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Ursat G, Corda M, Ryard J, Guillet C, Guigou C, Tissier C, Bozorg Grayeli A. Virtual-reality-enhanced mannequin to train emergency physicians to examine dizzy patients using the HINTS method. Front Neurol 2024; 14:1335121. [PMID: 38249749 PMCID: PMC10796789 DOI: 10.3389/fneur.2023.1335121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/05/2023] [Indexed: 01/23/2024] Open
Abstract
Introduction Acute vertigo is a frequent chief complaint in the emergency departments, and its efficient management requires thorough training. The HINTS protocol is a valid method to screen patients in the emergency room, but its application in routine is hindered by the lack of training. This study aimed to evaluate the training of emergency physicians for the HINTS method based on a mannequin-based virtual reality simulator (MBVRS). Methods We conducted a monocenter, prospective, longitudinal, and randomized cohort study in an Emergency Department at a regional university hospital. We included 34 emergency physicians randomized into two equal groups matched by age and professional experience. The control group attended a theoretical lesson with video demonstrations and the test group received a simulation-based training in addition to the lecture. Results We showed that the test group had a higher diagnosis performance for the HINTS method compared to the control group as evaluated by the simulator at 1 month (89% sensitivity versus 45, and 100% specificity versus 86% respectively, p < 001, Fisher's exact test). Evaluation at 6 months showed a similar advantage to the test group. Discussion The MBVRS is a useful pedagogic tool for the HINTS protocol in the emergency department. The advantage of a unique training session can be measured up to 6 months after the lesson.
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Affiliation(s)
- Guillaume Ursat
- Emergency Department, Dijon University Hospital, Dijon, France
| | - Morgane Corda
- Otolaryngology Department, Dijon University Hospital, Dijon, France
| | - Julien Ryard
- Institut Image, Ecole Nationale d’Arts-et-Métiers, Chalon-sur-Saône, France
| | - Christophe Guillet
- Institut Image, Ecole Nationale d’Arts-et-Métiers, Chalon-sur-Saône, France
| | - Caroline Guigou
- Otolaryngology Department, Dijon University Hospital, Dijon, France
- ICMUB, CNRS, Université Bourgogne-Franche-Comté, Dijon, France
| | - Cindy Tissier
- Emergency Department, Dijon University Hospital, Dijon, France
| | - Alexis Bozorg Grayeli
- Otolaryngology Department, Dijon University Hospital, Dijon, France
- ICMUB, CNRS, Université Bourgogne-Franche-Comté, Dijon, France
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Edlow JA, Carpenter C, Akhter M, Khoujah D, Marcolini E, Meurer WJ, Morrill D, Naples JG, Ohle R, Omron R, Sharif S, Siket M, Upadhye S, E Silva LOJ, Sundberg E, Tartt K, Vanni S, Newman-Toker DE, Bellolio F. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. Acad Emerg Med 2023; 30:442-486. [PMID: 37166022 DOI: 10.1111/acem.14728] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/14/2023] [Indexed: 05/12/2023]
Abstract
This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").
