1
|
Ohle R, Savage DW, Roy D, McIsaac S, Singh R, Lelli D, Tse D, Johns P, Yadav K, Perry JJ. Development of a Clinical Risk Score to Risk Stratify for a Serious Cause of Vertigo in Patients Presenting to the Emergency Department. Ann Emerg Med 2024:S0196-0644(24)00326-3. [PMID: 39093245 DOI: 10.1016/j.annemergmed.2024.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 05/14/2024] [Accepted: 06/03/2024] [Indexed: 08/04/2024]
Abstract
STUDY OBJECTIVE Identify high-risk clinical characteristics for a serious cause of vertigo in patients presenting to the emergency department (ED). METHODS Multicentre prospective cohort study over 3 years at three university-affiliated tertiary care EDs. Participants were patients presenting with vertigo, dizziness or imbalance. Main outcome measurement was an adjudicated serious diagnosis defined as stroke, transient ischemic attack, vertebral artery dissection or brain tumour. RESULTS A total of 2,078 of 2,618 potentially eligible patients (79.4%) were enrolled (mean age 77.1 years; 59% women). Serious events occurred in 111 (5.3%) patients. We used logistic regression to create a 7-item prediction model: male, age over 65, hypertension, diabetes, motor/sensory deficits, cerebellar signs/symptoms and benign paroxysmal positional vertigo diagnosis (C-statistic 0.96, 95% confidence interval [CI] 0.92 to 0.98). The risk of a serious diagnosis ranged from 0% for a score of <5, 2.1% for a score of 5 to 8, and 41% for a score >8. Sensitivity for a serious diagnosis was 100% (95% CI, 97.1% to 100%) and specificity 72.1% (95% CI, 70.1% to 74%) for a score <5. CONCLUSION The Sudbury Vertigo Risk Score identifies the risk of a serious diagnosis as a cause of a patient's vertigo and if validated could assist physicians in guiding further investigation, consultation, and treatment decisions, improving resource utilization and reducing missed diagnoses.
Collapse
Affiliation(s)
- Robert Ohle
- Department of Emergency Medicine, Health Sciences North, Health Sciences North Research Institute, Northern Ontario School of Medicine, Sudbury, ON, Canada.
| | - David W Savage
- Department of Emergency Medicine, Northern Ontario School of Medicine, Thunder Bay, ON, Canada
| | - Danielle Roy
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Sarah McIsaac
- Department of Critical Care, Department of Anesthesia, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Ravinder Singh
- Department of Neurology, Health Sciences North, Health Sciences North Research Institute, Northern Ontario School of Medicine, Sudbury, ON, Canada
| | - Daniel Lelli
- Department of Neurology and Otolaryngology, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Darren Tse
- Department of Neurology and Otolaryngology, University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Peter Johns
- Department of Emergency Medicine University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Krishan Yadav
- Department of Emergency Medicine University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine University of Ottawa and Ottawa Hospital Research Institute, Ottawa, ON, Canada
| |
Collapse
|
2
|
Tu LH, Tegtmeyer K, de Oliveira Santo ID, Venkatesh AK, Forman HP, Mahajan A, Melnick ER. Abbreviated MRI in the evaluation of dizziness: report turnaround times and impact on length of stay compared to CT, CTA, and conventional MRI. Emerg Radiol 2024:10.1007/s10140-024-02273-7. [PMID: 39034381 DOI: 10.1007/s10140-024-02273-7] [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: 06/26/2024] [Accepted: 07/16/2024] [Indexed: 07/23/2024]
Abstract
PURPOSE Neuroimaging is often used in the emergency department (ED) to evaluate for posterior circulation strokes in patients with dizziness, commonly with CT/CTA due to speed and availability. Although MRI offers more sensitive evaluation, it is less commonly used, in part due to slower turnaround times. We assess the potential for abbreviated MRI to improve reporting times and impact on length of stay (LOS) compared to conventional MRI (as well as CT/CTA) in the evaluation of acute dizziness. MATERIALS AND METHODS We performed a retrospective analysis of length of stay via LASSO regression for patients presenting to the ED with dizziness and discharged directly from the ED over 4 years (1/1/2018-12/31/2021), controlling for numerous patient-level and logistical factors. We additionally assessed turnaround time between order and final report for various imaging modalities. RESULTS 14,204 patients were included in our analysis. Turnaround time for abbreviated MRI was significantly lower than for conventional MRI (4.40 h vs. 6.14 h, p < 0.001) with decreased impact on LOS (0.58 h vs. 2.02 h). Abbreviated MRI studies had longer turnaround time (4.40 h vs. 1.41 h, p < 0.001) and was associated with greater impact on ED LOS than non-contrast CT head (0.58 h vs. 0.00 h), however there was no significant difference in turnaround time compared to CTA head and neck (4.40 h vs. 3.86 h, p = 0.06) with similar effect on LOS (0.58 h vs. 0.53 h). Ordering both CTA and conventional MRI was associated with a greater-than-linear increase in LOS (additional 0.37 h); the same trend was not seen combining CTA and abbreviated MRI (additional 0.00 h). CONCLUSIONS In the acute settings where MRI is available, abbreviated MRI protocols may improve turnaround times and LOS compared to conventional MRI protocols. Since recent guidelines recommend MRI over CT in the evaluation of dizziness, implementation of abbreviated MRI protocols has the potential to facilitate rapid access to preferred imaging, while minimizing impact on ED workflows.
