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Hoppes CW, Lambert KH, Whitney SL, Erbele ID, Esquivel CR, Yuan TT. Leveraging Technology for Vestibular Assessment and Rehabilitation in the Operational Environment: A Scoping Review. Bioengineering (Basel) 2024; 11:117. [PMID: 38391603 PMCID: PMC10886105 DOI: 10.3390/bioengineering11020117] [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: 12/29/2023] [Revised: 01/12/2024] [Accepted: 01/18/2024] [Indexed: 02/24/2024] Open
Abstract
INTRODUCTION The vestibular system, essential for gaze and postural stability, can be damaged by threats on the battlefield. Technology can aid in vestibular assessment and rehabilitation; however, not all devices are conducive to the delivery of healthcare in an austere setting. This scoping review aimed to examine the literature for technologies that can be utilized for vestibular assessment and rehabilitation in operational environments. MATERIALS AND METHODS A comprehensive search of PubMed was performed. Articles were included if they related to central or peripheral vestibular disorders, addressed assessment or rehabilitation, leveraged technology, and were written in English. Articles were excluded if they discussed health conditions other than vestibular disorders, focused on devices or techniques not conducive to the operational environment, or were written in a language other than English. RESULTS Our search strategy yielded 32 articles: 8 articles met our inclusion and exclusion criteria whereas the other 24 articles were rejected. DISCUSSION There is untapped potential for leveraging technology for vestibular assessment and rehabilitation in the operational environment. Few studies were found in the peer-reviewed literature that described the application of technology to improve the identification of central and/or peripheral vestibular system impairments; triage of acutely injured patients; diagnosis; delivery and monitoring of rehabilitation; and determination of readiness for return to duty. CONCLUSIONS This scoping review highlighted technology for vestibular assessment and rehabilitation feasible for use in an austere setting. Such technology may be leveraged for prevention; monitoring exposure to mechanisms of injury; vestibular-ocular motor evaluation; assessment, treatment, and monitoring of rehabilitation progress; and return-to-duty determination after vestibular injury. FUTURE DIRECTIONS The future of vestibular assessment and rehabilitation may be shaped by austere manufacturing and 3D printing; artificial intelligence; drug delivery in combination with vestibular implantation; organ-on-chip and organoids; cell and gene therapy; and bioprinting.
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Affiliation(s)
- Carrie W Hoppes
- Army-Baylor University Doctoral Program in Physical Therapy, 3630 Stanley Road, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
| | - Karen H Lambert
- Hearing Center of Excellence, 2200 Bergquist Drive, Lackland Air Force Base, TX 78236, USA
| | - Susan L Whitney
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh, Bridgeside Point 1, 100 Technology Drive, Pittsburgh, PA 15219, USA
| | - Isaac D Erbele
- Department of Otolaryngology-Head and Neck Surgery, San Antonio Uniformed Services Health Education Consortium, Brooke Army Medical Center, 3551 Roger Brooke Drive, Joint Base San Antonio-Fort Sam Houston, TX 78234, USA
- Department of Surgery, School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
| | - Carlos R Esquivel
- Wilford Hall Ambulatory Surgical Center, 2200 Bergquist Drive, Lackland Air Force Base, TX 78236, USA
| | - Tony T Yuan
- Department of Radiology and Radiological Sciences, School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA
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Bastani PB, Rieiro H, Badihian S, Otero‐Millan J, Farrell N, Parker M, Newman‐Toker D, Zhu Y, Saber Tehrani A. Quantifying Induced Nystagmus Using a Smartphone Eye Tracking Application (EyePhone). J Am Heart Assoc 2024; 13:e030927. [PMID: 38226513 PMCID: PMC10926800 DOI: 10.1161/jaha.123.030927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 12/10/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND There are ≈5 million annual dizziness visits to US emergency departments, of which vestibular strokes account for over 250 000. The head impulse, nystagmus, and test of skew eye examination can accurately distinguish vestibular strokes from peripheral dizziness. However, the eye-movement signs are subtle, and lack of familiarity and difficulty with recognition of abnormal eye movements are significant barriers to widespread emergency department use. To break this barrier, we sought to assess the accuracy of EyePhone, our smartphone eye-tracking application, for quantifying nystagmus. METHODS AND RESULTS We prospectively enrolled healthy volunteers and recorded the velocity of induced nystagmus using a smartphone eye-tracking application (EyePhone) and then compared the results with video oculography (VOG). Following a calibration protocol, the participants viewed optokinetic stimuli with incremental velocities (2-12 degrees/s) in 4 directions. We extracted slow phase velocities from EyePhone data in each direction and compared them with the corresponding slow phase velocities obtained by the VOG. Furthermore, we calculated the area under the receiver operating characteristic curve for nystagmus detection by EyePhone. We enrolled 10 volunteers (90% men) with an average age of 30.2±6 years. EyePhone-recorded slow phase velocities highly correlated with the VOG recordings (r=0.98 for horizontal and r=0.94 for vertical). The calibration significantly increased the slope of linear regression for horizontal and vertical slow phase velocities. Evaluating the EyePhone's performance using VOG data with a 2 degrees/s threshold showed an area under the receiver operating characteristic curve of 0.87 for horizontal and vertical nystagmus detection. CONCLUSIONS We demonstrated that EyePhone could accurately detect and quantify optokinetic nystagmus, similar to the VOG goggles.