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Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christopher Carpenter
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Emergency Medicine, Washington University, St. Louis, Missouri, USA
| | - Murtaza Akhter
- Department of Emergency Medicine, Penn State School of Medicine, State College, Pennsylvania, USA
- Hershey Medical Center, State College, Pennsylvania, USA
| | - Danya Khoujah
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Adventhealth Tampa, Tampa, Florida, USA
| | - Evie Marcolini
- Department of Emergency Medicine, Geisel School of Medicine, Dartmouth, Hanover, New Hampshire, USA
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - James G Naples
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Otolaryngology-Head & Neck Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Robert Ohle
- Department of Emergency Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
- Health Science North Research Institute, Sudbury, Ontario, Canada
- Department of Emergency Medicine, Health Sciences North, Sudbury, Ontario, Canada
| | - Rodney Omron
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sameer Sharif
- Division of Critical Care and Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Matt Siket
- Department of Emergency Medicine, Robert Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
- Department of Emergency Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Suneel Upadhye
- Emergency Medicine, Evidence and Impact (HEI), McMaster University, Burlington, Ontario, Canada
- Health Research Methods, Evidence and Impact (HEI), McMaster University, Burlington, Ontario, Canada
| | - Lucas Oliveira J E Silva
- Mayo Clinic, Rochester, Minnesota, USA
- Department of Emergency Medicine, Hospital de Clinicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Etta Sundberg
- COO Royal Oasis Pool and Spas, Las Vegas, Nevada, USA
| | - Karen Tartt
- Absinthe Brasserie & Bar, San Francisco, California, USA
- St. George Spirits, San Francisco, California, USA
| | - Simone Vanni
- Department of Emergency Medicine, University of Florence, Firenze, Italy
- Department of Emergency Medicine, University Hospital Careggi, Firenze, Italy
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fernanda Bellolio
- Mayo Clinic College of Medicine, Rochester, Minnesota, USA
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Alvarez G, Lucas S, Roura S. Osteopathic manipulative techniques in the treatment of vestibular dizziness not related to the cervical spine. J Osteopath Med 2023; 123:273-276. [PMID: 36732063 DOI: 10.1515/jom-2022-0224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/21/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Gerard Alvarez
- Spain National Center, Foundation Come Collaboration, Barcelona, Spain.,Iberoamerican Cochrane Centre - Biomedical Research Institute Sant Pau, IIB Sant Pau, C. Sant Atoni Maria Claret 167, Pavelló 18, Planta 0, 08025 Barcelona, Catalunya, Spain
| | - Sergi Lucas
- Institute for Vestibular Rehabilitation and Balance, Barcelona, Spain
| | - Sònia Roura
- Spain National Center, Foundation Come Collaboration, Barcelona, Spain.,PhD program on Biomedical Research Methodology and Public Health, Universitat Autònoma de Barcelona, Barcelona, Spain
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Yao K, Zu HB. Isolated transient vertigo due to TIA: challenge for diagnosis and therapy. J Neurol 2023; 270:769-779. [PMID: 36371598 DOI: 10.1007/s00415-022-11443-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 11/13/2022]
Abstract
As a prevalent vertigo disease in the clinic, isolated transient vertigo can present as a vertigo episode without focal signs and always free of symptoms on presentation. Previous studies showed a part of isolated transient vertigo events had a high risk of stroke during follow-up. However, how to discern posterior circulation ischemia become a great challenge for clinicians, especially in emergency, neurology, and ENT departments. Routine besides, hematological, and imaging examinations are often difficult provide a clear etiological diagnosis. Hence, this article reviews current knowledge about the epidemiology, risk factors, offending lesions, and clinical manifestation of transient ischemic attack (TIA) presenting as isolated transient vertigo. In addition, we summarize several advances in besides examinations, serum biomarkers, and imaging technologies to better identify stroke events. Finally, the current situation of therapy was briefly retrospected. Here we present a critical clinical puzzle that needs to be solved in the future. Of note, there is a still lack of high-quality studies in this field. The article reviews the keys to the diagnosis of isolated transient vertigo due to TIA and provides us with more methods to screen for high-risk stroke populations.
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Affiliation(s)
- Kai Yao
- Department of Neurology, Jinshan Hospital Affiliated to Fudan University, No. 1508 Longhang Road, Jinshan District, Shanghai, 201508, China
| | - Heng-Bing Zu
- Department of Neurology, Jinshan Hospital Affiliated to Fudan University, No. 1508 Longhang Road, Jinshan District, Shanghai, 201508, China.
