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Fountouki A, Tegos T, Psoma E, Makedou K, Kakaletsis N, Kaiafa G, Didangelos T, Theofanidis D, Savopoulos C. Glucose Fluctuations in Acute Ischemic Stroke. Cureus 2024; 16:e61939. [PMID: 38978906 PMCID: PMC11229048 DOI: 10.7759/cureus.61939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2024] [Indexed: 07/10/2024] Open
Abstract
INTRODUCTION The Oxfordshire Community Stroke Project denotes four subtypes of ischemic stroke (total and partial anterior infarct, posterior, and lacunar). Hyperglycemia has been associated with a larger infarct size and poor prognosis. AIM The purpose of the study was to investigate the correlation of glucose fluctuations with the Oxford sub-categories and patient outcomes using a blinded continuous glucose monitoring system. METHODS This is a non-interventional prospective observational study. Stroke patients with symptoms onset in the last 24h, participated in the study. A glucose sensor was placed for 72 hours. Disability was assessed using the modified Rankin Scale. Stroke subtypes were compared with total mean glucose and time in range using ANOVA analysis. Multiple ordinal logistic regression was employed to analyze outcomes and survival. RESULTS The sample consisted of 105 diabetic and non-diabetic patients. The overall mean glucose was 127.06 mg/dL and the time in range (70-140 mg/dL) was 70.98%. There was no significant difference between the stroke sub-categories and the total mean glucose. For every one-point increase in the time in range, we expect a 1.5% reduction in the odds of having a worse outcome. Patients with total anterior infarct are 2.31 times more likely to have a worse outcome than lacunar patients. CONCLUSION The utilization of the Oxford classification may not be necessary for managing acute ischemic stroke glucose levels. Achieving glucose regulation and an increase in time in range can be attained through meticulous control, potentially extending life expectancy. Continuous glucose monitors may aid in achieving this objective.
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Affiliation(s)
- Antigoni Fountouki
- Department of Nursing, International Hellenic University, Thessaloniki, GRC
| | - Thomas Tegos
- 1st Department of Neurology, AHEPA University General Hospital, School of Medicine, Aristotle University, Thessaloniki, GRC
| | - Elizabeth Psoma
- Department of Radiology, AHEPA University General Hospital, Aristotle University, Thessaloniki, GRC
| | - Keli Makedou
- Laboratory of Biochemistry, AHEPA University General Hospital, School of Medicine, Aristotle University, Thessaloniki, GRC
| | - Nikolaos Kakaletsis
- 1st Propaedeutic Department of Internal Medicine, AHEPA University General Hospital, Aristotle University, Thessaloniki, GRC
| | - Georgia Kaiafa
- 1st Propaedeutic Department of Internal Medicine, AHEPA University General Hospital, School of Medicine, Aristotle University, Thessaloniki, GRC
| | - Triantafyllos Didangelos
- 1st Propaedeutic Department of Internal Medicine/Diabetic Care Unit, AHEPA University General Hospital, School of Medicine, Aristotle University, Thessaloniki, GRC
| | | | - Christos Savopoulos
- 1st Propaedeutic Department of Internal Medicine, AHEPA University General Hospital, School of Medicine, Aristotle University, Thessaloniki, GRC
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Candelaresi P, Di Monaco C, Pisano E. Stroke chameleons: Diagnostic challenges. Eur J Radiol Open 2023; 11:100533. [PMID: 38028188 PMCID: PMC10652115 DOI: 10.1016/j.ejro.2023.100533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- P Candelaresi
- Neurology and Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
| | - C Di Monaco
- Neurology and Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
- Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University, Naples, Italy
| | - E Pisano
- Neurology and Stroke Unit, AORN Antonio Cardarelli, Naples, Italy
- Department of Neuroscience, Reproductive Science and Odontostomatology, Federico II University, Naples, Italy
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Gottlieb M, Peksa GD, Carlson JN. Head impulse, nystagmus, and test of skew examination for diagnosing central causes of acute vestibular syndrome. Cochrane Database Syst Rev 2023; 11:CD015089. [PMID: 37916744 PMCID: PMC10620998 DOI: 10.1002/14651858.cd015089.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
BACKGROUND Dizziness is a common reason for people to seek medical care. Acute vestibular syndrome (AVS) is a specific type of dizziness, which can include severe vertigo, nausea and vomiting, nystagmus, or unsteadiness. Acute vestibular syndrome can be due to peripheral or central causes. It is important to determine the cause, as the intervention and outcomes differ if it is from a peripheral or central cause. Clinicians can assess for the cause using risk factors, patient history, examination findings, or advanced imaging, such as a magnetic resonance imaging (MRI). The head impulse, nystagmus, test of skew (HINTS) examination is a three-part examination performed by clinicians to determine if AVS is due to a peripheral or central cause. This includes assessing how the eyes move in response to rapidly turning a person's head (head impulse), assessing the direction of involuntary eye movements (nystagmus), and assessing whether the eyes are aligned or misaligned (test of skew). The HINTS Plus examination includes an additional assessment of auditory function. OBJECTIVES To assess the diagnostic accuracy of the HINTS and HINTS Plus examinations, with or without video assistance, for identifying a central etiology for AVS. