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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.
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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
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Yao K, Zu HB. Isolated transient vertigo due to TIA: challenge for diagnosis and therapy. J Neurol 2023; 270:769-779. [PMID: 36371598 DOI: 10.1007/s00415-022-11443-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 10/19/2022] [Accepted: 10/19/2022] [Indexed: 11/13/2022]
Abstract
As a prevalent vertigo disease in the clinic, isolated transient vertigo can present as a vertigo episode without focal signs and always free of symptoms on presentation. Previous studies showed a part of isolated transient vertigo events had a high risk of stroke during follow-up. However, how to discern posterior circulation ischemia become a great challenge for clinicians, especially in emergency, neurology, and ENT departments. Routine besides, hematological, and imaging examinations are often difficult provide a clear etiological diagnosis. Hence, this article reviews current knowledge about the epidemiology, risk factors, offending lesions, and clinical manifestation of transient ischemic attack (TIA) presenting as isolated transient vertigo. In addition, we summarize several advances in besides examinations, serum biomarkers, and imaging technologies to better identify stroke events. Finally, the current situation of therapy was briefly retrospected. Here we present a critical clinical puzzle that needs to be solved in the future. Of note, there is a still lack of high-quality studies in this field. The article reviews the keys to the diagnosis of isolated transient vertigo due to TIA and provides us with more methods to screen for high-risk stroke populations.
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Affiliation(s)
- Kai Yao
- Department of Neurology, Jinshan Hospital Affiliated to Fudan University, No. 1508 Longhang Road, Jinshan District, Shanghai, 201508, China
| | - Heng-Bing Zu
- Department of Neurology, Jinshan Hospital Affiliated to Fudan University, No. 1508 Longhang Road, Jinshan District, Shanghai, 201508, China.
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Schuhbeck F, Strobl R, Conrad J, Möhwald K, Jaufenthaler P, Jahn K, Dieterich M, Grill E, Zwergal A. Determinants of functioning and health-related quality of life after vestibular stroke. Front Neurol 2022; 13:957283. [PMID: 36158947 PMCID: PMC9492892 DOI: 10.3389/fneur.2022.957283] [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: 05/30/2022] [Accepted: 08/16/2022] [Indexed: 11/23/2022] Open
Abstract
Background Stroke accounts for 5–10% of all presentations with acute vertigo and dizziness. The objective of the current study was to examine determinants of long-term functioning and health-related quality of life (HRQoL) in a patient cohort with vestibular stroke. Methods Thirty-six patients (mean age: 66.1 years, 39% female) with an MRI-proven vestibular stroke were followed prospectively (mean time: 30.2 months) in the context of the EMVERT (EMergency VERTigo) cohort study at the Ludwig-Maximilians Universität, Munich. The following scores were obtained once in the acute stage (<24 h of symptom onset) and once during long-term follow-up (preferably >1 year after stroke): European Quality of Life Scale-five dimensions-five levels questionnaire (EQ-5D-5L) and Visual Analog Scale (EQ-VAS) for HRQoL, Dizziness Handicap Inventory (DHI) for symptom severity, and modified Rankin Scale (mRS) for general functioning and disability. Anxiety state and trait were evaluated by STAI-S/STAI-T, and depression was evaluated by the Patient Health Questionnaire-9 (PHQ-9). Voxel-based lesion mapping was applied in normalized MRIs to analyze stroke volume and localization. Multiple linear regression models were calculated to determine predictors of functional outcome (DHI, EQ-VAS at follow-up). Results Mean DHI scores improved significantly from 45.0 in the acute stage to 18.1 at follow-up (p < 0.001), and mean mRS improved from 2.1 to 1.1 (p < 0.001). Mean HRQoL (EQ-5D-5L index/EQ-VAS) changed from 0.69/58.8 to 0.83/65.2 (p = 0.01/p = 0.11). Multiple linear regression models identified higher scores of STAI-T and DHI at the time of acute vestibular stroke and larger stroke volume as significant predictors for higher DHI at follow-up assessment. The effect of STAI-T was additionally enhanced in women. There was a significant effect of patient age on EQ-VAS, but not DHI during follow-up. Conclusion The average functional outcome of strokes with the chief complaint of vertigo and dizziness is favorable. The most relevant predictors for individual outcomes are the personal anxiety trait (especially in combination with the female sex), the initial symptom intensity, and lesion volume. These factors should be considered for therapeutic decisions both in the acute stage of stroke and during subsequent rehabilitation.
