1
|
de Souza DN, Bell CA, Elkin ZP, Grossman SN. Clues From Parinaud: Diagnostic Approaches in Neuro-Ophthalmology. J Neuroophthalmol 2024; 44:e455-e456. [PMID: 37540560 DOI: 10.1097/wno.0000000000001966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/06/2023]
Affiliation(s)
- Daniel N de Souza
- Departments of Neurology (DNdS, CAB, SNG) and Ophthalmology (ZPE), New York University Grossman School of Medicine, New York, New York
| | | | | | | |
Collapse
|
2
|
Vanni S, Vannucchi P, Pecci R, Pepe G, Paciaroni M, Pavellini A, Ronchetti M, Pelagatti L, Bartolucci M, Konze A, Castellucci A, Manfrin M, Fabbri A, de Iaco F, Casani AP. Consensus paper on the management of acute isolated vertigo in the emergency department. Intern Emerg Med 2024; 19:1181-1202. [PMID: 39001977 PMCID: PMC11364714 DOI: 10.1007/s11739-024-03664-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/28/2024] [Indexed: 07/15/2024]
Abstract
Acute vertigo is defined as the perception of movement of oneself or the surroundings in the absence of actual motion and it is a frequent cause for emergency department admissions. The utilization of medical resources and the duration of hospital stay for this kind of symptom is high. Furthermore, the efficiency of brain imaging in the acute phase is low, considering the limited sensitivity of both CT and MRI for diagnosing diseases that are the causes of central type of vertigo. Relying on imaging tests can provide false reassurance in the event of negative results or prolong the in-hospital work-up improperly. On the other hand, clinical examinations, notably the assessment of nystagmus' features, have proven to be highly accurate and efficient when performed by experts. Literature data point out that emergency physicians often do not employ these skills or use them incorrectly. Several clinical algorithms have been introduced in recent years with the aim of enhancing the diagnostic accuracy of emergency physicians when evaluating this specific pathology. Both the 'HINTS and 'STANDING' algorithms have undergone external validation in emergency physician hands, showing good diagnostic accuracy. The objective of this consensus document is to provide scientific evidence supporting the clinical decisions made by physicians assessing adult patients with acute vertigo in the emergency department, particularly in cases without clear associated neurological signs. The document aims to offer a straightforward and multidisciplinary approach. At the same time, it tries to delineate benchmarks for the formulation of local diagnostic and therapeutic pathways, as well as provide a base for the development of training and research initiatives.
Collapse
Affiliation(s)
- Simone Vanni
- Dipartimento di Medicina Sperimentale e Clinica, Università degli studi di Firenze, Largo Brambilla 3, 50134, Florence, Italy.
| | | | - Rudi Pecci
- Audiologia, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Giuseppe Pepe
- Medicina Emergenza Urgenza e Pronto Soccorso, Azienda USL Toscana Nord Ovest, Ospedale Versilia, Viareggio, Italy
| | - Maurizio Paciaroni
- Medicina Interna e Cardiovascolare, Stroke Unit, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Andrea Pavellini
- Medicina e Chirurgia d'Urgenza e Accettazione, AOU-Careggi, Florence, Italy
| | - Mattia Ronchetti
- Medicina e Chirurgia d'Urgenza e Accettazione, AOU-Careggi, Florence, Italy
| | - Lorenzo Pelagatti
- Medicina e Chirurgia d'Urgenza e Accettazione, AOU-Careggi, Florence, Italy
| | - Maurizio Bartolucci
- Dipartimento di Diagnostica per Immagini, Azienda Usl Toscana Centro, Prato, Italy
| | - Angela Konze
- Neuroradiologia, Azienda USL Toscana Centro, Florence, Italy
| | - Andrea Castellucci
- Otorinolaringoiatria, Arcispedale Santa Maria Nuova, IRCCS, Reggio Emilia, Italy
| | - Marco Manfrin
- Otorinolaringoiatria, Libero Professionista, Milan, Italy
| | - Andrea Fabbri
- Pronto Soccorso e Medicina d'Urgenza, AUSL della Romagna, Ospedale Morgagni-Pierantoni, Forlì, Italy
| | - Fabio de Iaco
- Medicina d'Urgenza, Ospedale Maria Vittoria, Turin, Italy
| | | |
Collapse
|
3
|
Happonen T, Nyman M, Ylikotila P, Mattila K, Hirvonen J. Imaging Outcomes of Emergency MR Imaging in Dizziness and Vertigo: A Retrospective Cohort Study. AJNR Am J Neuroradiol 2024; 45:819-825. [PMID: 38604735 PMCID: PMC11288592 DOI: 10.3174/ajnr.a8202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 01/19/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND AND PURPOSE Patients exhibiting acute dizziness or vertigo often represent a diagnostic challenge, and many undergo neuroimaging for stroke detection. We aimed to demonstrate the imaging outcomes of first-line emergency MR imaging among patients with acute dizziness or vertigo and to determine the clinical risk factors for stroke and other acute pathology. MATERIALS AND METHODS This retrospective study included consecutive patients with acute dizziness or vertigo referred for emergency MR imaging in a tertiary hospital during 5 years. We recorded and analyzed patient characteristics, relevant clinical information, and imaging outcomes. Risk score models were derived to predict which patients were more likely to present with positive MR imaging findings. RESULTS A total of 1169 patients were included. Acute stroke was found in 17%; other clinically significant pathology, in 8% of patients. In 75% of the patients, emergency MR imaging showed no significant abnormalities. Risk factors for acute stroke included older age, male sex, and a prevalence of cardiovascular risk factors and neurologic signs. Isolated dizziness had no discriminative power on imaging outcomes, and 14% of these patients showed acute stroke. Risk scores had only moderate performance in predicting acute ischemic stroke (receiver operating characteristic area under curve = 0.75) or any significant pathology (receiver operating characteristic area under curve = 0.70). CONCLUSIONS Acute dizziness and vertigo remain challenging even when emergency MR imaging is readily available. One in 4 patients had acute pathology on MR imaging. Predictors for acute pathology (older age, male sex, cardiovascular risk factors, and neurologic signs) may aid in patient selection for MR imaging, optimizing the yield and clinical impact of emergency neuroimaging. Low diagnostic yields of CT and internal acoustic canal MR imaging may offer an opportunity to reduce health care expenditures in the future.
Collapse
Affiliation(s)
- Tatu Happonen
- From the Department of Radiology (T.H., M.N., K.M., J.H.), Turku University Hospital and University of Turku, Turku, Finland
| | - Mikko Nyman
- From the Department of Radiology (T.H., M.N., K.M., J.H.), Turku University Hospital and University of Turku, Turku, Finland
| | - Pauli Ylikotila
- Neurocenter (P.Y.), Turku University Hospital and University of Turku, Turku, Finland
| | - Kimmo Mattila
- From the Department of Radiology (T.H., M.N., K.M., J.H.), Turku University Hospital and University of Turku, Turku, Finland
| | - Jussi Hirvonen
- From the Department of Radiology (T.H., M.N., K.M., J.H.), Turku University Hospital and University of Turku, Turku, Finland
- Department of Radiology (J.H.), Tampere University Hospital and Tampere University, Tampere, Finland
| |
Collapse
|
4
|
Wang LL, Thompson TA, Shih RY, Ajam AA, Bulsara K, Burns J, Davis MA, Ivanidze J, Kalnins A, Kuo PH, Ledbetter LN, Pannell JS, Pollock JM, Shakkottai VG, Shih RD, Soares BP, Soderlund KA, Utukuri PS, Woolsey S, Policeni B. ACR Appropriateness Criteria® Dizziness and Ataxia: 2023 Update. J Am Coll Radiol 2024; 21:S100-S125. [PMID: 38823940 DOI: 10.1016/j.jacr.2024.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/28/2024] [Indexed: 06/03/2024]
Abstract
Diagnostic evaluation of a patient with dizziness or vertigo is complicated by a lack of standardized nomenclature, significant overlap in symptom descriptions, and the subjective nature of the patient's symptoms. Although dizziness is an imprecise term often used by patients to describe a feeling of being off-balance, in many cases dizziness can be subcategorized based on symptomatology as vertigo (false sense of motion or spinning), disequilibrium (imbalance with gait instability), presyncope (nearly fainting or blacking out), or lightheadedness (nonspecific). As such, current diagnostic paradigms focus on timing, triggers, and associated symptoms rather than subjective descriptions of dizziness type. Regardless, these factors complicate the selection of appropriate diagnostic imaging in patients presenting with dizziness or vertigo. This document serves to aid providers in this selection by using a framework of definable clinical variants. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
Collapse
Affiliation(s)
- Lily L Wang
- University of Cincinnati Medical Center, Cincinnati, Ohio.
| | - Trevor A Thompson
- Research Author, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Robert Y Shih
- Panel Chair, Uniformed Services University, Bethesda, Maryland
| | | | - Ketan Bulsara
- UCONN Health, University of Connecticut, Farmington, Connecticut, Neurosurgery expert
| | | | - Melissa A Davis
- Yale University School of Medicine, New Haven, Connecticut; Committee on Emergency Radiology-GSER
| | | | | | - Phillip H Kuo
- University of Arizona, Tucson, Arizona; Commission on Nuclear Medicine and Molecular Imaging
| | | | | | | | - Vikram G Shakkottai
- University of Texas Southwestern Medical Center, Dallas, Texas; American Academy of Neurology
| | - Richard D Shih
- Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida; American College of Emergency Physicians
| | - Bruno P Soares
- The University of Vermont Medical Center, Burlington, Vermont
| | | | | | - Sarah Woolsey
- Association for Utah Community Health, Salt Lake City, Utah; American Academy of Family Physicians
| | - Bruno Policeni
- Specialty Chair, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| |
Collapse
|
5
|
von Werdt M, Korda A, Zamaro E, Wagner F, Kompis M, Caversaccio MD, Mantokoudis G. The acute vestibular syndrome: prevalence of new hearing loss and its diagnostic value. Eur Arch Otorhinolaryngol 2024; 281:1781-1787. [PMID: 37943315 PMCID: PMC10942940 DOI: 10.1007/s00405-023-08296-z] [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: 06/19/2023] [Accepted: 10/17/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVES To assess the prevalence of new hearing losses in patients with acute vestibular syndrome (AVS) and to start to evaluate its diagnostic value for the differentiation between peripheral and central causes. DESIGN We performed a cross-sectional prospective study in AVS patients presenting to our Emergency Department (ED) from February 2015 to November 2020. All patients received an MRI, Head-impulse test, Nystagmus test and Test of skew ('HINTS'), caloric testing and a pure-tone audiometry. RESULTS We assessed 71 AVS patients, 17 of whom had a central and 54 a peripheral cause of dizziness. 12.7% had an objective hearing loss. 'HINTS' had an accuracy of 78.9% to diagnose stroke, whereas 'HINTS' plus audiometry 73.2%. 'HINTS' sensitivity was 82.4% and specificity 77.8% compared to 'HINTS' plus audiometry showing a sensitivity of 82.4% and specificity of 70.4%. The four patients with stroke and minor stroke had all central 'HINTS'. 55% of the patients did not perceive their new unilateral hearing loss. CONCLUSIONS We found that almost one-eighth of the AVS patients had a new onset of hearing loss and only half had self-reported it. 'HINTS' plus audiometry proved to be less accurate to diagnose a central cause than 'HINTS' alone. Audiometry offered little diagnostic accuracy to detect strokes in the ED but might be useful to objectify a new hearing loss that was underestimated in the acute phase. Complete hearing loss should be considered a red flag, as three in four patients suffered from a central cause.
