Acute Vestibular Syndrome

Hotson, John R.; Baloh, Robert W.

doi:10.1056/nejm199809033391007

Cited by 280 publications

(203 citation statements)

References 41 publications

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“…8,18,[25][26][27] Most stroke patients present with persistent symptoms. Acute vestibular syndrome (AVS) is a well-defined clinical syndrome 28 of acute, persistent vertigo or dizziness lasting days to several weeks with associated nausea or vomiting, head motion intolerance, gait unsteadiness, and nystagmus. 8 AVS patients (10% to 20% of ED dizziness presentations 8 ) are at higher risk for stroke (25%) than average ED dizziness patients (4% to 6%), but the majority of AVS patients (70%) still have benign peripheral causes.…”

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confidence: 99%

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Newman‐Toker

Kerber

Hsieh

et al. 2013

Academic Emergency Medicine

307

351

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ObjectivesDizziness and vertigo account for about 4 million emergency department (ED) visits annually in the United States, and some 160,000 to 240,000 (4% to 6%) have cerebrovascular causes. Stroke diagnosis in ED patients with vertigo/dizziness is challenging because the majority have no obvious focal neurologic signs at initial presentation. The authors sought to compare the accuracy of two previously published approaches purported to be useful in bedside screening for possible stroke in dizziness: a clinical decision rule (head impulse, nystagmus type, test of skew [HINTS]) and a risk stratification rule (age, blood pressure, clinical features, duration of symptoms, diabetes [ABCD2]).MethodsThis was a cross‐sectional study of high‐risk patients (more than one stroke risk factor) with acute vestibular syndrome (AVS; acute, persistent vertigo or dizziness with nystagmus, plus nausea or vomiting, head motion intolerance, and new gait unsteadiness) at a single academic center. All underwent neurootologic examination, neuroimaging (97.4% by magnetic resonance imaging [MRI]), and follow‐up. ABCD2 risk scores (0–7 points), using the recommended cutoff of ≥4 for stroke, were compared to a three‐component eye movement battery (HINTS). Sensitivity, specificity, and positive and negative likelihood ratios (LR+, LR–) were assessed for stroke and other central causes, and the results were stratified by age. False‐negative initial neuroimaging was also assessed.ResultsA total of 190 adult AVS patients were assessed (1999–2012). Median age was 60.5 years (range = 18 to 92 years; interquartile range [IQR] = 52.0 to 70.0 years); 60.5% were men. Final diagnoses were vestibular neuritis (34.7%), posterior fossa stroke (59.5% [105 infarctions, eight hemorrhages]), and other central causes (5.8%). Median ABCD2 was 4.0 (range = 2 to 7; IQR = 3.0 to 4.0). ABCD2 ≥ 4 for stroke had sensitivity of 61.1%, specificity of 62.3%, LR+ of 1.62, and LR– of 0.62; sensitivity was lower for those younger than 60 years old (28.9%). HINTS stroke sensitivity was 96.5%, specificity was 84.4%, LR+ was 6.19, and LR– was 0.04 and did not vary by age. For any central lesion, sensitivity was 96.8%, specificity was 98.5%, LR+ was 63.9, and LR– was 0.03 for HINTS, and sensitivity was 99.2%, specificity was 97.0%, LR+ was 32.7, and LR– was 0.01 for HINTS “plus” (any new hearing loss added to HINTS). Initial MRIs were falsely negative in 15 of 105 (14.3%) infarctions; all but one was obtained before 48 hours after onset, and all were confirmed by delayed MRI.ConclusionsHINTS substantially outperforms ABCD2 for stroke diagnosis in ED patients with AVS. It also outperforms MRI obtained within the first 2 days after symptom onset. While HINTS testing has traditionally been performed by specialists, methods for empowering emergency physicians (EPs) to leverage this approach for stroke screening in dizziness should be investigated.

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confidence: 99%

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Newman‐Toker

Kerber

Hsieh

et al. 2013

Academic Emergency Medicine

307

351

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“…When dizziness de velops acutely, is accompanied by nausea or vomiting, unsteady gait, nystagmus and intolerance to head motion, and persists for a day or more, the clinical condition is known as acute vestibular syndrome. 5,6 We define isolated acute vestibular syndrome (with or without hearing loss) as occurring in the absence of focal neurologic signs such as hemiparesis, hemisensory loss or gaze palsy. Transient dizziness has a differential diagnosis distinct from that of acute vestibular syndrome, and the approach to diagnosis should differ accordingly.…”

mentioning

confidence: 99%

Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome

Tarnutzer

Berkowitz

Robinson

et al. 2011

CMAJ

357

385

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“…[19][20][21][22] The management of vestibular neuritis includes (1) symptomatic care for nausea/vomiting and vertigo, (2) etiological treatments, and (3) vestibular rehabilitation to improve central compensation.…”

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confidence: 99%