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Affiliation(s)
- Franziska Schuhbeck
- German Center for Vertigo and Balance Disorders, DSGZ, LMU Hospital, Ludwig-Maximilians Universität Munich, Munich, Germany
- Department of Neurology, LMU Hospital, Ludwig-Maximilians Universität Munich, Munich, Germany
| | - Ralf Strobl
- German Center for Vertigo and Balance Disorders, DSGZ, LMU Hospital, Ludwig-Maximilians Universität Munich, Munich, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians Universität Munich, Munich, Germany
| | - Julian Conrad
- German Center for Vertigo and Balance Disorders, DSGZ, LMU Hospital, Ludwig-Maximilians Universität Munich, Munich, Germany
- Department of Neurology, LMU Hospital, Ludwig-Maximilians Universität Munich, Munich, Germany
| | - Ken Möhwald
- German Center for Vertigo and Balance Disorders, DSGZ, LMU Hospital, Ludwig-Maximilians Universität Munich, Munich, Germany
- Department of Neurology, LMU Hospital, Ludwig-Maximilians Universität Munich, Munich, Germany
| | - Patricia Jaufenthaler
- German Center for Vertigo and Balance Disorders, DSGZ, LMU Hospital, Ludwig-Maximilians Universität Munich, Munich, Germany
- Department of Neurology, LMU Hospital, Ludwig-Maximilians Universität Munich, Munich, Germany
| | - Klaus Jahn
- German Center for Vertigo and Balance Disorders, DSGZ, LMU Hospital, Ludwig-Maximilians Universität Munich, Munich, Germany
- Schön Clinic Bad Aibling, Department of Neurology, Bad Aibling, Germany
| | - Marianne Dieterich
- German Center for Vertigo and Balance Disorders, DSGZ, LMU Hospital, Ludwig-Maximilians Universität Munich, Munich, Germany
- Department of Neurology, LMU Hospital, Ludwig-Maximilians Universität Munich, Munich, Germany
- Munich Cluster for Systems Neurology, SyNergy, Munich, Germany
| | - Eva Grill
- German Center for Vertigo and Balance Disorders, DSGZ, LMU Hospital, Ludwig-Maximilians Universität Munich, Munich, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians Universität Munich, Munich, Germany
- Munich Center for Health Sciences, Ludwig-Maximilians Universität Munich, Munich, Germany
| | - Andreas Zwergal
- German Center for Vertigo and Balance Disorders, DSGZ, LMU Hospital, Ludwig-Maximilians Universität Munich, Munich, Germany
- Department of Neurology, LMU Hospital, Ludwig-Maximilians Universität Munich, Munich, Germany
- *Correspondence: Andreas Zwergal
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Long-Term Evolution of Vestibular Compensation, Postural Control, and Perceived Disability in a Population of Patients with Vestibular Neuritis. J Clin Med 2022; 11:jcm11143941. [PMID: 35887704 PMCID: PMC9324005 DOI: 10.3390/jcm11143941] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 06/28/2022] [Accepted: 07/01/2022] [Indexed: 12/10/2022] Open
Abstract
Objectives. The aim was to analyze and compare the compensatory process, vestibular dysfunction, postural control, and perceived disability in a population of patients with vestibular neuritis (VN). Material and Methods. This is a prospective and longitudinal study of 67 patients diagnosed with VN. Inclusion criteria were sudden onset of vertigo, unidirectional spontaneous horizontal nystagmus, and impairment in vestibular test. Exclusion criteria were imaging or clinical findings of any neurotologic disorder. All vestibular tests were performed; vHIT, vestibular evoked myogenic potentials (VEMPs), caloric test and computerized dynamic posturography (CDP), dizziness handicap inventory (DHI), and visual analogue scale (VAS) were also performed at every follow up. Results. We observed a correlation between the composite score of CDP and baseline vestibular function elicited either by caloric test, VEMPs, or vHIT. There was a significant correlation between baseline vestibular function and first visit questionnaire scores. The main gain recovery for the horizontal canal was 0.1 ± 0.04 for the first three months. After that, the gain recovery significantly decreased. The presence of covert and overt saccades’, latency and amplitude decreased, respectively, after the 6-month period, when compared to the baseline results. We also observed a decrease in the PR score from 3 months after the vestibular insult until the last follow up. We observed a significant decrease in DHI and VAS from the first visit until the last one. Those patients with an initial HC gain below 0.5 had significantly higher DHI and VAS scores at every follow up. Conclusions. There are different measurements that could become a complete measurement of the state of compensation, postural control, and disability of the patients. There is a time window in which the vestibular restoration could give us clinical insights regarding the management of VN patients.