Collapse
Affiliation(s)
- Moritz von Werdt
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, 3010, Bern, Switzerland
| | - Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, 3010, Bern, Switzerland
| | - Ewa Zamaro
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, 3010, Bern, Switzerland
| | - Franca Wagner
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Martin Kompis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, 3010, Bern, Switzerland
| | - Marco D Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, 3010, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, 3010, Bern, Switzerland.
| |
Collapse
|
6
|
Michailidou E, Korda A, Wyss T, Bardins S, Schneider E, Morrison M, Wagner F, Caversaccio MD, Mantokoudis G. The value of saccade metrics and VOR gain in detecting a vestibular stroke. J Vestib Res 2024; 34:49-61. [PMID: 38160379 DOI: 10.3233/ves-230083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVE A normal video Head Impulse Test is the gold standard in the emergency department to rule-in patients with an acute vestibular syndrome and a stroke. We aimed to compare the diagnostic accuracy of vHIT metrics regarding the vestibulo-ocular reflex gain and the corrective saccades in detecting vestibular strokes. METHODS Prospective cross-sectional study (convenience sample) of patients presenting with acute vestibular syndrome in the emergency department of a tertiary referral centre between February 2015 and May 2020. We screened 1677 patients and enrolled 76 patients fulfilling the inclusion criteria of acute vestibular syndrome. All patients underwent video head impulse test with automated and manual data analysis. A delayed MRI served as a gold standard for vestibular stroke confirmation. RESULTS Out of 76 patients, 52 were diagnosed with acute unilateral vestibulopathy and 24 with vestibular strokes. The overall accuracy of detecting stroke with an automated vestibulo-ocular reflex gain was 86.8%, compared to 77.6% for cumulative saccade amplitude and automatic saccade mean peak velocity measured by an expert and 71% for cumulative saccade amplitude and saccade mean peak velocity measured automatically. Gain misclassified 13.1% of the patients as false positive or false negative, manual cumulative saccade amplitude and saccade mean peak velocity 22.3%, and automated cumulative saccade amplitude and saccade mean peak velocity 28.9% respectively. CONCLUSIONS We found a better accuracy of video head impulse test for the diagnosis of vestibular strokes when using the vestibulo-ocular reflex gain than using saccade metrics. Nevertheless, saccades provide an additional and important information for video head impulse test evaluation. The automated saccade detection algorithm is not yet perfect compared to expert analysis, but it may become a valuable tool for future non-expert video head impulse test evaluations.
Collapse
Affiliation(s)
- Efterpi Michailidou
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Thomas Wyss
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Stanislav Bardins
- Institute of Medical Technology, Brandenburg University of Technology Cottbus - Senftenberg, Cottbus, Germany
| | - Erich Schneider
- Institute of Medical Technology, Brandenburg University of Technology Cottbus - Senftenberg, Cottbus, Germany
| | - Miranda Morrison
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Franca Wagner
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marco D Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| |
Collapse
|
7
|
Nikles F, Kerkeni H, Zamaro E, Korda A, Wagner F, Sauter TC, Kalla R, Morrison M, Mantokoudis G. Do monosymptomatic stroke patients with dizziness present a vestibular syndrome without nystagmus? An underestimated entity. Eur J Neurol 2024; 31:e16066. [PMID: 37738525 PMCID: PMC11235630 DOI: 10.1111/ene.16066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 09/04/2023] [Accepted: 09/04/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND AND PURPOSE Vestibular symptoms are common in emergency department (ED) patients and have various causes, including stroke. Accurate identification of stroke in patients with vestibular symptoms is crucial for timely management. We conducted a prospective cross-sectional study from 2015 to 2019 to determine stroke prevalence and associated symptoms in ED patients with vestibular symptoms, aiming to improve diagnosis and outcomes. METHODS As part of the DETECT project, we screened 1647 ED patients with acute vestibular symptoms. Following a retrospective analysis of 961 head and neck magnetic resonance imaging (MRI) scans, we included 122 confirmed stroke cases and assessed them for vestibular signs and symptoms. RESULTS Stroke prevalence in dizzy patients was 13% (122/961 MRI scans). Most patients (95%) presented with acute vestibular symptoms with or without nystagmus, whereas 5% had episodic vestibular syndrome (EVS). Nystagmus was present in 50% of stroke patients. Eighty percent had a purely posterior circulation stroke, and nystagmus was absent in 46% of these patients. Seven patients (6%) had lesions in both the anterior and posterior circulation. Vertigo was experienced by 52% regardless of territory. CONCLUSIONS A stroke was identified in 13% of ED patients presenting with acute vestibular symptoms. In 5%, it was EVS. Most strokes were in the posterior circulation territory; vertigo occurred with similar frequency in anterior and posterior circulation stroke, and absence of nystagmus was common in both.
Collapse
Affiliation(s)
- Florence Nikles
- Department of Otorhinolaryngology, Head and Neck Surgery, InselspitalUniversity Hospital Bern and University of BernBernSwitzerland
| | - Hassen Kerkeni
- Department of Neurology, InselspitalUniversity Hospital Bern and University of BernBernSwitzerland
| | - Ewa Zamaro
- Department of Otorhinolaryngology, Head and Neck Surgery, InselspitalUniversity Hospital Bern and University of BernBernSwitzerland
| | - Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, InselspitalUniversity Hospital Bern and University of BernBernSwitzerland
| | - Franca Wagner
- University Institute of Diagnostic and Interventional Neuroradiology, InselspitalUniversity Hospital Bern and University of BernBernSwitzerland
| | - Thomas C. Sauter
- Department of Emergency Medicine, InselspitalUniversity Hospital Bern and University of BernBernSwitzerland
| | - Roger Kalla
- Department of Neurology, InselspitalUniversity Hospital Bern and University of BernBernSwitzerland
| | - Miranda Morrison
- Department of Otorhinolaryngology, Head and Neck Surgery, InselspitalUniversity Hospital Bern and University of BernBernSwitzerland
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, InselspitalUniversity Hospital Bern and University of BernBernSwitzerland
| |
Collapse
|
8
|
Halmágyi GM, Akdal G, Welgampola MS, Wang C. Neurological update: neuro-otology 2023. J Neurol 2023; 270:6170-6192. [PMID: 37592138 PMCID: PMC10632253 DOI: 10.1007/s00415-023-11922-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 08/01/2023] [Indexed: 08/19/2023]
Abstract
Much has changed since our last review of recent advances in neuro-otology 7 years ago. Unfortunately there are still not many practising neuro-otologists, so that most patients with vestibular problems need, in the first instance, to be evaluated and treated by neurologists whose special expertise is not neuro-otology. The areas we consider here are mostly those that almost any neurologist should be able to start managing: acute spontaneous vertigo in the Emergency Room-is it vestibular neuritis or posterior circulation stroke; recurrent spontaneous vertigo in the office-is it vestibular migraine or Meniere's disease and the most common vestibular problem of all-benign positional vertigo. Finally we consider the future: long-term vestibular monitoring and the impact of machine learning on vestibular diagnosis.
Collapse
Affiliation(s)
- Gábor M Halmágyi
- Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia.
- Central Clinical School, University of Sydney, Sydney, Australia.
| | - Gülden Akdal
- Neurology Department, Dokuz Eylül University Hospital, Izmir, Turkey
- Neurosciences Department, Dokuz Eylül University Hospital, Izmir, Turkey
| | - Miriam S Welgampola
- Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
- Central Clinical School, University of Sydney, Sydney, Australia
| | - Chao Wang
- Neurology Department, Royal Prince Alfred Hospital, Sydney, Australia
- Central Clinical School, University of Sydney, Sydney, Australia
| |
Collapse
|
9
|
Kattah JC. Concordant GRADE-3 Truncal Ataxia and Ocular Laterodeviation in Acute Medullary Stroke. Audiol Res 2023; 13:767-778. [PMID: 37887849 PMCID: PMC10604033 DOI: 10.3390/audiolres13050068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/08/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023] Open
Abstract
Background: Severe truncal ataxia associated with an inability to sit up without assistance (STA grade 3) is frequent in patients with central acute vestibular syndrome (AVS) involving the brainstem or cerebellum. When these patients have nystagmus, central HINTS excludes peripheral lesions; however, additional localization and lateralization signs are helpful, not only to resolve the peripheral versus central vestibular lesion dilemma, but to zero in on a precise lesion localization/lateralization to the lateral medulla, the most common ischemic lesion localization associated with an initially false-negative stroke MRI. Methods: This is a study of AVS patients with additional inclusion criteria: grades 2 or 3 ataxia with an eventual diagnosis of medullary stroke (MS), either involving the lateral medulla (LMS) or the medial medulla (MMS), and horizontal (h) gaze paralysis was the main exclusion criteria. All patients sat on the side of the bed or stretcher, with assistance if needed. A general neurologic examination followed in the sitting position, the testing protocol included the head impulse, spontaneous nystagmus, and skew deviation (HINTS) tests, followed by observation of the effect of brief 3-5 sec eyelid closure on ocular position, and saccade and pursuit eye movement tests. If they could sit, the protocol included the ability to stand with a wide base, then a narrow base, the Romberg test, and tandem gait. Radiographic lesion localization and horizontal gaze deviation concluded the protocol. Results: A total of 34 patients met the entry criteria, 34 MS (13 in the lateral medulla, 12 previously described, and 1 new patient), and 1 new MMS. Among them, n = 10/12 had grade 3 ataxia, and 3 (1 new patient) had grade 2 ataxia. In addition, overt ocular laterodeviation (OLD) was present in thirteen of them (35.3%). All OLD patients had gaze deviation and ipsilateral saccade and truncal lateropulsion, 1 medial medulla stroke patient had grade 3 truncal contrapulsion and contralateral hemiparesis without OLD, n = 20/21 patients with LMS without OLD had grade 3 truncal ataxia, and 1 had grade 2 truncal ataxia. Discussion: AVS patients with severe truncal ataxia (inability to sit without assistance) potentially have brainstem, cerebellum, or subcortical lesions. All patients had central HINTS; however, simultaneous direction-concordant STA 3 and OLD provided greater lateral medulla localization specificity, affecting the ipsilateral medulla. Future work to explore a practical posterior circulation stroke scale that includes HINTS, STA, and OLD will potentially select cases for thrombolysis even in the event of initially false-negative imaging.
Collapse
Affiliation(s)
- Jorge C Kattah
- College of Medicine, Neurology University of Illinois, Peoria, IL 61637, USA
| |
Collapse
|
10
|
Zwergal A, Mantokoudis G, Heg D, Kerkeni H, Diener S, Kalla R, Korda A, Candreia C, Welge-Lüssen A, Tarnutzer AA. What is the current status of primary care in the diagnosis and treatment of patients with vertigo and dizziness in Switzerland? A national survey. Front Neurol 2023; 14:1254080. [PMID: 37745663 PMCID: PMC10513417 DOI: 10.3389/fneur.2023.1254080] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 08/14/2023] [Indexed: 09/26/2023] Open
Abstract
Background Vertigo and dizziness are among the most frequent presenting symptoms in the primary care physicians' (PCPs) office. With patients facing difficulties in describing their complaints and clinical findings often being subtle and transient, the diagnostic workup of the dizzy patient remains challenging. We aimed to gain more insights into the current state of practice in order to identify the limitations and needs of the PCPs and define strategies to continuously improve their knowledge in the care of the dizzy patient. Materials and methods Board-certified PCPs working in Switzerland were invited to participate in an online survey. A descriptive statistical analysis was performed, and prospectively defined hypotheses were assessed using regression analyses. Results A vast majority of participating PCPs (n = 152) were familiar with the key questions when taking the dizzy patient's history and with performing provocation/repositioning maneuvers when posterior-canal benign paroxysmal positional vertigo (BPPV) was suspected (91%). In contrast, strong agreement that performing the alternating cover test (21%), looking for a spontaneous nystagmus with fixation removed (42%), and performing the head-impulse test (47%) were important was considerably lower, and only 19% of PCPs were familiar with lateral-canal BPPV treatment. No specific diagnosis could be reached in substantial fractions of patients with acute (35% [25; 50%], median [inter-quartile range]) and episodic/chronic (50% [40; 65.8%]) dizziness/vertigo. Referral to specialists was higher in patients with episodic/chronic dizziness than in acutely dizzy patients (50% [20.3; 75] vs. 30% [20; 50]), with younger PCPs (aged 30-40 years) demonstrating significantly increased odds of referral to specialists (odds ratio = 2.20 [1.01-4.81], p = 0.048). Conclusion The assessment of dizzy patients takes longer than that of average patients in most primary care practices. Many dizzy patients remain undiagnosed even after a thorough examination, highlighting the challenges faced by PCPs and potentially leading to frequent referrals to specialists. To address this, it is crucial to promote state-of-the-art neuro-otological examination and treatment techniques that are currently neglected by most PCPs, such as "HINTS" and lateral-canal BPPV treatment. This can help reduce referral rates allowing more targeted treatment and referrals.
