Diagnostic value of eye movement and vestibular function tests in patients with posterior circulation infarction

Xia, Ling; Sang, Wenwen; Shen, Bo; Li, Kangzhi; Si, Lihong; Yang, Xu

doi:10.1080/00016489.2018.1552367

Cited by 6 publications

(10 citation statements)

References 18 publications

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“…The systematic review that focused on the clinical examination 88 identified articles with data related to the general neurological examination, 115–119 cranial nerve testing, 120–122 limb weakness, 36,112,120,121,123,124 dysarthria assessment, 112,121 presence of spontaneous nystagmus, 3,119,122,125 truncal or gait ataxia, 36,115,116,120,126–128 tandem gait assessment, 120,126 limb ataxia, 36,115 any cerebellar sign (unspecified dysmetria, finger to nose, heel to shin, and rapid alternating movement), 112,120,121,126 and hearing loss 112,120,127 . Nearly all of the studies were judged to have moderate to high risk of bias.…”

Section: Methodsmentioning

confidence: 99%

“…The systematic review that focused on the clinical examination 88 identified articles with data related to the general neurological examination, [115][116][117][118][119] cranial nerve testing, [120][121][122] limb weakness, 36,112,120,121,123,124 dysarthria assessment, 112,121 presence of spontaneous nystagmus, 3,119,122,125 truncal or gait ataxia , 36,115,116,120,[126][127][128] tandem gait assessment, 120,126 limb ataxia, 36,115 four TIAs, and one hemorrhage)-these all had NIHSS scores of 0 (minimum) to 4 (maximum), with an interquartile range of 0 to 1. 130…”

Section: General Neurological Examinationmentioning

confidence: 99%

See 1 more Smart Citation

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

Edlow,

Carpenter,

Akhter

et al. 2023

Academic Emergency Medicine

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This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").

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Section: Methodsmentioning

confidence: 99%

Section: General Neurological Examinationmentioning

confidence: 99%

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

Edlow,

Carpenter,

Akhter

et al. 2023

Academic Emergency Medicine

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show abstract

“…The high rates of the absence of nystagmus recorded in PCS may be due to patients' delayed presentation to ER. However, the prevalence of nystagmus in earlier reports of PCS was less than 100% (24-63%) [37][38][39]. Our AVN group whilst having diagnostic quantitative vestibular testing, did not all receive MRI imaging.…”

Section: Study Limitationsmentioning

confidence: 57%

Capturing nystagmus in the emergency room: posterior circulation stroke versus acute vestibular neuritis

et al. 2022

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Objectives To compare acute nystagmus characteristics of posterior circulation stroke (PCS) and acute vestibular neuritis (AVN) in the emergency room (ER) within 24 h of presentation. Methods ER-based video-nystagmography (VNG) was conducted, recording ictal nystagmus in 101 patients with PCS (on imaging) and 104 patients with AVN, diagnosed on accepted clinical and vestibular test criteria. Results Patients with stroke in the brainstem (38/101, affecting midbrain (n = 7), pons (n = 19), and medulla (n = 12)), cerebellum (31/101), both (15/101) or other locations (17/101) were recruited. Common PCS territories included posterior-inferior-cerebellar-artery (41/101), pontine perforators (18/101), multiple-territories (17/101) and anterior-inferior-cerebellar-artery (7/101). In PCS, 44/101 patients had no spontaneous nystagmus. Remaining PCS patients had primary position horizontal (44/101), vertical (8/101) and torsional (5/101) nystagmus. Horizontal nystagmus was 50% ipsiversive and 50% contraversive in lateralised PCS. Most PCS patients with horizontal nystagmus (28/44) had unidirectional “peripheral-appearing” nystagmus. 32/101 of PCS patients had gaze-evoked nystagmus. AVN affected the superior, inferior or both divisions of the vestibular nerve in 55/104, 4/104 and 45/104. Most (102/104) had primary position horizontal nystagmus; none had gaze-evoked nystagmus. Two inferior VN patients had contraversive torsional-downbeat nystagmus. Horizontal nystagmus with SPV ≥ 5.8 °/s separated AVN from PCS with sensitivity and specificity of 91.2% and 83.0%. Absent nystagmus, gaze-evoked nystagmus, and vertical-torsional nystagmus were highly specific for PCS (100%, 100% and 98.1%). Conclusion Nystagmus is often absent in PCS and always present in AVN. Unidirectional ‘peripheral-appearing’ horizontal nystagmus can be seen in PCS. ER-based VNG nystagmus assessment could provide useful diagnostic information when separating PCS from AVN.

