Approach to Acute Dizziness/Vertigo in the Emergency Department: Selected Controversies Regarding Specialty Consultation

Acute dizziness and vertigo are common emergency department presentations (≈4% of annual visits) and sometimes, a life-threatening diagnosis like stroke is missed. Recent literature reviews the challenges in evaluation of these symptoms and offers guidelines for diagnostic approaches. Strong evidence indicates that when well-trained providers perform a high-quality bedside neurovestibular examination, accurate diagnosis of peripheral vestibular disorders and stroke increases. However, it is less clear who can and should be performing these assessments on a routine basis. This article offers a focused debate for and against routine specialty consultation for patients with acute dizziness or vertigo in the emergency department as well as a potential path forward utilizing new portable technologies to quantify eye movements.

[Increased report completeness and satisfaction with structured neurotological reporting in the interdisciplinary assessment of vertigo]

BACKGROUND

Results of neurotological function diagnostics in the context of interdisciplinary vertigo assessment are usually formulated as free-text reports (FTR). These are often subject to high variability, which may lead to loss of information. The aim of the present study was to evaluate the completeness of structured reports (SR) and referrer satisfaction in the neurotological assessment of vertigo.

MATERIALS AND METHODS

Neurotological function diagnostics performed as referrals (n = 88) were evaluated retrospectively. On the basis of the available raw data, SRs corresponding to FTRs from clinical routine were created by means of a specific SR template for neurotological function diagnostics. FTRs and SRs were evaluated for completeness and referring physician satisfaction (n = 8) using a visual analog scale (VAS) questionnaire.

RESULTS

Compared to FTRs, SRs showed significantly increased overall completeness (73.7% vs. 51.7%, p < 0.001), especially in terms of patient history (92.5% vs. 66.7%, p < 0.001), description of previous findings (87.5% vs. 38%, p < 0.001), and neurotological (33.5% vs. 26.7%, p < 0.001) and audiometric function diagnostics (58% vs. 32.3%, p < 0.001). In addition, SR showed significantly increased referring physician satisfaction (VAS 8.8 vs. 4.9, p < 0.001).

CONCLUSION

Neurotological SRs enable a significantly increased report completeness with higher referrer satisfaction in the context of interdisciplinary assessment of vertigo. Furthermore, SRs are particularly suitable for scientific data analysis, especially in the context of big data analyses.

Consensus paper on the management of acute isolated vertigo in the emergency department

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.

Recognizing Posterior Circulation Transient Ischemic Attacks Presenting as Episodic Isolated Dizziness

Diagnosing patients presenting to the emergency department with self-limited episodes of isolated dizziness (the episodic vestibular syndrome) requires a broad differential diagnosis that includes posterior circulation transient ischemic attack. Because these patients are, by definition, asymptomatic without new neurologic findings on examination, the diagnosis, largely based on history and epidemiologic context, can be challenging. We review literature that addresses the frequency of posterior circulation transient ischemic attack in this group of patients compared with other potential causes of episodic vestibular syndrome. We present ways of distinguishing posterior circulation transient ischemic attack from vestibular migraine, the most common cause of episodic vestibular syndrome. We also present a diagnostic algorithm that may help clinicians to work their way through the differential diagnosis.

The TriAGe + score for vertigo or dizziness: A validation study in a university hospital emergency department in Hong Kong

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.

Longitudinal Patient Outcomes in Chronic Dizziness: A Scoping Review

BACKGROUND

Chronic dizziness can cause significant functional impairment. Outcome measures used in this patient population have not been examined systematically. Consequently, providers lack consensus on the ideal outcome measures to assess the impact of their interventions.

OBJECTIVE AND METHODS

We conducted a scoping review to summarize existing literature on outcomes in chronic dizziness (with a minimum of 6 mo of patient follow-up). Among other details, we extracted and analyzed patient demographics, medical condition(s), and the specific outcome measures of each study.

RESULTS

Of 19,426 articles meeting the original search terms, 416 met final exclusion after title/abstract and full-text review. Most studies focused on Ménière's disease (75%) and recurrent benign paroxysmal positional vertigo (21%). The most common outcome measures were hearing (62%) and number of attacks by American Academy of Otolaryngology-Head & Neck Surgery criteria (60%). A minority (35%) looked formally at quality-of-life metrics (Dizziness Handicap Index or other).

CONCLUSIONS

Ménière's disease and benign paroxysmal positional vertigo are overrepresented in literature on outcome assessment in chronic dizziness. Objective clinical measures are used more frequently than quality-of-life metrics. Future work is needed to identify the optimal outcome measures that reflect new knowledge about the most common causes of chronic dizziness (including persistent postural-perceptual dizziness and vestibular migraine) and consider what is most important to patients.

Misdiagnosis-related harm quantification through mixture models and harm measures

Investigating and monitoring misdiagnosis-related harm is crucial for improving health care. However, this effort has traditionally focused on the chart review process, which is labor intensive, potentially unstable, and does not scale well. To monitor medical institutes' diagnostic performance and identify areas for improvement in a timely fashion, researchers proposed to leverage the relationship between symptoms and diseases based on electronic health records or claim data. Specifically, the elevated disease risk following a false-negative diagnosis can be used to signal potential harm. However, off-the-shelf statistical methods do not fully accommodate the data structure of a well-hypothesized risk pattern and thus fail to address the unique challenges adequately. To fill these gaps, we proposed a mixture regression model and its associated goodness-of-fit testing. We further proposed harm measures and profiling analysis procedures to quantify, evaluate, and compare misdiagnosis-related harm across institutes with potentially different patient population compositions. We studied the performance of the proposed methods through simulation studies. We then illustrated the methods through data analyses on stroke occurrence data from the Taiwan Longitudinal Health Insurance Database. From the analyses, we quantitatively evaluated risk factors for being harmed due to misdiagnosis, which unveiled some insights for health care quality research. We also compared general and special care hospitals in Taiwan and observed better diagnostic performance in special care hospitals using various new evaluation measures.

Impact of Clinician Training Background and Stroke Location on Bedside Diagnostic Test Accuracy in the Acute Vestibular Syndrome - A Meta-Analysis

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.

Diagnostic Contribution of Magnetic Resonance Imaging and Computerized Tomography in Patients with Unidentified Vertigo and Normal Neurologic Examination in Emergency Medicine

Background

Vertigo and dizziness are common symptoms in patients presenting to emergency medicine (ED) clinics. Vertigo may be caused by peripheral or central origin. Routine imaging is not indicated; however, neuroimaging is increasing, and published studies have revealed a small number of positive findings on imaging modalities.

Aims

The aim of this study was to investigate whether neurological imaging was necessary in patients classified as "unidentified vertigo," who were admitted to the emergency department with vertiginous complaints and not revealing typical peripheral vertigo findings and any neurological deficits.