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History Taking in Non-Acute Vestibular Symptoms: A 4-Step Approach. J Clin Med 2021; 10:jcm10245726. [PMID: 34945023 PMCID: PMC8703413 DOI: 10.3390/jcm10245726] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 11/26/2021] [Accepted: 12/06/2021] [Indexed: 01/20/2023] Open
Abstract
History taking is crucial in the diagnostic process for vestibular disorders. To facilitate the process, systems such as TiTrATE, SO STONED, and DISCOHAT have been used to describe the different paradigms; together, they address the most important aspects of history taking, viz. time course, triggers, and accompanying symptoms. However, multiple (vestibular) disorders may co-occur in the same patient. This complicates history taking, since the time course, triggers, and accompanying symptoms can vary, depending on the disorder. History taking can, therefore, be improved by addressing the important aspects of each co-occurring vestibular disorder separately. The aim of this document is to describe a 4-step approach for improving history taking in patients with non-acute vestibular symptoms, by guiding the clinician and the patient through the history taking process. It involves a systematic approach that explicitly identifies all co-occurring vestibular disorders in the same patient, and which addresses each of these vestibular disorders separately. The four steps are: (1) describing any attack(s) of vertigo and/or dizziness; (2) describing any chronic vestibular symptoms; (3) screening for functional, psychological, and psychiatric co-morbidity; (4) establishing a comprehensive diagnosis, including all possible co-occurring (vestibular) disorders. In addition, pearls and pitfalls will be discussed separately for each step.
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van Dam VS, Maas BDPJ, Schermer TR, van Benthem PPG, Bruintjes TD. Two Symptoms Strongly Suggest Benign Paroxysmal Positional Vertigo in a Dizzy Patient. Front Neurol 2021; 11:625776. [PMID: 33584519 PMCID: PMC7873998 DOI: 10.3389/fneur.2020.625776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/15/2020] [Indexed: 01/10/2023] Open
Abstract
Introduction: This prospective cohort study determined which questions in patient history are most likely to identify symptoms that are independently associated with a diagnosis of benign paroxysmal positional dizziness (BPPV) in patients presenting with dizziness, and to evaluate whether the patient's age and type of BPPV are of influence. Methods: We included adult patients with dizziness referred to our dizziness center, Apeldoorn, the Netherlands, from December 2018 to November 2019. All patients completed a questionnaire, underwent vestibular testing and received a diagnosis. Symptoms strongly suggesting BPPV were tested with multivariable analysis to determine their independent associations with BPPV. Subgroup analysis was performed for patient age, and the type of BPPV. Results: We included a total of 885 patients, 113 of whom (13%) were diagnosed with BPPV. The duration of dizziness spells <1 min (Q2) and dizziness provoked by rolling over in bed (Q4) were independently associated with the diagnosis BPPV. Q2 showed a sensitivity of 43%, and a specificity of 75%; Q4 scored 81% and 68%, respectively. Overall, the way patients perceived their dizziness (vertigo, light-headedness or instability) was not independently associated with the diagnosis BPPV. In younger patients, light-headedness and instability decreased the likelihood of BPPV compared to vertigo. Conclusion: The most reliable predictors for BPPV in patient history are a short duration of the dizziness spell and provocation of dizziness by rolling over in bed. Unlike younger patients, elderly patients with BPPV do not only perceive the dizziness as vertigo, but also as a feeling of instability.
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Affiliation(s)
- Victor S. van Dam
- Apeldoorn Dizziness Centre, Gelre Hospital, Apeldoorn, Netherlands
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | | | | | - Peter-Paul G. van Benthem
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Tjasse D. Bruintjes
- Apeldoorn Dizziness Centre, Gelre Hospital, Apeldoorn, Netherlands
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Centre, Leiden, Netherlands
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Balance and Dizziness Disorders in the Elderly: a Review. CURRENT OTORHINOLARYNGOLOGY REPORTS 2020. [DOI: 10.1007/s40136-020-00281-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Yeolekar AM, Shinde KJ, Qadri H. Innovative Use of Google Cardboard in Clinical Examination of Patients of Vertigo. CLINICAL MEDICINE INSIGHTS. EAR, NOSE AND THROAT 2019; 12:1179550619882012. [PMID: 31673230 PMCID: PMC6804355 DOI: 10.1177/1179550619882012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 09/22/2019] [Indexed: 11/15/2022]
Abstract
Background: Vertigo is 1 of the most prominent and frequent neurological symptom. It is estimated that about 30% of all people need medical care once in their life due to this index symptom. The neurological expertise required is usually scarce in underprivileged areas. One has to look for spontaneous nystagmus, and perform Dix–Hallpike maneuver and Head Impulse test specifically to differentiate central from peripheral vertigo. The nystagmus, that is spontaneous, involuntary to-and-fro movement of the eyeball which aids in the diagnosis, can be better elicited by Frenzel glasses, Munich glasses. These devices consist of the combination of magnifying glasses and a lighting system to detect eye movements better than routine examination. Objective: To test usefulness of modified Google cardboard as Frenzel glasses in poor resource setting. Study design: A modified Google cardboard was used in 52 consecutive cases of vertigo and compared with examination with naked eye. The device consists of 2 magnifying lenses, 1 for each eye with power of +24 dioptres. Observation: The tool was found to be better for identifying spontaneous nystagmus, in Dix–Hallpike maneuver and during head impulse test as compared with the naked eye owing to the property of magnification and inhibition of fixation. Being a cheaper alternative and handy, it could be carried by every doctor in any setting.