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Google Scholar, the International HTA database, and two trials registers to September 2022. SELECTION CRITERIA We included all retrospective and prospective diagnostic test accuracy studies that evaluated the HINTS or HINTS Plus test used in a primary care clinic, an urgent care clinic, the emergency department, or during inpatient hospitalization against a final diagnosis of a central etiology of AVS, as defined by the reference standard of advanced imaging or final diagnosis by a neurologist. DATA COLLECTION AND ANALYSIS Two review authors independently determined eligibility of each study according to eligibility criteria, extracted data, assessed the risk of bias, and determined the certainty of evidence. Disagreements were adjudicated by consensus or a third review author if needed. The primary outcome was the diagnostic accuracy of the HINTS and HINTS Plus examinations for identifying a central etiology for AVS, conducted clinically (clinician visual assessment) or with video assistance (e.g. video recording with goggles); we independently assessed the clinical and video-assisted examinations. Subgroup analyses were performed by provider type (e.g. physicians, non-physicians), time from symptom onset to presentation (e.g. less than 24 hours, longer than 24 hours), reference standard (e.g. advanced imaging, discharge diagnosis), underlying etiology (e.g. ischemic stroke, alternative etiologies [hemorrhagic stroke, intracranial mass]), study setting (e.g. outpatient [outpatient clinic, urgent care clinic, emergency department], inpatient), physician level of training (e.g. resident, fellow/attending), physician specialty (e.g. otolaryngology, emergency medicine, neurology, and neurologic subspecialist [e.g. neuro-ophthalmology, neuro-otology]), and individual diagnostic accuracy of each component of the examination (e.g. head impulse, direction-changing nystagmus, test of skew). We created 2 x 2 tables of the true positives, true negatives, false positives, and false negatives and used these data to calculate the sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio with 95% confidence intervals (95% CI) for each outcome. MAIN RESULTS We included 16 studies with a total of 2024 participants (981 women and 1043 men) with a mean age of 60 years. Twelve studies assessed the HINTS examination; five assessed the HINTS Plus examination. Thirteen studies were performed in the emergency department; half were performed by neurologists. The clinical HINTS examination (12 studies, 1890 participants) was 94.0% (95% confidence interval [CI] 82.0% to 98.2%) sensitive, and 86.9% (95% CI 75.3% to 93.6%) specific (low-certainty evidence). The video-assisted HINTS examination (3 studies, 199 participants) was 85.0% to 100% sensitive (low-certainty evidence), and 38.9% to 100% specific (very low-certainty evidence). The clinical HINTS Plus examination (5 studies, 451 participants) was 95.3% (95% CI 78.4% to 99.1%) sensitive, and 72.9% (95% CI 44.4% to 90.1%) specific (low-certainty evidence). The video-assisted HINTS Plus examination (2 studies, 163 participants) was 85.0% to 93.8% sensitive, and 28.6% to 38.9% specific (moderate-certainty evidence). Subgroup analyses were limited, as most studies were conducted in the emergency department, by physicians, and with MRI as a reference standard. Time from symptom onset to presentation varied across studies. Three studies were at high risk of bias and three studies were at unclear risk of bias for participant selection. Three studies were at unclear risk of bias for the index test. Four studies were at unclear risk of bias for the reference standard. Two studies were at unclear risk of bias for flow and timing. One study had unclear applicability concerns for participant selection. Two studies had high applicability concerns for the index test and two studies had unclear applicability concerns for the index test. No studies had applicability concerns for the reference standard. AUTHORS' CONCLUSIONS The HINTS and HINTS Plus examinations had good sensitivity and reasonable specificity for diagnosing a central cause for AVS in the emergency department when performed by trained clinicians. Overall, the evidence was of low certainty. There were limited data for the role of video-assistance or specific subgroups. Future research should include more high-quality studies of the HINTS and HINTS Plus examination; assessment of inter-rater reliability across users; accuracy across different providers, specialties, and experience; and direct comparison with no HINTS or MRI to assess the effect on clinical care.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Gary D Peksa
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Jestin N Carlson
- Emergency Department, Allegheny Health Network, Erie, Pennsylvania, USA
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Li Z, Miao L, Zhang T, Li X. Objective Neurological Testing Methods Used to Follow Up Vestibular Neuritis Depending on Different Factors. Int J Gen Med 2023; 16:4991-5002. [PMID: 37933252 PMCID: PMC10625780 DOI: 10.2147/ijgm.s436206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/20/2023] [Indexed: 11/08/2023] Open
Abstract
Purpose We analyze the impact of different factors on clinical performance and prognosis in vestibular neuritis (VN) and explore indicators that could accurately reflect changes in patients' symptoms at different stages. Methods We observed patients with VN during the acute and recovery phases. Clinical symptoms, vertigo-related scales, neurological examination, vestibular function tests (caloric test, video head impulse test (vHIT), vestibular evoked myogenic potential (VEMP)), and the history of disease (underlying diseases, glucocorticoid therapy) were recorded at onset and at 4 and 12 weeks after onset in VN patients. Multiple linear regression analysis was used to identify vestibular function tests that had a linear regression relationship with the subjective quantitative results. Results At 4 weeks after onset, the group without underlying disease had better improvement in EEV, gain, and UW than the group with underlying disease (P < 0.05). There was a significant difference in the change in DHI, EEV, gain of the affected horizontal semicircular canal in the vHIT and unilateral weakness (UW) between the glucocorticoid treatment group and the no glucocorticoid treatment group (P < 0.05), and glucocorticoid treatment group was better. The change value in the gain of horizontal canals in the vHIT was mainly positively and linearly correlated with the EEV scores (P<0.001). Possible dynamic correlation between vHIT results and vestibular symptoms. Conclusion The absence of underlying disease and the receipt of glucocorticoid therapy significantly contributed to the improvement of objective vestibular function tests in the short term, while the improvement of subjective vertigo may correlate with the different objective measures and questionnaire. We believe that the improvement of the affected horizontal semicircular canal gain value in the vHIT can be used as a reference indicator of the degree of improvement of vestibular symptoms with superior vestibular neuritis.