Collapse
Affiliation(s)
- Andreas Zwergal
- German Center for Vertigo and Balance Disorders (DSGZ), Ludwig Maximilian University Hospital, Munich, Germany
- Department of Neurology, Ludwig Maximilian University Hospital, Munich, Germany
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dierik Heg
- Clinical Trial Unit Bern, University of Bern, Bern, Switzerland
| | - Hassen Kerkeni
- Department of Neurology, Lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Suzie Diener
- Practice Neurology St. Gallen, St. Galen, Switzerland
| | - Roger Kalla
- Department of Neurology, Lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, Lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Claudia Candreia
- Department of Otorhinolaryngology, Head and Neck Surgery, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Antje Welge-Lüssen
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Basel, Basel, Switzerland
| | - Alexander A. Tarnutzer
- Neurology, Cantonal Hospital of Baden, Baden, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| |
Collapse
|
11
|
Tarnutzer AA, Edlow JA. Bedside Testing in Acute Vestibular Syndrome-Evaluating HINTS Plus and Beyond-A Critical Review. Audiol Res 2023; 13:670-685. [PMID: 37736940 PMCID: PMC10514811 DOI: 10.3390/audiolres13050059] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 08/16/2023] [Accepted: 08/28/2023] [Indexed: 09/23/2023] Open
Abstract
Acute vertigo and dizziness are frequent presenting symptoms in patients in the emergency department. These symptoms, which can be subtle and transient, present diagnostic challenges because they can be caused by a broad range of conditions that cut across many specialties and organ systems. Previous work has emphasized the value of combining structured history taking and a targeted examination focusing on subtle oculomotor signs. In this review, we discuss various diagnostic bedside algorithms proposed for the acutely dizzy patient. We analyzed these different approaches by calculating their area-under-the-curve (ROC) characteristics and sensitivity/specificity. We found that the algorithms that incorporated structured history taking and the use of subtle oculomotor signs had the highest diagnostic accuracy. In fact, both the HINTS+ bedside exam and the STANDING algorithm can more accurately diagnose acute strokes than early (<24 to 48 h after symptom onset) MRI with diffusion-weighted imaging (DWI). An important caveat is that HINTS and STANDING require moderate training to achieve this accuracy. Therefore, for physicians who have not undergone adequate training, other approaches are needed. These other approaches (e.g., ABCD2 score, PCI score, and TriAGe+ score) rely on vascular risk factors, clinical symptoms, and focal neurologic findings. While these other scores are easier for frontline providers to use, their diagnostic accuracy is far lower than HINTS+ or STANDING. Therefore, a focus on providing dedicated training in HINTS+ or STANDING techniques to frontline clinicians will be key to improving diagnostic accuracy and avoiding unnecessary brain imaging.
Collapse
Affiliation(s)
- Alexander A. Tarnutzer
- Department of Neurology, Cantonal Hospital of Baden, 5404 Baden, Switzerland
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
| | - Jonathan A. Edlow
- Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA;
- Emergency Medicine, Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
12
|
Mirabelli AG, Dick R, Infeld B, Gerraty RP. Acute vestibular neuritis may provoke atrial fibrillation. Intern Med J 2023; 53:1429-1434. [PMID: 35607774 DOI: 10.1111/imj.15826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/17/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Exclusion of stroke is the focus of guidelines in the emergency department assessment of acute vertigo, especially with new-onset atrial fibrillation (AF). Early diagnosis of vestibular neuritis (VN) is also important but may be deferred awaiting brain magnetic resonance imaging (MRI) for exclusion of stroke. This may delay potentially beneficial corticosteroid therapy. AIMS To highlight that VN can provoke acute AF. METHODS In the course of a prospective study of acute vertigo in patients assessable within 24 h of admission, we encountered three patients with acute onset transient AF associated with VN. We performed a detailed neurological examination and quantitated the vestibulo-ocular reflex (VOR) gain with video-oculography. Brain MRI was performed in all patients. RESULTS There were two men and one woman, aged 58-66 (mean 61) years. All patients had typical non-direction-changing rotatory nystagmus and positive head impulse tests. The horizontal VOR gains ranged 0.38-0.62 (mean 0.47). Diffusion-weighted MRI within 36 h was normal in all. AF reverted in all three within 24 h. CONCLUSIONS Acute AF can be precipitated by vertigo such as in VN. In VN, the concurrence of acute AF may distract from the correct neurological diagnosis, delaying potentially beneficial corticosteroid therapy, especially if exclusion of stroke is dependent on MRI, which may be delayed.
Collapse
Affiliation(s)
- Adam G Mirabelli
- Epworth Clinical School, Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Ronald Dick
- Cardiac Services Clinical Institute, Epworth HealthCare, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Bernard Infeld
- Cardiac Services Clinical Institute, Epworth HealthCare, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Neurosciences Clinical Institute, Epworth HealthCare, Melbourne, Victoria, Australia
| | - Richard P Gerraty
- Cardiac Services Clinical Institute, Epworth HealthCare, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Neurosciences Clinical Institute, Epworth HealthCare, Melbourne, Victoria, Australia
| |
Collapse
|
13
|
Wettstein VG, Feil B, Mono ML. Case report: A disconjugate pattern in video head impulse testing hints toward a central cause of acute vertigo. Front Neurol 2023; 14:1222475. [PMID: 37576019 PMCID: PMC10415030 DOI: 10.3389/fneur.2023.1222475] [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: 05/14/2023] [Accepted: 06/29/2023] [Indexed: 08/15/2023] Open
Abstract
When acute vertigo occurs, the challenge for the medical practitioner lies in the focused assessment to find the cause of its symptoms. Especially in the case of central pathology, a fast diagnosis is essential for therapy. The head impulse, nystagmus, test of skew (HINTS) protocol and the additional video head impulse test (VHIT) can distinguish between central and peripheral vestibular causes in the acute setting and thus help to set the right path for further evaluation and treatment. In this case, a patient with acute onset of vertigo presented with an unusual pattern in the VHIT. Binocular eye tracking showed a disconjugate horizontal vestibulo-ocular reflex (VOR) with severe loss or gain for the adducting eye yet with a lack of corrective saccades. The abducting eye produced a pattern of mild VOR gain loss yet with pronounced corrective saccades. Together with clinical findings that were compatible with internuclear ophthalmoplegia, a probable central lesion in the medial longitudinal fasciculus (MLF) region was suspected. The patient was sent to a tertiary hospital, where the initial MRI was negative, but due to additional neurological symptoms occurring later, multiple lesions in the cervical spine and cerebellum were detected. The hypothesis of an inflammatory demyelinating disease of the central nervous system (CNS) was made. A further workup led to the final diagnosis of neurosarcoidosis. In a retrospective neuroradiologic assessment, an alteration compatible with a non-active demyelinating lesion in the MLF was detected on secondary imaging as a probable cause of the initial pathophysiologic finding. In this report, we aimed to highlight the unusual case of a disconjugate VOR as a distinctive VHIT pattern hinting toward a central cause of acute vertigo that clinicians should be aware of.
Collapse
Affiliation(s)
| | - Bertram Feil
- Department of Radiology, Stadtspital Zürich Triemli, Zurich, Switzerland
| | - Marie-Luise Mono
- Department of Neurology, Stadtspital Zürich Triemli, Zurich, Switzerland
| |
Collapse
|
14
|
Busch JM, Arnold I, Karakoumis J, Winkel DJ, Segeroth M, Nickel CH, Bingisser R. Emergency Presentations for Dizziness-Radiological Findings, Final Diagnoses, and Mortality. Int J Clin Pract 2023; 2023:7450009. [PMID: 37383705 PMCID: PMC10299881 DOI: 10.1155/2023/7450009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/14/2023] [Accepted: 05/02/2023] [Indexed: 06/30/2023] Open
Abstract
Background Dizziness is a frequent presentation in patients presenting to emergency departments (EDs), often triggering extensive work-up, including neuroimaging. Therefore, gathering knowledge on final diagnoses and outcomes is important. We aimed to describe the incidence of dizziness as primary or secondary complaint, to list final diagnoses, and to determine the use and yield of neuroimaging and outcomes in these patients. Methods Secondary analysis of two observational cohort studies, including all patients presenting to the ED of the University Hospital of Basel from 30th January 2017-19th February 2017 and from 18th March 2019-20th May 2019. Baseline demographics, Emergency Severity Index (ESI), hospitalization, admission to Intensive Care Units (ICUs), and mortality were extracted from the electronic health record database. At presentation, patients underwent a structured interview about their symptoms, defining their primary and secondary complaints. Neuroimaging results were obtained from the picture archiving and communication system (PACS). Patients were categorized into three non-overlapping groups: dizziness as primary complaint, dizziness as secondary complaint, and absence of dizziness. Results Of 10076 presentations, 232 (2.3%) indicated dizziness as their primary and 984 (9.8%) as their secondary complaint. In dizziness as primary complaint, the three (out of 73 main conditions defined) main diagnoses were nonspecific dizziness (47, 20.3%), dysfunction of the peripheral vestibular system (37, 15.9%), as well as somatization, depression, and anxiety (20, 8.6%). 104 of 232 patients (44.8%) underwent neuroimaging, with relevant findings in 5 (4.8%). In dizziness as primary complaint 30-day mortality was 0%. Conclusion Work-up for dizziness in emergency presentations has to consider a broad differential diagnosis, but due to the low yield, it should include neuroimaging only in few and selected cases, particularly with additional neurological abnormalities. Presentation with primary dizziness carries a generally favorable prognosis lacking short-term mortality. .
Collapse
Affiliation(s)
| | - Isabelle Arnold
- Emergency Department, University Hospital Basel, Basel, Switzerland
| | - Julia Karakoumis
- Emergency Department, University Hospital Basel, Basel, Switzerland
| | - David J. Winkel
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Martin Segeroth
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | | | - Roland Bingisser
- Emergency Department, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
15
|
Du EHY, Tenenbaum MN, Bhadelia RA, Sotman TE, Edlow JA, Selim MH, Chang YM. Major radiological outcomes of CTA head and neck performed for dizziness in a major academic Emergency Department. Neuroradiol J 2023; 36:259-266. [PMID: 36045600 PMCID: PMC10268097 DOI: 10.1177/19714009221124304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose: Routine head and neck CTAs (CTAhead+neck) performed for dizziness in the Emergency Department (ED) has steadily increased, but its clinical utility is still poorly elucidated. Our purpose was to assess the radiologic outcomes of CTAhead+neck in ED dizziness patients.Methods: ED dizziness patients with CTAhead+neck from January 2010 through November 2019 were retrospectively identified and further stratified into central vertigo (CV), peripheral vertigo (PV), and non-specific dizziness (NSD) groups by final clinical diagnoses. Findings on CTAhead+neck (vessel stenosis >50%, occlusion, dissection, and infarct), and infarct on subsequent MRI if performed, were assessed. Differences in imaging findings were analyzed using chi-square or Fisher's exact tests.Results: Of 867 dizziness patients, 88 were diagnosed with CV, 383 with PV, and 396 with NSD. On CTAhead+neck, 11.4% of all patients had posterior CTA findings, including posterior occlusions (4.2%), dissections (1.2%), and infarcts (2.3%). CV patients had more posterior circulation findings (31.8%) versus PV (9.9%) and NSD (8.3%) patients (both p < 0.01). 21.6% of CV patients had acute infarcts on CT versus none for PV and 0.03% for NSD patients (both p < 0.01). On MRI, 46.6% of CV patients had acute posterior circulation infarcts versus none for PV and 0.3% for NSD patients (p < 0.01).Conclusion: Diagnostic yield for CTAhead+neck for dizziness patients is low except in central vertigo patients which constitute only 1/10th of CTAs performed. Our single institution results support that CTAhead+neck is likely low-yield in patients with high clinical suspicion for PV or NSD and further studies are needed to test this hypothesis.