Materials and Methods

All patients with "dizzy symptoms" were included in the study. For patients who met the definition of "unidentified vertigo," experimental neurological imaging studies were done. Head computerized tomography (CT), magnetic resonance imaging (MRI) with gradient-echo sequences (GRE), and diffusion weighted images (DWI) were used for imaging. Patients who underwent neuroimaging in the ED were followed up for 6 months in Neurology and ENT clinics.

Results

A total of 351 patients were included in the study. Experimental imaging was performed on 100 patients. CT detected a significant pathology associated with the vertigo complaint in only one patient. MRI results were similar to the CT results. MRI-GRE sequences showed some additional pathologies in 14 patients and 4 of them were thought to be related to vertiginous symptoms. None of the patients classified as "non-central causes of vertigo" in the neuroimaging group developed TIA or CVD during 6 months of follow-up.

Conclusion

Head CT can be adequate to exclude life-threatening central pathology in "undifferentiated vertigo patients" and the addition of MRI did not add any diagnostic accuracy in ED management. Using the physical examination findings effectively to make a specific diagnosis may reduce misdiagnosis and improve resource utilization.

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

OBJECTIVES

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

DESIGN

Retrospective cross-sectional study.

SETTING

Tertiary referral hospital.

PARTICIPANTS

Adult patients presenting with dizziness.

PRIMARY AND SECONDARY OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

[Vertigo from a neurological point of view]

Vertigo has many different causal disorders, ranging from general dizziness and orthostatic regulation disorders to attacks of rotary vertigo. A targeted anamnesis and clinical examination can be used to narrow down the differential diagnosis. Questions about the type of dizziness, the duration and accompanying symptoms must be clarified. Various methods are used for differentiation in clinical examinations: the head impulse test, testing of the vertical divergence of the eyes, positioning maneuvers and the ability to stand and walk. But diagnostic imaging is also important. MRI can be used to confirm or rule out vascular causes (cerebral infarction or minor bleeding) and inflammatory lesions. Because the most serious misdiagnosis of dizziness is overlooking a stroke.

Effectiveness and reliability of the four-step STANDING algorithm performed by interns and senior emergency physicians for predicting central causes of vertigo

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.

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

BACKGROUND

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

OBJECTIVE

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

METHODS AND RESULTS

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

CONCLUSION

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

The patient with acute vertigo - the role of clinical examination and imaging

Vertigo/dizziness or balance disorders are among the most common patients complaints in emergency clinics. Up to 25% of them are potentially life-threatening, especially cardiovascular or cerebrovascular events. The combination of a careful history taking (triggers, duration of difficulties, associated symptoms) and the performance of a basic vestibular examination (nystagmus, oculomotor, head impulse test, positional maneuvers, standing and walking examination) leads to a reliable differentiation of central and peripheral vestibular etiology. Standardized diagnostic algorithms (HINTS, HINTS+, STANDING) are used to identify high-risk patients requiring urgent care. Imaging methods must be interpreted with caution to their low sensitivity in acute phase (sensitivity of non-contrast brain CT for ischemia in the posterior cranial fossa is only 16%, MRI of the brain is false negative in up to 20% of cases in stroke patients in the first 48 hours).

Simulation-based team-training in acute stroke: Is it safe to speed up?

BACKGROUND

In acute ischemic stroke (AIS), rapid treatment with intravenous thrombolysis (IVT) is crucial for good clinical outcome. Weekly simulation-based team-training of the stroke treatment team was implemented, resulting in faster treatment times. The aim of this study was to assess whether this time reduction led to a higher proportion of stroke mimics (SMs) among patients who received IVT for presumed AIS, and whether these SM patients were harmed by intracranial hemorrhage (ICH).

METHODS

All suspected AIS patients treated with IVT between January 1, 2015 and December 31, 2020 were prospectively registered. In 2017, weekly in situ simulation-based team-training involving the whole stroke treatment team was introduced. To analyze possible unintended effects of simulation training, the proportion of SMs among patients who received IVT for presumed AIS were identified by clinical and radiological evaluation. Additionally, we identified the extent of symptomatic ICH (sICH) in IVT-treated SM patients.

RESULTS

From 2015 to 2020, 959 patients were treated with IVT for symptoms of AIS. After introduction of simulation training, the proportion of patients treated with IVT who were later diagnosed as SMs increased significantly (15.9% vs. 24.4%, p = .003). There were no ICH complications in the SM patients treated before, whereas two SM patients suffered from asymptomatic ICH after introduction of simulation training (p = 1.0). When subgrouping SMs into prespecified categories, only the group diagnosed with peripheral vertigo increased significantly (2.5% vs. 8.6%, p < .001).

CONCLUSIONS

Simulation training of the acute stroke treatment team was associated with an increase in the proportion of patients treated with IVT for a suspected AIS who were later diagnosed with peripheral vertigo. The proportion of other SM groups among IVT-treated patients did not change significantly. No sICH was detected in IVT-treated SM patients.

A Questionnaire-Based Ensemble Learning Model to Predict the Diagnosis of Vertigo: Model Development and Validation Study

Background

Questionnaires have been used in the past 2 decades to predict the diagnosis of vertigo and assist clinical decision-making. A questionnaire-based machine learning model is expected to improve the efficiency of diagnosis of vestibular disorders.

Objective

This study aims to develop and validate a questionnaire-based machine learning model that predicts the diagnosis of vertigo.

Methods

In this multicenter prospective study, patients presenting with vertigo entered a consecutive cohort at their first visit to the ENT and vertigo clinics of 7 tertiary referral centers from August 2019 to March 2021, with a follow-up period of 2 months. All participants completed a diagnostic questionnaire after eligibility screening. Patients who received only 1 final diagnosis by their treating specialists for their primary complaint were included in model development and validation. The data of patients enrolled before February 1, 2021 were used for modeling and cross-validation, while patients enrolled afterward entered external validation.

Results

A total of 1693 patients were enrolled, with a response rate of 96.2% (1693/1760). The median age was 51 (IQR 38-61) years, with 991 (58.5%) females; 1041 (61.5%) patients received the final diagnosis during the study period. Among them, 928 (54.8%) patients were included in model development and validation, and 113 (6.7%) patients who enrolled later were used as a test set for external validation. They were classified into 5 diagnostic categories. We compared 9 candidate machine learning methods, and the recalibrated model of light gradient boosting machine achieved the best performance, with an area under the curve of 0.937 (95% CI 0.917-0.962) in cross-validation and 0.954 (95% CI 0.944-0.967) in external validation.

Conclusions

The questionnaire-based light gradient boosting machine was able to predict common vestibular disorders and assist decision-making in ENT and vertigo clinics. Further studies with a larger sample size and the participation of neurologists will help assess the generalization and robustness of this machine learning method.

Internet-based vestibular rehabilitation versus standard care after acute onset vertigo: a study protocol for a randomized controlled trial

Background

Dizziness and vertigo affect around 15% of adults annually and represent common reasons for contacting health services, accounting for around 3% of all emergency department visits worldwide. Vertigo is also associated with excessive use of diagnostic imaging and emergency care and decreased productivity, primarily because of work absenteeism. Vestibular rehabilitation is an evidence-based treatment for chronic dizziness and supervised group exercise therapy has recently been shown to be effective after vestibular neuritis, a common cause of acute onset vertigo. However, such interventions are not readily available and there is a need for more easily accessible tools. The purpose of this study is to investigate the effects on vestibular symptoms of a 6-week online vestibular rehabilitation tool after acute onset vertigo, with the aim of aiding vestibular rehabilitation by presenting a more accessible tool that can help to reduce recovery time.