Collapse
Affiliation(s)
- Long H Tu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Tompkins East 2, New Haven, CT 06520, USA.
| | - Kyle Tegtmeyer
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Tompkins East 2, New Haven, CT 06520, USA
| | - Irene Dixe de Oliveira Santo
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Tompkins East 2, New Haven, CT 06520, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave # 260, New Haven, CT 06519, USA
| | - Howard P Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Tompkins East 2, New Haven, CT 06520, USA
| | - Amit Mahajan
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, Tompkins East 2, New Haven, CT 06520, USA
| | - Edward R Melnick
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave # 260, New Haven, CT 06519, USA
| |
Collapse
|
3
|
Rahmig J, Chanpura A, Schultz A, Barone FC, Gustafson D, Baird AE. Blood-based protein biomarkers during the acute ischemic stroke treatment window: a systematic review. Front Neurol 2024; 15:1411307. [PMID: 39091977 PMCID: PMC11291248 DOI: 10.3389/fneur.2024.1411307] [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: 04/02/2024] [Accepted: 07/04/2024] [Indexed: 08/04/2024] Open
Abstract
Background Rapid and accurate acute ischemic stroke (AIS) diagnosis is needed to expedite emergent thrombolytic and mechanical thrombectomy treatment. Changes in blood-based protein biomarkers during the first 24 h of AIS, the time window for treatment, could complement imaging techniques and facilitate rapid diagnosis and treatment. Methods We performed a systematic review according to PRISMA guidelines. MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were searched for eligible studies comparing levels of blood-based protein biomarkers in AIS patients with levels in healthy controls and stroke mimics. Protein biomarkers from the following pathophysiological categories were included: neurovascular inflammation (MMP-9, TNF-alpha), endothelial integrity (VCAM-1, ICAM-1), cell migration (E-Selectin, P-Selectin, L-Selectin), markers of glial and neuronal origin (GFAP, S100, S100B, NSE), and cardiac dysfunction (BNP, NT-proBNP). The literature search was limited to English-language publications before November 7th, 2023. Results A total of 61 studies from 20 different countries were identified, which included in total, 4,644 AIS patients, 2,242 stroke mimics, and 2,777 controls. Studies investigating TNF-alpha, MMP-9, VCAM-1, ICAM-1, E-Selectin, L-Selectin, GFAP, NSE, and S100B showed pronounced methodological heterogeneity, making between-study comparisons difficult. However, in 80% of NT-proBNP and BNP studies, and all P-selectin studies, higher biomarker levels were observed in AIS patients compared to healthy controls and/or patients with stroke mimics. Conclusion None of the biomarkers included showed sufficient evidence for additional diagnostic benefit for AIS. Comprehensive standardized global multicenter studies are needed to (1) permit comparability, (2) enable valid statements about protein-based biomarkers, and (3) reflect real-world scenarios.