Collapse
Affiliation(s)
- Elizabeth HY Du
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mary N Tenenbaum
- Department of Radiology, Baystate Medical Center, Springfield, MA, USA
| | - Rafeeque A Bhadelia
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Timothy E Sotman
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Magdy H Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Yu-Ming Chang
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| |
Collapse
|
16
|
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: 28] [Impact Index Per Article: 28.0] [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").
Collapse
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
| |
Collapse
|
17
|
Kaski D, Koohi N, Haider S, Chandratheva A, Simister R. The hyperacute vestibular syndrome: ear or brain? Lancet Neurol 2023; 22:377-378. [PMID: 37059503 DOI: 10.1016/s1474-4422(23)00115-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/15/2023] [Accepted: 03/15/2023] [Indexed: 04/16/2023]
Affiliation(s)
- Diego Kaski
- Department of Clinical and Movement Neurosciences, University College London, London WC1N 3BG, UK; UK Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, London, UK.
| | - Nehzat Koohi
- Department of Clinical and Movement Neurosciences, University College London, London WC1N 3BG, UK; UK Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, London, UK
| | - Salman Haider
- UK Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, London, UK
| | - Arvind Chandratheva
- UK Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, London, UK
| | - Robert Simister
- Department of Brain Repair and Rehabilitation, University College London, London WC1N 3BG, UK; Stroke Research Centre, Institute of Neurology, University College London, London WC1N 3BG, UK; UK Comprehensive Stroke Service, National Hospital for Neurology and Neurosurgery, London, UK
| |
Collapse
|
18
|
Lin G, Liu F, Xu H, Bao G. Development of a model to predict the risk of cerebral infarction in acute vestibular syndrome. Heliyon 2023; 9:e14852. [PMID: 37095950 PMCID: PMC10121405 DOI: 10.1016/j.heliyon.2023.e14852] [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: 10/13/2022] [Revised: 03/06/2023] [Accepted: 03/20/2023] [Indexed: 04/26/2023] Open
Abstract
Objectives This study aimed to develop a model to predict the risk of cerebral infarction in acute vestibular syndrome and assist emergency physicians in quickly identifying patients with cerebral infarction. Materials and methods We looked at 262 patients who were split into cerebral infarction and peripheral vertigo groups. Stepwise regression and Lasso's approach were used to screen for variables, and Boothstrap's method was used to evaluate the model's discrimination and calibration. The model's performance was compared against TriAGe+, ABCD2, and PCI scores using the area under the receiver operator characteristic curve. Clinical decision-making was aided by the use of clinical impact and decision curves. Results In the end, nine risk factors were chosen for model 2, and ten risk factors were chosen for model 1. Model 2 was adopted as the final model. The areas under the receiver operator curve value of the model2 were 0.910(P = 0.000), much higher than the areas under the receiver operator curve value of the TriAGe + scores system and that of the PCI scores system. The clinical decision curve shows that when the threshold probability is 0.05, using the nomogram to predict cerebral infarction has more benefits than either the treat-all-patients scheme or the treat-none scheme. The clinical impact curve shows that when the threshold probability is 0.6 the model predicts disease occurrence in general agreement with the occurrence of the real disease. Conclusion This study model can help emergency room physicians quickly triage and treat patients by accurately identifying cerebral infarction patients.
Collapse
Affiliation(s)
- Guiming Lin
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Mohe Road280, Baoshan District, Shanghai, China
| | - Fangfang Liu
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Mohe Road280, Baoshan District, Shanghai, China
| | - Hengshi Xu
- Department of Blood Transfusion, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Mohe Road280, Baoshan District, Shanghai, China
- Corresponding author. Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Mohe Road280, Baoshan District, Shanghai, China.
| | - Guanshui Bao
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Mohe Road280, Baoshan District, Shanghai, China
- Corresponding author. Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Mohe Road280, Baoshan District, Shanghai, China.
| |
Collapse
|
19
|
Comolli L, Korda A, Zamaro E, Wagner F, Sauter TC, Caversaccio MD, Nikles F, Jung S, Mantokoudis G. Vestibular syndromes, diagnosis and diagnostic errors in patients with dizziness presenting to the emergency department: a cross-sectional study. BMJ Open 2023; 13:e064057. [PMID: 36963793 PMCID: PMC10040076 DOI: 10.1136/bmjopen-2022-064057] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 03/14/2023] [Indexed: 03/26/2023] Open
Abstract
OBJECTIVES We aimed to determine the frequency of vestibular syndromes, diagnoses, diagnostic errors and resources used in patients with dizziness in the emergency department (ED). DESIGN Retrospective cross-sectional study. SETTING Tertiary referral hospital. PARTICIPANTS Adult patients presenting with dizziness. PRIMARY AND SECONDARY OUTCOME MEASURES We collected clinical data from the initial ED report from July 2015 to August 2020 and compared them with the follow-up report if available. We calculated the prevalence of vestibular syndromes and stroke prevalence in patients with dizziness. Vestibular syndromes are differentiated in acute (AVS) (eg, stroke, vestibular neuritis), episodic (EVS) (eg, benign paroxysmal positional vertigo, transient ischaemic attack) and chronic (CVS) (eg, persistent postural-perceptual dizziness) vestibular syndrome. We reported the rate of diagnostic errors using the follow-up diagnosis as the reference standard. RESULTS We included 1535 patients with dizziness. 19.7% (303) of the patients presented with AVS, 34.7% (533) with EVS, 4.6% (71) with CVS and 40.9% (628) with no or unclassifiable vestibular syndrome. The three most frequent diagnoses were stroke/minor stroke (10.1%, 155), benign paroxysmal positional vertigo (9.8%, 150) and vestibular neuritis (9.6%, 148). Among patients with AVS, 25.4% (77) had stroke. The cause of the dizziness remained unknown in 45.0% (692) and 18.0% received a false diagnosis. There was a follow-up in 662 cases (43.1%) and 58.2% with an initially unknown diagnoses received a final diagnosis. Overall, 69.9% of all 1535 patients with dizziness received neuroimaging (MRI 58.2%, CT 11.6%) in the ED. CONCLUSIONS One-fourth of patients with dizziness in the ED presented with AVS with a high prevalence (10%) of vestibular strokes. EVS was more frequent; however, the rate of undiagnosed patients with dizziness and the number of patients receiving neuroimaging were high. Almost half of them still remained without diagnosis and among those diagnosed were often misclassified. Many unclear cases of vertigo could be diagnostically clarified after a follow-up visit.
Collapse
Affiliation(s)
- Lukas Comolli
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Ewa Zamaro
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Franca Wagner
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marco D Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Florence Nikles
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| |
Collapse
|
20
|
Fattal D, Platti N. Ocular lateral deviation as a vestibular sign to improve detection of posterior circulation strokes: A review of the literature. J Emerg Med 2023; 64:610-619. [PMID: 37037761 DOI: 10.1016/j.jemermed.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 01/28/2023] [Accepted: 02/17/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Posterior circulation stroke can present with dizziness/vertigo without other general neurological symptoms or signs, making it difficult to detect, and missed stroke can deteriorate. Therefore, a sign that can be easily identified during an examination would be helpful to improve the detection of this type of stroke. OBJECTIVE The objective of this review is to highlight an ocular sign that is seen in posterior circulation strokes called ocular lateral deviation (OLD). OLD is mostly seen in dorsolateral medullary strokes, and it is also seen in pontine and cerebellar strokes. OLD is detected by asking a patient to look straight ahead and then briefly close their eyes. Upon re-opening their eyes, the examiner will see that the eyes have deviated to one side; the patient's eyes will then make corrective saccade(s) to return to looking straight ahead. Complete eye deviation is a central sign of posterior circulation stroke. DISCUSSION OLD is an under-recognized vestibular ocular sign of central vestibulopathies including posterior circulation stroke. The most common location is in the dorsolateral medulla, where one-third of such strokes have complete OLD. Eye deviation can also be appreciated on computed tomography or magnetic resonance imaging. OLD can be detected up to 6 months after a posterior circulation stroke. CONCLUSIONS Checking for the sign of complete eye deviation in patients with dizziness/vertigo could be a simple, quick method for detecting posterior circulation stroke, and a means to improving the patients' outcome.
Collapse
Affiliation(s)
- Deema Fattal
- Neurology Department, University of Iowa Health Care, Iowa City, Iowa; Iowa City VA Medical Center, Iowa City, Iowa
| | - Nicole Platti
- University of Iowa Carver College of Medicine, Iowa City, Iowa; (Present Institution) Neurology Department, University of South Florida, Tampa, Florida
| |
Collapse
|
21
|
Picciotti PM, Anzivino R, Galli J, Franceschi F, Conti G, Simeoni B, Covino M. Clinical Evolution of Acute Vestibular Syndrome: Longitudinal Retrospective Analysis of Epidemiological Data and Prognostic Factors for Recovery. J Pers Med 2023; 13:jpm13030407. [PMID: 36983588 PMCID: PMC10059062 DOI: 10.3390/jpm13030407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/23/2023] [Accepted: 02/23/2023] [Indexed: 03/03/2023] Open
Abstract
We evaluated the clinical features of patients admitted to the ED with acute vertigo, verifying symptoms after one month and one year to establish epidemiological factors and predictors of resolution. We reviewed 233 records of patients admitted to ED for acute vertigo (125 F and 85 M, mean age 56.12 years). We analyzed the correlation between time of resolution (at one month and one year) and symptoms duration (subjective and/or objective vertigo, instability, cervical pain, audiological, neurological, and neurovegetative symptoms), comorbidities, and therapies, the result of the clinical and instrumental vestibular examination. Resolution of acute vertigo occurred in 81.1%, while persistence of vertigo one year after ED access was reported in 18.8%. There were 135 patients who recovered in one month. The presence of instability, auditory and neurovegetative symptoms, and neck pain represents a significant factor for recovery within one year. Age over 65 and a history of hypertension are associated with a worst recovery. Patients with spontaneous Nystagmus or positive HIT showed a significant difference in symptoms recovery within one month and one year. Presence of positional Nystagmus represents a positive prognostic factor. Our findings emphasize the importance of clinical evaluation of the acute vertigo, helping the clinicians to define central or peripheral diagnosis and predict the resolution of vertigo.
Collapse
Affiliation(s)
- Pasqualina M. Picciotti
- Department of Head and Neck, Otolaryngology Institute, Fondazione Policlinico Universitario A. Gemelli IRCCS Università Cattolica del Sacro Cuore, 00168 Rome, Italy
- Correspondence:
| | - Roberta Anzivino
- Otolaryngology Unit, Sensorineural Department, Di Venere Hospital, ASL BARI, 70131 Bari, Italy
| | - Jacopo Galli
- Department of Head and Neck, Otolaryngology Institute, Fondazione Policlinico Universitario A. Gemelli IRCCS Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Francesco Franceschi
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Guido Conti
- Department of Head and Neck, Otolaryngology Institute, Fondazione Policlinico Universitario A. Gemelli IRCCS Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Benedetta Simeoni
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Marcello Covino
- Department of Emergency Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| |
Collapse
|
22
|
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.