Methods

Three hundred twenty individuals diagnosed with acute vestibular syndrome (AVS) will be recruited from multiple hospitals in Sweden and the effects of an online vestibular rehabilitation tool, YrselTräning, on vestibular symptoms after acute onset vertigo will be compared to standard care (written instructions leaflet) in a two-armed, evaluator-blinded, multicenter randomized controlled trial. The primary outcome will be the Vertigo Symptom Scale Short Form (VSS-SF) score at 6 weeks after symptom onset. Secondary outcomes include effects of the intervention on activities of daily living, mood and anxiety, vestibular function recovery, mobility measures, health economic effects, and the reliability of the Swedish VSS-SF translation.

Discussion

Participants using the online vestibular rehabilitation tool are expected to recover earlier and to a greater extent from their symptoms as compared to standard care. Since up to 50% of people with AVS without treatment develop persistent symptoms, effective treatment of AVS will likely lead to a higher quality of life and help reduce the societal costs associated with dizziness and vertigo.

Trial registration

Clinicaltrials.gov NCT05056324. Registered on September 24, 2021.

Validation of a comprehensive diagnostic algorithm for patients with acute vertigo and dizziness

BACKGROUND

Vertigo and dizziness are common complaints in emergency departments and primary care, which pose major diagnostic challenges due to various underlying etiologies. Most supportive diagnostic algorithms concentrate on either identifying cerebrovascular events or diagnosing specific vestibular disorders or are restricted to specific patient subgroups.

METHODS

The study was conducted in the scope of the 'PoiSe' project (prevention, online feedback, and interdisciplinary therapy of acute vestibular syndromes by e-health). A three-level algorithm was developed according to international guidelines and scientific evidence addressing both, the detection of cerebrovascular events and the classification to non-vascular vestibular disorders (unilateral vestibulopathy, benign paroxysmal positional vertigo, vestibular paroxysmia, Menière's disease, vestibular migraine, functional dizziness). The algorithm was validated on a prospectively collected dataset of 407 patients with acute vertigo and dizziness presenting to the emergency department at LMU Munich.

RESULTS

The algorithm assigned 287 of 407 patients to the correct diagnosis, corresponding to an overall accuracy of 71%. Cerebrovascular events were identified with high sensitivity of 94%. The six most common vestibular disorders were classified with high specificity above 95%. Random forest identified the presence of a paresis, sensory loss, central ocular motor and vestibular signs (HINTS), and older age as the most important variables indicating a cerebrovascular event.

CONCLUSIONS

The proposed diagnostic algorithm can correctly classify the most common vestibular disorders based on a comprehensive set of key questions and clinical examinations. It is easily applied, not limited to subgroups, and might therefore be transferred to broad clinical settings such as primary health care.

Vascular vertigo and dizziness: Diagnostic criteria

This paper presents diagnostic criteria for vascular vertigo and dizziness as formulated by the Committee for the Classification of Vestibular Disorders of the Bárány Society. The classification includes vertigo/dizziness due to stroke or transient ischemic attack as well as isolated labyrinthine infarction/hemorrhage, and vertebral artery compression syndrome. Vertigo and dizziness are among the most common symptoms of posterior circulation strokes. Vascular vertigo/dizziness may be acute and prolonged (≥24 hours) or transient (minutes to  < 24 hours). Vascular vertigo/dizziness should be considered in patients who present with acute vestibular symptoms and additional central neurological symptoms and signs, including central HINTS signs (normal head-impulse test, direction-changing gaze-evoked nystagmus, or pronounced skew deviation), particularly in the presence of vascular risk factors. Isolated labyrinthine infarction does not have a confirmatory test, but should be considered in individuals at increased risk of stroke and can be presumed in cases of acute unilateral vestibular loss if accompanied or followed within 30 days by an ischemic stroke in the anterior inferior cerebellar artery territory. For diagnosis of vertebral artery compression syndrome, typical symptoms and signs in combination with imaging or sonographic documentation of vascular compromise are required.

Curriculum for vestibular medicine (vestmed) proposed by the barany society

This document presents the initiative of the Bárány Society to improve diagnosis and care of patients presenting with vestibular symptoms worldwide.

The Vestibular Medicine (VestMed) concept embraces a wide approach to the potential causes of vestibular symptoms, acknowledging that vertigo, dizziness, and unsteadiness are non-specific symptoms that may arise from a broad spectrum of disorders, spanning from the inner ear to the brainstem, cerebellum and supratentorial cerebral networks, to many disorders beyond these structures.

The Bárány Society Vestibular Medicine Curriculum (BS-VestMed-Cur) is based on the concept that VestMed is practiced by different physician specialties and non-physician allied health professionals. Each profession has its characteristic disciplinary role and profile, but all work in overlapping areas. Each discipline requires good awareness of the variety of disorders that can present with vestibular symptoms, their underlying mechanisms and etiologies, diagnostic criteria and treatment options. Similarly, all disciplines require an understanding of their own limitations, the contribution to patient care from other professionals and when to involve other members of the VestMed community. Therefore, the BS-VestMed-Cur is the same for all health professionals involved, the overlaps and differences of the various relevant professions being defined by different levels of detail and depth of knowledge and skills.

The BS-VestMed-Cur defines a Basic and an Expert Level Curriculum. The Basic Level Curriculum covers the VestMed topics in less detail and depth, yet still conveys the concept of the wide net approach. It is designed for health professionals as an introduction to, and first step toward, VestMed expertise. The Expert Level Curriculum defines a Focused and Broad Expert. It covers the VestMed spectrum in high detail and requires a high level of understanding. In the Basic and Expert Level Curricula, the range of topics is the same and runs from anatomy, physiology and physics of the vestibular system, to vestibular symptoms, history taking, bedside examination, ancillary testing, the various vestibular disorders, their treatment and professional attitudes. Additionally, research topics relevant to clinical practice are included in the Expert Level Curriculum. For Focused Expert proficiency, the Basic Level Curriculum is required to ensure a broad overview and additionally requires an expansion of knowledge and skills in one or a few specific topics related to the focused expertise, e.g. inner ear surgery. Broad Expert proficiency targets professionals who deal with all sorts of patients presenting with vestibular symptoms (e.g. otorhinolaryngologists, neurologists, audiovestibular physicians, physical therapists), requiring a high level of VestMed expertise across the whole spectrum. For the Broad Expert, the Expert Level Curriculum is required in which the minimum attainment targets for all the topics go beyond the Basic Level Curriculum. The minimum requirements regarding knowledge and skills vary between Broad Experts, since they are tuned to the activity profile and underlying specialty of the expert.