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Affiliation(s)
- Zidong Li
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, People’s Republic of China
| | - Lu Miao
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, People’s Republic of China
| | - Tianyi Zhang
- School of Basic Medical Sciences, Shandong University, Jinan, 250000, People’s Republic of China
| | - Xinyi Li
- Third Hospital of Shanxi Medical University, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Tongji Shanxi Hospital, Taiyuan, 030032, People’s Republic of China
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Posterior circulation stroke diagnosis in unselected group of acutely dizzy patients. Clin Neurol Neurosurg 2022; 224:107541. [PMID: 36493551 DOI: 10.1016/j.clineuro.2022.107541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/13/2022] [Accepted: 11/23/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUNDS Diagnostics of a posterior circulation ischemia (POCI) in patients with acute vertigo is a challenging task. Recently, the combination of HINTS (Head Impulse, Nystagmus and Test of Skew) exam and ABCD2 has been recommended to identify stroke in these patients. Until now, studies regarding HINTS have mostly been tested on preselected patient groups and their results are only partially applicable to real clinical practice. AIMS To compare the sensitivity and specificity of HINTS and ABCD2 and their combination in unselected acutely dizzy patients in the emergency department (ED) toward posterior circulation stroke detection. METHODS A prospective cross-sectional monocentric study in ED patients with acute onset of dizziness lasting less than 72 h. Their clinical characteristics, HINTS, vascular risk factors, ABCD2 scores and neuroimaging data were analyzed. RESULTS 140 patients were recruited. Acute stroke was identified by MRI in 39 patients. All patients had central pattern nystagmus, skew deviation or further focal neurological finding. The age (≥60) and arterial hypertension clearly distinguished stroke and non-stroke group (p < 0001). The sensitivity of HINTS, ABCD2 and their combination in the unselected group was high (82,1 - 97,4%), but specificity low. After removing patients with inconclusive diagnosis, including transitory ischemic attack, specificity was much higher and comparable to previously published results. CONCLUSIONS The sensitivity and specificity of HINTS in previously published studies may vary because of their selection criteria. Even though, our study was performed on the unselected patient cohort, combination of HINTS and ABCD2 remained highly sensitive in detecting POCI and outperformed each of these tests alone.
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Mahmud M, Saad AR, Hadi Z, Elliot J, Prendergast M, Kwan J, Seemungal B. Prevalence of stroke in acute vertigo presentations: A UK tertiary stroke centre perspective. J Neurol Sci 2022; 442:120416. [PMID: 36115218 DOI: 10.1016/j.jns.2022.120416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 09/03/2022] [Accepted: 09/05/2022] [Indexed: 11/16/2022]
Abstract
The reported prevalence of stroke amongst patients presenting to hospital with acute vertigo and/or imbalance is c. 5%, leading to the pervasive notion amongst emergency and stroke physicians, that stroke is uncommon in this cohort. To interrogate the veracity of this notion, we systematically and retrospectively screened the electronic care records in our institution of patients referred as suspected stroke, to a hyperacute stroke service at a large tertiary referral centre. We screened 24,310 consecutive patients' electronic case records presenting to our hospital as an emergency over a 4-month period, 332 of whom were referred as suspected stroke whose case records were assessed via structured review. Of these 332 cases, 61 presented with a vestibular syndrome, i.e. having at least one of imbalance, dizziness or vertigo. Of the 61 vestibular cases, 38 (62%) were diagnosed as stroke confirmed by imaging in 25/38 or upon clinical grounds only (13/38). None of the 38 vestibular stroke cases received thrombolysis or thrombectomy treatment. In a UK urban population (2.5mn), acute vestibular syndrome cases referred to stroke services have a 50% stroke prevalence. None of the vestibular stroke cases received hyperacute stroke treatment e.g., thrombolysis, due to delay in diagnosis. The high stroke prevalence in our cohort may indicate an excessively high threshold for referring acute vestibular cases for stroke, implying a high number of missed stroke cases. We suggest that early access to vestibular neurologists in acute vestibular cases should improve the proportion of vestibular stroke cases receiving definitive stroke treatment.
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Affiliation(s)
- Mohammad Mahmud
- Department of Brain Sciences, Charing Cross Hospital, Imperial College London, Fulham Palace Road, London W6 8RF, UK.
| | - Abdel Rahman Saad
- Department of Brain Sciences, Charing Cross Hospital, Imperial College London, Fulham Palace Road, London W6 8RF, UK
| | - Zaeem Hadi
- Department of Brain Sciences, Charing Cross Hospital, Imperial College London, Fulham Palace Road, London W6 8RF, UK
| | - Jordan Elliot
- Department of Brain Sciences, Charing Cross Hospital, Imperial College London, Fulham Palace Road, London W6 8RF, UK
| | - Mabel Prendergast
- Department of Brain Sciences, Charing Cross Hospital, Imperial College London, Fulham Palace Road, London W6 8RF, UK
| | - Joseph Kwan
- Department of Brain Sciences, Charing Cross Hospital, Imperial College London, Fulham Palace Road, London W6 8RF, UK
| | - Barry Seemungal
- Department of Brain Sciences, Charing Cross Hospital, Imperial College London, Fulham Palace Road, London W6 8RF, UK.
