medicine, Robert Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
- Department of Emergency Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Suneel Upadhye
- Emergency Medicine, Evidence and Impact (HEI), McMaster University, Burlington, Ontario, Canada
- Health Research Methods, Evidence and Impact (HEI), McMaster University, Burlington, Ontario, Canada
| | - Lucas Oliveira J E Silva
- Mayo Clinic, Rochester, Minnesota, USA
- Department of Emergency Medicine, Hospital de Clinicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Etta Sundberg
- COO Royal Oasis Pool and Spas, Las Vegas, Nevada, USA
| | - Karen Tartt
- Absinthe Brasserie & Bar, San Francisco, California, USA
- St. George Spirits, San Francisco, California, USA
| | - Simone Vanni
- Department of Emergency Medicine, University of Florence, Firenze, Italy
- Department of Emergency Medicine, University Hospital Careggi, Firenze, Italy
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fernanda Bellolio
- Mayo Clinic College of Medicine, Rochester, Minnesota, USA
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Lin G, Liu F, Xu H, Bao G. Development of a model to predict the risk of cerebral infarction in acute vestibular syndrome. Heliyon 2023; 9:e14852. [PMID: 37095950 PMCID: PMC10121405 DOI: 10.1016/j.heliyon.2023.e14852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 03/06/2023] [Accepted: 03/20/2023] [Indexed: 04/26/2023] Open
Abstract
Objectives This study aimed to develop a model to predict the risk of cerebral infarction in acute vestibular syndrome and assist emergency physicians in quickly identifying patients with cerebral infarction. Materials and methods We looked at 262 patients who were split into cerebral infarction and peripheral vertigo groups. Stepwise regression and Lasso's approach were used to screen for variables, and Boothstrap's method was used to evaluate the model's discrimination and calibration. The model's performance was compared against TriAGe+, ABCD2, and PCI scores using the area under the receiver operator characteristic curve. Clinical decision-making was aided by the use of clinical impact and decision curves. Results In the end, nine risk factors were chosen for model 2, and ten risk factors were chosen for model 1. Model 2 was adopted as the final model. The areas under the receiver operator curve value of the model2 were 0.910(P = 0.000), much higher than the areas under the receiver operator curve value of the TriAGe + scores system and that of the PCI scores system. The clinical decision curve shows that when the threshold probability is 0.05, using the nomogram to predict cerebral infarction has more benefits than either the treat-all-patients scheme or the treat-none scheme. The clinical impact curve shows that when the threshold probability is 0.6 the model predicts disease occurrence in general agreement with the occurrence of the real disease. Conclusion This study model can help emergency room physicians quickly triage and treat patients by accurately identifying cerebral infarction patients.
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Affiliation(s)
- Guiming Lin
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Mohe Road280, Baoshan District, Shanghai, China
| | - Fangfang Liu
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Mohe Road280, Baoshan District, Shanghai, China
| | - Hengshi Xu
- Department of Blood Transfusion, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Mohe Road280, Baoshan District, Shanghai, China
- Corresponding author. Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Mohe Road280, Baoshan District, Shanghai, China.
| | - Guanshui Bao
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Mohe Road280, Baoshan District, Shanghai, China
- Corresponding author. Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Mohe Road280, Baoshan District, Shanghai, China.
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Neely P, Patel H, McTaggart J, Bright S, Wellings T. EVESTA: Emergency VESTibular Algorithm and its impact on the acute management of benign paroxysmal positional vertigo. Emerg Med Australas 2023; 35:312-318. [PMID: 36344257 DOI: 10.1111/1742-6723.14124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 10/13/2022] [Accepted: 10/13/2022] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Prue Neely
- Physiotherapy Department, Central Coast Local Health District, Hamlyn Terrace, New South Wales, Australia
- Emergency Department, Central Coast Local Health District, Hamlyn Terrace, New South Wales, Australia
| | - Hemal Patel
- Emergency Department, Central Coast Local Health District, Hamlyn Terrace, New South Wales, Australia
- School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | | | - Stephen Bright
- Emergency Department, Central Coast Local Health District, Hamlyn Terrace, New South Wales, Australia
| | - Tom Wellings
- Department of Neurology, Hunter New England Local Health District, Newcastle, New South Wales, Australia
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Comolli L, Korda A, Zamaro E, Wagner F, Sauter TC, Caversaccio MD, Nikles F, Jung S, Mantokoudis G. Vestibular syndromes, diagnosis and diagnostic errors in patients with dizziness presenting to the emergency department: a cross-sectional study. BMJ Open 2023; 13:e064057. [PMID: 36963793 PMCID: PMC10040076 DOI: 10.1136/bmjopen-2022-064057] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 03/14/2023] [Indexed: 03/26/2023] Open
Abstract
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.