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Filippopulos FM, Strobl R, Belanovic B, Dunker K, Grill E, Brandt T, Zwergal A, Huppert D. Validation of a comprehensive diagnostic algorithm for patients with acute vertigo and dizziness. Eur J Neurol 2022; 29:3092-3101. [PMID: 35708513 DOI: 10.1111/ene.15448] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 05/24/2022] [Accepted: 06/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Vertigo and dizziness are common complaints in emergency departments and primary care, which pose major diagnostic challenges due to various underlying etiologies. Most supportive diagnostic algorithms concentrate on either identifying cerebrovascular events or diagnosing specific vestibular disorders or are restricted to specific patient subgroups. METHODS The study was conducted in the scope of the 'PoiSe' project (prevention, online feedback, and interdisciplinary therapy of acute vestibular syndromes by e-health). A three-level algorithm was developed according to international guidelines and scientific evidence addressing both, the detection of cerebrovascular events and the classification to non-vascular vestibular disorders (unilateral vestibulopathy, benign paroxysmal positional vertigo, vestibular paroxysmia, Menière's disease, vestibular migraine, functional dizziness). The algorithm was validated on a prospectively collected dataset of 407 patients with acute vertigo and dizziness presenting to the emergency department at LMU Munich. RESULTS The algorithm assigned 287 of 407 patients to the correct diagnosis, corresponding to an overall accuracy of 71%. Cerebrovascular events were identified with high sensitivity of 94%. The six most common vestibular disorders were classified with high specificity above 95%. Random forest identified the presence of a paresis, sensory loss, central ocular motor and vestibular signs (HINTS), and older age as the most important variables indicating a cerebrovascular event. CONCLUSIONS The proposed diagnostic algorithm can correctly classify the most common vestibular disorders based on a comprehensive set of key questions and clinical examinations. It is easily applied, not limited to subgroups, and might therefore be transferred to broad clinical settings such as primary health care.
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Affiliation(s)
- Filipp M Filippopulos
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany.,Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany
| | - Ralf Strobl
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany.,Institute for Medical Information Processing, Biometrics and Epidemiology, Ludwig-Maximilians-Universität München (LMU), Marchioninistr. 15, Munich, Germany
| | - Bozidar Belanovic
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany
| | - Konstanze Dunker
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany
| | - Eva Grill
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany.,Institute for Medical Information Processing, Biometrics and Epidemiology, Ludwig-Maximilians-Universität München (LMU), Marchioninistr. 15, Munich, Germany
| | - Thomas Brandt
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany
| | - Andreas Zwergal
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany.,Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany
| | - Doreen Huppert
- German Center for Vertigo and Balance Disorders, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany.,Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, Munich, Germany
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6
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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.