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Kepka S, Zarca K, Lersy F, Moris M, Godet J, Deur J, Stoessel M, Muller J, Le Borgne P, Baloglu S, Fleury MC, Anheim M, Bilbault P, Bierry G, Durand Zaleski I, Kremer S. MRI dedicated to the emergency department for diplopia or dizziness: a cost-effectiveness analysis. Eur Radiol 2022; 32:7344-7353. [PMID: 35554653 DOI: 10.1007/s00330-022-08791-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 03/29/2022] [Accepted: 04/03/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVES The purpose of this study was to compare the costs and organizational benefits of diagnostic workup without and with MRI dedicated to the ED. METHODS We conducted a prospective observational uncontrolled before-after study in one ED of a university hospital in France from July 1, 2018, and January 3, 2020. We included all consecutive patients presenting with dizziness or diplopia. The main outcomes were the clinical decision time of ED physicians and the total costs for each strategy. Outcomes were compared using propensity score with inverse probability weighting in the 2 arms and an incremental cost-effectiveness ratio (ICER) was calculated. RESULTS Among the 199 patients during the "before" period (average age: 60.4 years ± 17.6): 112 men (57%), and 181 during the "after" period (average age, 54.8 years ± 18.5): 107 men (59%), the average costs were €2701 (95% CI 1918; 3704) and €2389 (95% CI: €1627; 3280) per patient, respectively. The average time to clinical decision was 9.8 h (95% CI: 8.9 10.7) in the group "before" and 7.7 h (95% CI: 7.1; 8.4) in the group "after" (ICER: €151 saved for a reduction of 1 h in clinical decision time). The probabilistic sensitivity analysis estimated a 71% chance that the MRI dedicated to ED was dominant (less costly and more effective). CONCLUSION Easy access to MRI in the ED for posterior circulation stroke-like symptoms must be considered a relevant approach to help physicians for an appropriate and rapid diagnostic with reduction of costs. TRIAL REGISTRATION NCT03660852 KEY POINTS: • A dedicated MRI in the ED for diplopia or dizziness may be considered an efficient strategy improving diagnostic performance, reducing physicians' decision time, and decreasing hospital costs. • This strategy supports clinical decision-making with early treatment and management of patients with posterior circulation-like symptoms in the ED. • There is 71% chance that the MRI dedicated to ED was dominant (less costly and more effective) compared with a strategy without dedicated MRI.
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Affiliation(s)
- Sabrina Kepka
- Emergency Department, Hôpitaux Universitaires de Strasbourg, 1 place de l'hopital, CHRU Strasbourg - Nouvel hôpital civil, 67091, Strasbourg, France. .,URCEco, Hôtel Dieu, AP-HP, 1 Place du Parvis Notre Dame, 75004, Paris, France. .,IMAGEs laboratory ICUBE UMR 7357 CNRS, 300 Bd Sébastien Brant, 67400, Illkirch-Graffenstaden, France.
| | - Kevin Zarca
- URCEco, Hôtel Dieu, AP-HP, 1 Place du Parvis Notre Dame, 75004, Paris, France
| | - François Lersy
- Imaging Department 2, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67200, Strasbourg, France
| | - Mylène Moris
- Emergency Department, Hôpitaux Universitaires de Strasbourg, 1 place de l'hopital, CHRU Strasbourg - Nouvel hôpital civil, 67091, Strasbourg, France
| | - Julien Godet
- Public Health Department, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, CHRU of Strasbourg, 67091, Strasbourg, France
| | - Jeanne Deur
- Imaging Department 2, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67200, Strasbourg, France
| | - Marie Stoessel
- Imaging Department 2, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67200, Strasbourg, France
| | - Joris Muller
- Public Health Department, Hôpitaux Universitaires de Strasbourg, 1 place de l'hôpital, CHRU of Strasbourg, 67091, Strasbourg, France
| | - Pierrick Le Borgne
- Emergency Department, Hôpitaux Universitaires de Strasbourg, 1 place de l'hopital, CHRU Strasbourg - Nouvel hôpital civil, 67091, Strasbourg, France.,UMR 1260, INSERM/Université de Strasbourg CRBS, 1 Rue Eugene Boeckel, 67000, Strasbourg, France
| | - Seyyid Baloglu
- Imaging Department 2, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67200, Strasbourg, France
| | - Marie Céline Fleury
- Neurology Department, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67200, Strasbourg, France
| | - Mathieu Anheim
- Neurology Department, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67200, Strasbourg, France.,Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), INSERM-U964/CNRS-UMR7104/Université de Strasbourg, Illkirch, France
| | - Pascal Bilbault
- Emergency Department, Hôpitaux Universitaires de Strasbourg, 1 place de l'hopital, CHRU Strasbourg - Nouvel hôpital civil, 67091, Strasbourg, France.,UMR 1260, INSERM/Université de Strasbourg CRBS, 1 Rue Eugene Boeckel, 67000, Strasbourg, France
| | - Guillaume Bierry
- Imaging Department 2, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67200, Strasbourg, France.,Engineering Science, Computer Science and Imaging Laboratory (ICube), Integrative Multimodal Imaging in Healthcare, UMR 7357, University of Strasbourg-CNRS, Strasbourg, France
| | - Isabelle Durand Zaleski
- URCEco, Hôtel Dieu, AP-HP, 1 Place du Parvis Notre Dame, 75004, Paris, France.,Univ Paris Est Creteil (UPEC), Université de Paris, CRESS, INSERM, INRA, 74 rue Marcel Cachin, 93017, Bobigny, France
| | - Stéphane Kremer
- Imaging Department 2, Hôpitaux Universitaires de Strasbourg, 1 avenue Molière, 67200, Strasbourg, France.,Engineering Science, Computer Science and Imaging Laboratory (ICube), Integrative Multimodal Imaging in Healthcare, UMR 7357, University of Strasbourg-CNRS, Strasbourg, France
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Berge JE, Goplen FK, Aarstad HJ, Storhaug TA, Nordahl SHG. The Romberg sign, unilateral vestibulopathy, cerebrovascular risk factors, and long-term mortality in dizzy patients. Front Neurol 2022; 13:945764. [PMID: 35989919 PMCID: PMC9389400 DOI: 10.3389/fneur.2022.945764] [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: 05/16/2022] [Accepted: 07/07/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives Describe the relationship between unsteadiness, canal paresis, cerebrovascular risk factors, and long-term mortality in patients examined for dizziness of suspected vestibular origin. Study design Observational cohort with prospective collection of survival data. Setting University clinic neurotological unit. Patients Consecutive patients aged 18–75 years examined in the period 1992–2004 for dizziness of suspected vestibular origin. Outcome measures Overall survival. Standardized mortality ratio (SMR). Factors: Unsteadiness, canal paresis, age, sex, patient-reported diabetes, hypertension, heart disease, stroke, or TIA/minor stroke. Patients were classified as steady or unsteady based on static posturography at baseline compared to normative values. Results The study included 1,561 patients with mean age 48 years and 60 % females. Mean follow-up was 22 years. Unsteadiness was associated with higher age, heart disease, diabetes, hypertension, and cerebrovascular dizziness. There were 336 deaths over 31,335 person-years (SMR 0.96; 95 % confidence interval: 0.86–1.07). Canal paresis was not related to unsteadiness (chi square: p = 0.46) or to mortality (unadjusted Cox hazard ratio: 1.04, 95% CI: 0.80–1.34). Unsteadiness was an independent predictor of mortality (adjusted Cox hazard ratio: 1.44, 95% CI: 1.14–1.82). Conclusions Unsteadiness measured by static posturography is associated with higher age, known cerebrovascular risk factors, and with increased long-term mortality, but not with canal paresis in patients evaluated for dizziness. The study highlights the importance of evaluating patients with conspicuous postural instability for non-vestibular causes.