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Affiliation(s)
- Lukas Comolli
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Ewa Zamaro
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Franca Wagner
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marco D Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Florence Nikles
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
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Liberman AL, Holl JL, Romo E, Maas M, Song S, Prabhakaran S. Risk assessment of the acute stroke diagnostic process using failure modes, effects, and criticality analysis. Acad Emerg Med 2023; 30:187-195. [PMID: 36565234 DOI: 10.1111/acem.14648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 12/03/2022] [Accepted: 12/21/2022] [Indexed: 12/25/2022]
Abstract
INTRODUCTION To date, many emergency department (ED)-based quality improvement studies and interventions for acute stroke patients have focused on expediting time-sensitive treatments, particularly reducing door-to-needle time. However, prior to treatment, a diagnosis of stroke must be reached. The ED-based stroke diagnostic process has been understudied despite its importance in assuring high-quality and safe care. METHODS We used a learning collaborative to conduct a failure modes, effects, and criticality analysis (FMECA) of the acute stroke diagnostic process at three health systems in Chicago, IL. Our FMECA was designed to prospectively identify, characterize, and rank order failures in the systems and processes of care that offer opportunities for redesign to improve stroke diagnostic accuracy. Multidisciplinary teams involved in stroke care at five different sites participated in moderated sessions to create an acute stroke diagnostic process map as well as identify failures and existing safeguards. For each failure, a risk priority number and criticality score were calculated. Failures were then ranked, with the highest scores representing the most critical failures to be targeted for redesign. RESULTS A total of 28 steps were identified in the acute stroke diagnostic process. Iterative steps in the process include information gathering, clinical examination, interpretation of diagnostic test results, and reassessment. We found that failure to use existing screening scales to identify patients with large-vessel occlusions early on in their ED course ranked highest. Failure to obtain an accurate history of the index event, failure to suspect acute stroke in triage, and failure to use established stroke screening tools at ED arrival to identify potential stroke patients were also highly ranked. CONCLUSIONS Our study results highlight the critical importance of upstream steps in the acute stroke diagnostic process, particularly the use of existing tools to identify stroke patients who may be eligible for time-sensitive treatments.
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Affiliation(s)
- Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Jane L Holl
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Elida Romo
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Matthew Maas
- Department of Neurology, Northwestern University, Chicago, Illinois, USA
| | - Sarah Song
- Department of Neurology, Rush University, Chicago, Illinois, USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
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Fattal D, Platti N. Ocular lateral deviation as a vestibular sign to improve detection of posterior circulation strokes: A review of the literature. J Emerg Med 2023; 64:610-619. [PMID: 37037761 DOI: 10.1016/j.jemermed.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 01/28/2023] [Accepted: 02/17/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Posterior circulation stroke can present with dizziness/vertigo without other general neurological symptoms or signs, making it difficult to detect, and missed stroke can deteriorate. Therefore, a sign that can be easily identified during an examination would be helpful to improve the detection of this type of stroke. OBJECTIVE The objective of this review is to highlight an ocular sign that is seen in posterior circulation strokes called ocular lateral deviation (OLD). OLD is mostly seen in dorsolateral medullary strokes, and it is also seen in pontine and cerebellar strokes. OLD is detected by asking a patient to look straight ahead and then briefly close their eyes. Upon re-opening their eyes, the examiner will see that the eyes have deviated to one side; the patient's eyes will then make corrective saccade(s) to return to looking straight ahead. Complete eye deviation is a central sign of posterior circulation stroke. DISCUSSION OLD is an under-recognized vestibular ocular sign of central vestibulopathies including posterior circulation stroke. The most common location is in the dorsolateral medulla, where one-third of such strokes have complete OLD. Eye deviation can also be appreciated on computed tomography or magnetic resonance imaging. OLD can be detected up to 6 months after a posterior circulation stroke. CONCLUSIONS Checking for the sign of complete eye deviation in patients with dizziness/vertigo could be a simple, quick method for detecting posterior circulation stroke, and a means to improving the patients' outcome.