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Affiliation(s)
- Aditya M Yeolekar
- Department of ENT & Head and Neck Surgery, Smt. Kashibai Navale Medical College, Pune, India
| | - Kiran J Shinde
- Department of ENT & Head and Neck Surgery, Smt. Kashibai Navale Medical College, Pune, India
| | - Haris Qadri
- Department of ENT & Head and Neck Surgery, Smt. Kashibai Navale Medical College, Pune, India
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10
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Edlow JA, Gurley KL, Newman-Toker DE. A New Diagnostic Approach to the Adult Patient with Acute Dizziness. J Emerg Med 2018; 54:469-483. [PMID: 29395695 PMCID: PMC6049818 DOI: 10.1016/j.jemermed.2017.12.024] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 10/21/2017] [Accepted: 12/01/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND Dizziness, a common chief complaint, has an extensive differential diagnosis that includes both benign and serious conditions. Emergency physicians must distinguish the majority of patients with self-limiting conditions from those with serious illnesses that require acute treatment. OBJECTIVE OF THE REVIEW This article presents a new approach to diagnosis of the acutely dizzy patient that emphasizes different aspects of the history to guide a focused physical examination with the goal of differentiating benign peripheral vestibular conditions from dangerous posterior circulation strokes in the emergency department. DISCUSSION Currently, misdiagnoses are frequent and diagnostic testing costs are high. This relates in part to use of an outdated, prevalent, diagnostic paradigm. The traditional approach, which relies on dizziness symptom quality or type (i.e., vertigo, presyncope, or disequilibrium) to guide inquiry, does not distinguish benign from dangerous causes, and is inconsistent with current best evidence. A new approach divides patients into three key categories using timing and triggers, guiding a differential diagnosis and targeted bedside examination protocol: 1) acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke; 2) spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack; and 3) triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions. CONCLUSIONS The timing and triggers diagnostic approach for the acutely dizzy patient derives from current best evidence and offers the potential to reduce misdiagnosis while simultaneously decreases diagnostic test overuse, unnecessary hospitalization, and incorrect treatments.
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Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Kiersten L Gurley
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Mount Auburn Hospital, Cambridge, Massachusetts
| | - David E Newman-Toker
- Division of Neuro-Visual and Vestibular Disorders, Department of Neurology, Otolaryngology, and Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Saber Tehrani AS, Kattah JC, Kerber KA, Gold DR, Zee DS, Urrutia VC, Newman-Toker DE. Diagnosing Stroke in Acute Dizziness and Vertigo: Pitfalls and Pearls. Stroke 2018; 49:788-795. [PMID: 29459396 PMCID: PMC5829023 DOI: 10.1161/strokeaha.117.016979] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 11/17/2017] [Accepted: 11/21/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Ali S Saber Tehrani
- From the Department of Neuro-Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston (A.S.S.T.); Department of Neurology, University of Illinois College of Medicine in Peoria (J.C.K.); Department of Neurology, University of Michigan Health System, Ann Arbor (K.A.K.); and Department of Neurology (D.R.G., D.S.Z., D.E.N.-T.) and Department of Neurology, The Johns Hopkins Hospital Comprehensive Stroke Center (V.C.U.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jorge C Kattah
- From the Department of Neuro-Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston (A.S.S.T.); Department of Neurology, University of Illinois College of Medicine in Peoria (J.C.K.); Department of Neurology, University of Michigan Health System, Ann Arbor (K.A.K.); and Department of Neurology (D.R.G., D.S.Z., D.E.N.-T.) and Department of Neurology, The Johns Hopkins Hospital Comprehensive Stroke Center (V.C.U.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kevin A Kerber
- From the Department of Neuro-Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston (A.S.S.T.); Department of Neurology, University of Illinois College of Medicine in Peoria (J.C.K.); Department of Neurology, University of Michigan Health System, Ann Arbor (K.A.K.); and Department of Neurology (D.R.G., D.S.Z., D.E.N.-T.) and Department of Neurology, The Johns Hopkins Hospital Comprehensive Stroke Center (V.C.U.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Daniel R Gold
