A comparison of benign positional vertigo and stroke patients presenting to the emergency department with vertigo or dizziness

Hanna, Jonathan; Malhotra, Ajay; Brauer, Philip R.; Luryi, Alexander L.; Michaelides, Elias

doi:10.1016/j.amjoto.2019.07.007

Cited by 10 publications

(13 citation statements)

References 41 publications

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“…There has been an emphasis placed on optimizing neuroimaging use for acute dizziness in ED settings, where urgency is associated with reduced in-the-moment payer and health system scrutiny. The ED neuroimaging rates that we observed (28% at presentation and 36% over 6 months) are consistent with the prior estimates of 18% to 48% from US health system ED records and the National Hospital Ambulatory Medical Care Survey . These studies and our study documented reliance on the insensitive head CT scan in the urgent time frame, which is concerning because 35% of strokes among patients presenting to the ED with dizziness are missed .…”

Section: Discussionsupporting

confidence: 88%

“…The ED neuroimaging rates that we observed (28% at presentation and 36% over 6 months) are consistent with the prior estimates of 18% to 48% from US health system ED records and the National Hospital Ambulatory Medical Care Survey. 1,[24][25][26][27][28] These studies and our study documented reliance on the insensitive head CT scan in the urgent time frame, which is concerning because 35% of strokes among patients presenting to the ED with dizziness are missed. 29 Among ED presentations for dizziness, only 0.6% to 3.6% of CT scans and 3.9% to 12.2% of MRI scans revealed clinically significant findings.…”

Section: Discussionmentioning

confidence: 87%

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Use of Neuroimaging for Patients With Dizziness Who Present to Outpatient Clinics vs Emergency Departments in the US

Adams

Karaca‐Mandic

Marmor

2022

JAMA Otolaryngol Head Neck Surg

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IMPORTANCEOveruse 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 (Ն18 years of age) with new diagnoses of dizziness was

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Section: Discussionsupporting

confidence: 88%

Section: Discussionmentioning

confidence: 87%

Use of Neuroimaging for Patients With Dizziness Who Present to Outpatient Clinics vs Emergency Departments in the US

Adams

Karaca‐Mandic

Marmor

2022

JAMA Otolaryngol Head Neck Surg

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“…Studies have shown that patients with a history of ischemic stroke have a high probability of dizziness of central origin when they visit the ED with symptoms of dizziness 12,25 . According to Cheung et al, 25 central‐origin dizziness showed a high probability of association with age ≥ 65 years, history of diabetes, ataxia, focal neurologic symptoms, and a history of ischemic stroke.…”

Section: Discussionmentioning

confidence: 99%

“…To diagnose central lesions among patients with isolated dizziness, it is important to conduct a careful Head Impulse–Nystagmus–Test of Skew (HINTS) examination, followed by imaging studies for confirmation 12 . Magnetic resonance imaging (MRI) is more useful than computed tomography (CT) for diagnosing acute stroke or acute and chronic cerebral hemorrhage 13 .…”

Section: Introductionmentioning

confidence: 99%

Predictive model for diagnosing central lesions in emergency department patients with isolated dizziness who undergo diffusion‐weighted magnetic resonance imaging

Han

Kim

You

et al. 2021

Academic Emergency Medicine

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Objectives Only 5% to 10% of patients who visit the emergency department (ED) with isolated dizziness without neurologic abnormalities may have central lesions; however, it is important to distinguish central lesions through brain imaging. This study was conducted to create a nomogram to provide an objective medical basis for selectively performing magnetic resonance imaging (MRI) among patients with isolated dizziness. Methods This retrospective observational study enrolled patients who visited the ED of a tertiary hospital with isolated dizziness and underwent diffusion‐weighted MRI and subsequently consulted with the departments of neurology, neurosurgery, or otorhinolaryngology. Multivariable logistic regression analysis was performed to identify risk factors in patients diagnosed with central lesions to create a nomogram with the significant variables. Results Of the 1,078 patients who were screened, 119 were diagnosed with central lesions. Significant variables in the multivariable logistic regression analysis were albumin levels (odds ratio [OR] = 0.339, 95% confidence interval [CI] = 0.188 to 0.610, p = 0.0003), inorganic phosphate levels (OR = 0.891, 95% CI = 0.832 to 0.954, p = 0.0010), history of ischemic stroke (OR = 3.170, 95% CI = 1.807 to 5.560, p < 0.0001), presyncope (OR = 3.152, 95% CI = 1.184 to 8.389, p = 0.0216), and nystagmus (OR = 0.365, 95% CI = 0.237 to 0.561, p < 0.0001). The area under the receiver operating characteristic curve of the nomogram created with these variables was 0.7315 (95% CI = 0.6842 to 0.7788, p < 0.0001). Conclusions Albumin, inorganic phosphate, previous stroke, presyncope, and nystagmus were associated with the predictive diagnosis of central lesions among patients admitted to the ED with isolated dizziness. The novel nomogram created using these variables can help in objectively determining the need for MRI in patients presenting with isolated dizziness to the ED.

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“…; 2016 , Hanna et al. ; 2019 ). Clinicians need to be properly trained in basic clinical examination, which reduces the high cost associated with imaging and unnecessarily elevates the threshold for imaging patients with acute vertigo and dizziness.…”

Section: Vertigo and Dizzinessmentioning

confidence: 99%

Neuroimaging for differential diagnosis of transient neurological attacks

Wang

Zha

2022

Brain and Behavior

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Background: Rapid yet comprehensive neuroimaging protocols are required for patients with suspected acute stroke. However, stroke mimics can account for approximately one in five clinically diagnosed acute ischemic strokes and the rate of thrombolyzed mimics can be as high as 17%. Therefore, to accurately determine the diagnosis and differentiate mimics from true transient ischemic attacks, acute ischemic stroke is a challenge to every clinician. Discussion: Medical history and neurological examination, noncontract head computed tomography, and routine magnetic resonance imaging play important roles in the assessment and management of patients with transient neurological attacks in the emergency department. This review attempts to summarize how neuroimaging can be utilized to help differentiate the most common mimics from transient ischemic attack and acute ischemic stroke. Conclusion: Although imaging can help direct critical triage decisions for intravenous thrombolysis or endovascular therapy, more detailed medical history and neurological examination are crucial for making a prompt and accurate diagnosis for transient neurological attack patients. K E Y W O R D S acute ischemic stroke, computed tomography, magnetic resonance image, transient and neurological attack, transient ischemic attack 1 INTRODUCTION Transient neurological attacks (TNAs) are common causes of emergency department (ED) visits. The final diagnosis of patients with TNAs can be divided into three categories: transient ischemic attack (TIA), acute ischemic stroke (AIS), and mimics (Mimics) after obtaining medical history, neurological examination, laboratory tests, and neuroimaging. As the risk of stroke recurrence or progression is highest in the 90 days following the first episode of either TIA or AIS, these two causes are of greatest concern. However, focal ischemia is not the cause of most TNAs. According to the literature, Mimics account for This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

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A comparison of benign positional vertigo and stroke patients presenting to the emergency department with vertigo or dizziness

Cited by 10 publications

References 41 publications

Use of Neuroimaging for Patients With Dizziness Who Present to Outpatient Clinics vs Emergency Departments in the US

Use of Neuroimaging for Patients With Dizziness Who Present to Outpatient Clinics vs Emergency Departments in the US

Predictive model for diagnosing central lesions in emergency department patients with isolated dizziness who undergo diffusion‐weighted magnetic resonance imaging

Neuroimaging for differential diagnosis of transient neurological attacks

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