  The BS-VestMed-Cur aims to provide a basis for current and future teaching and training programs for physicians and non-physicians. The Basic Level Curriculum could also serve as a resource for inspiration for teaching VestMed to students, postgraduate generalists such as primary care physicians and undergraduate health professionals, or anybody wishing to enter VestMed.

  VestMed is considered a set of competences related to an area of practice of established physician specialties and non-physician health professions rather than a separate clinical specialty. This curriculum does not aim to define a new single clinical specialty.

  The BS-VestMed-Cur should also integrate with, facilitate and encourage translational research in the vestibular field.

Choice of intravenous thrombolysis therapy in patients with mild stroke complaining of acute dizziness

BACKGROUND

Quick identification of patients with mild ischemic stroke complaining of dizziness from other patients with benign peripheral vestibular disorders who also experience dizziness in the emergency department (ED) may be difficult. Decision-making on intravenous thrombolysis therapy (IVT) in patients whose chief symptoms include acute dizziness or vertigo remains a severe challenge for ED physicians. This study evaluated the diagnosis, treatment processes and the short-term outcomes in patients with mild vestibular stroke in the ED.

METHODS

A total of 89 consecutive patients with mild ischemic stroke primarily presenting with vestibular symptoms, who arrived at ED within 4.5 after onset, and were admitted at the stroke center of Zhejiang Provincial People's Hospital between January 2015 and March 2021 were retrospectively enrolled. Patients treated with IVT (n = 47) were compared to patients without IVT (n = 42) in terms of demographics, onset-to-door time (ODT), baseline clinical characteristics, risk factors of stroke, imaging findings, and short-term outcomes. The correlation between these parameters and IVT decision-making was analyzed.

RESULTS

Patients in IVT group more frequently presented with shorter ODT, focal neurological deficits (dysarthria, facial palsy, hemiglossoplegia, hemiparesis, hemisensory loss), disabling deficits, higher baseline National Institute of Health Stroke Scale (NIHSS) scores, and underwent multi-mode imaging before a decision. A higher proportion of isolated vestibular symptoms, acute transient vestibular syndrome, and vestibulo-vagal symptoms were found in the no-IVT group. There were no differences in demographics between the two groups. ODT was negatively correlated with the decision-making on IVT, and baseline NIHSS scores were positively correlated with the decision-making on IVT.

CONCLUSION

ODT and baseline NIHSS scores were correlated with the IVT decision in mild stroke patients primarily presenting with vestibular symptoms. Severe vestibular symptoms and disabling deficits were weakly associated with IVT decision, while the vestibulo-oculomotor signs and multi-mode imaging did not result as the influencing factors promoting the IVT decision-making for mild vestibular stroke.

A Simple Gain-Based Evaluation of the Video Head Impulse Test Reliably Detects Normal Vestibulo-Ocular Reflex Indicative of Stroke in Patients With Acute Vestibular Syndrome

Objective: The head impulse test (HIT) assesses the vestibulo-ocular reflex (VOR) and is used to differentiate vestibular neuritis (abnormal VOR) from stroke (normal VOR) in patients presenting with an acute vestibular syndrome (AVS). The video-oculography-based HIT (vHIT) quantifies VOR function and provides information imperceptible for the clinician during clinical bedside HIT. However, the vHIT—like an electrocardiogram—requires experienced interpretation, which is especially difficult in the emergency setting. This calls for a simple, reliable and rater-independent way of analysis.

Methods: We retrospectively collected 171 vHITs performed in patients presenting with AVS to our emergency department. Three neuro-otological experts comprehensively assessed the vHITs including interpretability (artifacts), VOR gain (eye/head velocity ratio), velocity profile (abrupt decline) and corrective saccades (overt/covert). Their consensus rating (abnormal/peripheral vs. normal/central) was compared to a simple algorithm that automatically classified the vHITs based on a single VOR gain cutoff (0.7).

Results: Inter-rater agreement between experts was high (Fleiss' kappa = 0.74). Five (2.9 %) vHITs were “uninterpretable” according to experts' consensus, 80 (46.8 %) were rated “normal” and 86 (50.3 %) “abnormal”. The algorithm had substantial agreement with the experts' consensus (Cohen's kappa = 0.75). Importantly, it correctly classified all of the normal/central vHITs denoted by the experts (100% specificity) and at the same time it had sufficient sensitivity (75.6%) in detecting abnormal/peripheral vHITs.

Conclusion: A simple, automated, gain-based evaluation of the vHIT reliably detects normal/central VOR and may be a feasible and effective tool to screen AVS patients for potentially underlying stroke in the emergency setting.

Statistical insights for crude-rate-based operational measures of misdiagnosis-related harms

In longitudinal event data, a crude rate is a simple quantification of the event rate, defined as the number of events during an evaluation window, divided by the at-risk population size at the beginning or mid-time point of that window. The crude rate recently received revitalizing interest from medical researchers who aimed to improve measurement of misdiagnosis-related harms using administrative or billing data by tracking unexpected adverse events following a "benign" diagnosis. The simplicity of these measures makes them attractive for implementation and routine operational monitoring at hospital or health system level. However, relevant statistical inference procedures have not been systematically summarized. Moreover, it is unclear to what extent the temporal changes of the at-risk population size would bias analyses and affect important conclusions concerning misdiagnosis-related harms. In this article, we present statistical inference tools for using crude-rate based harm measures, as well as formulas and simulation results that quantify the deviation of such measures from those based on the more sophisticated Nelson-Aalen estimator. Moreover, we present results for a generalized multibin version of the crude rate, for which the usual crude rate is a single-bin special case. The generalized multibin crude rate is more straightforward to compute than the Nelson-Aalen estimator and can reduce potential biases of the single-bin crude rate. For studies that seek to use multibin measures, we provide simulations to guide the choice regarding number of bins. We further bolster these results using a worked example of stroke after "benign" dizziness from a large data set.

[Update on diagnosis and therapy in frequent vestibular and balance disorders]

The 8 most frequent vestibular disorders account for more than 70% of all presentations of vertigo, dizziness, and imbalance. In acute (and mostly non-repetitive) vestibular disorders acute unilateral vestibulopathy and vestibular stroke are most important, in episodic vestibulopathies benign paroxysmal positional vertigo (BPPV), Menière's disease and vestibular migraine, and in chronic vestibular disorders bilateral vestibulopathy/presbyvestibulopathy, functional dizziness and cerebellar dizziness. In the last decade, internationally consented diagnostic criteria and nomenclature were established for the most frequent vestibular disorders, which can be easily applied in clinical practice. The diagnostic guidelines are based on history taking (including onset, duration, course, triggers, accomanying symptoms), clinical examination, and only a few apparative tests (by videooculography and audiometry) for securing the diagnosis. Treatment of vestibular disorders includes physical training (repositioning maneuvers, multimodal balance training) and pharmacological approaches (e.g., corticosteroids, antiepileptics, antidepressants, potassium-canal-blockers, drugs enhancing neuroplasticity). For most drugs, high-level evidence from prospective controlled trials is lacking. In clinical practice, the most frequent vestibular disorders can be treated effectively, thus avoiding chronicity and secondary comorbidity (by immobility, falls or psychiatric disorders such as anxiety or depression).