Collapse
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.
| |
Collapse
|
23
|
Getz DR, Mangalampalli A, Klopfenstein J, Tsung AJ, Kattah JC. Role of bedside video-oculography in selecting neuroimaging in patients with acute vertigo and ataxia posterior fossa mass lesions. J Neurol Sci 2023; 444:120513. [PMID: 36502577 DOI: 10.1016/j.jns.2022.120513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/06/2022] [Accepted: 11/26/2022] [Indexed: 12/04/2022]
Affiliation(s)
- Daniel R Getz
- Department of Neurology, University of Illinois College of Medicine and the Illinois Neurologic Institute Peoria, IL, United States of America
| | - Anusha Mangalampalli
- Department of Neurology, University of Illinois College of Medicine and the Illinois Neurologic Institute Peoria, IL, United States of America
| | - Jeffrey Klopfenstein
- Department of Neurosurgery, University of Illinois College of Medicine and the Illinois Neurologic Institute Peoria, IL, United States of America
| | - Andrew J Tsung
- Department of Neurosurgery, University of Illinois College of Medicine and the Illinois Neurologic Institute Peoria, IL, United States of America
| | - Jorge C Kattah
- Department of Neurology, University of Illinois College of Medicine and the Illinois Neurologic Institute Peoria, IL, United States of America; Department of Neurosurgery, University of Illinois College of Medicine and the Illinois Neurologic Institute Peoria, IL, United States of America.
| |
Collapse
|
24
|
Gerlier C, Fels A, Vitaux H, Mousset C, Perugini A, Chatellier G, Ganansia O. Effectiveness and reliability of the four-step STANDING algorithm performed by interns and senior emergency physicians for predicting central causes of vertigo. Acad Emerg Med 2023; 30:487-500. [PMID: 36628557 DOI: 10.1111/acem.14659] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Revised: 12/20/2022] [Accepted: 01/06/2023] [Indexed: 01/12/2023]
Abstract
BACKGROUND For emergency physicians (EPs), acute vertigo is a challenging complaint and learning a reliable clinical approach is needed. STANDING is a four-step bedside algorithm that requires (1) identifying spontaneous nystagmus with Frenzel glasses or, alternatively, a positional nystagmus; (2) characterizing the nystagmus direction; (3) assessing the vestibuloocular reflex (head impulse test); and (4) assessing the gait. The objective was to determine its accuracy for diagnosing central vertigo when using by naïve examiners as such as interns and its agreement with senior EPs. METHODS This was a prospective 1-year diagnostic cohort study among patients with vertigo, vestibulovisual symptoms, or postural symptoms seen by 20 interns trained in the four-step examination. The algorithm was performed first by an intern and second by a senior EP and categorized as either worrisome when indicating a central diagnosis and benign or inconclusive when indicating a peripheral diagnosis. The reference test was diffusion-weighted brain magnetic resonance imaging. RESULTS Among 312 patients included, 57 had a central diagnosis including 33 ischemic strokes (10.5%). The main etiology was benign paroxysmal positional vertigo (32.7%). The likelihood ratios were 4.63 and 10.33 for a worrisome STANDING, 0.09 and 0.01 for a benign STANDING, and 0.21 and 0.35 for an inconclusive STANDING, for interns and senior EPs, respectively. The algorithm showed sensitivities of 84.8% (95% CI 75.6%-93.9%) and 89.8% (95% CI 82.1%-97.5%), negative predictive values of 96.2% (95% CI 93.7%-98.6%) and 97.5% (95% CI 95.5%-99.5%), specificities of 88.9% (95% CI 85.1%-92.8%) and 91.3% (95% CI 87.8%-94.8%), and positive predictive values of 64.1% (95% CI 53.5%-74.8%) and 70.7% (95% CI 60.4%-81.0%), respectively. The agreement between interns and senior EPs was very substantial (B-statistic coefficient: 0.77) and almost perfect for each step: (1) 0.87, (2) 0.98, (3) 0.95, and (4) 0.99. CONCLUSIONS With a single training session, the algorithm reached high accuracy and reliability for ruling out central causes of vertigo in the hands of both novices and experienced EPs. A future multicenter randomized controlled trial should further its impact on unnecessary neuroimaging use and patient's satisfaction.
Collapse
Affiliation(s)
- Camille Gerlier
- Department of Emergency, Paris Saint Joseph Hospital Group, Paris, France
| | - Audrey Fels
- Department of Clinical Research, Paris Saint Joseph Hospital Group, Paris, France
| | - Hélène Vitaux
- Department of Otolaryngology, Paris Saint Joseph Hospital Group, Paris, France
| | - Carole Mousset
- Department of Otolaryngology, Paris Saint Joseph Hospital Group, Paris, France
| | - Alberto Perugini
- Department of Emergency, Paris Saint Joseph Hospital Group, Paris, France
| | - Gilles Chatellier
- Department of Clinical Research, Paris Saint Joseph Hospital Group, Paris, France.,University of Paris-Cité, Paris, France
| | - Olivier Ganansia
- Department of Emergency, Paris Saint Joseph Hospital Group, Paris, France
| |
Collapse
|
25
|
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.
Collapse
|
26
|
Fracica E, Hale D, Gold DR. Diagnosing and localizing the acute vestibular syndrome - Beyond the HINTS exam. J Neurol Sci 2022; 442:120451. [PMID: 36270149 DOI: 10.1016/j.jns.2022.120451] [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: 06/20/2022] [Revised: 09/11/2022] [Accepted: 10/02/2022] [Indexed: 10/31/2022]
Abstract
When assessing the acutely dizzy patient, the HINTS 'Plus' (Head Impulse, Nystagmus, Test of Skew, 'Plus' a bedside assessment of auditory function) exam is a crucial component of the bedside exam. However, there are additional ocular motor findings that can help the clinician distinguish peripheral from central etiologies and enable accurate localization, especially when the patient has acute dizziness, vertigo and/or imbalance but without spontaneous nystagmus. We will review the literature on these findings which are 'beyond HINTS' and include saccades/ocular lateropulsion, smooth pursuit, and provocative maneuvers including head-shaking and positional testing (not part of the HINTS exam). Additionally, we will expound on the localizing value of nystagmus, ocular alignment and the ocular tilt reaction (parts of the HINTS exam). The paper has been organized neuroanatomically, based on brainstem and cerebellar structures that have been reported to cause the acute vestibular syndrome.
Collapse
Affiliation(s)
- Elizabeth Fracica
- The Johns Hopkins Hospital, Department of Neurology, United States of America.
| | - David Hale
- The Johns Hopkins Hospital, Department of Neurology, United States of America
| | - Daniel R Gold
- The Johns Hopkins Hospital, Department of Neurology, United States of America; The Johns Hopkins Hospital, Department of Neurology, Division of Neuro-Visual & Vestibular Disorders, United States of America
| |
Collapse
|
27
|
Qiu T, Dai X, Xu X, Zhang G, Huang L, Gong Q. A prospective study on the application of HINTS in distinguishing the localization of acute vestibular syndrome. BMC Neurol 2022; 22:378. [PMID: 36199036 PMCID: PMC9533484 DOI: 10.1186/s12883-022-02904-x] [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: 07/06/2022] [Accepted: 09/26/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute vestibular syndrome (AVS) is a common clinical syndrome in neurology clinics and emergency department. Canonical standard for AVS diagnosis requires the presence of persistent vertigo for more than 24 h. HINTS (head impulse-nystagmus-test of skew) is an emerging scheme in the diagnosis of AVS. In this prospective study, we evaluated the specificity and sensitivity of HINTS in distinguishing between central and peripheral AVS. METHODS A cohort of 239 cases with complete clinical record was recruited in the study. All patients completed emergency brain CT examination to exclude hemorrhagic stroke. HINTS examination was conducted to distinguish between central AVS and peripheral AVS, and all patients completed head MRI, BAEP and vestibular function examinations within one week. Patients diagnosed as central AVS were subject to angiography (CTA/MRA/DSA), and patients with peripheral AVS were considered for a 3-month follow-up to correct the initial diagnosis. RESULTS Patients with central AVS were associated with an elder age, higher incidences of hypertension, atrial fibrillation, family history of stroke and previous history of stroke. Posterior circulation cerebral infarction, vestibular migraine and cerebellitis were the dominant diseases associated with central AVS. The sensitivities of HIT, GE, and TS in the diagnosis of central AVS were 73.5%, 61.2%, and 26.5%, and the specificities were 97.9%, 92.6%, and 93.2% respectively. CONCLUSIONS The sensitivity of HINTS for central AVS diagnosis is 89.8% and the specificity is 84.2%. HINTS is an easy-to-operate, low-cost, high-sensitivity and specific examination technique, which is practical in neurology outpatient clinics and emergency departments.
Collapse
Affiliation(s)
- Tao Qiu
- Department of Neurology, Zigong First People's Hospital, No. 42, shangyihao 1st branch road, Ziliujing, Zigong, 643000, Sichuan, China
| | - Xiaoyan Dai
- Outpatient department, Zigong First People's Hospital, No. 42, Shangyihao 1st Branch Road, Ziliujing District, Zigong, 643000, Sichuan, China
| | - Xiaoya Xu
- Department of Neurology, Zigong First People's Hospital, No. 42, shangyihao 1st branch road, Ziliujing, Zigong, 643000, Sichuan, China
| | - Guiqin Zhang
- Department of Neurology, Zigong First People's Hospital, No. 42, shangyihao 1st branch road, Ziliujing, Zigong, 643000, Sichuan, China
| | - Linming Huang
- Department of Neurology, Zigong First People's Hospital, No. 42, shangyihao 1st branch road, Ziliujing, Zigong, 643000, Sichuan, China
| | - Qingping Gong
- Department of Neurology, Zigong First People's Hospital, No. 42, shangyihao 1st branch road, Ziliujing, Zigong, 643000, Sichuan, China.
| |
Collapse
|
28
|
Wang W, Ji J, Wang C, Wang Y. Topography and etiologies of cerebellar infarcts presenting as isolated acute vestibular syndrome. Neurol Sci 2022; 43:5969-5976. [DOI: 10.1007/s10072-022-06249-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 06/28/2022] [Indexed: 11/28/2022]
|
29
|
Viola P, Gioacchini FM, Astorina A, Pisani D, Scarpa A, Marcianò G, Casarella A, Basile E, Rania V, Re M, Chiarella G. The pharmacological treatment of acute vestibular syndrome. Front Neurol 2022; 13:999112. [PMID: 36158968 PMCID: PMC9500199 DOI: 10.3389/fneur.2022.999112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 08/17/2022] [Indexed: 11/21/2022] Open
Abstract
Acute vestibular syndrome (AVS) represents a clinical picture that involves urgent management due to the important procession of symptoms accompanying the event, which can be positively or negatively influenced by therapeutic choices and intervention timing. This forces a differential diagnosis and therapeutic choices to be made in conditions that are not always favorable and often not in the specialist field. In this work, we will examine in detail the pharmacological therapeutic possibilities, correlating them to the differential and, as far as possible, to the etiological diagnosis. In particular, the pharmacological possibilities for the two main conditions we can face will be investigated, namely, vestibular neuritis and posterior circulation stroke.
Collapse
Affiliation(s)
- Pasquale Viola
- Unit of Audiology, Department of Experimental and Clinical Medicine, Regional Centre of Cochlear Implants and ENT Diseases, Magna Graecia University, Catanzaro, Italy
| | - Federico Maria Gioacchini
- ENT Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Alessia Astorina
- Unit of Audiology, Department of Experimental and Clinical Medicine, Regional Centre of Cochlear Implants and ENT Diseases, Magna Graecia University, Catanzaro, Italy
| | - Davide Pisani
- Unit of Audiology, Department of Experimental and Clinical Medicine, Regional Centre of Cochlear Implants and ENT Diseases, Magna Graecia University, Catanzaro, Italy
| | - Alfonso Scarpa
- Department of Medicine and Surgery, University of Salerno, Salerno, Italy
- *Correspondence: Alfonso Scarpa
| | - Gianmarco Marcianò
- Department of Health Science, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Alessandro Casarella
- Department of Health Science, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Emanuele Basile
- Department of Health Science, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Vincenzo Rania
- Department of Health Science, School of Medicine, University “Magna Graecia” of Catanzaro, Catanzaro, Italy
| | - Massimo Re
- ENT Unit, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
| | - Giuseppe Chiarella
- Unit of Audiology, Department of Experimental and Clinical Medicine, Regional Centre of Cochlear Implants and ENT Diseases, Magna Graecia University, Catanzaro, Italy
| |
Collapse
|
30
|
Korda A, Wimmer W, Wyss T, Michailidou E, Zamaro E, Wagner F, Caversaccio MD, Mantokoudis G. Artificial intelligence for early stroke diagnosis in acute vestibular syndrome. Front Neurol 2022; 13:919777. [PMID: 36158956 PMCID: PMC9492879 DOI: 10.3389/fneur.2022.919777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/15/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Measuring the Vestibular-Ocular-Reflex (VOR) gains with the video head impulse test (vHIT) allows for accurate discrimination between peripheral and central causes of acute vestibular syndrome (AVS). In this study, we sought to investigate whether the accuracy of artificial intelligence (AI) based vestibular stroke classification applied in unprocessed vHIT data is comparable to VOR gain classification. Methods We performed a prospective study from July 2015 until April 2020 on all patients presenting at the emergency department (ED) with signs of an AVS. The patients underwent vHIT followed by a delayed MRI, which served as a gold standard for stroke confirmation. The MRI ground truth labels were then applied to train a recurrent neural network (long short-term memory architecture) that used eye- and head velocity time series extracted from the vHIT examinations. Results We assessed 57 AVS patients, 39 acute unilateral vestibulopathy patients (AUVP) and 18 stroke patients. The overall sensitivity, specificity and accuracy for detecting stroke with a VOR gain cut-off of 0.57 was 88.8, 92.3, and 91.2%, respectively. The trained neural network was able to classify strokes with a sensitivity of 87.7%, a specificity of 88.4%, and an accuracy of 87.9% based on the unprocessed vHIT data. The accuracy of these two methods was not significantly different (p = 0.09). Conclusion AI can accurately diagnose a vestibular stroke by using unprocessed vHIT time series. The quantification of eye- and head movements with the use of machine learning and AI can serve in the future for an automated diagnosis in ED patients with acute dizziness. The application of different neural network architectures can potentially further improve performance and enable direct inference from raw video recordings.