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Affiliation(s)
- Pouya B. Bastani
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMDUSA
- Armstrong Institute Center for Diagnostic ExcellenceBaltimoreMDUSA
| | - Hector Rieiro
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMDUSA
- Armstrong Institute Center for Diagnostic ExcellenceBaltimoreMDUSA
| | - Shervin Badihian
- Armstrong Institute Center for Diagnostic ExcellenceBaltimoreMDUSA
- Neurological Institute, Cleveland ClinicClevelandOHUSA
| | - Jorge Otero‐Millan
- Herbert Wertheim School of Optometry and Vision ScienceUniversity of CaliforniaBerkeleyCAUSA
| | - Nathan Farrell
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMDUSA
- Armstrong Institute Center for Diagnostic ExcellenceBaltimoreMDUSA
| | - Max Parker
- Department of Neurology, NYU Langone HealthNew YorkNYUSA
| | - David Newman‐Toker
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMDUSA
- Armstrong Institute Center for Diagnostic ExcellenceBaltimoreMDUSA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public HealthBaltimoreMDUSA
| | - Yuxin Zhu
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMDUSA
- Armstrong Institute Center for Diagnostic ExcellenceBaltimoreMDUSA
- Department of BiostatisticsJohns Hopkins University Bloomberg School of Public HealthBaltimoreMDUSA
| | - Ali Saber Tehrani
- Department of NeurologyJohns Hopkins University School of MedicineBaltimoreMDUSA
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Nerdal PT, Gandor F, Friedrich MU, Schappe L, Ebersbach G, Maetzler W. Vestibulo-Ocular Reflex Suppression: Clinical Relevance and Assessment in the Digital Age. Digit Biomark 2024; 8:52-58. [PMID: 38617128 PMCID: PMC11014718 DOI: 10.1159/000537842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 02/11/2024] [Indexed: 04/16/2024] Open
Abstract
Background Visual acuity and image stability are crucial for daily activities, particularly during head motion. The vestibulo-ocular reflex (VOR) and its suppression (VORS) support stable fixation of objects of interest. The VOR drives a reflexive eye movement to counter retinal slip of a stable target during head motion. In contrast, VORS inhibits this countermovement when the target stimulus is in motion. The VORS allows for object fixation when it aligns with the direction of the head's movement, or when an object within or outside the peripheral vision needs to be focused upon. Summary Deficits of the VORS have been linked to age-related diseases such as balance deficits associated with an increased fall risk. Therefore, the accurate assessment of the VORS is of particular clinical relevance. However, current clinical assessment methods for VORS are mainly qualitative and not sufficiently standardised. Recent advances in digital health technology, such as smartphone-based videooculography, offer a promising alternative for assessing VORS in a more accessible, efficient, and quantitative manner. Moreover, integrating mobile eye-tracking technology with virtual reality environments allows for the implementation of controlled VORS assessments with different visual inputs. These assessment approaches allow the extraction of novel parameters with potential pathomechanistic and clinical relevance. Key Messages We argue that researchers and clinicians can obtain a more nuanced understanding of this ocular stabilisation reflex and its associated pathologies by harnessing digital health technology for VORS assessment. Further research is warranted to explore the technologies' full potential and utility in clinical practice.
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Affiliation(s)
- Patrik Theodor Nerdal
- Department of Neurology, University Hospital Schleswig-Holstein and Kiel University, Kiel, Germany
| | - Florin Gandor
- Movement Disorders Hospital, Beelitz-Heilstätten, Beelitz, Germany
- Department of Neurology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Maximilian Uwe Friedrich
- Center for Brain Circuit Therapeutics, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Laurin Schappe
- Department of Neurology, Saarland University, Saarbrücken, Germany
| | - Georg Ebersbach
- Movement Disorders Hospital, Beelitz-Heilstätten, Beelitz, Germany
| | - Walter Maetzler
- Department of Neurology, University Hospital Schleswig-Holstein and Kiel University, Kiel, Germany
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Barahim Bastani P, Saber Tehrani AS, Badihian S, Rieiro H, Rastall D, Farrell N, Parker M, Otero-Millan J, Hassoon A, Newman-Toker D, Clawson LL, Uchil A, Riley K, Zeiler SR. Self-Recording of Eye Movements in Amyotrophic Lateral Sclerosis Patients Using a Smartphone Eye-Tracking App. Digit Biomark 2024; 8:111-119. [PMID: 39015513 PMCID: PMC11250669 DOI: 10.1159/000538992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 04/04/2024] [Indexed: 07/18/2024] Open
Abstract
Introduction Amyotrophic lateral sclerosis (ALS) can affect various eye movements, making eye tracking a potential means for disease monitoring. In this study, we evaluated the feasibility of ALS patients self-recording their eye movements using the "EyePhone," a smartphone eye-tracking application. Methods We prospectively enrolled ten participants and provided them with an iPhone equipped with the EyePhone app and a PowerPoint presentation with step-by-step recording instructions. The goal was for the participants to record their eye movements (saccades and smooth pursuit) without the help of the study team. Afterward, a trained physician administered the same tests using video-oculography (VOG) goggles and asked the participants to complete a questionnaire regarding their self-recording experience. Results All participants successfully completed the self-recording process without assistance from the study team. Questionnaire data indicated that participants viewed self-recording with EyePhone favorably, considering it easy and comfortable. Moreover, 70% indicated that they prefer self-recording to being recorded by VOG goggles. Conclusion With proper instruction, ALS patients can effectively use the EyePhone to record their eye movements, potentially even in a home environment. These results demonstrate the potential for smartphone eye-tracking technology as a viable and self-administered tool for monitoring disease progression in ALS, reducing the need for frequent clinic visits.