Acute Dizziness, Vertigo, and Unsteadiness

Vestibular symptoms, including dizziness, vertigo, and unsteadiness, are common presentations in the emergency department. Most cases have benign causes, such as vestibular apparatus dysfunction or orthostatic hypotension. However, dizziness can signal a more sinister condition, such as an acute cerebrovascular event or high-risk cardiac arrhythmia. A contemporary approach to clinical evaluation that emphasizes symptom duration and triggers along with a focused oculomotor and neurologic examination can differentiate peripheral causes from more serious central causes of vertigo. Patients with high-risk features should get brain MRI as the diagnostic investigation of choice.

Neurologists' Diagnostic Accuracy and Interspecialties' Diagnostic Concordance of Acute Vertigo: Observational Study at the Emergency Department in a Tertiary Center

BACKGROUND

Acute vertigo (AV) is often a challenging condition. Because of its multiple causes, patients are frequently observed by neurologists and physicians from other areas of specialites, particularly Ear, Nose, and Throat (ENT). We aimed to assess the diagnostic accuracy of AV in patients observed by Neurology and other medical specialties.

MATERIALS AND METHODS

Retrospective cross-sectional study with the selection of all patients with AV observed by Neurology at the Emergency Department (ED) of a tertiary center in 2019, regarding demographic data, imaging studies, diagnosis by Neurology and ENT at the ED, and diagnosis after ED discharge by different medical specialties.

RESULTS

In all, 54 patients were selected, 28 (52%) of them were women. The mean age was 59.96±14.88 years; 48% had a history of AV and 89% underwent imaging studies (computed tomography scan and/or magnetic resonance imaging scan). The most frequent diagnosis established by Neurology was benign paroxysmal positional vertigo, followed by vestibular neuronitis; 28 patients were also observed by ENT with an overall concordance rate of diagnosis of 39%. After ED discharge, most patients were observed at the Balance Disorders Outpatient Clinic. Diagnosis by Neurology at the ED was not significantly different from observation by other medical specialties after ED discharge regarding the distinction between peripheral and central causes of AV (κ=0.840, 95% confidence interval: 0.740 to 0.941, P<0.005).

CONCLUSIONS

Neurologists can effectively differentiate central and peripheral causes of AV at the ED. Patients with AV should be primarily evaluated by Neurology at the ED, avoiding redundant observations and allowing faster patient management.

Diagnostic Error of Neuro-ophthalmologic Conditions: State of the Science

BACKGROUND

Diagnostic error is prevalent and costly, occurring in up to 15% of US medical encounters and affecting up to 5% of the US population. One-third of malpractice payments are related to diagnostic error. A complex and specialized diagnostic process makes neuro-ophthalmologic conditions particularly vulnerable to diagnostic error.

EVIDENCE ACQUISITION

English-language literature on diagnostic errors in neuro-ophthalmology and neurology was identified through electronic search of PubMed and Google Scholar and hand search.

RESULTS

Studies investigating diagnostic error of neuro-ophthalmologic conditions have revealed misdiagnosis rates as high as 60%-70% before evaluation by a neuro-ophthalmology specialist, resulting in unnecessary tests and treatments. Correct performance and interpretation of the physical examination, appropriate ordering and interpretation of neuroimaging tests, and generation of a differential diagnosis were identified as pitfalls in the diagnostic process. Most studies did not directly assess patient harms or financial costs of diagnostic error.

CONCLUSIONS

As an emerging field, diagnostic error in neuro-ophthalmology offers rich opportunities for further research and improvement of quality of care.

Teleconsultation and Teletreatment Protocol to Diagnose and Manage Patients with Benign Paroxysmal Positional Vertigo (BPPV) during the COVID-19 Pandemic

Introduction  Telehealth consists in the application of technology to provide remote health service. This resource is considered safe and effective and has attracted an exponential interest in the context of the COVID pandemic. Expanded to dizzy patients, it would be able to provide diagnosis and treatment, minimizing the risk of disease transmission. Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder. The diagnosis typically rests on the description of the symptoms along with the nystagmus observed at a well-established positional testing.

Objectives  The aim of the present study was to propose a teleconsultation and teletreatment protocol to manage patients with BPPV during the COVID-19 pandemic.

Methods  Specialists in the vestibular field met through remote access technologies to discuss the best strategy to manage BPPV patients by teleconsultation and teletreatment system. Additionally, several scientific sources were consulted. Technical issues, patient safety, and clinical assessment were independently analyzed. All relevant information was considered in order to design a clinical protocol to manage BPPV patients in the pandemic context.

Results  Teleconsultation for BPPV patients requires a double way (video and audio) digital system. An adapted informed consent to follow good clinical practice statements must be considered. The time, trigger and target eye bedside examination (TiTRaTe) protocol has proven to be a valuable first approach. The bow and lean test is the most rational screening maneuver for patients with suspected positional vertigo, followed by most specific maneuvers to diagnostic the sub-variants of BPPV.

Conclusion  Although with limited evidence, teleconsultation and teletreatment are both reasonable and feasible strategies for the management of patients with BPPV in adverse situations for face-to-face consultation.

Vertigo and dizziness in the emergency room

PURPOSE OF REVIEW

To provide an update on diagnostic algorithms for differential diagnosis of acute vertigo and dizziness and swift identification of potentially harmful causes.

RECENT FINDINGS

About 25% of patients with acute vertigo and dizziness have a potentially life-threatening diagnosis, including stroke in 4-15%. Diagnostic work-up relies on the combination of symptom features (triggers, duration, history of vertigo/dizziness, accompanying symptoms) and a comprehensive vestibular, ocular motor, and balance exam. The latter includes head impulse, head-shaking nystagmus, positional nystagmus, gaze-holding, smooth pursuit, skew deviation, and Romberg's test. Recent standardized diagnostic algorithms (e.g., HINTS, TriAGe+) suggest the combination of several elements to achieve a good diagnostic accuracy in differentiation of central and peripheral vestibular causes. Neuroimaging with MRI must be applied and interpreted with caution, as small strokes are frequently overlooked, especially in the acute setting (false-negative rate of up to 50%).

SUMMARY

Diagnostic differentiation of acute vertigo and dizziness remains a complex task, which can be tackled by a structured clinical assessment focusing on symptom characteristics and constellations of ocular motor and vestibular findings. Specific challenges arise in cases of transient or atypical vestibular syndromes.

Usability of the head impulse test in routine clinical practice in the emergency department to differentiate vestibular neuritis from stroke

BACKGROUND AND PURPOSE

The bedside head impulse test (bHIT) is used to differentiate vestibular neuritis (VN) from posterior circulation stroke (PCS) in patients presenting with acute vestibular syndrome (AVS). If assessed by neuro-otological experts, diagnostic accuracy is high. We report on its diagnostic accuracy when applied by nonexperts during routine clinical practice in the emergency department (ED), its impact on patient management, and the potential diagnostic yield of the video-oculography-supported head impulse test (vHIT).

