Impact of Clinician Training Background and Stroke Location on Bedside Diagnostic Test Accuracy in the Acute Vestibular Syndrome – A Meta‐Analysis

Tarnutzer, Alexander A.; Gold, Daniel R.; Wang, Zheyu; Robinson, Karen A.; Kattah, Jorge C.; Mantokoudis, Georgios; Tehrani, Ali S. Saber; Zee, David S.; Edlow, Jonathan A.; Newman‐Toker, David E.

doi:10.1002/ana.26661

Cited by 20 publications

(16 citation statements)

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“…However, in our survey, only a minority of participating PCPs identified the key bedside tests for reliably differentiating between peripheral and central causes in acute prolonged vertigo and dizziness [i.e., HINTS(+) ( 22 )] as being very important, which is also reflected in the distribution of the HINTS(+) score in Figures 4B , C . Furthermore, early MR imaging bears the risk of false-negative findings ( 26 ). This is especially true for small brainstem strokes ( 27 ).…”

Section: Discussionmentioning

confidence: 99%

What is the current status of primary care in the diagnosis and treatment of patients with vertigo and dizziness in Switzerland? A national survey

Zwergal,

Mantokoudis,

Heg

et al. 2023

Front. Neurol.

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BackgroundVertigo 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 methodsBoard-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.ResultsA 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).ConclusionThe 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.

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Section: Discussionmentioning

confidence: 99%

What is the current status of primary care in the diagnosis and treatment of patients with vertigo and dizziness in Switzerland? A national survey

Zwergal,

Mantokoudis,

Heg

et al. 2023

Front. Neurol.

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“…A recent meta-analysis of acute vestibular syndrome ( AVS ), defined as acute, prolonged vertigo/dizziness accompanied by nausea, vomiting, gait imbalance, nystagmus and motion intolerance, lasting longer than 24 h, found the HINTS-plus examination performed by experienced clinicians as a strong diagnostic tool with higher diagnostic accuracy for stroke diagnosis than MRI-DWI in the first 24–48 h [ 5 ▪▪ ]. The Bárány Society Vascular Committee proposed additional temporal profiles: Transient vascular vertigo/dizziness in evolution , which included vertigo lasting <24 h with imaging evidence of ischemia or hemorrhage within an appropriate lesion localization.…”

Section: The Diagnostic Challenge Of a Transient Ischemic Attack Pres...mentioning

confidence: 99%

“…Therefore, it is only simultaneous compromise of other structures in the arterial distribution of the anterior/inferior cerebellar arteries (AICA) that can be utilized to infer labyrinthine ischemia/infarction, with few exceptions, most notably labyrinthine hemorrhage [ 6 ▪ ]. In addition, small strokes in AICA and PICA vascular territory may be initially false negative [ 5 ▪▪ ]. The recommendation from the Bárány Society consensus for the evaluation transient vascular vertigo/dizziness, suggests any vascular imaging available to demonstrate narrowing of extra and intracranial vertebrobasilar arterial vessels or cranio-cervical pain, the latter considering that vertebrobasilar arterial dissection associates with pain [ 7 ].…”

Section: The Diagnostic Challenge Of a Transient Ischemic Attack Pres...mentioning

confidence: 99%

Vascular neuro-otology: vestibular transient ischemic attacks and chronic dizziness in the elderly

Bronstein,

Kattah

2023

Current Opinion in Neurology

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Purpose of review To explore the differential diagnosis of posterior fossa transient ischemic attacks (TIA) associated with vertigo and/or imbalance. To review the contribution of cerebral small vessel (SVD) disease to balance dysfunction and dizziness in the elderly. Main findings TIAs involving vestibular structures that mediate the vestibulo-ocular and vestibulospinal reflexes remain a diagnostic challenge because they overlap with causes of benign episodic vertigo. Here, we summarize the results of multidisciplinary specialty efforts to improve timely recognition and intervention of peripheral and central vestibular ischemia. More papers confirm that SVD is a major cause of gait disability, falls and cognitive disorder in the elderly. Recent work shows that early stages of SVD may also be responsible for dizziness in the elderly. The predominant location of the white matter changes, in the frontal deep white matter and genu of the corpus callosum, explains the association between cognitive and balance dysfunction in SVD related symptoms. Summary The evaluation of patients with intermittent vascular vertigo represent a major diagnostic challenge, recent reviews explore the ideal design approach for a multidisciplinary study to increase early recognition and intervention. Hemispheric white matter microvascular ischemia has been the subject of research progress - advanced stages are known to cause gait disorder and dementia but early stages are associated with “idiopathic” dizziness in the elderly.

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“… 6 Evaluating nystagmus and accurate classification pose a challenge to nonexpert physicians, which hampers the correct application and interpretation of the HINTS examination. 8 , 9 Furthermore, studies show that the nystagmus caused by vestibular strokes has a significantly lower mean slow phase velocity (SPV) than that of peripheral pathologies, which makes identifying the nystagmus in patients with stroke even more challenging in the absence of a quantified eye movement recording. 10 Video oculography (VOG) goggles can address such issues by quantifying eye movements and providing eye position traces and close‐up recording of the eye movements, which assist clinicians in detecting the presence, direction, and velocity of nystagmus.…”

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confidence: 99%

Quantifying Induced Nystagmus Using a Smartphone Eye Tracking Application (EyePhone)

Bastani,

Rieiro,

Badihian

et al. 2024

JAHA

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Background There are ≈5 million annual dizziness visits to US emergency departments, of which vestibular strokes account for over 250 000. The head impulse, nystagmus, and test of skew eye examination can accurately distinguish vestibular strokes from peripheral dizziness. However, the eye‐movement signs are subtle, and lack of familiarity and difficulty with recognition of abnormal eye movements are significant barriers to widespread emergency department use. To break this barrier, we sought to assess the accuracy of EyePhone, our smartphone eye‐tracking application, for quantifying nystagmus. Methods and Results We prospectively enrolled healthy volunteers and recorded the velocity of induced nystagmus using a smartphone eye‐tracking application (EyePhone) and then compared the results with video oculography (VOG). Following a calibration protocol, the participants viewed optokinetic stimuli with incremental velocities (2–12 degrees/s) in 4 directions. We extracted slow phase velocities from EyePhone data in each direction and compared them with the corresponding slow phase velocities obtained by the VOG. Furthermore, we calculated the area under the receiver operating characteristic curve for nystagmus detection by EyePhone. We enrolled 10 volunteers (90% men) with an average age of 30.2±6 years. EyePhone‐recorded slow phase velocities highly correlated with the VOG recordings (r=0.98 for horizontal and r=0.94 for vertical). The calibration significantly increased the slope of linear regression for horizontal and vertical slow phase velocities. Evaluating the EyePhone's performance using VOG data with a 2 degrees/s threshold showed an area under the receiver operating characteristic curve of 0.87 for horizontal and vertical nystagmus detection. Conclusions We demonstrated that EyePhone could accurately detect and quantify optokinetic nystagmus, similar to the VOG goggles.

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Impact of Clinician Training Background and Stroke Location on Bedside Diagnostic Test Accuracy in the Acute Vestibular Syndrome – A Meta‐Analysis

Cited by 20 publications

References 46 publications

What is the current status of primary care in the diagnosis and treatment of patients with vertigo and dizziness in Switzerland? A national survey

What is the current status of primary care in the diagnosis and treatment of patients with vertigo and dizziness in Switzerland? A national survey

Vascular neuro-otology: vestibular transient ischemic attacks and chronic dizziness in the elderly

Quantifying Induced Nystagmus Using a Smartphone Eye Tracking Application (EyePhone)

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