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Affiliation(s)
- Pouya Barahim Bastani
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, MD, USA
| | - Ali S. Saber Tehrani
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Shervin Badihian
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, MD, USA
- Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Hector Rieiro
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, MD, USA
| | - David Rastall
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nathan Farrell
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Max Parker
- Department of Neurology, NYU Langone Health, New York, NY, USA
| | - Jorge Otero-Millan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Herbert Wertheim School of Optometry and Vision Science, University of California, Berkeley, CA, USA
| | - Ahmed Hassoon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - David Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lora L. Clawson
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alpa Uchil
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kristen Riley
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven R. Zeiler
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Noda M, Kuroda T, Nomura A, Ito M, Yoshizaki T, Fushiki H. Smartphone-Assisted Medical Care for Vestibular Dysfunction as a Telehealth Strategy for Digital Therapy Beyond COVID-19: Scoping Review. JMIR Mhealth Uhealth 2023; 11:e48638. [PMID: 37695671 PMCID: PMC10496931 DOI: 10.2196/48638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/13/2023] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Dizziness and vertigo can be caused by various factors, such as peripheral vestibular and central disorders. Although consultations with specialists are advisable when necessary, patients with severe vertigo symptoms may have limited mobility, which may interfere with hospital visits. The spread of COVID-19 has further limited the number of hospital visits for patients with dizziness; therefore, a method of medical care that enables more accurate treatment under time and geographical constraints is needed. Telemedicine has become widespread, owing to the popularity of smartphone and tablet devices in recent years, and the use of devices and systems has made it possible to provide efficient medical care. However, no previous scoping review has mapped existing studies on telemedicine for vertigo and dizziness, and no recommendations have been made regarding which devices and systems should be used for specific diseases. OBJECTIVE The aim of this review was to map and assess previous studies on the use of information communications technology, smartphones, and apps for treating patients with vertigo and discuss the added value of introducing telemedicine to improve the quality of medical care and create an environment that builds security and trust among patients. METHODS A scoping review was conducted with the methodological framework of Arksey and O'Malley and in accordance with the of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews) guidelines. The PubMed, MEDLINE, and Cochrane Library databases were searched to retrieve previous reports on smartphone-assisted telemedicine treatment for vertigo published between January 2000 and May 2023. Two authors independently assessed eligibility and extracted data. RESULTS This review included 20 papers that reported devices or systems for telemedicine for vestibular dysfunction. Among studies that reported the use of a device or app, 2 were related to anamnesis and subjective symptoms, 12 were related to objective examination, 7 were related to remote diagnosis, and 7 were related to treatment and rehabilitation. CONCLUSIONS With the advancement of technology, the use of telemedicine in patients with dizziness may be feasible. In the future, it will be necessary to consider how telemedicine can be used in dizziness treatment and develop an effective treatment system combining in-person medical care and the effective use of devices for the management of severe vertigo and related diseases. The smooth introduction of telemedicine in vertigo treatment is expected to improve the quality of treatment, increase opportunities for patients to receive medical care, and reduce time and travel costs, leading to a sense of security and trust among patients.