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Affiliation(s)
- Jan Erik Berge
- Norwegian National Advisory Unit for Vestibular Disorders, Haukeland University Hospital, Bergen, Norway
- Department of Otorhinolaryngology and Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Frederik Kragerud Goplen
- Norwegian National Advisory Unit for Vestibular Disorders, Haukeland University Hospital, Bergen, Norway
- Department of Otorhinolaryngology and Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- *Correspondence: Frederik Kragerud Goplen
| | - Hans Jørgen Aarstad
- Department of Otorhinolaryngology and Head and Neck Surgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Tobias Andre Storhaug
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Anesthesiology and Intensive Care, Vestre Viken Hospital Trust, Drammen, Norway
| | - Stein Helge Glad Nordahl
- Norwegian National Advisory Unit for Vestibular Disorders, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Orinx C, Mat Q, Tainmont S, Cabaraux P, Duterme JP. Moving from H.I.N.T.S. to H.I.N.T.S. PLUS in the Management of Acute Vestibular Syndrome. EAR, NOSE & THROAT JOURNAL 2022:1455613221088702. [PMID: 35546789 DOI: 10.1177/01455613221088702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Cindy Orinx
- Department of Otorhinolaryngology, 82159C.H.U. Charleroi, Charleroi, Belgium
| | - Quentin Mat
- Department of Otorhinolaryngology, 82159C.H.U. Charleroi, Charleroi, Belgium
- Faculty of Medicine and Pharmacy, University of Mons (UMons), Mons, Belgium
| | - Sophie Tainmont
- Department of Otorhinolaryngology, 82159C.H.U. Charleroi, Charleroi, Belgium
| | - Pierre Cabaraux
- Department of Neurology, 82159C.H.U. Charleroi, Charleroi, Belgium
| | - Jean-Pierre Duterme
- Department of Otorhinolaryngology, 82159C.H.U. Charleroi, Charleroi, Belgium
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Adams ME, Karaca-Mandic P, Marmor S. Use of Neuroimaging for Patients With Dizziness Who Present to Outpatient Clinics vs Emergency Departments in the US. JAMA Otolaryngol Head Neck Surg 2022; 148:465-473. [PMID: 35389454 PMCID: PMC8990360 DOI: 10.1001/jamaoto.2022.0329] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Overuse of costly neuroimaging technology is associated with low-value care for the prevalent symptom of dizziness. Although quality improvement initiatives have focused on the overuse of computed tomography (CT) scans in emergency departments (EDs), most patients with dizziness present to outpatient clinics. To inform practice and policy, a comprehensive understanding of the uses and costs of neuroimaging across settings and episodes of care is needed. Objective To characterize neuroimaging use, timing, and spending as well as factors associated with imaging acquisition within 6 months of presentation for dizziness in outpatient vs ED settings. Design, Setting, and Participants This cross-sectional study of commercial and Medicare Advantage claims for 805 454 adults (≥18 years of age) with new diagnoses of dizziness was conducted from January 1, 2006, through December 31, 2015. Data were analyzed from October 1, 2020, to September 30, 2021. Main Outcomes and Measures Use of neuroimaging (CT scan, magnetic resonance imaging [MRI], angiography, and ultrasonography) and total spending on neuroimaging were measured. Kaplan-Meier analysis was performed. The associations of neuroimaging with setting, sociodemographic characteristics, and clinicians were estimated with multivariable analyses. Results A total of 805 454 individuals with dizziness (502 055 women [62%]; median age, 52 years [range, 18-87 years]) were included in this study; 156 969 (20%) underwent neuroimaging within 6 months of presentation (65 738 of 185 338 [36%] presented to EDs and 91 231 of 620 116 [15%] presented to outpatient clinics). The median time to neuroimaging was 0 days (95% CI, 0-2 days) after ED presentation and 10 days (95% CI, 9-10 days) after outpatient presentation. Neuroimaging was independently associated with advanced age, comorbidity, race and ethnicity, ED presentation, and outpatient clinician specialty. Across sites, a head CT scan was the most used test on presentation date (92% of tests [46 852 of 51 022]). Within 6 months of presentation, a head CT scan was the most used test (47% of all tests [177 949 of 376 149]), followed by brain MRI (25% [93 130 of 376 149]), cerebrovascular ultrasonography (15% [56 175 of 376 149]), and magnetic resonance angiography (9% [34 026 of 376 149]). Of $88 646 047.03 in total neuroimaging spending, MRI accounted for 70% ($61 730 251.95), CT scans for 19% ($16 910 506.24), and ultrasonography for 11% ($10 005 288.84). Per-test median spending ranged from $68.97 (CT scan of the head) to $319.63 (MRI of the brain) among commercially insured individuals and $43.21 (CT scan of the head) to $362.02 (MRI of the orbit, face, and neck) among Medicare Advantage beneficiaries. Conclusions and Relevance The findings of this cross-sectional study suggest that use of neuroimaging for dizziness is prevalent across settings. Interventions to optimize the use of neuroimaging must occur early in the patient care journey to discourage guideline-discordant use of CT scans, advocate for judicious MRI use (particularly in ambulatory settings), and account for the effects of price transparency.