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Affiliation(s)
- Deema Fattal
- Neurology Department, University of Iowa Health Care, Iowa City, Iowa; Iowa City VA Medical Center, Iowa City, Iowa
| | - Nicole Platti
- University of Iowa Carver College of Medicine, Iowa City, Iowa; (Present Institution) Neurology Department, University of South Florida, Tampa, Florida
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Monak AA, Kaileva NA, Kulesh AA, Guseva AL, Usmanov VB, Parfenov VA. Labyrinthine infarction as a cause of acute cochleovestibular syndrome. NEUROLOGY, NEUROPSYCHIATRY, PSYCHOSOMATICS 2023. [DOI: 10.14412/2074-2711-2023-1-71-76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Affiliation(s)
- A. A. Monak
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
| | - N. A. Kaileva
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
| | - A. A. Kulesh
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia; City Clinical Hospital Four
| | - A. L. Guseva
- N.I. Pirogov Russian National Research Medical University, Ministry of Health of Russia
| | - V. B. Usmanov
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
| | - V. A. Parfenov
- Department of Nervous Diseases and Neurosurgery, N.V. Sklifosovsky Institute of Clinical Medicine, I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
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Effects of saccade delay, side of deficit, and training on detection of catch-up saccades during head-impulse test in virtual-reality-enhanced mannequin. Sci Rep 2023; 13:2718. [PMID: 36792772 PMCID: PMC9931711 DOI: 10.1038/s41598-023-29801-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 02/10/2023] [Indexed: 02/17/2023] Open
Abstract
In this study, a training simulator for the examination of dizzy patients based on a virtual-reality-enhanced mannequin (VREM) was developed to evaluate the detection of catch-up saccades during head impulse test (HIT) and the effect of training in VREM. For novices (n = 35), 2 trials were conducted before and after a training session. Experts (n = 7) were submitted to an evaluation session. In each trial, a left or a right horizontal canal deficit with an overt catch-up saccade (delay between 110 and 320 ms) was randomly presented. Participants scored the difficulty in performing the maneuver, in recognizing the saccades, and the self-confidence in the diagnosis using a visual analogue scale (VAS). Saccade delay significantly influenced the performance. Training significantly improved the sensitivity in the residents (69.1% before to 97.9% after the training, p < 0.001, Fisher's exact test, n = 560 tests), surpassing experts' performances (p < 0.001, versus 87% in experts, Fisher's exact test). The specificity also increased to the expert level (78% before to 95% after the training, and 95% in experts, p < 0.001, Fisher's exact test). The VAS showed a decrease difficulty to execute the HIT, with an increase in the confidence after training. VREM improved the HIT execution performance and the confidence in novice practitioners.
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Lee SH, Kim JM, Kim JT, Tarnutzer AA. Video head impulse testing in patients with isolated (hemi)nodular infarction. Front Neurol 2023; 14:1124217. [PMID: 36814996 PMCID: PMC9939438 DOI: 10.3389/fneur.2023.1124217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/18/2023] [Indexed: 02/08/2023] Open
Abstract
Background Isolated (hemi)nodular strokes as underlying cause of acute dizziness are rare, thus there are still gaps of knowledge in the clinical presentation of affected patients. Clinical and experimental evidence has suggested that lesions involving the nodulus lead to various vestibulo-ocular deficits including prolonged velocity-storage, periodic-alternating nystagmus, positional nystagmus, abolished suppression of post-rotatory nystagmus by head-tilt and impaired verticality perception. At the bedside, the angular vestibulo-ocular reflex (aVOR), as assessed by the horizontal head-impulse test (HIT), has been reported to be normal, however quantitative assessments of all six semicircular canals are lacking. Objective The primary aim of this case series was to characterize the spectrum of clinical presentations in isolated (hemi)nodular strokes. Furthermore, based on preliminary observations, we hypothesized that the aVOR is within normal limits in isolated nodular strokes. Methods We retrospectively included patients with isolated (hemi)nodular stroke on diffusion-weighted MR-imaging from a prospective stroke-registry. All patients received a standardized bedside neuro-otological assessment and quantitative, video-based HIT (vHIT) of all six semicircular canals. Overall ratings of vHIT (normal vs. abnormal function) were performed independently by two reviewers and disagreements were resolved. Results Between January 2015 and December 2021 six patients with isolated nodular (n = 1) or heminodular (n = 5) ischemic stroke were included. Clinical presentation met diagnostic criteria for acute vestibular syndrome (AVS) in 5/6 patients and for episodic vestibular syndrome (EVS) in 1/6 patients. Ocular motor abnormalities observed included the presence of spontaneous horizontal nystagmus (n = 2), positional nystagmus (5/6), head-shaking nystagmus (3/6), skew deviation (n = 1), and moderate or severe truncal ataxia (5/6). Bedside HIT was normal in all patients and no gaze-evoked or periodic alternating nystagmus was observed. aVOR-gains were within normal range in all patients and overall aVOR-function as assessed by vHIT was rated as normal in all six patients. Conclusions Using quantitative, video-based testing of the horizontal and vertical aVOR, preserved integrity of the aVOR in (hemi)nodular strokes was confirmed, extending preliminary findings at the bedside. Furthermore, widespread deficits of both ocular stability, postural control and volitional eye movements were observed in our study cohort, being consistent with findings reported in previous studies.
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Affiliation(s)
- Seung-Han Lee
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Jae-Myung Kim
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Alexander Andrea Tarnutzer
- Department of Neurology, Cantonal Hospital, Baden, Switzerland,Faculty of Medicine, University of Zurich, Zurich, Switzerland,*Correspondence: Alexander Andrea Tarnutzer ✉
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Yao K, Zu HB. Isolated transient vertigo due to TIA: challenge for diagnosis and therapy. J Neurol 2023; 270:769-779. [PMID: 36371598 DOI: 10.1007/s00415-022-11443-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 11/13/2022]
Abstract
As a prevalent vertigo disease in the clinic, isolated transient vertigo can present as a vertigo episode without focal signs and always free of symptoms on presentation. Previous studies showed a part of isolated transient vertigo events had a high risk of stroke during follow-up. However, how to discern posterior circulation ischemia become a great challenge for clinicians, especially in emergency, neurology, and ENT departments. Routine besides, hematological, and imaging examinations are often difficult provide a clear etiological diagnosis. Hence, this article reviews current knowledge about the epidemiology, risk factors, offending lesions, and clinical manifestation of transient ischemic attack (TIA) presenting as isolated transient vertigo. In addition, we summarize several advances in besides examinations, serum biomarkers, and imaging technologies to better identify stroke events. Finally, the current situation of therapy was briefly retrospected. Here we present a critical clinical puzzle that needs to be solved in the future. Of note, there is a still lack of high-quality studies in this field. The article reviews the keys to the diagnosis of isolated transient vertigo due to TIA and provides us with more methods to screen for high-risk stroke populations.