- From the Department of Neuro-Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston (A.S.S.T.); Department of Neurology, University of Illinois College of Medicine in Peoria (J.C.K.); Department of Neurology, University of Michigan Health System, Ann Arbor (K.A.K.); and Department of Neurology (D.R.G., D.S.Z., D.E.N.-T.) and Department of Neurology, The Johns Hopkins Hospital Comprehensive Stroke Center (V.C.U.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - David S Zee
- From the Department of Neuro-Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston (A.S.S.T.); Department of Neurology, University of Illinois College of Medicine in Peoria (J.C.K.); Department of Neurology, University of Michigan Health System, Ann Arbor (K.A.K.); and Department of Neurology (D.R.G., D.S.Z., D.E.N.-T.) and Department of Neurology, The Johns Hopkins Hospital Comprehensive Stroke Center (V.C.U.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Victor C Urrutia
- From the Department of Neuro-Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston (A.S.S.T.); Department of Neurology, University of Illinois College of Medicine in Peoria (J.C.K.); Department of Neurology, University of Michigan Health System, Ann Arbor (K.A.K.); and Department of Neurology (D.R.G., D.S.Z., D.E.N.-T.) and Department of Neurology, The Johns Hopkins Hospital Comprehensive Stroke Center (V.C.U.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - David E Newman-Toker
- From the Department of Neuro-Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston (A.S.S.T.); Department of Neurology, University of Illinois College of Medicine in Peoria (J.C.K.); Department of Neurology, University of Michigan Health System, Ann Arbor (K.A.K.); and Department of Neurology (D.R.G., D.S.Z., D.E.N.-T.) and Department of Neurology, The Johns Hopkins Hospital Comprehensive Stroke Center (V.C.U.), Johns Hopkins University School of Medicine, Baltimore, MD.
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Misdiagnosis of cerebellar hemorrhage – features of ‘pseudo-gastroenteritis’ clinical presentations to the ED and primary care. Diagnosis (Berl) 2017. [DOI: 10.1515/dx-2016-0038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AbstractBackground:Early-stage cerebellar hemorrhage can present with nausea or vomiting absent other neurological symptoms or signs, potentially leading to an incorrect diagnosis of gastroenteritis. We sought to determine the frequency of gastroenteritis-like presentations and delayed or missed diagnoses among patients with spontaneous cerebellar hemorrhage.Methods:This is a retrospective, case-control analysis of atraumatic, primary cerebellar hemorrhages derived from a systematic search of surgical pathology and autopsy databases at two large urban, academic medical centers from 1984 to 2006. Hospital visit and clinical symptom data were abstracted from electronic and paper medical records for included patients. Delayed or missed diagnoses were defined as those at least one previous visit for relevant clinical symptoms in the 7 days prior to the correct diagnosis being confirmed.Results:Among 254 records captured by our search filter, we identified 35 cases of pathologically proven primary cerebellar hemorrhage. Four patients (11%) were misdiagnosed initially – three with “gastroenteritis” and one with “hypertension”. In this small sample, misdiagnosed patients presented more often with normal mental state (100% vs. 35%, p=0.07) and nausea/vomiting (100% vs. 58%, p=0.22). Although patients deteriorated clinically after the initial misdiagnosis, and potentially dangerous diagnostic tests and treatment strategies were instituted as a result of misdiagnosis, none of the misdiagnosed patients died or suffered major permanent harms due to diagnostic delay.Conclusions:Our study is limited by the small number of identified cases. Nevertheless, it appears that patients with cerebellar hemorrhages can present with relatively unimpressive clinical findings without obvious neurological manifestations. Such individuals are sometimes misdiagnosed with gastroenteritis or other benign disorders initially, possibly when neurologic examination, particularly gait testing, is omitted or abridged. A careful search for subtle cerebellar signs, including dysarthria, limb ataxia, nystagmus or tandem gait instability, absent in true gastroenteritis cases, could potentially reduce misdiagnosis.