Collapse
Affiliation(s)
- Jan Rahmig
- Department of Neurology, State University of New York Downstate Health Sciences University, Brooklyn, NY, United States
- Department of Neurology, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Aditya Chanpura
- Department of Neurology, State University of New York Downstate Health Sciences University, Brooklyn, NY, United States
| | - Aaliyah Schultz
- Department of Neurology, State University of New York Downstate Health Sciences University, Brooklyn, NY, United States
| | - Frank C. Barone
- Department of Neurology, State University of New York Downstate Health Sciences University, Brooklyn, NY, United States
| | - Deborah Gustafson
- Department of Neurology, State University of New York Downstate Health Sciences University, Brooklyn, NY, United States
| | - Alison E. Baird
- Department of Neurology, State University of New York Downstate Health Sciences University, Brooklyn, NY, United States
| |
Collapse
|
4
|
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.
Collapse
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.
| |
Collapse
|
5
|
Smiley K, Yoo MJ, Long B. Are the HINTS and HINTS Plus Examinations Accurate for Identifying a Central Cause of Acute Vestibular Syndrome? Ann Emerg Med 2024; 84:60-62. [PMID: 38385911 DOI: 10.1016/j.annemergmed.2024.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 01/19/2024] [Accepted: 01/19/2024] [Indexed: 02/23/2024]
Affiliation(s)
- Kyle Smiley
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX
| | - Michael Jay Yoo
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX
| |
Collapse
|
6
|
Happonen T, Nyman M, Ylikotila P, Mattila K, Hirvonen J. Imaging Outcomes of Emergency MR Imaging in Dizziness and Vertigo: A Retrospective Cohort Study. AJNR Am J Neuroradiol 2024; 45:819-825. [PMID: 38604735 PMCID: PMC11288592 DOI: 10.3174/ajnr.a8202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/19/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND AND PURPOSE Patients exhibiting acute dizziness or vertigo often represent a diagnostic challenge, and many undergo neuroimaging for stroke detection. We aimed to demonstrate the imaging outcomes of first-line emergency MR imaging among patients with acute dizziness or vertigo and to determine the clinical risk factors for stroke and other acute pathology. MATERIALS AND METHODS This retrospective study included consecutive patients with acute dizziness or vertigo referred for emergency MR imaging in a tertiary hospital during 5 years. We recorded and analyzed patient characteristics, relevant clinical information, and imaging outcomes. Risk score models were derived to predict which patients were more likely to present with positive MR imaging findings. RESULTS A total of 1169 patients were included. Acute stroke was found in 17%; other clinically significant pathology, in 8% of patients. In 75% of the patients, emergency MR imaging showed no significant abnormalities. Risk factors for acute stroke included older age, male sex, and a prevalence of cardiovascular risk factors and neurologic signs. Isolated dizziness had no discriminative power on imaging outcomes, and 14% of these patients showed acute stroke. Risk scores had only moderate performance in predicting acute ischemic stroke (receiver operating characteristic area under curve = 0.75) or any significant pathology (receiver operating characteristic area under curve = 0.70). CONCLUSIONS Acute dizziness and vertigo remain challenging even when emergency MR imaging is readily available. One in 4 patients had acute pathology on MR imaging. Predictors for acute pathology (older age, male sex, cardiovascular risk factors, and neurologic signs) may aid in patient selection for MR imaging, optimizing the yield and clinical impact of emergency neuroimaging. Low diagnostic yields of CT and internal acoustic canal MR imaging may offer an opportunity to reduce health care expenditures in the future.
