Do monosymptomatic stroke patients with dizziness present a vestibular syndrome without nystagmus? An underestimated entity

R-cVR, a two-step bedside algorithm for the differential diagnosis of acute dizziness and vertigo

Background

The ability to quickly and accurately differentiate between peripheral and central dizziness or vertigo is vital. We developed the R-cVR algorithm for the early identification of central-type dizziness or vertigo.

Methods

In this single-center, retrospective cohort study, we assessed patients with isolated dizziness or vertigo between December 10, 2023, and February 28, 2024. Classification into central or peripheral types was based on magnetic resonance imaging (MRI)-diffusion-weighted imaging (DWI) results. We reevaluated the diagnostic value of the Romberg test for acute dizziness or vertigo by quantifying the duration of standing and created the R-cVR algorithm. The algorithm's accuracy was subsequently validated against the MRI-DWI results.

Results

After screening, 109 patients were recruited and divided into central (n = 25) and peripheral (n = 84) groups. The central group had a high incidence of cerebral infarction (88.0 %), whereas the peripheral group included patients with vestibular neuronitis, benign paroxysmal positional vertigo, and Meniere's disease (96.4 %). Significant disparities in the incidence of balance disorders were noted between the groups (92.0 % vs. 15.5 %, p < 0.001). Multivariate logistic regression revealed an odds ratio of 61.82 for balance disorders (p < 0.001). The R-cVR algorithm, which integrates the Romberg test and the V-shaped stance with closed-eyes protocol, was tested against MRI-DWI and yielded high diagnostic agreement (kappa = 0.80), with a sensitivity and specificity of 88.0 % and 94.0 %, respectively. There was no significant difference in the diagnostic efficacy of this algorithm for acute dizziness or vertigo with or without nystagmus.

Conclusion

The R-cVR algorithm effectively identifies central-type dizziness or vertigo and is simple for general practitioners to use without specialized equipment, which may be valuable in various clinical settings.

Distinguishing Peripheral from Central Causes of Dizziness and Vertigo without using HINTS or STANDING

Three validated diagnostic algorithms for diagnosing patients with acute onset dizziness or vertigo (HINTS, HINTS-plus and STANDING) exist. All are extremely accurate in distinguishing peripheral from central causes of dizziness when done by experienced clinicians. However, uptake of these diagnostic tools in routine emergency medicine practice has been sub-optimal, in part, due to clinicians' unease with the head impulse test, the most useful component contained of these algorithms. Use of these validated algorithms is the best way to accurately diagnose patients with acute dizziness. For clinicians who are unfamiliar with or uncomfortable performing or interpreting HINTS and STANDING, this article will suggest alternative approaches to help with accurate diagnosis of patients with acute dizziness or vertigo.