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Newman-Toker DE, Edlow JA. TiTrATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo. Neurol Clin 2016; 33:577-99, viii. [PMID: 26231273 DOI: 10.1016/j.ncl.2015.04.011] [Citation(s) in RCA: 134] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Diagnosing dizziness can be challenging, and the consequences of missing dangerous causes, such as stroke, can be substantial. Most physicians use a diagnostic paradigm developed more than 40 years ago that focuses on the type of dizziness, but this approach is flawed. This article proposes a new paradigm based on symptom timing, triggers, and targeted bedside eye examinations (TiTrATE). Patients fall into 1 of 4 major syndrome categories, each with its own differential diagnosis and set of targeted examination techniques that help make a specific diagnosis. Following an evidence-based approach could help reduce the frequency of misdiagnosis of serious causes of dizziness. In the spirit of the flipped classroom, the editors of this Neurologic Clinics issue on emergency neuro-otology have assembled a collection of unknown cases to be accessed electronically in multimedia format. By design, cases are not linked with specific articles, to avoid untoward cueing effects for the learner. The cases are real and are meant to demonstrate and reinforce lessons provided in this and subsequent articles. In addition to pertinent elements of medical history, cases include videos of key examination findings.
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Affiliation(s)
- David E Newman-Toker
- Johns Hopkins Hospital, CRB-II, Room 2M-03 North, 1550 Orleans Street, Baltimore, MD 21231, USA.
| | - Jonathan A Edlow
- Department of Emergency Medicine Administrative Offices, Beth Israel Deaconess Medical Center, West CC-2, 1 Deaconess Place, Boston, MA 02215, USA
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14
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Friedland DR, Tarima S, Erbe C, Miles A. Development of a Statistical Model for the Prediction of Common Vestibular Diagnoses. JAMA Otolaryngol Head Neck Surg 2016; 142:351-6. [PMID: 26913615 PMCID: PMC5070446 DOI: 10.1001/jamaoto.2015.3663] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE Treatment of patients with vestibular disorders can be complex, requires lengthy clinic visit time, and uses greater clinical resources for diagnosis. A pre-encounter intake questionnaire may predict the most common disorders, allowing for more efficient allocation of resources and use of clinicians. OBJECTIVE To develop a statistical model for predicting vestibular diagnoses, prior to clinical evaluation, from an intake questionnaire. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of 414 consecutive new vestibular patient intake questionnaires (September 2012 through January 2014) and associated medical records with performance of logistic regression analyses and development of predictive models (July 2013 through May 2015). INTERVENTIONS Use of a vestibular intake questionnaire for triaging of new patients with complaints of dizziness. MAIN OUTCOMES AND MEASURES Predictors for the diagnosis of benign paroxysmal positional vertigo (BPPV), Ménière's disease, and vestibular migraine. RESULTS Of the 414 questionnaires analyzed, 381 (92%) had clinician information necessary to define a final diagnosis. Patients were 34% male and had a mean (range) age of 57 (19-91) years. Of the diagnoses, 183 (48%) were ear related (including 103 BPPV and 49 Meniere's disease), 141 (37%) neurological (including 109 vestibular migraine), 36 (9%) medical, 8 (2%) of psychological origin, 46 (12%) of unknown etiology, and 33 (9%) other causes. The diagnosis of BPPV could be predicted from 4 variables with a sensitivity of 79% and specificity of 65%. The diagnosis of Ménière's disease could be predicted from 5 variables with a sensitivity of 81% and specificity of 85%. The diagnosis of vestibular migraine could be predicted from 4 variables with a sensitivity of 76% and specificity of 59%. CONCLUSIONS AND RELEVANCE A pre-encounter history questionnaire can provide useful diagnostic information for common vestibular disorders. This can help direct appointment scheduling to improve clinical efficiency, time to intervention, and use of resources. Further refinement may enable the use of shorter questionnaires or screening algorithms.