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Affiliation(s)
- Masao Noda
- Department of Otolaryngology, Jichi Medical University, Shimotsuke, Japan
- Mejiro University Ear Institute Clinic, Saitama, Japan
| | - Tatsuaki Kuroda
- Mejiro University Ear Institute Clinic, Saitama, Japan
- Kuroda Ear, Nose and Throat Clinic, Kumamoto, Japan
| | - Akihiro Nomura
- College of Transdisciplinary Sciences for Innovation, Kanazawa University, Kanazawa, Japan
| | - Makoto Ito
- Department of Otolaryngology, Jichi Medical University, Shimotsuke, Japan
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Kuroda T, Kuroda K, Fushiki H. Development of a Prototype Video Head Impulse Test System Using an iPhone for Screening of Peripheral Vestibular Dysfunction. Digit Biomark 2023; 7:150-156. [PMID: 37928503 PMCID: PMC10622167 DOI: 10.1159/000534543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 10/01/2023] [Indexed: 11/07/2023] Open
Abstract
Introduction Head impulse, nystagmus, and test of skew (HINTS) is more accurate for the early diagnosis of occipital fossa stroke than magnetic resonance imaging. However, the head impulse test (HIT) is relatively challenging to perform, as it is subjective. Herein, we developed a prototype video HIT (vHIT) system using an iPhone (Apple, Cupertino, CA, USA) that is compact, easy to operate, and analyzable by our iPhone application. Methods The iPhone-vHIT and a vHIT using EyeSeeCam (Interacoustics, Eden Prairie, NM, USA) were performed on a healthy man in his 30s and on a patient with vestibular neuritis who visited the Mejiro University Ear Institute Clinic. For the iPhone-vHIT, eye movements were detected by analyzing high-speed videos captured using an iPhone camera, and head movements were followed using an iPhone gyro sensor. An iPhone fixation brace was used to capture the video without any blurring. Results The iPhone-vHIT system obtained vHIT waveforms similar to those of the EyeSeeCam-vHIT system in the healthy man and the patient with vestibular neuritis. The iPhone-vHIT system effectively detected the reduced vestibulo-ocular reflex gain in patients with vestibular neuritis. The iPhone-vHIT system at 120 frames per second was less sensitive to catch-up saccades than the EyeSeeCam. Conclusion vHIT systems using a smartphone have been reported but are currently unavailable. At present, the iPhone-vHIT application in this study is the only available smartphone-based vHIT system for screening of peripheral vestibular dysfunction. We believe that the prototype iPhone-vHIT with a high-speed camera will be clinically used to perform the vHIT, even though it only examines the lateral semicircular canal.
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Affiliation(s)
- Tatsuaki Kuroda
- Kuroda ENT Clinic, Yatsushiro-Shi Kumamoto Prefecture, Yatsushiro, Japan
- Otolaryngology, Mejiro University Ear Institute Clinic, Saitama, Japan
| | - Kazuhiro Kuroda
- Kuroda ENT Clinic, Yatsushiro-Shi Kumamoto Prefecture, Yatsushiro, Japan
| | - Hiroaki Fushiki
- Otolaryngology, Mejiro University Ear Institute Clinic, Saitama, Japan
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Smartphone video nystagmography using convolutional neural networks: ConVNG. J Neurol 2022; 270:2518-2530. [PMID: 36422668 PMCID: PMC10129923 DOI: 10.1007/s00415-022-11493-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/14/2022] [Accepted: 11/16/2022] [Indexed: 11/27/2022]
Abstract
Abstract
Background
Eye movement abnormalities are commonplace in neurological disorders. However, unaided eye movement assessments lack granularity. Although videooculography (VOG) improves diagnostic accuracy, resource intensiveness precludes its broad use. To bridge this care gap, we here validate a framework for smartphone video-based nystagmography capitalizing on recent computer vision advances.
Methods
A convolutional neural network was fine-tuned for pupil tracking using > 550 annotated frames: ConVNG. In a cross-sectional approach, slow-phase velocity of optokinetic nystagmus was calculated in 10 subjects using ConVNG and VOG. Equivalence of accuracy and precision was assessed using the “two one-sample t-test” (TOST) and Bayesian interval-null approaches. ConVNG was systematically compared to OpenFace and MediaPipe as computer vision (CV) benchmarks for gaze estimation.
Results
ConVNG tracking accuracy reached 9–15% of an average pupil diameter. In a fully independent clinical video dataset, ConVNG robustly detected pupil keypoints (median prediction confidence 0.85). SPV measurement accuracy was equivalent to VOG (TOST p < 0.017; Bayes factors (BF) > 24). ConVNG, but not MediaPipe, achieved equivalence to VOG in all SPV calculations. Median precision was 0.30°/s for ConVNG, 0.7°/s for MediaPipe and 0.12°/s for VOG. ConVNG precision was significantly higher than MediaPipe in vertical planes, but both algorithms’ precision was inferior to VOG.
Conclusions
ConVNG enables offline smartphone video nystagmography with an accuracy comparable to VOG and significantly higher precision than MediaPipe, a benchmark computer vision application for gaze estimation. This serves as a blueprint for highly accessible tools with potential to accelerate progress toward precise and personalized Medicine.