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“…While in some studies results from both the initial bedside oculomotor examination and a subsequent dedicated quantitative oculomotor examination are reported, we focused on the findings from the clinical bedside oculomotor exam. In two studies initially included, no bedside testing could be identified, thus these studies were excluded from further analysis (30,31). In another study included it remained unclear if reported qualitative spontaneous nystagmus patterns were based on bedside testing or on quantitative VOG recordings (32).…”

Section: Resultsmentioning

confidence: 99%

Systematic review and meta-analysis of the diagnostic accuracy of spontaneous nystagmus patterns in acute vestibular syndrome

Wang

Martínez³

et al. 2023

Front. Neurol.

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ObjectivesFor the assessment of patients presenting with acute prolonged vertigo meeting diagnostic criteria for acute vestibular syndrome (AVS), bedside oculomotor examinations are essential to distinguish peripheral from central causes. Here we assessed patterns of spontaneous nystagmus (SN) observed in AVS and its diagnostic accuracy at the bedside.MethodsMEDLINE and Embase were searched for studies (1980–2022) reporting on the bedside diagnostic accuracy of SN-patterns in AVS patients. Two independent reviewers determined inclusion. We identified 4,186 unique citations, examined 219 full manuscripts, and analyzed 39 studies. Studies were rated on risk of bias (QUADAS-2). Diagnostic data were extracted and SN beating-direction patterns were correlated with lesion locations and lateralization.ResultsIncluded studies reported on 1,599 patients, with ischemic strokes (n = 747) and acute unilateral vestibulopathy (n = 743) being most frequent. While a horizontal or horizontal-torsional SN was significantly more often found in peripheral AVS (pAVS) than in central AVS (cAVS) patients (672/709 [94.8%] vs. 294/677 [43.4%], p < 0.001), torsional and/or vertical SN-patterns were more prevalent in cAVS than in pAVS (15.1 vs. 2.6%, p < 0.001). For an (isolated) vertical/vertical-torsional SN or an isolated torsional SN specificity (97.7% [95% CI = 95.1–100.0%]) for a central origin etiology was high, whereas sensitivity (19.1% [10.5–27.7%]) was low. Absence of any horizontal SN was more frequently observed in cAVS than in pAVS (55.2 vs. 7.0%, p < 0.001). Ipsilesional and contralesional beating directions of horizontal SN in cAVS were found at similar frequency (28.0 vs. 21.7%, p = 0.052), whereas for pAVS a contralesional SN was significantly more frequent (95.2 vs. 2.5%, p < 0.001). For PICA strokes presenting with horizontal SN, beating direction was ipsilesional more often than contralesional (23.9 vs. 6.4%, p = 0.006), while the opposite was observed for AICA strokes (2.2 vs. 63.0%, p < 0.001).Conclusions(Isolated) vertical and/or torsional SN is found in a minority (15.1%) of cAVS patients only. When present, it is highly predictive for a central cause. A combined torsional-downbeating SN-pattern may be observed in pAVS also in cases with isolated lesions of the inferior branch of the vestibular nerve. Furthermore, in cAVS patients the SN beating direction itself does not allow a prediction on the lesion side.

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Diagnostic value of eye movement and vestibular function tests in patients with posterior circulation infarction

Cited by 6 publications

References 18 publications

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

Capturing nystagmus in the emergency room: posterior circulation stroke versus acute vestibular neuritis

Systematic review and meta-analysis of the diagnostic accuracy of spontaneous nystagmus patterns in acute vestibular syndrome

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