METHODS

Medical chart review of 38 AVS patients presenting to our university medical center's ED, assessed by neurology residents. We collected bHIT results (abnormal/peripheral or normal/central) and whether patients were admitted to the stroke unit or general neurological ward. Final diagnosis (VN, n = 24; PCS, n = 14) was determined by clinical course, magnetic resonance imaging, and vHIT.

RESULTS

The bHIT's accuracy was only 58%. Its sensitivity for VN was high (88%), but due to many false-abnormal bHITs in PCS (36%), the specificity was low (64%). The vHIT yielded excellent specificity (100%) and moderate sensitivity (67%). The decision on the patient's further care was almost arbitrary and independent from the bHIT: 58% of VN and 57% of PCS patients were admitted to the stroke unit.

CONCLUSIONS

The bHIT, applied by nonexperts during routine practice in the ED, has low accuracy, is too often mistaken as abnormal/peripheral, and is not consistently used for patients' in-hospital triage. As false-abnormal bHITs can lead to misdiagnosis/mistreatment of stroke patients, we recommend that bHIT applied by nonexperts should be reassessed by a neuro-otological expert or preferably quantitative vHIT in the ED.

Modern machine-learning can support diagnostic differentiation of central and peripheral acute vestibular disorders

BACKGROUND

Diagnostic classification of central vs. peripheral etiologies in acute vestibular disorders remains a challenge in the emergency setting. Novel machine-learning methods may help to support diagnostic decisions. In the current study, we tested the performance of standard and machine-learning approaches in the classification of consecutive patients with acute central or peripheral vestibular disorders.

METHODS

40 Patients with vestibular stroke (19 with and 21 without acute vestibular syndrome (AVS), defined by the presence of spontaneous nystagmus) and 68 patients with peripheral AVS due to vestibular neuritis were recruited in the emergency department, in the context of the prospective EMVERT trial (EMergency VERTigo). All patients received a standardized neuro-otological examination including videooculography and posturography in the acute symptomatic stage and an MRI within 7 days after symptom onset. Diagnostic performance of state-of-the-art scores, such as HINTS (Head Impulse, gaze-evoked Nystagmus, Test of Skew) and ABCD2 (Age, Blood, Clinical features, Duration, Diabetes), for the differentiation of vestibular stroke vs. peripheral AVS was compared to various machine-learning approaches: (i) linear logistic regression (LR), (ii) non-linear random forest (RF), (iii) artificial neural network, and (iv) geometric deep learning (Single/MultiGMC). A prospective classification was simulated by ten-fold cross-validation. We analyzed whether machine-estimated feature importances correlate with clinical experience.

RESULTS

Machine-learning methods (e.g., MultiGMC) outperform univariate scores, such as HINTS or ABCD2, for differentiation of all vestibular strokes vs. peripheral AVS (MultiGMC area-under-the-curve (AUC): 0.96 vs. HINTS/ABCD2 AUC: 0.71/0.58). HINTS performed similarly to MultiGMC for vestibular stroke with AVS (AUC: 0.86), but more poorly for vestibular stroke without AVS (AUC: 0.54). Machine-learning models learn to put different weights on particular features, each of which is relevant from a clinical viewpoint. Established non-linear machine-learning methods like RF and linear methods like LR are less powerful classification models (AUC: 0.89 vs. 0.62).

CONCLUSIONS

Established clinical scores (such as HINTS) provide a valuable baseline assessment for stroke detection in acute vestibular syndromes. In addition, machine-learning methods may have the potential to increase sensitivity and selectivity in the establishment of a correct diagnosis.

Diagnosis of Patients with Acute Dizziness

Using an algorithmic approach to acutely dizzy patients, physicians can often confidently make a specific diagnosis that leads to correct treatment and should reduce the misdiagnosis of cerebrovascular events. Emergency clinicians should try to become familiar with an approach that exploits timing and triggers as well as some basic "rules" of nystagmus. The gait should always be tested in all patients who might be discharged. Computed tomographic scans are unreliable to exclude posterior circulation stroke presenting as dizziness, and early MRI (within the first 72 hours) also misses 10% to 20% of these cases.

Physician-related factors associated with unscheduled revisits to the emergency department and admission to the intensive care unit within 72 h

Investigation of physician-related causes of unscheduled revisits to the emergency department (ED) within 72 h with subsequent admission to the intensive care unit (ICU) is an important parameter of emergency care quality. Between 2012 and 2017, medical records of all adult patients who visited the ED and returned within 72 h with subsequent ICU admission were retrospectively reviewed by three experienced emergency physicians. Study parameters were categorized into "input" (Patient characteristics), "throughput" (Time spent on first ED visit and seniority of emergency physicians, and "output" (Charlson Comorbidity Index). Of the 147 patients reviewed for the causes of ICU admission, 35 were physician-related (23.8%). Eight belonged to more urgent categories, whereas the majority (n = 27) were less urgent. Patients who spent less time on their first ED visits before discharge (< 2 h) were significantly associated with physician-related causes of ICU admission, whereas there was no significant difference in other "input," "throughput," and "output" parameters between the "physician-related" and "non-physician-related" groups. Short initial management time was associated with physician-related causes of ICU admission in patients with initial less urgent presentations, highlighting failure of the conventional triage system to identify potentially life-threatening conditions and possibility of misjudgement because of the patients' apparently minor initial presentations.

Characteristics of Acute Nystagmus in the Pediatric Emergency Department

OBJECTIVES

Acute nystagmus (AN) is an uncommon neurologic sign in children presenting to pediatric emergency departments. We described the epidemiology, clinical features, and underlying causes of AN in a large cohort of children, aiming at identifying features associated with higher risk of severe underlying urgent conditions (UCs).

METHODS

Clinical records of all patients aged 0 to 18 years presenting for AN to the pediatric emergency departments of 9 Italian hospitals in an 8-year period were retrospectively reviewed. Clinical and demographic features and the underlying causes were analyzed. A logistic regression model was applied to detect predictive variables associated with a higher risk of UCs.

RESULTS

A total of 206 patients with AN were included (male-to-female ratio: 1.01; mean age: 8 years 11 months). The most frequently associated symptoms were headache (43.2%) and vertigo (42.2%). Ataxia (17.5%) and strabismus (13.1%) were the most common neurologic signs. Migraine (25.7%) and vestibular disorders (14.1%) were the most common causes of AN. Idiopathic infantile nystagmus was the most common cause in infants <1 year of age. UCs accounted for 18.9% of all cases, mostly represented by brain tumors (8.3%). Accordant with the logistic model, cranial nerve deficits, ataxia, or strabismus were strongly associated with an underlying UC. Presence of vertigo or attribution of a nonurgent triage code was associated with a reduced risk of UCs.