Collapse
Affiliation(s)
- Tatu Happonen
- From the Department of Radiology (T.H., M.N., K.M., J.H.), Turku University Hospital and University of Turku, Turku, Finland
| | - Mikko Nyman
- From the Department of Radiology (T.H., M.N., K.M., J.H.), Turku University Hospital and University of Turku, Turku, Finland
| | - Pauli Ylikotila
- Neurocenter (P.Y.), Turku University Hospital and University of Turku, Turku, Finland
| | - Kimmo Mattila
- From the Department of Radiology (T.H., M.N., K.M., J.H.), Turku University Hospital and University of Turku, Turku, Finland
| | - Jussi Hirvonen
- From the Department of Radiology (T.H., M.N., K.M., J.H.), Turku University Hospital and University of Turku, Turku, Finland
- Department of Radiology (J.H.), Tampere University Hospital and Tampere University, Tampere, Finland
| |
Collapse
|
7
|
Edlow JA, Marcolini E. Biomarkers for acute dizziness: Nowhere near ready for prime time. Acad Emerg Med 2024; 31:412-413. [PMID: 38380760 DOI: 10.1111/acem.14863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 12/23/2023] [Indexed: 02/22/2024]
Affiliation(s)
- Jonathan A Edlow
- Harvard Medical School, Boston, Massachusetts, USA
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Evie Marcolini
- Department of Emergency Medicine, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Ohle R, Savage DW, Caswell J, McIsaac S, Yadav K, Conlon M. Mortality and risk factors associated with misdiagnosis of acute aortic syndrome in Ontario, Canada: a population-based study. Emerg Med J 2024; 41:145-150. [PMID: 38253363 DOI: 10.1136/emermed-2023-213331] [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: 05/04/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024]
Abstract
INTRODUCTION Acute aortic syndrome (AAS) is a life-threatening aortic emergency. It describes three diagnoses: acute aortic dissection, acute intramural haematoma and penetrating atherosclerotic ulcer. Unfortunately, there are no accurate estimates of the miss rate for AAS, risk factors for missed diagnosis or its effect on outcomes. METHODS A population-based retrospective cohort study of anonymously linked data for residents of Ontario, Canada, was carried out. Incident cases of AAS were identified between 2003 and 2018 using a validated algorithm based on ICD codes and death. Before multivariate modelling, all categorical variables were analysed for an association with missed AAS diagnosis using χ2 tests. These preliminary analyses were unadjusted for clustering or any covariates. Finally, we performed multilevel logistic regression analysis using a generalised linear mixed model approach to model the probability of a missed case occurring. RESULTS There were 1299 cases of AAS (age mean (SD) 68.03±14.70, woman 500 (38.5%), rural areas (n=111, 8.55%)) over the study period. Missed cases accounted for 163 (12.5%) of the cohort. Mortality (non-missed AAS 59.7% vs missed AAS 54.6%) and surgical intervention (non-missed AAS 31% vs missed AAS 30.7%) were similar in missed and non-missed cases. However, lower acuity (Canadian triage acuity scale >2 (OR 2.45 95% CI 1.71 to 3.52) (the scale is from 1 to 5, with 1 indicating high acuity) had a higher odds of being a missed case and non-ambulatory presentation (OR 0.47 95% CI 0.33 to 0.67) and presenting to a teaching (OR 0.60 95% CI 0.40 to 0.90)) or cardiac centre (OR 0.41 95% CI 0.27 to 0.62) were associated with a lower odds of being a missed case. CONCLUSIONS The high rate of misdiagnosis has remained stable for over a decade. Non-teaching and non-cardiac hospitals had a higher incidence of missed cases. Mortality and rates of surgery were not associated with a missed diagnosis of AAS. Educational interventions should be prioritised in non-teaching hospitals and non-cardiac centres.
Collapse
Affiliation(s)
- Robert Ohle
- Department of Emergency Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - David W Savage
- Emergency Medicine, Northern Ontario School of Medicine University, Thunder Bay, Ontario, Canada
| | - Joseph Caswell
- Health Sciences North Research Institute, Sudbury, Ontario, Canada
| | - Sarah McIsaac
- Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
| | - Krishan Yadav
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michael Conlon
- Health Sciences North Research Institute, Sudbury, Ontario, Canada
| |
Collapse
|
10
|
Tu LH, Navaratnam D, Melnick ER, Forman HP, Venkatesh AK, Malhotra A, Yaesoubi R, Sureshanand S, Sheth KN, Mahajan A. CT With CTA Versus MRI in Patients Presenting to the Emergency Department With Dizziness: Analysis Using Propensity Score Matching. AJR Am J Roentgenol 2023; 221:836-845. [PMID: 37404082 DOI: 10.2214/ajr.23.29617] [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: 07/06/2023]
Abstract