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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
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7
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Kim JS, Newman-Toker DE, Kerber KA, Jahn K, Bertholon P, Waterston J, Lee H, Bisdorff A, Strupp M. Vascular vertigo and dizziness: Diagnostic criteria. J Vestib Res 2022; 32:205-222. [PMID: 35367974 PMCID: PMC9249306 DOI: 10.3233/ves-210169] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This paper presents diagnostic criteria for vascular vertigo and dizziness as formulated by the Committee for the Classification of Vestibular Disorders of the Bárány Society. The classification includes vertigo/dizziness due to stroke or transient ischemic attack as well as isolated labyrinthine infarction/hemorrhage, and vertebral artery compression syndrome. Vertigo and dizziness are among the most common symptoms of posterior circulation strokes. Vascular vertigo/dizziness may be acute and prolonged (≥24 hours) or transient (minutes to < 24 hours). Vascular vertigo/dizziness should be considered in patients who present with acute vestibular symptoms and additional central neurological symptoms and signs, including central HINTS signs (normal head-impulse test, direction-changing gaze-evoked nystagmus, or pronounced skew deviation), particularly in the presence of vascular risk factors. Isolated labyrinthine infarction does not have a confirmatory test, but should be considered in individuals at increased risk of stroke and can be presumed in cases of acute unilateral vestibular loss if accompanied or followed within 30 days by an ischemic stroke in the anterior inferior cerebellar artery territory. For diagnosis of vertebral artery compression syndrome, typical symptoms and signs in combination with imaging or sonographic documentation of vascular compromise are required.
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Affiliation(s)
- Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Kevin A Kerber
- Department of Neurology, University of Michigan Health System, Ann Arbor, USA
| | - Klaus Jahn
- Department of Neurology Schoen Clinic Bad Aibling and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
| | | | - John Waterston
- Monash Department of Neuroscience, Alfred Hospital, Melbourne, Australia
| | - Hyung Lee
- Department of Neurology, Brain Research Institute, Keimyung University School of Medicine, Daegu, Korea
| | - Alexandre Bisdorff
- Department of Neurology, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg
| | - Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
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8
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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.
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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.
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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.
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Zwergal A, Dieterich M. [Update on diagnosis and therapy in frequent vestibular and balance disorders]. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2021; 89:211-220. [PMID: 33873210 DOI: 10.1055/a-1432-1849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The 8 most frequent vestibular disorders account for more than 70% of all presentations of vertigo, dizziness, and imbalance. In acute (and mostly non-repetitive) vestibular disorders acute unilateral vestibulopathy and vestibular stroke are most important, in episodic vestibulopathies benign paroxysmal positional vertigo (BPPV), Menière's disease and vestibular migraine, and in chronic vestibular disorders bilateral vestibulopathy/presbyvestibulopathy, functional dizziness and cerebellar dizziness. In the last decade, internationally consented diagnostic criteria and nomenclature were established for the most frequent vestibular disorders, which can be easily applied in clinical practice. The diagnostic guidelines are based on history taking (including onset, duration, course, triggers, accomanying symptoms), clinical examination, and only a few apparative tests (by videooculography and audiometry) for securing the diagnosis. Treatment of vestibular disorders includes physical training (repositioning maneuvers, multimodal balance training) and pharmacological approaches (e.g., corticosteroids, antiepileptics, antidepressants, potassium-canal-blockers, drugs enhancing neuroplasticity). For most drugs, high-level evidence from prospective controlled trials is lacking. In clinical practice, the most frequent vestibular disorders can be treated effectively, thus avoiding chronicity and secondary comorbidity (by immobility, falls or psychiatric disorders such as anxiety or depression).