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Affiliation(s)
- Meredith E Adams
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis.,OptumLabs Visiting Fellow
| | - Pinar Karaca-Mandic
- OptumLabs Visiting Fellow.,Department of Finance, Carlson School of Management, University of Minnesota, Minneapolis
| | - Schelomo Marmor
- Department of Otolaryngology-Head and Neck Surgery, University of Minnesota, Minneapolis.,OptumLabs Visiting Fellow.,Department of Surgery, University of Minnesota, Minneapolis.,Center for Clinical Quality & Outcomes Discovery and Evaluation (C-QODE), University of Minnesota, Minneapolis
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11
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Kim JS, Newman-Toker DE, Kerber KA, Jahn K, Bertholon P, Waterston J, Lee H, Bisdorff A, Strupp M. Vascular vertigo and dizziness: Diagnostic criteria. J Vestib Res 2022; 32:205-222. [PMID: 35367974 PMCID: PMC9249306 DOI: 10.3233/ves-210169] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Kevin A Kerber
- Department of Neurology, University of Michigan Health System, Ann Arbor, USA
| | - Klaus Jahn
- Department of Neurology Schoen Clinic Bad Aibling and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
| | | | - John Waterston
- Monash Department of Neuroscience, Alfred Hospital, Melbourne, Australia
| | - Hyung Lee
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
| | - Alexandre Bisdorff
- Department of Neurology, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg
| | - Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
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12
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Sahu AK, Shrimal P, Ekka M, Amrithanand VT, Nayer J, Aggarwal P. Isolated vertigo in a young male, HINTS examination and vertebral artery dissection in emergency department - A case report. J Family Med Prim Care 2022; 11:784-786. [PMID: 35360753 PMCID: PMC8963626 DOI: 10.4103/jfmpc.jfmpc_1248_21] [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: 06/24/2021] [Revised: 10/01/2021] [Accepted: 10/16/2021] [Indexed: 12/02/2022] Open
Abstract
Vertigo is not an uncommon presenting symptom in patients presenting to the emergency department (ED) and primary physician's clinic, and around one-tenth of these patients have a central cause, i.e., posterior circulation stroke. HINTS, the acronym for head impulse (HI) test, nystagmus (N), and test of skew (TS), is a neurological examination utilized for differentiating a peripheral cause of vertigo from a sinister central cause. It is a simple, easy-to-do, inexpensive, and less time-consuming test. Here, we present a 27-year young male case without any known comorbidity or trauma, presented to the ED, with complaints of sudden onset isolated vertigo for 2 hours. HINTS examination pointed towards a central cause (normal head impulse test and direction-changing nystagmus). Other neurological and systemic examinations were normal. Non-contrast computed tomography of the brain was normal. Further, computed tomography angiography of head and neck vessels was performed, showing left vertebral artery dissection (VAD). The patient's neurological status deteriorated in the next 8 hours. The patient underwent decompressive craniotomy and got discharged after two weeks. Early performance of the HINTS examination by the primary care physicians and emergency physicians lead to early diagnosis and treatment of this common cause of posterior circulation stroke in young patients. Essential take-home points are the importance of the HINTS test and not to forget VAD as a cause of isolated vertigo without any neck manipulation or trauma.
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Affiliation(s)
- Ankit Kumar Sahu
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Prawal Shrimal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Meera Ekka
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - V T Amrithanand
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Jamshed Nayer
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Praveen Aggarwal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
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13
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Ng MA. Posterior Circulation Ischaemic Stroke. Am J Med Sci 2022; 363:388-398. [PMID: 35104439 DOI: 10.1016/j.amjms.2021.10.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 06/09/2021] [Accepted: 10/21/2021] [Indexed: 11/16/2022]
Abstract
Posterior circulation ischaemic stroke (PCIS) is a disease of high burden. They account for 20-25% of all ischaemic strokes. However, it is relatively under-researched and requires more clinical attention, since it carries worse functional outcomes. Vertigo, visual disturbances and sensory/motor disturbances are found in PCIS. Large artery atherosclerosis and embolism are main causes of PCIS, while there is growing evidence that vertebrobasilar dolichoectasia is a key association. Hypertension is the commonest risk factor, while diabetes mellitus is more specific to PCIS. PCIS is diagnosed through neuroimaging techniques, which examine structural brain abnormalities, vascular patency and perfusion. PCIS, in line with ischaemic stroke in general, requires medical treatment and lifestyle modifications. This includes smoking cessation, weight control, and dietary alterations. Aspirin use also significantly improves survival outcomes. While intravascular and intra-arterial thrombolysis improve clinical outcomes, this is not proven conclusively for stenting and angioplasty. Future research on PCIS can focus on multi-centre epidemiological studies, clinically significant anatomical variants, and collateralisation.
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Affiliation(s)
- Mr Alexander Ng
- Department of Diagnostic Radiology, Li Ka Shing Faculty of Medicine, University of Hong Kong, Full Address: Block K, Queen Mary Hospital, Pokfulam Road, Hong Kong.