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Wagle N, Morkos J, Liu J, Reith H, Greenstein J, Gong K, Gangan I, Pakhomov D, Hira S, Komogortsev OV, Newman-Toker DE, Winslow R, Zee DS, Otero-Millan J, Green KE. aEYE: A deep learning system for video nystagmus detection. Front Neurol 2022; 13:963968. [PMID: 36034311 PMCID: PMC9403604 DOI: 10.3389/fneur.2022.963968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 07/20/2022] [Indexed: 11/25/2022] Open
Abstract
Background Nystagmus identification and interpretation is challenging for non-experts who lack specific training in neuro-ophthalmology or neuro-otology. This challenge is magnified when the task is performed via telemedicine. Deep learning models have not been heavily studied in video-based eye movement detection. Methods We developed, trained, and validated a deep-learning system (aEYE) to classify video recordings as normal or bearing at least two consecutive beats of nystagmus. The videos were retrospectively collected from a subset of the monocular (right eye) video-oculography (VOG) recording used in the Acute Video-oculography for Vertigo in Emergency Rooms for Rapid Triage (AVERT) clinical trial (#NCT02483429). Our model was derived from a preliminary dataset representing about 10% of the total AVERT videos (n = 435). The videos were trimmed into 10-sec clips sampled at 60 Hz with a resolution of 240 × 320 pixels. We then created 8 variations of the videos by altering the sampling rates (i.e., 30 Hz and 15 Hz) and image resolution (i.e., 60 × 80 pixels and 15 × 20 pixels). The dataset was labeled as "nystagmus" or "no nystagmus" by one expert provider. We then used a filtered image-based motion classification approach to develop aEYE. The model's performance at detecting nystagmus was calculated by using the area under the receiver-operating characteristic curve (AUROC), sensitivity, specificity, and accuracy. Results An ensemble between the ResNet-soft voting and the VGG-hard voting models had the best performing metrics. The AUROC, sensitivity, specificity, and accuracy were 0.86, 88.4, 74.2, and 82.7%, respectively. Our validated folds had an average AUROC, sensitivity, specificity, and accuracy of 0.86, 80.3, 80.9, and 80.4%, respectively. Models created from the compressed videos decreased in accuracy as image sampling rate decreased from 60 Hz to 15 Hz. There was only minimal change in the accuracy of nystagmus detection when decreasing image resolution and keeping sampling rate constant. Conclusion Deep learning is useful in detecting nystagmus in 60 Hz video recordings as well as videos with lower image resolutions and sampling rates, making it a potentially useful tool to aid future automated eye-movement enabled neurologic diagnosis.
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Affiliation(s)
- Narayani Wagle
- Department of Biomedical Engineering, The John Hopkins University, Baltimore, MD, United States
- Department of Computer Science, The Johns Hopkins University, Baltimore, MD, United States
| | - John Morkos
- The John Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jingyan Liu
- Department of Biomedical Engineering, The John Hopkins University, Baltimore, MD, United States
| | - Henry Reith
- Department of Biomedical Engineering, The John Hopkins University, Baltimore, MD, United States
| | - Joseph Greenstein
- Institute for Computational Medicine, The Johns Hopkins University, Baltimore, MD, United States
| | - Kirby Gong
- Department of Biomedical Engineering, The John Hopkins University, Baltimore, MD, United States
| | - Indranuj Gangan
- Department of Biomedical Engineering, The John Hopkins University, Baltimore, MD, United States
| | - Daniil Pakhomov
- Department of Computer Science, The Johns Hopkins University, Baltimore, MD, United States
| | - Sanchit Hira
- Department of Biomedical Engineering, The John Hopkins University, Baltimore, MD, United States
| | - Oleg V. Komogortsev
- Department of Computer Science, Texas State University, San Marcos, TX, United States
| | - David E. Newman-Toker
- Institute for Computational Medicine, The Johns Hopkins University, Baltimore, MD, United States
- Departments of Ophthalmology and Otolaryngology, The John Hopkins University School of Medicine, Baltimore, MD, United States
- Department of Emergency Medicine, The John Hopkins University School of Medicine, Baltimore, MD, United States
| | - Raimond Winslow
- Department of Biomedical Engineering, The John Hopkins University, Baltimore, MD, United States
- Department of Computer Science, The Johns Hopkins University, Baltimore, MD, United States
- Departments of Electrical and Computer Engineering, The John Hopkins University, Baltimore, MD, United States
| | - David S. Zee
- Institute for Computational Medicine, The Johns Hopkins University, Baltimore, MD, United States
- Departments of Electrical and Computer Engineering, The John Hopkins University, Baltimore, MD, United States
- Department of Neurosciences, The John Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jorge Otero-Millan
- Department of Neurosciences, The John Hopkins University School of Medicine, Baltimore, MD, United States
- School of Optometry University of California–Berkeley, Berkeley, CA, United States
| | - Kemar E. Green
- Department of Biomedical Engineering, The John Hopkins University, Baltimore, MD, United States
- Institute for Computational Medicine, The Johns Hopkins University, Baltimore, MD, United States
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The HINTS examination and STANDING algorithm in acute vestibular syndrome: A systematic review and meta-analysis involving frontline point-of-care emergency physicians. PLoS One 2022; 17:e0266252. [PMID: 35511910 PMCID: PMC9070939 DOI: 10.1371/journal.pone.0266252] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/16/2022] [Indexed: 12/22/2022] Open
Abstract
This systematic review aims to evaluate whether point-of-care emergency physicians, without special equipment, can perform the HINTS examination or STANDING algorithm to differentiate between central and non-central vertigo in acute vestibular syndrome with diagnostic accuracy and reliability comparable to more specialized physicians (neuro-ophthalmologists and neuro-otologists). Previous research has concluded that emergency physicians are unable to utilize the HINTS examination with sufficient accuracy, without providing any appropriate education or training. A comprehensive systematic search was performed using MEDLINE, Embase, the Cochrane CENTRAL register of controlled trials, Web of Science Core Collection, Scopus, Google Scholar, the World Health Organization International Clinical Trials Registry Platform, and conference programs and abstracts from six medical organizations. Of the 1,757 results, only 21 were eligible for full-text screening. Two further studies were identified by a manual search of references and an electronic search for any missed studies associated with the authors. Five studies were included in the qualitative synthesis. For the STANDING algorithm, there were two studies of 450 patients who were examined by 11 emergency physicians. Our meta-analysis showed that emergency physicians who had received prior education and training were able to utilize the STANDING algorithm with a sensitivity of 0.96 (95% confidence interval: 0.87–1.00) and a specificity of 0.88 (0.85–0.91). No data was available for the HINTS examination. When emergency physicians are educated and trained, they can use the STANDING algorithm with confidence. There is a lack of evidence regarding the HINTS examination; however, two ongoing studies seek to remedy this deficit.