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Affiliation(s)
- Andreas Zwergal
- LMU Klinikum, Neurologische Klinik und Deutsches Schwindel- und Gleichgewichtszentrum (DSGZ)
| | - Marianne Dieterich
- LMU Klinikum, Neurologische Klinik und Deutsches Schwindel- und Gleichgewichtszentrum (DSGZ)
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Ahmadi SA, Vivar G, Navab N, Möhwald K, Maier A, Hadzhikolev H, Brandt T, Grill E, Dieterich M, Jahn K, Zwergal A. Modern machine-learning can support diagnostic differentiation of central and peripheral acute vestibular disorders. J Neurol 2020; 267:143-152. [PMID: 32529578 PMCID: PMC7718180 DOI: 10.1007/s00415-020-09931-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Diagnostic classification of central vs. peripheral etiologies in acute vestibular disorders remains a challenge in the emergency setting. Novel machine-learning methods may help to support diagnostic decisions. In the current study, we tested the performance of standard and machine-learning approaches in the classification of consecutive patients with acute central or peripheral vestibular disorders. METHODS 40 Patients with vestibular stroke (19 with and 21 without acute vestibular syndrome (AVS), defined by the presence of spontaneous nystagmus) and 68 patients with peripheral AVS due to vestibular neuritis were recruited in the emergency department, in the context of the prospective EMVERT trial (EMergency VERTigo). All patients received a standardized neuro-otological examination including videooculography and posturography in the acute symptomatic stage and an MRI within 7 days after symptom onset. Diagnostic performance of state-of-the-art scores, such as HINTS (Head Impulse, gaze-evoked Nystagmus, Test of Skew) and ABCD2 (Age, Blood, Clinical features, Duration, Diabetes), for the differentiation of vestibular stroke vs. peripheral AVS was compared to various machine-learning approaches: (i) linear logistic regression (LR), (ii) non-linear random forest (RF), (iii) artificial neural network, and (iv) geometric deep learning (Single/MultiGMC). A prospective classification was simulated by ten-fold cross-validation. We analyzed whether machine-estimated feature importances correlate with clinical experience. RESULTS Machine-learning methods (e.g., MultiGMC) outperform univariate scores, such as HINTS or ABCD2, for differentiation of all vestibular strokes vs. peripheral AVS (MultiGMC area-under-the-curve (AUC): 0.96 vs. HINTS/ABCD2 AUC: 0.71/0.58). HINTS performed similarly to MultiGMC for vestibular stroke with AVS (AUC: 0.86), but more poorly for vestibular stroke without AVS (AUC: 0.54). Machine-learning models learn to put different weights on particular features, each of which is relevant from a clinical viewpoint. Established non-linear machine-learning methods like RF and linear methods like LR are less powerful classification models (AUC: 0.89 vs. 0.62). CONCLUSIONS Established clinical scores (such as HINTS) provide a valuable baseline assessment for stroke detection in acute vestibular syndromes. In addition, machine-learning methods may have the potential to increase sensitivity and selectivity in the establishment of a correct diagnosis.
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Affiliation(s)
- Seyed-Ahmad Ahmadi
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany
- Computer Aided Medical Procedures, Technical University, Munich, Germany
| | - Gerome Vivar
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany
- Computer Aided Medical Procedures, Technical University, Munich, Germany
| | - Nassir Navab
- Computer Aided Medical Procedures, Technical University, Munich, Germany
| | - Ken Möhwald
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany
- Department of Neurology, Ludwig-Maximilians-University, Marchioninistrasse 15, 81377, Munich, Germany
| | - Andreas Maier
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany
- Department of Neurology, Ludwig-Maximilians-University, Marchioninistrasse 15, 81377, Munich, Germany
| | - Hristo Hadzhikolev
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany
- Department of Neurology, Ludwig-Maximilians-University, Marchioninistrasse 15, 81377, Munich, Germany
| | - Thomas Brandt
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany
- Clinical Neurosciences, Ludwig-Maximilians-University, Munich, Germany
| | - Eva Grill
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany
- Institute for Medical Information Processing, Ludwig-Maximilians-University, Biometry, and Epidemiology, Munich, Germany
| | - Marianne Dieterich
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany
- Department of Neurology, Ludwig-Maximilians-University, Marchioninistrasse 15, 81377, Munich, Germany
- Munich Cluster of Systems Neurology, SyNergy, Munich, Germany
| | - Klaus Jahn
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany
- Department of Neurology, Schön Klinik Bad Aibling, Munich, Germany
| | - Andreas Zwergal
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany.
- Department of Neurology, Ludwig-Maximilians-University, Marchioninistrasse 15, 81377, Munich, Germany.
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