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Affiliation(s)
- Kai Yao
- Department of Neurology, Jinshan Hospital Affiliated to Fudan University, No. 1508 Longhang Road, Jinshan District, Shanghai, 201508, China
| | - Heng-Bing Zu
- Department of Neurology, Jinshan Hospital Affiliated to Fudan University, No. 1508 Longhang Road, Jinshan District, Shanghai, 201508, China.
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Gerlier C, Fels A, Vitaux H, Mousset C, Perugini A, Chatellier G, Ganansia O. Effectiveness and reliability of the four-step STANDING algorithm performed by interns and senior emergency physicians for predicting central causes of vertigo. Acad Emerg Med 2023; 30:487-500. [PMID: 36628557 DOI: 10.1111/acem.14659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/20/2022] [Accepted: 01/06/2023] [Indexed: 01/12/2023]
Abstract
BACKGROUND For emergency physicians (EPs), acute vertigo is a challenging complaint and learning a reliable clinical approach is needed. STANDING is a four-step bedside algorithm that requires (1) identifying spontaneous nystagmus with Frenzel glasses or, alternatively, a positional nystagmus; (2) characterizing the nystagmus direction; (3) assessing the vestibuloocular reflex (head impulse test); and (4) assessing the gait. The objective was to determine its accuracy for diagnosing central vertigo when using by naïve examiners as such as interns and its agreement with senior EPs. METHODS This was a prospective 1-year diagnostic cohort study among patients with vertigo, vestibulovisual symptoms, or postural symptoms seen by 20 interns trained in the four-step examination. The algorithm was performed first by an intern and second by a senior EP and categorized as either worrisome when indicating a central diagnosis and benign or inconclusive when indicating a peripheral diagnosis. The reference test was diffusion-weighted brain magnetic resonance imaging. RESULTS Among 312 patients included, 57 had a central diagnosis including 33 ischemic strokes (10.5%). The main etiology was benign paroxysmal positional vertigo (32.7%). The likelihood ratios were 4.63 and 10.33 for a worrisome STANDING, 0.09 and 0.01 for a benign STANDING, and 0.21 and 0.35 for an inconclusive STANDING, for interns and senior EPs, respectively. The algorithm showed sensitivities of 84.8% (95% CI 75.6%-93.9%) and 89.8% (95% CI 82.1%-97.5%), negative predictive values of 96.2% (95% CI 93.7%-98.6%) and 97.5% (95% CI 95.5%-99.5%), specificities of 88.9% (95% CI 85.1%-92.8%) and 91.3% (95% CI 87.8%-94.8%), and positive predictive values of 64.1% (95% CI 53.5%-74.8%) and 70.7% (95% CI 60.4%-81.0%), respectively. The agreement between interns and senior EPs was very substantial (B-statistic coefficient: 0.77) and almost perfect for each step: (1) 0.87, (2) 0.98, (3) 0.95, and (4) 0.99. CONCLUSIONS With a single training session, the algorithm reached high accuracy and reliability for ruling out central causes of vertigo in the hands of both novices and experienced EPs. A future multicenter randomized controlled trial should further its impact on unnecessary neuroimaging use and patient's satisfaction.
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Affiliation(s)
- Camille Gerlier
- Department of Emergency, Paris Saint Joseph Hospital Group, Paris, France
| | - Audrey Fels
- Department of Clinical Research, Paris Saint Joseph Hospital Group, Paris, France
| | - Hélène Vitaux
- Department of Otolaryngology, Paris Saint Joseph Hospital Group, Paris, France
| | - Carole Mousset
- Department of Otolaryngology, Paris Saint Joseph Hospital Group, Paris, France
| | - Alberto Perugini
- Department of Emergency, Paris Saint Joseph Hospital Group, Paris, France
| | - Gilles Chatellier
- Department of Clinical Research, Paris Saint Joseph Hospital Group, Paris, France.,University of Paris-Cité, Paris, France
| | - Olivier Ganansia
- Department of Emergency, Paris Saint Joseph Hospital Group, Paris, France
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Nouini A, Mat Q, Van Nechel C, Bostan A, Dachy B, Ourtani A. Diagnosis of dizziness in the emergency department: A 1-year prospective single-center study. J Vestib Res 2023; 33:195-202. [PMID: 36911955 DOI: 10.3233/ves-220109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
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.