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Parker TM, Badihian S, Hassoon A, Saber Tehrani AS, Farrell N, Newman-Toker DE, Otero-Millan J. Eye and Head Movement Recordings Using Smartphones for Telemedicine Applications: Measurements of Accuracy and Precision. Front Neurol 2022; 13:789581. [PMID: 35370913 PMCID: PMC8975177 DOI: 10.3389/fneur.2022.789581] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 02/08/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Smartphones have shown promise in the assessment of neuro-ophthalmologic and vestibular disorders. We have shown that the head impulse test results recorded using our application are comparable with measurements from clinical video-oculography (VOG) goggles. The smartphone uses ARKit's capability to acquire eye and head movement positions without the need of performing a calibration as in most eye-tracking devices. Here, we measure the accuracy and precision of the eye and head position recorded using our application. Methods We enrolled healthy volunteers and asked them to direct their eyes, their heads, or both to targets on a wall at known eccentricities while recording their head and eye movements with our smartphone application. We measured the accuracy as the error between the eye or head movement measurement and the location of each target and the precision as the standard deviation of the eye or head position for each of the target positions. Results The accuracy of head recordings (15% error) was overall better than the accuracy of eye recordings (23% error). We also found that the accuracy for horizontal eye movements (17% error) was better than for vertical (27% error). Precision was also better for head movement (0.8 degrees) recordings than eye movement recordings (1.3 degrees) and variability tended to increase with eccentricity. Conclusion Our results provide basic metrics evaluating the utility of smartphone applications in the quantitative assessment of head and eye movements. While the new method may not replace the more accurate dedicated VOG devices, they provide a more accessible quantitative option. It may be advisable to include a calibration recording together with any planned clinical test to improve the accuracy.
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Affiliation(s)
- T. Maxwell Parker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, MD, United States
| | - Shervin Badihian
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, MD, United States
| | - Ahmed Hassoon
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Ali S. Saber Tehrani
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Nathan Farrell
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, MD, United States
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - David E. Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Armstrong Institute Center for Diagnostic Excellence, Baltimore, MD, United States
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Jorge Otero-Millan
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Herbert Wertheim School of Optometry and Vision Science, University of California, Berkeley, Berkeley, CA, United States
- *Correspondence: Jorge Otero-Millan
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Müller-Barna P, Leinweber C, Pfaffenrath J, Schütt-Becker N, von Martial R, Greck S, Hubert N, Rambold H, Haberl R, Hubert GJ. Identification of Stroke and TIA in Patients With Acute Dizziness, Vertigo or Imbalance in Emergency Departments of Primary Care Hospitals: Early Experiences With a Network-Based Telemedical Approach. Front Neurol 2022; 13:766685. [PMID: 35309564 PMCID: PMC8924543 DOI: 10.3389/fneur.2022.766685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAcute dizziness, vertigo, and imbalance are frequent and difficult to interpret symptoms in the emergency department (ED). Primary care hospitals often lack the expertise to identify stroke or TIA as underlying causes. A telemedical approach based on telestroke networks may offer adequate diagnostics and treatment.AimThe aim of this study is to evaluate the accuracy of a novel ED algorithm in differentiating between peripheral and central vestibular causes.MethodsWithin the Telemedical Project for Integrative Stroke Care (TEMPiS), a telemedical application including a videooculography (VOG) system was introduced in 2018 in 19 primary care spoke hospitals. An ED triage algorithm was established for all patients with acute dizziness, vertigo, or imbalance of unknown cause (ADVIUC) as a leading complaint. In three predefined months, all ADVIUC cases were prospectively registered and discharge letters analyzed. Accuracy of the ED triage algorithm in differentiation between central and peripheral vestibular cases was analyzed by comparison of ED diagnoses to final discharge diagnoses. The rate of missed strokes was calculated in relation to all cases with a suitable brain imaging. Acceptance of teleconsultants and physicians in spoke hospitals was assessed by surveys.ResultsA total number of 388 ADVIUC cases were collected, with a median of 12 cases per months and hospital (IQR 8–14.5). The most frequent hospital discharge diagnoses are vestibular neuritis (22%), stroke/TIA (18%), benign paroxysmal positioning vertigo (18%), and dizziness due to internal medicine causes (15%). Detection of a central vestibular cause by the ED triage algorithm has a high sensitivity (98.6%), albeit poor specificity (45.9%). One stroke out of 32 verified by brain scan was missed (3.1%). User satisfaction, helpfulness of the project, improvement of care, personal competence, and satisfaction about handling of the VOG systems were rated consistently positive.DiscussionThe concept shows good acceptance for a telemedical and network-based approach to manage ADVIUC cases in the ED of primary care hospitals. Identification of stroke cases is accurate, while specificity needs further improvement. The concept could be a major step toward a broadly available state of the art diagnostics and therapy for patients with ADVIUC in primary care hospitals.