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Affiliation(s)
- David R Friedland
- Department of Otolaryngology and Communications Sciences, Medical College of Wisconsin, Milwaukee
| | - Sergey Tarima
- Institute for Health and Society, Division of Biostatistics, Medical College of Wisconsin, Milwaukee
| | - Christy Erbe
- Department of Otolaryngology and Communications Sciences, Medical College of Wisconsin, Milwaukee
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15
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Eid E, Dastan S, Heckmann JG. Acute dizziness in rural practice: Proposal of a diagnostic procedure. J Neurosci Rural Pract 2015; 6:272-6. [PMID: 25883501 PMCID: PMC4387832 DOI: 10.4103/0976-3147.153238] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Acute dizziness is a frequent index symptom in the emergency department as well as in the rural practice office. Most acute dizziness, however, is not dangerous, but some types are highly dangerous. Clinical routine acute dizziness can be separated into frequent benign syndromes including benign paroxysmal positional vertigo (BPPV), vestibular neuritis, Meniθre's disease or vestibular migraine, and what is here referred to as the “white shark” of dizziness, i.e. a stroke in the posterior circulation or more rarely a tumor in the posterior fossa. A practical concept is presented to clarify most frequent acute dizziness syndromes using clinical and low budget methods.
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Affiliation(s)
- Ehab Eid
- Medical School, University of Alexandria, Alexandria, Egypt ; Department of Neurology, Municipal Hospital Landshut, Landshut, Germany
| | - Sajed Dastan
- Medical School, Iran University of Medical Sciences, Teheran, Iran ; Department of Neurology, Municipal Hospital Landshut, Landshut, Germany
| | - Josef G Heckmann
- Department of Neurology, Municipal Hospital Landshut, Landshut, Germany
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16
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Tarnutzer AA, Lee SH, Robinson KA, Kaplan PW, Newman-Toker DE. Clinical and electrographic findings in epileptic vertigo and dizziness: a systematic review. Neurology 2015; 84:1595-604. [PMID: 25795644 DOI: 10.1212/wnl.0000000000001474] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 12/22/2014] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Seizures can cause vestibular symptoms, even without obvious epileptic features. We sought to characterize epileptic vertigo or dizziness (EVD) to improve differentiation from nonepileptic causes, particularly when vestibular symptoms are the sole manifestation. METHODS We conducted a systematic review with electronic (Medline) and manual search for English-language studies (1955-2014). Two independent reviewers selected studies. Study/patient characteristics were abstracted. We defined 3 study population types: (1) seizures, some experiencing vertigo/dizziness (disease cohort); (2) vertigo/dizziness, some due to seizures (symptom cohort); (3) vertigo/dizziness due to seizures in all patients (EVD-only cohort). RESULTS We identified 84 studies describing 11,354 patients (disease cohort = 8,129; symptom cohort = 2,965; EVD-only cohort = 260). Among 1,055 EVD patients in whom a distinction could be made, non-isolated EVD was present in 8.5%, isolated EVD in 0.8%. Thorough diagnostic workups (ictal EEG, vestibular testing, and brain MRI to exclude other causes) were rare (<0.1%). Ictal EEG was reported in 487 (4.3%), formal neuro-otologic assessment in 1,107 (9.7%). Localized EEG abnormalities (n = 350) were most frequently temporal (79.8%) and uncommonly parietal (11.8%). Duration of episodic vestibular symptoms varied, but was very brief (<30 seconds) in 69.6% of isolated EVD and 6.9% of non-isolated EVD. CONCLUSIONS Non-isolated EVD is much more prevalent than isolated EVD, which appears to be rare. Diagnostic evaluations for EVD are often incomplete. EVD is primarily associated with temporal lobe seizures; whether this reflects greater epidemiologic prevalence of temporal lobe seizures or a tighter association with dizziness/vertigo presentations than with other brain regions remains unknown. Consistent with clinical wisdom, isolated EVD spells often last just seconds, although many patients experience longer spells.