Collapse
Affiliation(s)
- Athanasia Korda
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Wilhelm Wimmer
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- Hearing Research Laboratory, ARTORG Center, University of Bern, Bern, Switzerland
| | - Thomas Wyss
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Efterpi Michailidou
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Ewa Zamaro
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Franca Wagner
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marco D. Caversaccio
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- *Correspondence: Georgios Mantokoudis
| |
Collapse
|
31
|
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.
Collapse
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
| |
Collapse
|
32
|
Shah VP, Oliveira J E Silva L, Farah W, Seisa M, Kara Balla A, Christensen A, Farah M, Hasan B, Bellolio F, Murad MH. Diagnostic accuracy of neuroimaging in emergency department patients with acute vertigo or dizziness: A systematic review and meta-analysis for the Guidelines for Reasonable and Appropriate Care in the Emergency Department. Acad Emerg Med 2022; 30:517-530. [PMID: 35876220 DOI: 10.1111/acem.14561] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/02/2022] [Accepted: 07/06/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Patients presenting to the emergency department (ED) with acute vertigo or dizziness represent a diagnostic challenge. Neuroimaging has variable indications and yield. We aimed to conduct a systematic review and meta-analysis of the diagnostic test accuracy of neuroimaging for patients presenting with acute vertigo or dizziness. METHODS An electronic search was designed following patient-intervention-control-outcome (PICO) question, (P) adult patients with acute vertigo or dizziness presenting to the ED; (I) Neuroimaging including Computed tomography (CT), CT Angiogram (CTA), Magnetic Resonance Imaging (MRI), Magnetic Resonance Angiogram (MRA), and Ultrasound (US); (C) MRI/clinical gold standard; (O) central causes (stroke, hemorrhage, tumor, others) versus peripheral causes of symptoms. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) was used to assess certainty of evidence in pooled estimates. RESULTS We included studies that reported diagnostic test accuracy. Articles were assessed in duplicated. From 6,309 titles, 460 articles were retrieved, and 12 included. Non-contrast CT scan: 6 studies, 771 patients, pooled sensitivity 28.5% (95%CI 14.4-48.5%, moderate certainty) and specificity 98.9% (95%CI 93.4-99.8%, moderate certainty). MRI: 5 studies, 943 patients, sensitivity 79.8% (CI 71.4-86.2%, high certainty) and specificity 98.8% (CI 96.2-100%, high certainty). CTA: 1 study, 153 patients, sensitivity 14.3% (CI 1.8-42.8%) and specificity 97.7% (CI 93.8-99.6%). CT had higher sensitivity than CTA (21.4% and 14.3%) for central etiology. MRA: 1 study, 24 patients, sensitivity 60.0% (CI 26.2-87.8%) and specificity 92.9% (CI 66.1-99.8%). US: 3 studies, 258 patients, sensitivity ranged from 30-53.6%, specificity from 94.9-100%. CONCLUSION Non-contrast CT has very low sensitivity and MRI will miss approximately one in five patients with stroke if imaging is obtained early after symptom onset. Neuroimaging should not be used as the only tool for ruling out stroke and other central causes in patients with acute dizziness or vertigo presenting to the ED.
Collapse
Affiliation(s)
- Vishal Paresh Shah
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, United States
| | - Lucas Oliveira J E Silva
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States.,Department of Emergency Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Wigdan Farah
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, United States
| | - Mohamad Seisa
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, United States
| | - Abdalla Kara Balla
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, United States
| | - April Christensen
- Department of Medicine, Division of Community Internal Medicine, Mayo Clinic, Rochester, MN, United States
| | - Magdoleen Farah
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, United States
| | - Bashar Hasan
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, United States
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, United States
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic, Rochester, MN, United States
| |
Collapse
|
33
|
Yao Q, Li Z, Xu M, Jiang Y, Wang J, Wang H, Yu D, Yin S. The Spectrum of Vestibular Disorders Presenting With Acute Continuous Vertigo. Front Neurosci 2022; 16:933520. [PMID: 35911992 PMCID: PMC9326068 DOI: 10.3389/fnins.2022.933520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo explore the composition of vestibular disorders presenting with the acute vestibular syndrome (AVS).MethodsWe performed a case analysis of 209 AVS patients between January 2016 and December 2020. These patients were grouped into different disorder categories according to the relevant diagnostic criteria.ResultsWe classified the 209 patients into 14 disorder categories, including 110 cases of vestibular neuritis, 30 of idiopathic sudden sensorineural hearing loss with vertigo, 17 of the first attack of continuous vertigo with migraine, 15 of Ramsay Hunt syndrome, 11 of acute labyrinthitis secondary to chronic otitis media, 8 of vestibular schwannoma, 6 of posterior circulation infarction and/or ischemia, 3 of cerebellar abscess secondary to chronic otitis media, 3 of AVS caused by trauma or surgery, 2 of AVS with down-beating nystagmus, 1 of multiple sclerosis of the medulla oblongata, 1 of epidermoid cyst of the posterior cranial fossa, 1 of a probable acute otolithic lesion, and 1 of AVS without measurable vestibular dysfunction.ConclusionWhen a group of disorders present with AVS, characteristic clinical manifestations and imaging help with an accurate diagnosis.
Collapse
Affiliation(s)
- Qingxiu Yao
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
- Department of Otolaryngology, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Zhuangzhuang Li
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Maoxiang Xu
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Yumeng Jiang
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Jingjing Wang
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Hui Wang
- Department of Otorhinolaryngology, ENT Institute, Affiliated Eye and ENT Hospital, Fudan University, Shanghai, China
| | - Dongzhen Yu
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
- *Correspondence: Dongzhen Yu,
| | - Shankai Yin
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
- Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| |
Collapse
|
34
|
Kim M, Park SY, Lee SE, Lee JS, Hong JM, Lee SJ. Significance of Vertigo, Imbalance, and Other Minor Symptoms in Hyperacute Treatment of Posterior Circulation Stroke. Front Neurol 2022; 13:845707. [PMID: 35651338 PMCID: PMC9150563 DOI: 10.3389/fneur.2022.845707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 04/25/2022] [Indexed: 12/01/2022] Open
Abstract
Background This study aimed to determine the clinical significance of acute vestibular syndrome (AVS)/acute imbalance syndrome (AIS) in posterior circulation stroke (PCS) and how it should be addressed in the thrombolysis code. Methods Our institution has recently changed its thrombolysis code from one that is generous to AVS/AIS to one that is exclusive. The subjects in this study were patients with PCS who presented before this transition (May 2016 to April 2018, period 1) and those who presented after (January 2019 to December 2020, period 2) with an onset-to-door time of 4.5 h. Hyperacute stroke treatment was compared between the two periods. The clinical significance of AVS/AIS was evaluated by dichotomizing the patients' clinical severity to minor or major deficits, then evaluating the significance of AVS/AIS in each group. Presenting symptoms of decreased mental alertness, hemiparesis, aphasia (anarthria), or hemianopsia were considered major PCS symptoms, and patients who did not present with these symptoms were considered minor PCS. Results In total, 114 patients presented in period 1 and 114 in period 2. Although the code activation rate was significantly lower in period 2 (72.8% vs. 59.7%), p = 0.04, there were no between-group differences in functional outcomes (mRS score at 3 months; 1 [0–3] vs. 0 [0–3], p = 0.18). In 77 patients with PCS and AVS/AIS, the difference in code activation rate was not significant according to changes in thrombolysis code. In minor PCS, AVS/AIS was associated with lower NIHSS scores, lower early neurological deterioration rates, and favorable outcomes. In major PCS, while AVS/AIS was not associated with outcomes, the majority of cases were prodromal AVS/AIS which simple vertigo and imbalance symptoms were followed by a major PCS symptom. Conclusions This study failed to show differences in outcome in patients with PCS according to how AVS/AIS is addressed in the stroke thrombolysis code. In patients with minor PCS, AVS/AIS was associated with a benign clinical course. Prompt identification of prodromal AVS/AIS is essential.
Collapse
Affiliation(s)
- Min Kim
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - So Young Park
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - Sung Eun Lee
- Department of Emergency Medicine, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| | - Seong-Joon Lee
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, South Korea
| |
Collapse
|
35
|
Thomas JO, Sharobeam A, Venkat A, Blair C, Ozalp N, Calic Z, Wyllie P, Middleton PM, Welgampola M, Cordato D, Cappelen-Smith C. Video head impulse testing to differentiate vestibular neuritis from posterior circulation stroke in the emergency department: a prospective observational study. BMJ Neurol Open 2022; 4:e000284. [PMID: 35571585 PMCID: PMC9066478 DOI: 10.1136/bmjno-2022-000284] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 03/31/2022] [Indexed: 11/23/2022] Open
Abstract
Background and aims Vertigo is a common presentation to the emergency department (ED) with 5% of presentations due to posterior circulation stroke (PCS). Bedside investigations such as the head impulse test (HIT) are used to risk stratify patients, but interpretation is operator dependent. The video HIT (v-HIT) provides objective measurement of the vestibular-ocular-reflex (VOR) and may improve diagnostic accuracy in acute vestibular syndrome (AVS). We aimed to evaluate the use of v-HIT as an adjunct to clinical assessment to acutely differentiate vestibular neuritis (VN) from PCS. Methods 133 patients with AVS were consecutively enrolled from the ED of our comprehensive stroke centre between 2018 and 2021. Patient assessment included a targeted vestibular history, HINTs examination (Head Impulse, Nystagmus and Test of Skew), v-HIT and MRI>48 hours after symptom onset. The HINTS/v-HIT findings were analysed and compared between VN, PCS and other cause AVS. Clinical course, v-HIT and MRI findings were used to determine diagnosis. Results Final diagnosis was VN in 40%, PCS 15%, migraine 16% and other cause AVS 29%. PCS patients were older than VN patients (mean age 68.5±10.6 vs 60.1±14.2 years, p=0.14) and had more cardiovascular risk factors (3 vs 2, p=0.002). Mean VOR gain was reduced (<0.8) in ipsilateral horizontal and (<0.7) anterior canals in VN but was normal in PCS, migraine and other cause AVS. V-HIT combined with HINTs was 89% sensitive and 96% specific for a diagnosis of VN. Conclusions V-HIT combined with HINTs is a reliable tool to exclude PCS in the ED.