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Affiliation(s)
- Peter Müller-Barna
- Department of Neurology, TEMPiS Telestroke Center, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Germany
- *Correspondence: Peter Müller-Barna
| | - Christina Leinweber
- Department of Neurology, TEMPiS Telestroke Center, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Julia Pfaffenrath
- Department of Neurology, TEMPiS Telestroke Center, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Nina Schütt-Becker
- Department of Neurology, TEMPiS Telestroke Center, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Rascha von Martial
- Department of Neurology, TEMPiS Telestroke Center, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Susanne Greck
- Department of Neurology, TEMPiS Telestroke Center, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Nikolai Hubert
- Department of Neurology, TEMPiS Telestroke Center, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Holger Rambold
- Department of Neurology, InnKlinikum Altötting, Altötting, Germany
- Department of Neurology, University of Regensburg, Regensburg, Germany
- MVZ Kliniken Mühldorf, Mühldorf am Inn, Germany
| | - Roman Haberl
- Department of Neurology, TEMPiS Telestroke Center, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Germany
| | - Gordian Jan Hubert
- Department of Neurology, TEMPiS Telestroke Center, München Klinik, Academic Teaching Hospital of the Ludwig-Maximilians-University, Munich, Germany
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12
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von Martial R, Leinweber C, Hubert N, Rambold H, Haberl RL, Hubert GJ, Müller-Barna P. Feasibility of Telemedical HINTS (Head Impulse-Nystagmus-Test of Skew) Evaluation in Patients With Acute Dizziness or Vertigo in the Emergency Department of Primary Care Hospitals. Front Neurol 2022; 12:768460. [PMID: 35222226 PMCID: PMC8873087 DOI: 10.3389/fneur.2021.768460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 12/09/2021] [Indexed: 01/22/2023] Open
Abstract
Background Acute dizziness, vertigo and imbalance are common symptoms in emergency departments. Stroke needs to be distinguished from vestibular diseases. A battery of three clinical bedside tests (HINTS: Head Impulse Test, Nystagmus, Test of Skew) has been shown to detect stroke as underlying cause with high reliability, but implementation is challenging in primary care hospitals. Aim of this study is to prove the feasibility of a telemedical HINTS examination via a remotely controlled videooculography (VOG) system. Methods The existing video system of our telestroke network TEMPiS (Telemedic Project for Integrative Stroke Care) was expanded through a VOG system. This feature enables the remote teleneurologist to assess a telemedical HINTS examination based on inspection of eye movements and quantitative video head impulse test (vHIT) evaluation. ED doctors in 11 spoke hospitals were trained in performing vHIT, nystagmus detection and alternating cover test. Patients with first time acute dizziness, vertigo or imbalance, whether ongoing or resolved, presented to the teleneurologist were included in the analysis, as long as no focal neurological deficit according to the standard teleneurological examination or obvious internal medicine cause was present and a fully trained team was available. Primary outcome was defined as the feasibility of the telemedical HINTS examination. Results From 01.06.2019 to 31.03.2020, 81 consecutive patients were included. In 72 (88.9%) cases the telemedical HINTS examination was performed. The complete telemedical HINTS examination was feasible in 46 cases (63.9%), nystagmus detection in all cases (100%) and alternating covert test in 70 cases (97.2%). The vHIT was recorded and interpretable in 47 cases (65.3%). Results of the examination with the VOG system yielded clear results in 21 cases (45.7%) with 14 central and 7 peripheral lesions. The main reason for incomplete examination was the insufficient generation of head impulses. Conclusion In our analysis the telemedical HINTS examination within a telestroke network was feasible in two thirds of the patients. This offers the opportunity to improve specific diagnostics and therapy for patients with acute dizziness and vertigo even in primary care hospitals. Improved training for spoke hospital staff is needed to further increase the feasibility of vHIT.