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Affiliation(s)
- Adrâa Nouini
- Department of Neurology, Centre Hospitalier Universitaire Brugmann, ULB, Brussels, Belgium
| | - Quentin Mat
- Department of Otorhinolaryngology, Centre Hospitalier Universitaire Charleroi, Charleroi, Belgium
| | | | - Alionka Bostan
- Department of Neurology, Centre Hospitalier Universitaire Brugmann, ULB, Brussels, Belgium
| | - Bernard Dachy
- Department of Neurology, Centre Hospitalier Universitaire Brugmann, ULB, Brussels, Belgium
| | - Anissa Ourtani
- Department of Neurology, Centre Hospitalier Universitaire Brugmann, ULB, Brussels, Belgium
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Kim YS, Tehrani ASS, Lee HS. Sudden unilateral hearing loss and vertigo following isolated cerebellar hypoperfusion without infarction due to vertebral artery dissection. BMC Neurol 2022; 22:489. [PMID: 36536304 PMCID: PMC9762102 DOI: 10.1186/s12883-022-03024-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The definition of sudden sensorineural hearing loss (SSNHL) is broadly accepted as acute sensorineural hearing loss of more than 30 dB over at least three consecutive frequencies in a pure-tone audiogram (PTA). Acute audiovestibular loss is common with ischaemic stroke in the territory of the anterior inferior cerebellar artery (AICA). However, cases in which SSNHL and vertigo occur with hypoperfusion alone are very rare. We describe a patient who developed unilateral SSNHL and vertigo as initial symptoms caused by cerebellar hypoperfusion by vertebral artery (VA) dissection without the occurrence of infarction. CASE PRESENTATION A 51-year-old man suddenly developed acute hearing loss (AHL) in his left ear and vertigo. On neurological examination, he had vibration-induced right-beating nystagmus and left-beating nystagmus after a head-shaking test. Additionally, he had apogeotropic nystagmus during head turns to either side. The head impulse test (HIT) was normal. PTA showed mild unilateral SSNHL in the left ear. Diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) showed territorial perfusion deficits in the left posterior inferior cerebellar artery (PICA) and anterior inferior cerebellar artery (AICA) without infarction. Two months later, the patient had no vertigo but still had hearing impairment in his left ear. A follow-up PTA documented persistent unilateral SSNHL in the left ear. Additionally, perfusion computed tomography (CT) showed that perfusion deficits remained in the left cerebellum along the PICA and AICA territories. CONCLUSIONS Our case highlights a case of AHL and vertigo presented by isolated cerebellar hypoperfusion without infarction. It is necessary to consider the possibility of a central cause in patients with AHL and vertigo, and it is important to confirm this possibility through brain magnetic resonance imaging (MRI), including PWI, and magnetic resonance angiography (MRA).
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Affiliation(s)
- Young Seo Kim
- Department of Neurology, Institute of Wonkwang Medical Science, Wonkwnag University School of Medicine, Iksan, South Korea ,grid.413112.40000 0004 0647 2826Department of Neurology, Jeonbuk Regional Cardiocerebrovascular Center, Wonkwang University Hospital, 895 Muwang-ro, Iksan, Jeollabuk-do 54538 South Korea
| | - Ali S. Saber Tehrani
- grid.21107.350000 0001 2171 9311Department of Neurology, Division of Neuro-Visual and Vestibular Disorders, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Hak Seung Lee
- Department of Neurology, Institute of Wonkwang Medical Science, Wonkwnag University School of Medicine, Iksan, South Korea ,grid.413112.40000 0004 0647 2826Department of Neurology, Jeonbuk Regional Cardiocerebrovascular Center, Wonkwang University Hospital, 895 Muwang-ro, Iksan, Jeollabuk-do 54538 South Korea
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Alfarghal M, Algarni MA, Sinha SK, Nagarajan A. VOR gain of lateral semicircular canal using video head impulse test in acute unilateral vestibular hypofunction: A systematic review. Front Neurol 2022; 13:948462. [PMID: 36570452 PMCID: PMC9773140 DOI: 10.3389/fneur.2022.948462] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 11/11/2022] [Indexed: 12/13/2022] Open
Abstract
Introduction Acute unilateral vestibular hypofunction is characterized by sudden onset of vertigo or dizziness, vomiting/nausea, gait instability, and nystagmus. This is commonly described as an acute vestibular syndrome and usually attributed to vestibular neuritis; however, up to 25% of acute vestibular syndrome is caused by a stroke of posterior circulations. The video head impulse test is a recent tool in the vestibular test battery that assesses the vestibule-ocular reflex by measuring the VOR gain and recording overt and covert saccades, these findings have been found to be helpful in the diagnosis of various vestibular disorders. Method A literature search was conducted in databases, including PubMed Central, PubMed, and Web of Science. All the articles that define video head impulse test (vHIT), acute vestibular hypofunction, and vestibular neuritis were considered for the preliminary search. No limits were placed on the date of publication. The searches were limited to studies with full-text availability, published in English, and including human subjects. Search words such as "head