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14
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Capturing vertigo in the emergency room: three tools to double the rate of diagnosis. J Neurol 2022; 269:294-306. [PMID: 34398269 DOI: 10.1007/s00415-021-10627-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 05/23/2021] [Accepted: 05/24/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Many patients attending the emergency room (ER) with vertigo, leave without a diagnosis. We assessed whether the three tools could improve ER diagnosis of vertigo. METHODS A prospective observational study was undertaken on 539 patients presenting to ER with vertigo. We used three tools: a structured-history and examination, nystagmus video-oculography (VOG) in all patients, additional video head-impulse testing (vHIT) for acute-vestibular-syndrome (AVS). RESULTS In the intervention-group (n = 424), case-history classified AVS in 34.9%, episodic spontaneous-vertigo (ESV 32.1%), and episodic positional-vertigo (EPV 22.6%). In AVS, we employed "Quantitative-HINTS plus" (Head-Impulse, Nystagmus and Test-of-Skew quantified by vHIT and VOG, audiometry) to identify vestibular-neuritis (VN) and stroke (41.2 and 31.1%). vHIT gain ≤ 0.72, catch-up saccade amplitude > 1.4○, saccade-frequency > 154%, and unidirectional horizontal-nystagmus, separated stroke from VN with 93.1% sensitivity and 88.5% specificity. In ESV, 66.2 and 14% were diagnosed with vestibular migraine and Meniere's Disease by using history and audiometry. Horizontal-nystagmus velocity was lower in migraine 0.4 ± 1.6○/s than Meniere's 5.7 ± 5.5○/s (p < 0.01). In EPV, benign positional vertigo (BPV) was identified in 82.3% using VOG. Paroxysmal positional-nystagmus lasting < 60 s separated BPV from non-BPV with 90% sensitivity and 100% specificity. In the control group of ER patients undergoing management-as-usual (n = 115), diagnoses included BPV (38.3%) and non-specific vertigo (41.7%). Unblinded assessors reached a final diagnosis in 90.6 and 30.4% of the intervention and control groups. Blinded assessors provided with the data gathered from each group reached a diagnosis in 86.3 and 41.1%. CONCLUSION Three tools: a structured-assessment, vHIT and VOG doubled the rate of diagnosis in the ER.
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15
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Samreen R A, Bhattacharjee S, Shetty SS, Bathala L, Anuradha HK, Sharma VK. MRI outcomes in patients with acute-onset vertigo in the emergency department - A prospective study. Clin Neurol Neurosurg 2021; 209:106916. [PMID: 34507129 DOI: 10.1016/j.clineuro.2021.106916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 08/22/2021] [Accepted: 08/25/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Vertigo is an abnormal sensation of motion which arises due to a mismatch between various sensory modalities involved in maintaining balance. Vertigo can be due to central or peripheral causes and intensely debilitating for some patients. Acute onset vertigo is defined as the commencement of vertigo within 24 h. This can present with a variety of overlapping symptoms, making it difficult to distinguish central from peripheral causes. In the emergency setting, mis-diagnosing acute onset vertigo as benign may have serious implications. METHODS This prospective study included consecutive patients presenting to our Emergency Department with acute vertigo between March 2019 and March 2020. We aimed to evaluate and validate the utility of magnetic resonance imaging (MRI) of the brain among patients with acute onset vertigo. RESULTS A total of 70 patients with acute onset vertigo were recruited. MRI of the brain revealed acute changes in 23 (32.9%) out of the 70 patients included in the study. Even among the 29 (41.4%) patients who presented with isolated vertigo without any other clinical signs, MRI of the brain showed acute changes in 3 (10.3%) of them. CONCLUSION MRI is a useful tool in diagnosing and differentiating peripheral from a central cause of vertigo. It avoids misdiagnosis in the emergency setting and facilitates early administration of appropriate treatment.
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Affiliation(s)
- Arfa Samreen R
- Dept. of Emergency Medicine, Aster CMI Hospital, Bangalore, India.
| | | | | | - Lokesh Bathala
- Dept. of Neurology, Aster CMI Hospital, Bangalore, India.
| | - H K Anuradha
- Dept. of Neurology, Aster CMI Hospital, Bangalore, India.
| | - Vijay K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore and Division of Neurology, National University Hospital, Singapore.
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16
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Neely P, Patel H, Wellings T. Benign paroxysmal positional vertigo in the emergency department: An observational study of an Australian regional hospital's acute clinical practice. Emerg Med Australas 2021; 33:1082-1087. [PMID: 34092036 DOI: 10.1111/1742-6723.13810] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 04/30/2021] [Accepted: 05/16/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To analyse adherence to evidence based practice in the diagnosis and treatment of benign paroxysmal positional vertigo (BPPV) in a regional ED. METHODS Retrospective observational population study. Wyong Hospital's ED, Central Coast Local Health District, New South Wales, Australia. Medical records of patients with an ED diagnosis of BPPV (n = 101) between 2017 and 2018 were included for auditing. Adherence to clinical practice guidelines for BPPV4 statements 1a, 3a, 4a and 6 were reviewed as primary outcomes using a de-identified binary data excel tool. These outcomes were compared to available data from metropolitan tertiary EDs both in Australia and the USA. RESULTS General compliance to best practice standards was low. Of patients diagnosed with BPPV in the ED only 45% (95% CI 35-54%) were diagnosed with the recommended Hallpike-Dix positional test. Of those patients who did receive diagnosis via the Hallpike-Dix test only 41% (95% CI 28-56%) went on to receive gold standard recommended treatment of a canalith repositioning manoeuvre/technique. In regards to the recommendations against practice, 36% (95% CI 28-46%) had neuroimaging performed in the ED and 58% (95% CI 48-68%) received vestibular suppressant medication as their only treatment prior to discharge. CONCLUSION Adherence to best practice diagnosis and management of BPPV was low in Wyong Hospital's ED. Although low, Wyong Hospital's ED appeared to perform better in compliance to the clinical guidelines to its metropolitan Australian peer. There is opportunity to improve the efficiency and effectiveness in the management of acute peripheral dizziness in EDs.