BACKGROUND. CT with CTA is widely used to exclude stroke in patients with dizziness, although MRI has higher sensitivity. OBJECTIVE. The purpose of this article was to compare patients presenting to the emergency department (ED) with dizziness who undergo CT with CTA alone versus those who undergo MRI in terms of stroke-related management and outcomes. METHODS. This retrospective study included 1917 patients (mean age, 59.5 years; 776 men, 1141 women) presenting to the ED with dizziness from January 1, 2018, to December 31, 2021. A first propensity score matching analysis incorporated demographic characteristics, medical history, findings from the review of systems, physical examination findings, and symptoms to construct matched groups of patients discharged from the ED after undergoing head CT with head and neck CTA alone and patients who underwent brain MRI (with or without CT and CTA). Outcomes were compared. A second analysis compared matched patients discharged after CT with CTA alone and patients who underwent specialized abbreviated MRI using multiplanar high-resolution DWI for increased sensitivity for posterior circulation stroke. Sensitivity analyses were performed involving MRI examinations performed as the first or only neuroimaging examination and involving alternative matching and imputation techniques. RESULTS. In the first analysis (406 patients per group), patients who underwent MRI, compared with patients who underwent CT with CTA alone, showed greater frequency of critical neuroimaging results (10.1% vs 4.7%, p = .005), change in secondary stroke prevention medication (9.6% vs 3.2%, p = .001), and subsequent echocardiography evaluation (6.4% vs 1.0%, p < .001). In the second analysis (100 patients per group), patients who underwent specialized abbreviated MRI, compared with patients who underwent CT with CTA alone, showed greater frequency of critical neuroimaging results (10.0% vs 2.0%, p = .04), change in secondary stroke prevention medication (14.0% vs 1.0%, p = .001), and subsequent echocardiography evaluation (12.0% vs 2.0%, p = .01) and lower frequency of 90-day ED readmissions (12.0% vs 28.0%, p = .008). Sensitivity analyses showed qualitatively similar findings. CONCLUSION. A proportion of patients discharged after CT with CTA alone may have benefitted from alternative or additional evaluation by MRI (including MRI using a specialized abbreviated protocol). CLINICAL IMPACT. Use of MRI may motivate clinically impactful management changes in patients presenting with dizziness.
Collapse
Affiliation(s)
- Long H Tu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, PO Box 208042, Tompkin's East 2, New Haven, CT 06510
| | | | - Edward R Melnick
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Howard P Forman
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, PO Box 208042, Tompkin's East 2, New Haven, CT 06510
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, PO Box 208042, Tompkin's East 2, New Haven, CT 06510
| | - Reza Yaesoubi
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
| | | | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Amit Mahajan
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, PO Box 208042, Tompkin's East 2, New Haven, CT 06510
| |
Collapse
|
11
|
Herdman D, Ahmad H, Antoniades G, Bailur G, Pajaniappane A, Moss P. Developing an implementation intervention for managing acute vertigo in the emergency department. Emerg Med J 2023; 40:840-846. [PMID: 37875319 DOI: 10.1136/emermed-2023-213344] [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: 05/10/2023] [Accepted: 10/07/2023] [Indexed: 10/26/2023]
Abstract
BACKGROUND There are evidence-based bedside tests for diagnosing acute vertigo, but no evidence-based strategies to support clinicians in implementing them. The purpose of this study was to design an implementation strategy for treating acute vertigo by examining current facilitators and barriers to using these tests in the ED using the principles of implementation science. METHODS A survey was developed using the Theoretical Domains Framework and Consolidated Framework for Implementation Research to examine barriers and facilitators for using HINTS+ (head impulse, nystagmus, test of skew, plus hearing) and Dix-Hallpike tests. The survey was sent to emergency clinicians (ECs) in a teaching hospital in London, UK, between May and September 2022. Semistructured interviews were conducted simultaneously, and data examined using direct content analysis. Implementation strategies were then selected based on the Expert Recommendations for Implementing Change framework. RESULTS Fifty-one ECs responded to the survey and six ECs volunteered for interview. Less than half reported using the bedside tests to make a diagnosis. The most common barriers were beliefs about complexity, a lack of supporting materials, memory, lack of skills and negative experiences. The interview data revealed negative beliefs about the necessity, validity, safety and practicality. There were also barriers in the ED environment (eg, lack of space). There was a strong perception that the current approach to managing acute vertigo needed to change and ECs view this as part of their professional role and responsibility. Based on clinician input, the authors selected strategies to improve diagnostic efforts, which included guidelines for training, developing vertigo champions, protocols, memory aids, audit and feedback. CONCLUSION This study found several barriers to managing acute vertigo such as memory constraints, and inadequate supporting materials and training, although a robust desire for change. The implementation strategy's initial phase is described, which must now be tested.