impulse test," "video head impulse test," "vestibular ocular reflex," "acute vestibular syndrome," "acute vestibular hypofunction," "vestibular neuritis," and "vHIT in central vestibular disorders" were entered into different databases in different combinations using boolean operators such as AND, OR, and NOT. Results Searches across different databases, including Web of Science, PubMed Central, and PubMed, resulted in a total of 1,790 articles. Title screening was done for all the articles. Out of the 1,790 articles, we found that 245 articles were related to vestibular hypofunction i.e., 1,545 articles were removed at this stage. A further 56 duplicate articles were removed. This led to a final screening of 189 articles. The exclusion criteria included unavailability of full text, studies reported in languages other than English, case reports, reviews, and articles including participants having other comorbid conditions. This final screening led to 133 articles being excluded, which led to the full-text screening of 56 articles. After screening the full-text articles as per the eligibility criteria, 21 articles were found to be eligible for the systematic review. Among the remaining studies, six articles were excluded due to different specific reasons. A total of 15 articles were included in this systematic review. The mean VOR gain for the patients with vestibular neuritis was 0.48 ± 0.14 for the ipsilesional ear, whereas the mean VOR gain was > 0.80 in the contralesional ear for all the patients with acute vestibular neuritis. In patients with PICA lesions, the VOR gain for the ipsilesional ear was 0.90 (range 0.87-0.94) and for the contralesional ear was 0.88 (range 0.84-0.93). In patients with AICA lesions, the mean VOR gain was variable. Based on the above mean VOR gain findings, the authors propose the following adjective description scale of VOR of the lateral canal using vHIT: normal VOR gain above 0.80, mild VOR gain loss for 0.70-0.79, moderate loss for 0.69-0.4, severe loss for 0.39-0.2, and profound loss for < 0.2.
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Affiliation(s)
- Mohamad Alfarghal
- Otorhinolaryngology - Head and Neck Section, Surgery Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia,*Correspondence: Mohamad Alfarghal
| | - Mohammed Abdullah Algarni
- Otorhinolaryngology - Head and Neck Section, Surgery Department, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
| | - Sujeet Kumar Sinha
- Department of Audiology, All India Institute of Speech and Hearing, Mysore, India
| | - Aishwarya Nagarajan
- Department of Audiology, All India Institute of Speech and Hearing, Mysore, India
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Shah VP, Oliveira J E Silva L, Farah W, Seisa MO, Balla AK, Christensen A, Farah M, Hasan B, Bellolio F, Murad MH. Diagnostic accuracy of the physical examination in emergency department patients with acute vertigo or dizziness: A systematic review and meta-analysis for GRACE-3. Acad Emerg Med 2022; 30:552-578. [PMID: 36453134 DOI: 10.1111/acem.14630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 11/07/2022] [Accepted: 11/07/2022] [Indexed: 12/03/2022]
Abstract
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.
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Affiliation(s)
| | - Lucas Oliveira J E Silva
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA.,Department of Emergency Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Wigdan Farah
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamed O Seisa
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | | | - April Christensen
- Department of Medicine, Division of Community Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Magdoleen Farah
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Bashar Hasan
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, Minnesota, USA
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Wang Y, Zha H. Neuroimaging for differential diagnosis of transient neurological attacks. Brain Behav 2022; 12:e2780. [PMID: 36350080 PMCID: PMC9759151 DOI: 10.1002/brb3.2780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/04/2022] [Accepted: 09/14/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Rapid yet comprehensive neuroimaging protocols are required for patients with suspected acute stroke. However, stroke mimics can account for approximately one in five clinically diagnosed acute ischemic strokes and the rate of thrombolyzed mimics can be as high as 17%. Therefore, to accurately determine the diagnosis and differentiate mimics from true transient ischemic attacks, acute ischemic stroke is a challenge to every clinician. DISCUSSION Medical history and neurological examination, noncontract head computed tomography, and routine magnetic resonance imaging play important roles in the assessment and management of patients with transient neurological attacks in the emergency department. This review attempts to summarize how neuroimaging can be utilized to help differentiate the most common mimics from transient ischemic attack and acute ischemic stroke. CONCLUSION Although imaging can help direct critical triage decisions for intravenous thrombolysis or endovascular therapy, more detailed medical history and neurological examination are crucial for making a prompt and accurate diagnosis for transient neurological attack patients.