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Affiliation(s)
- Prue Neely
- Physiotherapy Department, Central Coast Local Health District, Central Coast, New South Wales, Australia.,Emergency Department, Central Coast Local Health District, Central Coast, New South Wales, Australia
| | - Hemal Patel
- Emergency Department, Central Coast Local Health District, Central Coast, New South Wales, Australia.,School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Tom Wellings
- Department of Neurology, Hunter New England Local Health District, Newcastle, New South Wales, Australia
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17
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Hong SI, Kim JS, Bae HJ, Kim WY. C-reactive Protein for Stroke Detection in the Emergency Department in Patients With Dizziness Without Neurological Deficits. Front Neurol 2021; 12:662510. [PMID: 34135849 PMCID: PMC8200534 DOI: 10.3389/fneur.2021.662510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 05/11/2021] [Indexed: 12/01/2022] Open
Abstract
Background: Stroke diagnosis can be challenging in patients with dizziness without neurologic deficits. The aim of this study was to evaluate the predictive value of C-reactive protein (CRP) for identifying acute stroke in such patients. Methods: Data from adult patients (>18 years) admitted to the emergency department from August 2019 to February 2020 were evaluated. The study subjects were 1,188 patients presenting with dizziness without neurological deficits whose serum CRP level was measured within 2 h of arriving at the emergency department and who underwent brain magnetic resonance imaging. The relationship between CRP and acute stroke was analyzed using univariable and multivariable models. Results: Acute stroke was detected in 53 (4.4%) patients (40 with brain infarction, 10 with vertebrobasilar insufficiency, 2 with intracerebral hemorrhage, and 1 with subarachnoid hemorrhage). The CRP levels did not differ significantly between the acute stroke and non-stroke groups [0.10 (0.10–0.31) vs. 0.10 (0.10–0.16), P = 0.074]. The area under receiver operating characteristic curve of CRP for acute stroke was not statistically significant (0.567, P = 0.101). On multivariable analysis, the following variables were associated with acute stroke: age (odds ratio [OR], 1.041; 95% confidence interval [CI], 1.011–1.071), history of cerebrovascular accidents (OR, 1.823; 95% CI, 1.068–3.110), white blood cell count (OR, 1.126; 95% CI, 1.017–1.248), and hemoglobin (OR, 1.316; 95% CI, 1.056–1.640). However, CRP (P = 0.183) was not associated with acute stroke. Conclusion: Serum CRP levels do not have significant discriminative value for identifying acute stroke in patients with dizziness without definite neurologic deficits.
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Affiliation(s)
- Seok-In Hong
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - June-Sung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hong Jun Bae
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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18
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Maarsingh OR, van Vugt VA. Ten Vestibular Tools for Primary Care. Front Neurol 2021; 12:642137. [PMID: 33643214 PMCID: PMC7907175 DOI: 10.3389/fneur.2021.642137] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/12/2021] [Indexed: 12/26/2022] Open
Affiliation(s)
- Otto R Maarsingh
- Department of General Practice, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Amsterdam Public Health, Amsterdam, Netherlands
| | - Vincent A van Vugt
- Department of General Practice, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Amsterdam Public Health, Amsterdam, Netherlands
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19
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Rivlin W, Habershon C, Tsang BKT, Kaski D. A Practical Approach to Vertigo: A Synthesis of the Emerging Evidence. Intern Med J 2020; 52:356-364. [PMID: 32786023 DOI: 10.1111/imj.15013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/27/2020] [Accepted: 08/08/2020] [Indexed: 11/29/2022]
Abstract
Vestibular presentations represent a large financial and symptomatic burden of disease1,2 , while remaining one of the most elusive presentations to accurately and confidently diagnose. A primary cause for this is that the same symptom can be the end-product of numerous aetiologies, and uncertainties can lead to unnecessary investigations and associated increased cost and delays in diagnosis. An effective method to narrow the diagnosis is firstly to determine, from a limited list, which type of vestibular syndrome the patient possesses, and then apply a focussed history and examination to define the most likely aetiology within that syndrome. This review provides a diagnostic approach to the vertiginous patient, outlining the underlying pathophysiology that accounts for the clinical symptoms and signs. With this approach, physicians should be able to diagnose the majority of common vestibular presentations and know when to refer the urgent, complex, or rare cases to sub-specialist neuro-otologists for prompt and appropriate management. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Warwick Rivlin
- Medical Registrar, Sunshine Coast University Hospital, QLD, Australia
| | | | | | - Diego Kaski
- Neurologist, University College London Hospital, London, United Kingdom
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20
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Abstract
Acute ischaemic stroke is a major public health priority and will become increasingly relevant to neurologists of the future. The cornerstone of effective stroke care continues to be timely reperfusion treatment. This requires early recognition of symptoms by the public and first responders, triage to an appropriate stroke centre and efficient assessment and investigation by the attending stroke team. The aim of treatment is to achieve recanalisation and reperfusion of the ischaemic penumbra with intravenous thrombolysis and/or endovascular thrombectomy in appropriately selected patients. All patients should be admitted directly to an acute stroke unit for close monitoring for early neurological deterioration and prevention of secondary complications. Prompt investigation of the mechanism of stroke allows patients to start appropriate secondary preventative treatment. Future objectives include improving accessibility to endovascular thrombectomy, using advanced imaging to extend therapeutic windows and developing neuroprotective agents to prevent secondary neuronal damage.
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Affiliation(s)
- Robert Hurford
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Alakendu Sekhar
- Department of Neurology, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Tom A T Hughes
- Department of Neurology, University Hospital of Wales Healthcare NHS Trust, Cardiff, UK
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Glasgow, UK
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21
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Telling friend from foe in emergency vertigo and dizziness: does season and daytime of presentation help in the differential diagnosis? J Neurol 2020; 267:118-125. [PMID: 32654062 PMCID: PMC7718175 DOI: 10.1007/s00415-020-10019-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 11/02/2022]
Abstract
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.
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