CONCLUSIONS

AN should be considered an alarming finding in children given the risk of severe UCs. Cranial nerve palsy, ataxia, and strabismus should be considered red flags during the assessment of a child with AN.

Telling friend from foe in emergency vertigo and dizziness: does season and daytime of presentation help in the differential diagnosis?

Distinguishing between serious (e.g., stroke) and benign (e.g., benign paroxysmal positional vertigo, BPPV) disorders remains challenging in emergency consultations for vertigo and dizziness (VD). A number of clues from patient history and clinical examination, including several diagnostic index tests have been reported recently. The objective of the present study was to analyze frequency and distribution patterns of specific vestibular and non-vestibular diagnoses in an interdisciplinary university emergency room (ER), including data on daytime and season of presentation. A retrospective chart analysis of all patients seen in a one-year period was performed. In the ER 4.23% of all patients presented with VD (818 out of 19,345). The most frequent-specific diagnoses were BPPV (19.9%), stroke/transient ischemic attack (12.5%), acute unilateral vestibulopathy/vestibular neuritis (UVH; 8.3%), and functional VD (8.3%). Irrespective of the diagnosis, the majority of patients presented to the ER between 8 a.m. and 4 p.m. There are, however, seasonal differences. BPPV was most prevalent in December/January and rare in September. UVH was most often seen in October/November; absolute and relative numbers were lowest in August. Finally, functional/psychogenic VD was common in summer and autumn with highest numbers in September/October and lowest numbers in March. In summary, daytime of presentation did not distinguish between diagnoses as most patients presented during normal working hours. Seasonal presentation revealed interesting fluctuations. The UVH peak in autumn supports the viral origin of the condition (vestibular neuritis). The BPPV peak in winter might be related to reduced physical activity and low vitamin D. However, it is likely that multiple factors contribute to the fluctuations that have to be disentangled in further studies.

Approaching Acute Vertigo With Diplopia: A Rare Skew Deviation in Vestibular Neuritis

Evaluating the patient with acute constant vertigo or diplopia can be a daunting task for clinicians, who recognize that such symptoms can be the manifestation of potentially devastating disorders like stroke but may be uncomfortable eliciting and interpreting the key symptoms and subtle signs that distinguish dangerous from benign causes. We present a novel and highly instructive case of a patient with acute vertigo and binocular diplopia from a large skew deviation due to vestibular neuritis. As the case unfolds, text and video commentary guide the clinician through the important elements of the history, bedside examination, and laboratory evaluation necessary for accurate diagnosis in the acute vestibular syndrome. We demonstrate how to interpret nystagmus and properly perform the head impulse test and test of skew deviation and discuss the pitfalls of overreliance on imaging when evaluating patients with acute vertigo.

A Systematic Review of the Reported Proportions of Diagnoses for Dizziness and Vertigo

OBJECTIVES

To determine the typical proportions of diagnoses for patients presenting with dizziness or vertigo based on clinical speciality and to assess the change in proportions of diagnoses over time.

DATA SOURCES

Following PRISMA guidelines, systematic searches of PubMed and CINAHL databases and follow-up reference searches were performed for articles published in English up to October 2016.

STUDY SELECTION

Analysis of searches yielded 42 studies meeting the criteria of case series of adult patients with dizziness and/or vertigo presenting to general practice, emergency departments or specialist outpatient clinics.

DATA EXTRACTION

Data comprising demographics, diagnostic cases, and the total number of cases were recorded and independently tested, followed by a risk of bias analysis.

DATA SYNTHESIS

Sample size weighted proportions expressed as percentages with confidence intervals were calculated and compared using χ analysis and a reference proportion formed by the combination of Ear Nose and Throat and Neurotology case series published between 2010 and 2016. Analysis of diagnostic trends over time used Poisson regression with consideration for overdispersion.

CONCLUSIONS

This systematic review of case series demonstrated significant differences in the proportions of diagnoses for patients presenting with dizziness or vertigo, depending on the specialty making the diagnosis. ENT proportions were dominated by BPPV, Psychogenic and Menière's disease diagnostic categories, whereas emergency proportions were dominated by Other, Cardiac, and Neurological categories. Analysis of case series proportions over time revealed increases in diagnoses such as Benign Paroxysmal Positional Vertigo and Vestibular Migraine, and a corresponding decrease in the diagnoses of Menière's disease.

A comparison of benign positional vertigo and stroke patients presenting to the emergency department with vertigo or dizziness

PURPOSE

To compare imaging utilization between patients presenting to the emergency department (ED) with vertigo and dizziness (VDS) who are diagnosed with stroke and benign paroxysmal positional vertigo (BPPV).

METHODS

All patients presenting to the ED with VDS (January 2014-June 2018) were identified. Those with a discharge diagnosis of stroke and BPPV were analyzed.

RESULTS

17,884 patients presented to with VDS. 452 were diagnosed with BPPV and 174 with acute stroke. 55.7% of stroke patients had at least one neurologic symptom beyond VDS, 63.8% had a positive neurologic exam, and 80.5% had either; 90.2% had at least one stroke risk factor (RF). 42.0% of BPPV patients received imaging, of which 24.7% had neurologic symptoms beyond VDS, 16.3% had neurologic exam findings, and 34.2% had either (P < 0.001, as compared to stroke). 43 patients (22.6%) lacked neurologic symptoms, exam findings, and stroke RFs; 40 had an adequate HINTS (head impulse, nystagmus, skew) exam. The most common imaging modality received by BPPV patients was plain CT Head (54.2%), followed by CT/CTA (43.7%), and MRI brain (26.3%). CT head was the initial imaging of choice in 44.7% and CT/CTA in 42.6%.

CONCLUSIONS

Imaging utilization in BPPV patients presenting with VDS is high. The profile of patients with BPPV that received imaging was substantially more benign than that of stroke patients (a quarter had no neurologic symptoms, exam findings, or stroke RFs). The HINTS exam was underutilized, and computed tomography was heavily utilized despite well-established limitations in diagnosing posterior circulation strokes. This study highlights the need for increased training in the HINTS exam, narrowing of the scope for computed tomography, and a higher threshold for imaging patients with isolated VDS.

Innovative Use of Google Cardboard in Clinical Examination of Patients of Vertigo

Background:

Vertigo is 1 of the most prominent and frequent neurological symptom. It is estimated that about 30% of all people need medical care once in their life due to this index symptom. The neurological expertise required is usually scarce in underprivileged areas. One has to look for spontaneous nystagmus, and perform Dix–Hallpike maneuver and Head Impulse test specifically to differentiate central from peripheral vertigo. The nystagmus, that is spontaneous, involuntary to-and-fro movement of the eyeball which aids in the diagnosis, can be better elicited by Frenzel glasses, Munich glasses. These devices consist of the combination of magnifying glasses and a lighting system to detect eye movements better than routine examination.

Objective:

To test usefulness of modified Google cardboard as Frenzel glasses in poor resource setting.

Study design:

A modified Google cardboard was used in 52 consecutive cases of vertigo and compared with examination with naked eye. The device consists of 2 magnifying lenses, 1 for each eye with power of +24 dioptres.