Collapse
Affiliation(s)
- David Herdman
- Audiovestibular Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Hena Ahmad
- Neurology Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - George Antoniades
- Emergency Department Clinical Research Group, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Gokul Bailur
- Emergency Department Clinical Research Group, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Arun Pajaniappane
- Audiovestibular Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Phil Moss
- Emergency Department Clinical Research Group, St George's University Hospitals NHS Foundation Trust, London, UK
| |
Collapse
|
12
|
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.
Collapse
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.
| |
Collapse
|
13
|
Edlow JA, Carpenter CR, Newman-Toker D, Bellolio F. Response to "Give us some GRACE, we can't take the HINT". Acad Emerg Med 2023; 30:1080-1082. [PMID: 37460899 DOI: 10.1111/acem.14778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 08/02/2023]
Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - David Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
14
|
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: 10] [Impact Index Per Article: 10.0] [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.
Collapse
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
| |
Collapse
|
15
|
Busch JM, Arnold I, Karakoumis J, Winkel DJ, Segeroth M, Nickel CH, Bingisser R. Emergency Presentations for Dizziness-Radiological Findings, Final Diagnoses, and Mortality. Int J Clin Pract 2023; 2023:7450009. [PMID: 37383705 PMCID: PMC10299881 DOI: 10.1155/2023/7450009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/14/2023] [Accepted: 05/02/2023] [Indexed: 06/30/2023] Open
Abstract
Background Dizziness is a frequent presentation in patients presenting to emergency departments (EDs), often triggering extensive work-up, including neuroimaging. Therefore, gathering knowledge on final diagnoses and outcomes is important. We aimed to describe the incidence of dizziness as primary or secondary complaint, to list final diagnoses, and to determine the use and yield of neuroimaging and outcomes in these patients. Methods Secondary analysis of two observational cohort studies, including all patients presenting to the ED of the University Hospital of Basel from 30th January 2017-19th February 2017 and from 18th March 2019-20th May 2019. Baseline demographics, Emergency Severity Index (ESI), hospitalization, admission to Intensive Care Units (ICUs), and mortality were extracted from the electronic health record database. At presentation, patients underwent a structured interview about their symptoms, defining their primary and secondary complaints. Neuroimaging results were obtained from the picture archiving and communication system (PACS). Patients were categorized into three non-overlapping groups: dizziness as primary complaint, dizziness as secondary complaint, and absence of dizziness. Results Of 10076 presentations, 232 (2.3%) indicated dizziness as their primary and 984 (9.8%) as their secondary complaint. In dizziness as primary complaint, the three (out of 73 main conditions defined) main diagnoses were nonspecific dizziness (47, 20.3%), dysfunction of the peripheral vestibular system (37, 15.9%), as well as somatization, depression, and anxiety (20, 8.6%). 104 of 232 patients (44.8%) underwent neuroimaging, with relevant findings in 5 (4.8%). In dizziness as primary complaint 30-day mortality was 0%. Conclusion Work-up for dizziness in emergency presentations has to consider a broad differential diagnosis, but due to the low yield, it should include neuroimaging only in few and selected cases, particularly with additional neurological abnormalities. Presentation with primary dizziness carries a generally favorable prognosis lacking short-term mortality. .
Collapse
Affiliation(s)
| | - Isabelle Arnold
- Emergency Department, University Hospital Basel, Basel, Switzerland
| | - Julia Karakoumis
- Emergency Department, University Hospital Basel, Basel, Switzerland
| | - David J. Winkel
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Martin Segeroth
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | | | - Roland Bingisser
- Emergency Department, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
16
|
Edlow JA, Carpenter C, Akhter M, Khoujah D, Marcolini E, Meurer WJ, Morrill D, Naples JG, Ohle R, Omron R, Sharif S, Siket M, Upadhye S, E Silva LOJ, Sundberg E, Tartt K, Vanni S, Newman-Toker DE, Bellolio F. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. Acad Emerg Med 2023; 30:442-486. [PMID: 37166022 DOI: 10.1111/acem.14728] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/14/2023] [Indexed: 05/12/2023]
Abstract
This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").
Collapse
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
| |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|