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Affiliation(s)
- Ying Wang
- Department of Neurology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Hao Zha
- Department of Reproductive and Genetics, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
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Posterior circulation stroke diagnosis in unselected group of acutely dizzy patients. Clin Neurol Neurosurg 2022; 224:107541. [PMID: 36493551 DOI: 10.1016/j.clineuro.2022.107541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/13/2022] [Accepted: 11/23/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUNDS Diagnostics of a posterior circulation ischemia (POCI) in patients with acute vertigo is a challenging task. Recently, the combination of HINTS (Head Impulse, Nystagmus and Test of Skew) exam and ABCD2 has been recommended to identify stroke in these patients. Until now, studies regarding HINTS have mostly been tested on preselected patient groups and their results are only partially applicable to real clinical practice. AIMS To compare the sensitivity and specificity of HINTS and ABCD2 and their combination in unselected acutely dizzy patients in the emergency department (ED) toward posterior circulation stroke detection. METHODS A prospective cross-sectional monocentric study in ED patients with acute onset of dizziness lasting less than 72 h. Their clinical characteristics, HINTS, vascular risk factors, ABCD2 scores and neuroimaging data were analyzed. RESULTS 140 patients were recruited. Acute stroke was identified by MRI in 39 patients. All patients had central pattern nystagmus, skew deviation or further focal neurological finding. The age (≥60) and arterial hypertension clearly distinguished stroke and non-stroke group (p < 0001). The sensitivity of HINTS, ABCD2 and their combination in the unselected group was high (82,1 - 97,4%), but specificity low. After removing patients with inconclusive diagnosis, including transitory ischemic attack, specificity was much higher and comparable to previously published results. CONCLUSIONS The sensitivity and specificity of HINTS in previously published studies may vary because of their selection criteria. Even though, our study was performed on the unselected patient cohort, combination of HINTS and ABCD2 remained highly sensitive in detecting POCI and outperformed each of these tests alone.
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Wang Y, Huang Y, Li S, Lin J, Liu Y, Gao Y, Zhao J. The value of circulating lymphocytic subpopulations in the diagnosis and repair of ischemic stroke patients with dizziness. Front Aging Neurosci 2022; 14:1042123. [PMID: 36408111 PMCID: PMC9670111 DOI: 10.3389/fnagi.2022.1042123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022] Open
Abstract
Background To determine whether dizziness can contribute to stroke as a main cause still remains challenging. This study aims to explore clinical biomarkers in the identification of ischemic stroke patients from people with dizziness and the prediction of their long-term recovery. Methods From January 2018 to June 2019, 21 ischemic stroke patients with a main complaint of dizziness, 84 non-stroke dizziness patients and 87 healthy volunteers were recruited in this study. Then, their peripheral blood samples were collected, and the percentages of circulating lymphocytes T cells, CD4+ T cells, CD8+ T cells, T−/− cells (DNTs), CD4+ regulatory T cells (Tregs), CD8+ Tregs, B cells and regulatory B cells (Bregs) were examined to identify biomarkers with clinical value. Results According to our data, a significant difference in the DNTs proportion was detected between non-stroke dizziness and ischemic stroke patients with dizziness (p = 0.0009). The Bregs proportion in ischemic stroke patients with dizziness was lower than that in non-stroke dizziness patients (p = 0.035). In addition, the percentage of Bregs and DNTs within lymphocytes in patients’ peripheral blood exhibited a significant negative correlation with stroke occurrence (Bregs, p = 0.039; DNTs, p = 0.046). Moreover, the Bregs and DNTs within lymphocytes were negatively related to participants’ age, while presented a weak relationship with clinical risks like smoking, hypertension, and diabetes. Then, area under the receiver operating characteristic curve (AUC) of Bregs and DNTs together was 0.768, the risk factors and Bregs or DNTs ranged from 0.795 and 0.792, respectively, and the AUC value of risk factors, Bregs and DNTs combination was further increased to 0.815. Furthermore, the Bregs percentage within lymphocytes at admission was also a potential predictor of repair at discharge and the following 3 months. Conclusion Bregs and DNTs could be the clinical biomarkers together in the identification of ischemic stroke patients from people with dizziness.
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Affiliation(s)
- Yong Wang
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, China
| | - Yichen Huang
- State Key Laboratory of Medical Neurobiology, MOE Frontier Center for Brain Science, and Institutes of Brain Science, Fudan University, Shanghai, China
| | - Sicheng Li
- State Key Laboratory of Medical Neurobiology, MOE Frontier Center for Brain Science, and Institutes of Brain Science, Fudan University, Shanghai, China
| | - Jixian Lin
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, China
| | - Yang Liu
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, China
| | - Yanqin Gao
- State Key Laboratory of Medical Neurobiology, MOE Frontier Center for Brain Science, and Institutes of Brain Science, Fudan University, Shanghai, China
- *Correspondence: Yanqin Gao,
| | - Jing Zhao
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, China
- Jing Zhao,