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Affiliation(s)
- Alexander A Tarnutzer
- From the Department of Neurology (A.A.T.), University Hospital Zurich and the University of Zurich, Switzerland; the Department of Neurology (S.-H.L.), Chonnam National University Medical School, Gwangju, South Korea; the Departments of Medicine (K.A.R.), Neurology (D.E.N.-T.), and Otolaryngology Head & Neck Surgery (D.E.N.-T.), The Johns Hopkins University School of Medicine; and the Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD.
| | - Seung-Han Lee
- From the Department of Neurology (A.A.T.), University Hospital Zurich and the University of Zurich, Switzerland; the Department of Neurology (S.-H.L.), Chonnam National University Medical School, Gwangju, South Korea; the Departments of Medicine (K.A.R.), Neurology (D.E.N.-T.), and Otolaryngology Head & Neck Surgery (D.E.N.-T.), The Johns Hopkins University School of Medicine; and the Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Karen A Robinson
- From the Department of Neurology (A.A.T.), University Hospital Zurich and the University of Zurich, Switzerland; the Department of Neurology (S.-H.L.), Chonnam National University Medical School, Gwangju, South Korea; the Departments of Medicine (K.A.R.), Neurology (D.E.N.-T.), and Otolaryngology Head & Neck Surgery (D.E.N.-T.), The Johns Hopkins University School of Medicine; and the Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - Peter W Kaplan
- From the Department of Neurology (A.A.T.), University Hospital Zurich and the University of Zurich, Switzerland; the Department of Neurology (S.-H.L.), Chonnam National University Medical School, Gwangju, South Korea; the Departments of Medicine (K.A.R.), Neurology (D.E.N.-T.), and Otolaryngology Head & Neck Surgery (D.E.N.-T.), The Johns Hopkins University School of Medicine; and the Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
| | - David E Newman-Toker
- From the Department of Neurology (A.A.T.), University Hospital Zurich and the University of Zurich, Switzerland; the Department of Neurology (S.-H.L.), Chonnam National University Medical School, Gwangju, South Korea; the Departments of Medicine (K.A.R.), Neurology (D.E.N.-T.), and Otolaryngology Head & Neck Surgery (D.E.N.-T.), The Johns Hopkins University School of Medicine; and the Department of Neurology (P.W.K.), Johns Hopkins Bayview Medical Center, Baltimore, MD
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17
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Aptikeeva NV. Central and peripheral vestibular vertigo in neurological practice. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:110-114. [DOI: 10.17116/jnevro201511551110-114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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18
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Mantokoudis G, Saber Tehrani AS, Kattah JC, Eibenberger K, Guede CI, Zee DS, Newman-Toker DE. Quantifying the vestibulo-ocular reflex with video-oculography: nature and frequency of artifacts. Audiol Neurootol 2014; 20:39-50. [PMID: 25501133 DOI: 10.1159/000362780] [Citation(s) in RCA: 113] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 04/09/2014] [Indexed: 11/19/2022] Open
Abstract
Video-oculography devices are now used to quantify the vestibulo-ocular reflex (VOR) at the bedside using the head impulse test (HIT). Little is known about the impact of disruptive phenomena (e.g. corrective saccades, nystagmus, fixation losses, eye-blink artifacts) on quantitative VOR assessment in acute vertigo. This study systematically characterized the frequency, nature, and impact of artifacts on HIT VOR measures. From a prospective study of 26 patients with acute vestibular syndrome (16 vestibular neuritis, 10 stroke), we classified findings using a structured coding manual. Of 1,358 individual HIT traces, 72% had abnormal disruptive saccades, 44% had at least one artifact, and 42% were uninterpretable. Physicians using quantitative recording devices to measure head impulse VOR responses for clinical diagnosis should be aware of the potential impact of disruptive eye movements and measurement artifacts.
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Affiliation(s)
- Georgios Mantokoudis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Md., USA
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