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Affiliation(s)
- Rascha von Martial
- Department of Neurology, TEMPiS Telestroke Center, Academic Teaching Hospital of the Ludwig-Maximilians-University, München Klinik, Munich, Germany
| | - Christina Leinweber
- Department of Neurology, TEMPiS Telestroke Center, Academic Teaching Hospital of the Ludwig-Maximilians-University, München Klinik, Munich, Germany
| | - Nikolai Hubert
- Department of Neurology, TEMPiS Telestroke Center, Academic Teaching Hospital of the Ludwig-Maximilians-University, München Klinik, Munich, Germany
| | - Holger Rambold
- Department of Neurology, InnKlinikum gKU Altötting und Mühldorf, InnKlinikum Altötting, Altötting, Germany
- Department of Neurology, University of Regensburg, Regensburg, Germany
- Department of Neurology, MVZ Kliniken Mühldorf, Mühldorf am Inn, Germany
| | - Roman Ludwig Haberl
- Department of Neurology, TEMPiS Telestroke Center, Academic Teaching Hospital of the Ludwig-Maximilians-University, München Klinik, Munich, Germany
| | - Gordian Jan Hubert
- Department of Neurology, TEMPiS Telestroke Center, Academic Teaching Hospital of the Ludwig-Maximilians-University, München Klinik, Munich, Germany
| | - Peter Müller-Barna
- Department of Neurology, TEMPiS Telestroke Center, Academic Teaching Hospital of the Ludwig-Maximilians-University, München Klinik, Munich, Germany
- *Correspondence: Peter Müller-Barna
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13
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Rosengren SM, Young AS, Taylor RL, Welgampola MS. Vestibular function testing in the 21st century: video head impulse test, vestibular evoked myogenic potential, video nystagmography; which tests will provide answers? Curr Opin Neurol 2022; 35:64-74. [PMID: 34889807 DOI: 10.1097/wco.0000000000001023] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To most neurologists, assessing the patient with vertigo is an unpleasant and worrisome task. A structured history and focused examination can be complemented by carefully selected laboratory tests, to reach an early and accurate diagnosis. We provide evidence-based recommendations for vestibular test selection. RECENT FINDINGS The video head impulse test (vHIT), cervical and ocular vestibular evoked myogenic potential (VEMP) and home-video nystagmography are four modern, noninvasive methods of assessing vestibular function, which are equally applicable in the hospital and office-practice. Collectively, they enable assessment of all five vestibular end-organs. The prevalence and patterns of test abnormalities are distinct for each vestibular disorder. We summarize typical abnormalities encountered in four common vestibular syndromes. SUMMARY In the context of acute vestibular syndrome, an abnormal vHIT with low gain and large amplitude refixation saccades and an asymmetric oVEMP separates innocuous vestibular neuritis from stroke. In episodic spontaneous vertigo, high-velocity ictal nystagmus and asymmetric cVEMP help separate Ménière's disease from vestibular migraine. In chronic imbalance, all three tests help detect unilateral or bilateral vestibular loss as the root cause. Recurrent positional vertigo requires no laboratory test and can be diagnosed and treated at the bedside, guided by video nystagmography.
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Affiliation(s)
- Sally M Rosengren
- Central Clinical School, Faculty of Medicine and Health, University of Sydney
- Neurology Department and Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, Australia
| | - Allison S Young
- Neurology Department and Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, Australia
| | - Rachael L Taylor
- Department of Physiology and Centre for Brain Research, The University of Auckland, Auckland, New Zealand
| | - Miriam S Welgampola
- Central Clinical School, Faculty of Medicine and Health, University of Sydney
- Neurology Department and Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Sydney, Australia
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14
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Schoo DP, Ward BK. New Frontiers in Managing the Dizzy Patient. Otolaryngol Clin North Am 2021; 54:1069-1080. [PMID: 34294438 DOI: 10.1016/j.otc.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Despite progress in vestibular research in the last 20 years, much remains poorly understood about vestibular pathophysiology and its management. A shared language is a critical first step in understanding vestibular disorders and is under development. Telehealth will continue for patients with dizziness, and ambulatory monitoring of nystagmus will become a diagnostic tool. In the next 2 decades, it is anticipated that vestibular perceptual threshold testing will become common in tertiary centers, imaging with improved spatial resolution will yield better understanding of vestibular pathophysiology, and that vestibular implants will become a part of clinical practice.
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Affiliation(s)
- Desi P Schoo
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287, USA
| | - Bryan K Ward
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287, USA.
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15
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Hoyer C, Szabo K. Pitfalls in the Diagnosis of Posterior Circulation Stroke in the Emergency Setting. Front Neurol 2021; 12:682827. [PMID: 34335448 PMCID: PMC8317999 DOI: 10.3389/fneur.2021.682827] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/14/2021] [Indexed: 12/14/2022] Open
Abstract
Posterior circulation stroke (PCS), caused by infarction within the vertebrobasilar arterial system, is a potentially life-threatening condition and accounts for about 20–25% of all ischemic strokes. Diagnosing PCS can be challenging due to the vast area of brain tissue supplied by the posterior circulation and, as a consequence, the wide range of—frequently non-specific—symptoms. Commonly used prehospital stroke scales and triage systems do not adequately represent signs and symptoms of PCS, which may also escape detection by cerebral imaging. All these factors may contribute to causing delay in recognition and diagnosis of PCS in the emergency context. This narrative review approaches the issue of diagnostic error in PCS from different perspectives, including anatomical and demographic considerations as well as pitfalls and problems associated with various stages of prehospital and emergency department assessment. Strategies and approaches to improve speed and accuracy of recognition and early management of PCS are outlined.
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Affiliation(s)
- Carolin Hoyer
- Department of Neurology and Mannheim Center for Translational Neuroscience, University Medical Center Mannheim, Mannheim, Germany
| | - Kristina Szabo
- Department of Neurology and Mannheim Center for Translational Neuroscience, University Medical Center Mannheim, Mannheim, Germany
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