Collapse
Affiliation(s)
- James Orton Thomas
- Department of Neurophysiology, Liverpool Hospital, Liverpool, New South Wales, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Angelos Sharobeam
- Melbourne Brain Centre at Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Abhay Venkat
- Department of Neurology, Wollongong Hospital, Wollongong, New South Wales, Australia
| | - Christopher Blair
- Department of Neurophysiology, Liverpool Hospital, Liverpool, New South Wales, Australia
- Ingham Institute, Liverpool, New South Wales, Australia
| | - Nese Ozalp
- Department of Neurophysiology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Zeljka Calic
- Department of Neurophysiology, Liverpool Hospital, Liverpool, New South Wales, Australia
- South Western Clinical School, University of New South Wales, Liverpool, New South Wales, Australia
| | - Peter Wyllie
- Emergency Medicine, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Paul M Middleton
- South Western Clinical School, University of New South Wales, Liverpool, New South Wales, Australia
- South Western Emergency Research Institute, Liverpool, New South Wales, Australia
| | - Miriam Welgampola
- Neurology, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Dennis Cordato
- Department of Neurophysiology, Liverpool Hospital, Liverpool, New South Wales, Australia
- South Western Clinical School, University of New South Wales, Liverpool, New South Wales, Australia
| | - Cecilia Cappelen-Smith
- Department of Neurophysiology, Liverpool Hospital, Liverpool, New South Wales, Australia
- South Western Clinical School, University of New South Wales, Liverpool, New South Wales, Australia
| |
Collapse
|
36
|
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.
Collapse
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
| |
Collapse
|
37
|
Özel HE, Karakuzu AT, Temir H, Alpay M, Özdoğan F, Genç S. Effect of ocular fixation on positional nystagmus in BPPV patients. Int J Audiol 2022:1-6. [PMID: 35438599 DOI: 10.1080/14992027.2022.2062579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE The quantitative suppression rate of positional nystagmus (PN) by ocular fixation (OF) is unknown. This study aims to analyse the effect of OF on the slow phase velocity (SPV) of PN during diagnostic positional manoeuvres (DPMs) with videonystagmography in patients with benign paroxysmal positional vertigo (BPPV). DESIGN DPMs were performed on 58 patients with BPPV, 33 (56.9%) of whom were women. OF was initiated when PN was most evident, and recording was continued. The mean SPV of three consecutive nystagmus before (F0) and after (F1) OF initiation was calculated. The rate of suppression of PN by OF was found in percent with the formula (F0 - F1) x 100/F0. STUDY SAMPLE 58 patients were included in this study. RESULTS The mean age was 56.1 ± 11.2 (range 27-76). F0 and F1 values were calculated as 5.742 ± 5.589 and 1.948 ± 3.424 degrees/second, respectively (p < 0.001). The rate of suppression of PN by OF was found to be 66.1%. CONCLUSIONS OF significantly suppresses PN during DPMs in BPPV patients. Elimination of OF during DPMs is important for accurate diagnosis.
Collapse
Affiliation(s)
- Halil Erdem Özel
- Department of Otolaryngology, University of Health Sciences Derince Research and Training Hospital, Kocaeli, Turkey
| | - Ahmet Taha Karakuzu
- Department of Otolaryngology, University of Health Sciences Derince Research and Training Hospital, Kocaeli, Turkey
| | - Hümeyra Temir
- Department of Audiology, University of Health Sciences Derince Research and Training Hospital, Kocaeli, Turkey
| | - Muhammed Alpay
- Department of Audiology, University of Health Sciences Derince Research and Training Hospital, Kocaeli, Turkey
| | - Fatih Özdoğan
- Department of Otolaryngology, University of Health Sciences Derince Research and Training Hospital, Kocaeli, Turkey
| | - Selahattin Genç
- Department of Otolaryngology, University of Health Sciences Derince Research and Training Hospital, Kocaeli, Turkey
| |
Collapse
|
38
|
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.
Collapse
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
| |
Collapse
|
39
|
Bi Y, Cao F. A Dynamic Nomogram to Predict the Risk of Stroke in Emergency Department Patients With Acute Dizziness. Front Neurol 2022; 13:839042. [PMID: 35250839 PMCID: PMC8896851 DOI: 10.3389/fneur.2022.839042] [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: 12/19/2021] [Accepted: 01/17/2022] [Indexed: 11/25/2022] Open
Abstract
Objective To develop a risk prediction tool for acute ischemic stroke (AIS) for patients presenting to the emergency department (ED) with acute dizziness/vertigo or imbalance. Method A prospective, multicenter cohort study was designed, and adult patients presenting with dizziness/vertigo or imbalance within 14 days were consecutively enrolled from the EDs of 4 tertiary hospitals between August 10, 2020, and June 10, 2021. Stroke was diagnosed by CT or MRI performed within 14 days of symptom onset. Participants were followed-up for 30 days. The least absolute shrinkage and selection operator (LASSO) logistic regression analysis was conducted to extract predictive factors that best identified patients at high risk of stroke to establish a prediction model. Model discrimination and calibration were assessed and its prediction performance was compared with the age, blood pressure, clinical features, duration, and diabetes (ABCD2) score, nystagmus scheme, and finger to nose test. Results In this study, 790 out of 2,360 patients were enrolled {median age, 60.0 years [interquartile range (IQR), 51–68 years]; 354 (44.8%) men}, with complete follow-up data available. AIS was identified in 80 patients. An online web service tool (https://neuroby.shinyapps.io/dynnomapp/) was developed for stroke risk prediction, including the variables of sex, trigger, isolated symptom, nausea, history of brief dizziness, high blood pressure, finger to nose test, and tandem gait test. The model exhibited excellent discrimination with an area under the receiver operating characteristic (ROC) curve (AUC) of 0.889 (95% CI: 0.855–0.923), compared with the ABCD2 score, nystagmus scheme, and finger to nose test [0.712 (95% CI, 0.652–0.771), 0.602 (95% CI, 0.556–0.648), and 61.7 (95% CI, 0.568–0.666) respectively]. Conclusion Our new prediction model exhibited good performance and could be useful for stroke identification in patients presenting with dizziness, vertigo, or imbalance. Further externally validation study is needed to increase the strength of our findings.
Collapse
|
40
|
Abstract
PURPOSE OF REVIEW We present here neuro-otological tests using portable video-oculography (VOG) and strategies assisting physicians in the process of decision making beyond the classical 'HINTS' testing battery at the bedside. RECENT FINDINGS Patients with acute vestibular syndrome (AVS) experience dizziness, gait unsteadiness and nausea/vomiting. A variety of causes can lead to this condition, including strokes. These patients cannot be adequately identified with the conventional approach by stratifying based on risk factors and symptom type. In addition to bedside methods such as HINTS and HINTS plus, quantitative methods for recording eye movements using VOG can augment the ability to diagnose and localize the lesion. In particular, the ability to identify and quantify the head impulse test (VOR gain, saccade metrics), nystagmus characteristics (waveform, beating direction and intensity), skew deviation, audiometry and lateropulsion expands our diagnostic capabilities. In addition to telemedicine, algorithms and artificial intelligence can be used to support emergency physicians and nonexperts in the future. SUMMARY VOG, telemedicine and artificial intelligence may assist physicians in the diagnostic process of AVS patients.
Collapse
Affiliation(s)
- Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, lnselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jorge Otero-Millan
- Optometry and Vision Science, University of California, Berkeley, Berkeley, California
- Department of Neurology
| | - Daniel R. Gold
- Departments of Neurology, Ophthalmology, Otolaryngology – Head & Neck Surgery, Neurosurgery, Emergency Medicine, and Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
41
|
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.
Collapse
|
42
|
Rickenbacher-Frey S, Zimmerli L, Ernst S. [Dizziness - What Next?]. PRAXIS 2022; 111:745-748. [PMID: 36221966 DOI: 10.1024/1661-8157/a003895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Dizziness - What Next? Abstract. Dizziness is a very common symptom with an extensive differential diagnosis that includes both benign and serious conditions. Acute care physicians must be able to distinguish the majority of patients with self-limiting benign complaints from those with serious conditions. Our structured approach is intended to serve as a guide for acute medicine.
Collapse
Affiliation(s)
- Sarah Rickenbacher-Frey
- Medizinische Klinik und interdisziplinäre Notfallstation, Kantonsspital Olten, Olten, Schweiz
| | - Lukas Zimmerli
- Medizinische Klinik und interdisziplinäre Notfallstation, Kantonsspital Olten, Olten, Schweiz
| | - Susanne Ernst
- Medizinische Klinik und interdisziplinäre Notfallstation, Kantonsspital Olten, Olten, Schweiz
| |
Collapse
|
43
|
Tu LH, Mahajan A, Minja FJ, Navaratnam D, Melnick ER. Pilot MRI-based strategies to improve the detection of stroke in patients with dizziness/vertigo. Clin Imaging 2021; 82:234-236. [PMID: 34902799 DOI: 10.1016/j.clinimag.2021.12.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 11/15/2021] [Accepted: 12/06/2021] [Indexed: 11/17/2022]
Abstract
Posterior strokes are frequently misdiagnosed as they present with non-specific complaints such as dizziness/vertigo. Emergency department (ED) practice often relies on CT/CTA to "exclude" infarct in such patients, providing false reassurance due to lower sensitivity of CT (42%) for stroke in the posterior circulation. We describe a pilot at our institution using a specialized MRI protocol with 95% sensitivity for posterior stroke, which may be used in place of CT/CTA or conventional MRI for stroke evaluation. Further development of this approach may help reduce the high rate of missed posterior stroke in patients presenting with dizziness.
Collapse
Affiliation(s)
- Long H Tu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, 330 Cedar St, New Haven, CT 06520, United States of America.
| | - Amit Mahajan
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, 330 Cedar St, New Haven, CT 06520, United States of America.
| | - Frank J Minja
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, 100 Woodruff Circle, Atlanta, GA 30322, United States of America.
| | - Dhasakumar Navaratnam
- Department of Emergency Medicine, Yale School of Medicine, 800 Howard Ave, New Haven, CT 06519, United States of America.
| | - Edward R Melnick
- Department of Emergency Medicine, Yale School of Medicine, 464 Congress Ave # 260, New Haven, CT 06519, United States of America.
| |
Collapse
|
44
|
Puetz V, Strbian D, Nguyen TN, Nagel S. Editorial: Challenges in Posterior Circulation Ischemic Stroke. Front Neurol 2021; 12:789836. [PMID: 34867771 PMCID: PMC8637862 DOI: 10.3389/fneur.2021.789836] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Dresden Neurovascular Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Daniel Strbian
- Department of Neurology and Neurosciences, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Thanh N Nguyen
- Department of Neurology and Radiology, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|
45
|
Gerlier C, Hoarau M, Fels A, Vitaux H, Mousset C, Farhat W, Firmin M, Pouyet V, Paoli A, Chatellier G, Ganansia O. Differentiating central from peripheral causes of acute vertigo in an emergency setting with the HINTS, STANDING, and ABCD2 tests: A diagnostic cohort study. Acad Emerg Med 2021; 28:1368-1378. [PMID: 34245635 DOI: 10.1111/acem.14337] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/24/2021] [Accepted: 06/25/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Diagnosing stroke in dizzy patients remains a challenge in emergency medicine. The accuracy of the neuroophthalmologic examination HINTS performed by emergency physicians (EPs) is unknown. Our objective was to determine the accuracy of the HINTS examination performed by trained EPs for diagnosing central cause of acute vertigo and unsteadiness and to compare it with another bedside clinical tool, STANDING, and with the history-based score ABCD2. METHODS This was a prospective diagnostic cohort study among patients with isolated vertigo and unsteadiness seen in a single emergency department (ED). Trained EPs performed HINTS and STANDING tests blinded to attending physicians. ABCD2 ≥ 4 was used as the threshold and was calculated retrospectively. The criterion standard was diffusion-weighted brain magnetic resonance imaging (MRI). Peripheral diagnoses were established by a normal MRI, and etiologies were further refined by an otologic examination. RESULTS We included 300 patients of whom 62 had a central lesion on neuroimaging including 49 strokes (79%). Of the 238 peripheral diagnoses, 159 were vestibulopathies, mainly benign paroxysmal positional vertigo (40%). HINTS and STANDING tests reached high sensitivities at 97% and 94% and NPVs at 99% and 98%, respectively. The ABCD2 score failed to predict half of central vertigo cases and had a sensitivity of 55% and a NPV of 87%. The STANDING test was more specific and had a better positive predictive value (PPV; 75% and 49%, respectively; positive likelihood ratio [LR+] = 3.71, negative likelihood ratio [LR-] = 0.09) than the HINTS test (67% and 44%, respectively; LR+ = 2.96, LR- = 0.04). The ABCD2 score was specific (82%, LR+ = 3.04, LR- = 0.56) but had a very low PPV (44%). CONCLUSIONS In the hands of EPs, HINTS and STANDING tests outperformed ABCD2 in identifying central causes of vertigo. For diagnosing peripheral disorders, the STANDING algorithm is more specific than the HINTS test. HINTS and STANDING could be useful tools saving both time and costs related to unnecessary neuroimaging use.