Observation:

The tool was found to be better for identifying spontaneous nystagmus, in Dix–Hallpike maneuver and during head impulse test as compared with the naked eye owing to the property of magnification and inhibition of fixation. Being a cheaper alternative and handy, it could be carried by every doctor in any setting.

Evaluating the Diagnostic Accuracy of the Head-Impulse Test: A Scoping Review

Importance

Vestibular symptoms rank among the most common complaints in medicine worldwide. Underlying disorders manifested by these symptoms are generally associated with an impairment of the vestibular-ocular reflex and can be assessed with different diagnostic procedures. In recent years, an increasing number of diagnostic test accuracy studies comparing various head-impulse test (HIT) methods with other diagnostic procedures have been published but not systematically reviewed.

Objective

To conduct a scoping review and describe key characteristics of the growing number of diagnostic studies in patients presenting with vestibular symptoms.

Evidence Review

In April 2017, published studies were identified through searches of 4 bibliographic databases: Medline, Science Citation Index Expanded, the Cochrane Library, and ScienceDirect. Studies were included if they provided diagnostic accuracy data (sensitivity and specificity) for any HIT method with reference to any other vestibular test or clinical diagnosis in patients with vestibular symptoms. Study key characteristics were extracted, and the current literature was described narratively. All analysis took place between June 2017 and July 2018.

Findings

We identified a total of 27 diagnostic studies (including 3821 participants). There were disagreements between diagnostic test accuracy data both within and between studies when different HIT methods were compared with other diagnostic procedures. The proportion of correctly identified people having the disease (sensitivity) ranged between 0% and 100% (median, 41%), whereas the proportion of correctly identified people without the disease (specificity) was higher and ranged between 56% and 100% (median, 94%).

Conclusions and Relevance

Based on the studies included in this review, sensitivity, specificity, and, more importantly, the risk of misdiagnosis and associated undertreatment or overtreatment cannot be reliably estimated by HIT methods for patients with vestibular symptoms. We recommend that further diagnostic studies consider (1) multiple possible underlying causes of vestibular symptoms and multiple test thresholds, (2) a representative sample of patients with and without the disease, and (3) reporting guidelines for diagnostic test accuracy studies.

Ischemic Stroke Predictors in Patients Presenting with Dizziness, Imbalance, and Vertigo

OBJECTS

To identify predictors of acute ischemic stroke (AIS) among patients presenting to the Emergency Department (ED) with dizziness, imbalance, or vertigo (DIV) based on demographic and clinical characteristics.

METHODS

We identified patients admitted to the hospital after presenting to the ED with DIV from the Statewide Planning and Research Cooperative System database of New York from 2010 to 2014. Demographic and clinical characteristics were systematically collected. Multivariable logistic regression was used to determine predictors of a discharge diagnosis of AIS.

RESULTS

Among 77,993 patients with DIV, 3857 (4.9%) had a discharge diagnosis of AIS. Admission presentation of imbalance, African-American race, history of hypertension, diabetes mellitus, hypercholesterolemia, tobacco use, atrial fibrillation, and prior AIS due to extracranial artery atherosclerosis were each positively associated with an AIS diagnosis independently. Factors negatively associated with an AIS discharge diagnosis included: admission presentation of vertigo, female sex, age > 81, history of anemia, coronary artery disease, asthma, depressive disorders, and anxiety disorders.

CONCLUSIONS

Multiple potential positive and negative predictive AIS risk factors were identified. Combining with currently available centrally-caused dizziness prediction tools, these newly identified factors could provide more accurate AIS risk stratifying method for DIV patients.

Unique Clinical Language Patterns Among Expert Vestibular Providers Can Predict Vestibular Diagnoses

OBJECTIVE

To identify novel language usage by expert providers predictive of specific vestibular conditions.

STUDY DESIGN

Retrospective chart review and natural language processing. Level IV.

SETTING

Tertiary referral center.

PATIENTS

Patients seen for vestibular complaint.

INTERVENTION(S)

Natural language processing and machine learning analyses of semantic and syntactic patterns in clinical documentation from vestibular patients.

MAIN OUTCOME MEASURE

Accuracy of Naïve Bayes predictive models correlating language usage with clinical diagnoses.

RESULTS

Natural language analyses on 866 physician-generated histories from vestibular patients found 3,286 unique examples of language usage of which 614 were used 10 or greater times. The top 15 semantic types represented only 11% of all Unified Medical Language System semantic types but covered 86% of language used in vestibular patient histories. Naïve Bayes machine learning algorithms on a subset of 255 notes representing benign paroxysmal positional vertigo, vestibular migraine, anxiety-related dizziness and central dizziness generated strong predictive models showing an average sensitivity rate of 93.4% and a specificity rate of 98.2%. A binary model for assessing whether a subject had a specific diagnosis or not had an average AUC for the receiver operating characteristic curves of .995 across all conditions.

CONCLUSIONS

These results indicate that expert providers utilize unique language patterns in vestibular notes that are highly conserved. These patterns have strong predictive power toward specific vestibular diagnoses. Such language elements can provide a simple vocabulary to aid nonexpert providers in formulating a differential diagnosis. They can also be incorporated into clinical decision support systems to facilitate accurate vestibular diagnosis in ambulatory settings.

A New Diagnostic Approach to the Adult Patient with Acute Dizziness

BACKGROUND

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

OBJECTIVE OF THE REVIEW

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

DISCUSSION

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

CONCLUSIONS

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

[Vertigo and dizziness in the emergency room]

Vertigo and dizziness are among the most common chief complaints in the emergency department. Etiologies can be categorized into three subgroups: neurootological (vestibular), medical (especially cardiovascular, metabolic), and psychiatric disorders. The diagnostic approach in the emergency department is based on a systematic analysis of case history (type, time course of symptoms, modulating factors, associated symptoms), clinical examination of the vestibular, ocular motor, and cerebellar systems (head impulse test, nystagmus, skew deviation, positioning maneuver, test of gait and stance), as well as a basal monitoring (vital signs, 12-lead ECG, blood tests). For differentiation of peripheral and central etiologies in acute vestibular syndrome, the HINTS exam (head impulse test, nystagmus, test of skew) and examination of smooth pursuit and saccades should be applied. Nonselective use of neuroimaging is not indicated due to a low diagnostic yield. Cranial imaging should be done in the following constellations: (1) detection of focal neurological or central ocular motor and vestibular signs on clinical exam, (2) acute abasia with only minor ocular motor signs, (3) presence of various cardiovascular risk factors, (4) headache of unknown quality as an accompanying symptom. Besides the symptomatic therapy of vertigo and dizziness with antiemetics or analgesics, further diagnostic differentiation is urgent to guide proper treatment. Examples are the acute therapy in cerebral ischemia, the execution of positioning maneuvers in benign paroxysmal positional vertigo, the use of corticosteroids in acute unilateral vestibulopathy, as well as the readjustment of metabolic homeostasis in medical disorders.