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Kepka S, Zarca K, Lersy F, Moris M, Godet J, Deur J, Stoessel M, Muller J, Le Borgne P, Baloglu S, Fleury MC, Anheim M, Bilbault P, Bierry G, Durand Zaleski I, Kremer S. MRI dedicated to the emergency department for diplopia or dizziness: a cost-effectiveness analysis. Eur Radiol 2022; 32:7344-7353. [PMID: 35554653 DOI: 10.1007/s00330-022-08791-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/29/2022] [Accepted: 04/03/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The purpose of this study was to compare the costs and organizational benefits of diagnostic workup without and with MRI dedicated to the ED. METHODS We conducted a prospective observational uncontrolled before-after study in one ED of a university hospital in France from July 1, 2018, and January 3, 2020. We included all consecutive patients presenting with dizziness or diplopia. The main outcomes were the clinical decision time of ED physicians and the total costs for each strategy. Outcomes were compared using propensity score with inverse probability weighting in the 2 arms and an incremental cost-effectiveness ratio (ICER) was calculated. RESULTS Among the 199 patients during the "before" period (average age: 60.4 years ± 17.6): 112 men (57%), and 181 during the "after" period (average age, 54.8 years ± 18.5): 107 men (59%), the average costs were €2701 (95% CI 1918; 3704) and €2389 (95% CI: €1627; 3280) per patient, respectively. The average time to clinical decision was 9.8 h (95% CI: 8.9 10.7) in the group "before" and 7.7 h (95% CI: 7.1; 8.4) in the group "after" (ICER: €151 saved for a reduction of 1 h in clinical decision time). The probabilistic sensitivity analysis estimated a 71% chance that the MRI dedicated to ED was dominant (less costly and more effective). CONCLUSION Easy access to MRI in the ED for posterior circulation stroke-like symptoms must be considered a relevant approach to help physicians for an appropriate and rapid diagnostic with reduction of costs. TRIAL REGISTRATION NCT03660852 KEY POINTS: • A dedicated MRI in the ED for diplopia or dizziness may be considered an efficient strategy improving diagnostic performance, reducing physicians' decision time, and decreasing hospital costs. • This strategy supports clinical decision-making with early treatment and management of patients with posterior circulation-like symptoms in the ED. • There is 71% chance that the MRI dedicated to ED was dominant (less costly and more effective) compared with a strategy without dedicated MRI.
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Affiliation(s)
- Sabrina Kepka
- Emergency Department, Hôpitaux Universitaires de Strasbourg, 1 place de l'hopital, CHRU Strasbourg - Nouvel hôpital civil, 67091, Strasbourg, France. .,URCEco, Hôtel Dieu, AP-HP, 1 Place du Parvis Notre Dame, 75004, Paris, France. .,IMAGEs laboratory ICUBE UMR 7357 CNRS, 300 Bd Sébastien Brant, 67400, Illkirch-Graffenstaden, France.
| | - Kevin Zarca
- URCEco, Hôtel Dieu, AP-HP, 1 Place du Parvis Notre Dame, 75004, Paris, France
| | - François Lersy
- Imaging Department 2, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67200, Strasbourg, France
| | - Mylène Moris
- Emergency Department, Hôpitaux Universitaires de Strasbourg, 1 place de l'hopital, CHRU Strasbourg - Nouvel hôpital civil, 67091, Strasbourg, France
| | - Julien Godet
- Public Health Department, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, CHRU of Strasbourg, 67091, Strasbourg, France
| | - Jeanne Deur
- Imaging Department 2, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67200, Strasbourg, France
| | - Marie Stoessel
- Imaging Department 2, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67200, Strasbourg, France
| | - Joris Muller
- Public Health Department, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, CHRU of Strasbourg, 67091, Strasbourg, France
| | - Pierrick Le Borgne
- Emergency Department, Hôpitaux Universitaires de Strasbourg, 1 place de l'hopital, CHRU Strasbourg - Nouvel hôpital civil, 67091, Strasbourg, France.,UMR 1260, INSERM/Université de Strasbourg CRBS, 1 Rue Eugene Boeckel, 67000, Strasbourg, France
| | - Seyyid Baloglu
- Imaging Department 2, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67200, Strasbourg, France
| | - Marie Céline Fleury
- Neurology Department, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67200, Strasbourg, France
| | - Mathieu Anheim
- Neurology Department, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67200, Strasbourg, France.,Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), INSERM-U964/CNRS-UMR7104/Université de Strasbourg, Illkirch, France
| | - Pascal Bilbault
- Emergency Department, Hôpitaux Universitaires de Strasbourg, 1 place de l'hopital, CHRU Strasbourg - Nouvel hôpital civil, 67091, Strasbourg, France.,UMR 1260, INSERM/Université de Strasbourg CRBS, 1 Rue Eugene Boeckel, 67000, Strasbourg, France
| | - Guillaume Bierry
- Imaging Department 2, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67200, Strasbourg, France.,Engineering Science, Computer Science and Imaging Laboratory (ICube), Integrative Multimodal Imaging in Healthcare, UMR 7357, University of Strasbourg-CNRS, Strasbourg, France
| | - Isabelle Durand Zaleski
- URCEco, Hôtel Dieu, AP-HP, 1 Place du Parvis Notre Dame, 75004, Paris, France.,Univ Paris Est Creteil (UPEC), Université de Paris, CRESS, INSERM, INRA, 74 rue Marcel Cachin, 93017, Bobigny, France
| | - Stéphane Kremer
- Imaging Department 2, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67200, Strasbourg, France.,Engineering Science, Computer Science and Imaging Laboratory (ICube), Integrative Multimodal Imaging in Healthcare, UMR 7357, University of Strasbourg-CNRS, Strasbourg, France
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