Collapse
Affiliation(s)
- Camille Gerlier
- Emergency Department Groupe Hospitalier Paris Saint‐Joseph Paris France
| | - Maëlle Hoarau
- Emergency Department Groupe Hospitalier Paris Saint‐Joseph Paris France
| | - Audrey Fels
- Clinical Research Center Groupe Hospitalier Paris Saint‐Joseph Paris France
| | - Hélène Vitaux
- Department of Otolaryngology Groupe Hospitalier Paris Saint‐Joseph Paris France
| | - Carole Mousset
- Department of Otolaryngology Groupe Hospitalier Paris Saint‐Joseph Paris France
| | - Wassim Farhat
- Departments of Neurology Groupe Hospitalier Paris Saint‐Joseph Paris France
| | - Marine Firmin
- Emergency Department Groupe Hospitalier Paris Saint‐Joseph Paris France
| | - Victorine Pouyet
- Emergency Department Groupe Hospitalier Paris Saint‐Joseph Paris France
| | - Audrey Paoli
- Emergency Department Groupe Hospitalier Paris Saint‐Joseph Paris France
| | - Gilles Chatellier
- Faculté de Paris INSERM CIC 14‐18Hôpital Européen Georges Pompidou Paris France
| | - Olivier Ganansia
- Emergency Department Groupe Hospitalier Paris Saint‐Joseph Paris France
| |
Collapse
|
46
|
Brune AJ, Eggenberger ER. The Outpatient Approach to Dizziness. Semin Neurol 2021; 41:771-780. [PMID: 34826878 DOI: 10.1055/s-0041-1726369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The evaluation of the dizzy patient is complicated by many common pitfalls. The patient's description of symptoms and the standard neurologic examination are often nonspecific or unrevealing, and neuroimaging is most often normal. Over the past several years, research has demonstrated that a refocusing of history taking results in more reliable and diagnostically helpful information. This can guide a targeted expansion of the exam, often with an emphasis on eye movements.
Collapse
Affiliation(s)
- Anthony J Brune
- Department of Neuro-ophthalmology and Vestibular Neurology, Institute for Neuroscience Memorial Healthcare, Owosso, Michigan
| | - Eric R Eggenberger
- Department of Ophthalmology, Neurology and Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida
| |
Collapse
|
47
|
Shi T, Zhang Z, Jin B, Wang J, Wu H, Zheng J, Hu X. Choice of intravenous thrombolysis therapy in patients with mild stroke complaining of acute dizziness. Am J Emerg Med 2021; 52:20-24. [PMID: 34861516 DOI: 10.1016/j.ajem.2021.11.020] [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: 09/14/2021] [Revised: 11/09/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022] Open
Abstract
BACKGROUND Quick identification of patients with mild ischemic stroke complaining of dizziness from other patients with benign peripheral vestibular disorders who also experience dizziness in the emergency department (ED) may be difficult. Decision-making on intravenous thrombolysis therapy (IVT) in patients whose chief symptoms include acute dizziness or vertigo remains a severe challenge for ED physicians. This study evaluated the diagnosis, treatment processes and the short-term outcomes in patients with mild vestibular stroke in the ED. METHODS A total of 89 consecutive patients with mild ischemic stroke primarily presenting with vestibular symptoms, who arrived at ED within 4.5 after onset, and were admitted at the stroke center of Zhejiang Provincial People's Hospital between January 2015 and March 2021 were retrospectively enrolled. Patients treated with IVT (n = 47) were compared to patients without IVT (n = 42) in terms of demographics, onset-to-door time (ODT), baseline clinical characteristics, risk factors of stroke, imaging findings, and short-term outcomes. The correlation between these parameters and IVT decision-making was analyzed. RESULTS Patients in IVT group more frequently presented with shorter ODT, focal neurological deficits (dysarthria, facial palsy, hemiglossoplegia, hemiparesis, hemisensory loss), disabling deficits, higher baseline National Institute of Health Stroke Scale (NIHSS) scores, and underwent multi-mode imaging before a decision. A higher proportion of isolated vestibular symptoms, acute transient vestibular syndrome, and vestibulo-vagal symptoms were found in the no-IVT group. There were no differences in demographics between the two groups. ODT was negatively correlated with the decision-making on IVT, and baseline NIHSS scores were positively correlated with the decision-making on IVT. CONCLUSION ODT and baseline NIHSS scores were correlated with the IVT decision in mild stroke patients primarily presenting with vestibular symptoms. Severe vestibular symptoms and disabling deficits were weakly associated with IVT decision, while the vestibulo-oculomotor signs and multi-mode imaging did not result as the influencing factors promoting the IVT decision-making for mild vestibular stroke.
Collapse
Affiliation(s)
- Tianming Shi
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Department of Neurology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Zheyu Zhang
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Bo Jin
- Department of Neurology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Jingwen Wang
- Department of Neurology, Tiantai People's Hospital of Zhejiang Province, Tiantai, China
| | - Huadong Wu
- Department of Neurology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Junxia Zheng
- Department of General Practice, the First People's Hospital of Hangzhou Lin'an District, Hangzhou, China
| | - Xingyue Hu
- Department of Neurology, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, China.
| |
Collapse
|
48
|
Machner B, Erber K, Choi JH, Sprenger A, Helmchen C, Trillenberg P. A Simple Gain-Based Evaluation of the Video Head Impulse Test Reliably Detects Normal Vestibulo-Ocular Reflex Indicative of Stroke in Patients With Acute Vestibular Syndrome. Front Neurol 2021; 12:741859. [PMID: 34777209 PMCID: PMC8585749 DOI: 10.3389/fneur.2021.741859] [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: 07/15/2021] [Accepted: 10/06/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: The head impulse test (HIT) assesses the vestibulo-ocular reflex (VOR) and is used to differentiate vestibular neuritis (abnormal VOR) from stroke (normal VOR) in patients presenting with an acute vestibular syndrome (AVS). The video-oculography-based HIT (vHIT) quantifies VOR function and provides information imperceptible for the clinician during clinical bedside HIT. However, the vHIT—like an electrocardiogram—requires experienced interpretation, which is especially difficult in the emergency setting. This calls for a simple, reliable and rater-independent way of analysis. Methods: We retrospectively collected 171 vHITs performed in patients presenting with AVS to our emergency department. Three neuro-otological experts comprehensively assessed the vHITs including interpretability (artifacts), VOR gain (eye/head velocity ratio), velocity profile (abrupt decline) and corrective saccades (overt/covert). Their consensus rating (abnormal/peripheral vs. normal/central) was compared to a simple algorithm that automatically classified the vHITs based on a single VOR gain cutoff (0.7). Results: Inter-rater agreement between experts was high (Fleiss' kappa = 0.74). Five (2.9 %) vHITs were “uninterpretable” according to experts' consensus, 80 (46.8 %) were rated “normal” and 86 (50.3 %) “abnormal”. The algorithm had substantial agreement with the experts' consensus (Cohen's kappa = 0.75). Importantly, it correctly classified all of the normal/central vHITs denoted by the experts (100% specificity) and at the same time it had sufficient sensitivity (75.6%) in detecting abnormal/peripheral vHITs. Conclusion: A simple, automated, gain-based evaluation of the vHIT reliably detects normal/central VOR and may be a feasible and effective tool to screen AVS patients for potentially underlying stroke in the emergency setting.
Collapse
Affiliation(s)
- Björn Machner
- Department of Neurology, University Hospitals Schleswig-Holstein, Lübeck, Germany
| | - Kira Erber
- Department of Anesthesiology and Intensive Care, University Hospitals Schleswig-Holstein, Lübeck, Germany
| | - Jin Hee Choi
- Department of Neurology, University Hospitals Schleswig-Holstein, Lübeck, Germany
| | - Andreas Sprenger
- Department of Neurology, University Hospitals Schleswig-Holstein, Lübeck, Germany
| | - Christoph Helmchen
- Department of Neurology, University Hospitals Schleswig-Holstein, Lübeck, Germany
| | - Peter Trillenberg
- Department of Neurology, University Hospitals Schleswig-Holstein, Lübeck, Germany
| |
Collapse
|
49
|
Vocal cord paresis on CTA - A novel tool for the diagnosis of lateral medullary syndrome. J Neurol Sci 2021; 429:117576. [PMID: 34455209 DOI: 10.1016/j.jns.2021.117576] [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: 03/18/2021] [Revised: 06/27/2021] [Accepted: 07/10/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Diagnosis of lateral medullary syndrome (LMS) is often delayed due to elusive clinical presentations and frequently non-revealing neuroimaging tests. We aimed to investigate the use of ipsilateral vocal cord paresis (VCP) identified on neck computed tomography angiography (CTA) as an early diagnostic sign for LMS. METHODS Medical records were queried for patients admitted with LMS between 1/2012 and 10/2020. A control group of patients undergoing CTA for transient or no neurological symptoms was matched for sex and age. Clinical data were collected by a stroke neurologist. Two neuroradiologists independently and blindly assessed CTA images for radiological signs of VCP. RESULTS Fifteen LMS and 15 control patients were included in the analysis. Median time from arrival to LMS diagnosis was 29.4 h [IQR 7,47] and twice as long in patients who suffered aspiration pneumonia. Thrombolysis rate was 0% in LMS patients versus 14.5% in general stroke patients. Dysphonia was noted in the emergency department in three (20%) patients, whereas all 15 patients had radiological signs of VCP on CTA. Medialization of a true vocal cord was the most sensitive (100%) and specific (80-87%) sign for LMS, with good inter-rater agreement (kappa 0.66). Timely detection of VCP on CTA could have shortened median time to LMS diagnosis by 14 h and enabled thrombolytic therapy in 3 (20%) patients. CONCLUSIONS VCP on CTA is a valuable sign for the diagnosis of LMS. If detected early, it may enable reperfusion therapy and prevent aspiration pneumonia, consequently saving life and diminishing disability.
Collapse
|
50
|
Video-Oculography-Assisted Head Impulse Test and Caloric Testing for Detecting Stroke in Acute Vertigo Patients via Modified HINTS Plus. J Clin Med 2021; 10:jcm10194471. [PMID: 34640489 PMCID: PMC8509535 DOI: 10.3390/jcm10194471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 09/24/2021] [Accepted: 09/27/2021] [Indexed: 12/13/2022] Open
Abstract
Background: We assessed whether detection of stroke underlying acute vertigo using HINTS plus (head-impulse test, nystagmus type, test of skew, hearing loss) can be improved by video-oculography for automated head-impulse test (V-HIT) analysis. Methods: We evaluated patients with acute vestibular syndrome (AVS) presenting to the emergency room using HINTS plus and V-HIT-assisted HINTS plus in a randomized sequence followed by cranial MRI and caloric testing. Image-confirmed posterior circulation stroke or vertebrobasilar TIA were the reference standards to calculate diagnostic accuracy. We repeated statistical analysis for a third protocol that was composed post hoc by replacing the head-impulse test with caloric testing in the HINTS plus protocol. Results: We included 30 AVS patients (ages 55.4 ± 17.2 years, 14 females). Of these, 11 (36.7%) had posterior circulation stroke (n = 4) or TIA (n = 7). Acute V-HIT-assisted HINTS plus was feasible and displayed tendentially higher accuracy than conventional HINTS plus (sensitivity: 81.8%, 95% CI 48.2–97.7%; specificity 31.6%, 95% CI 12.6–56.6% vs. sensitivity 72.7%, 95% CI 39.0–94.0%; specificity 36.8%, 95% CI 16.3–61.6%). The new caloric-supported algorithm showed high accuracy (sensitivity 100%, 95% CI 66.4–100%; specificity 66.7%, 95% CI 41–86.7%). Conclusions: Our study provides pilot data on V-HIT-assisted HINTS plus for acute AVS assessment and indicates the diagnostic value of integrated acute caloric testing.
Collapse
|