Rate and Predictors of Serious Neurologic Causes of Dizziness in the Emergency Department

Navi, Babak B.; Kamel, Hooman; Shah, Maulik P.; Grossman, Aaron W.; Wong, Christine; Poisson, Sharon N.; Whetstone, William D.; Josephson, S. Andrew; Johnston, S. Claiborne; Kim, Anthony

doi:10.1016/j.mayocp.2012.05.023

Cited by 113 publications

(121 citation statements)

References 19 publications

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“…A single‐center study found that 11% of ED visits related to complaints of vertigo or dizziness (Lammers et al., 2011). Isolated vertigo or dizziness can be symptoms preceding posterior circulation stroke or the only symptom of cerebral infarction, results of other studies found that among patients with isolated vertigo or dizziness, about 0.7%–10% are due to acute cerebral infarction (Doijiri, Uno, Miyashita, Ihara, & Nagatsuka, 2016; Kerber, Brown, Lisabeth, Smith, & Morgenstern, 2006; Mosarrezai et al., 2012; Navi et al., 2012; Paul, Simoni, & Rothwell, 2013). In the present study, we found a diagnosis of cerebral infarction among 46/273 (16.8%) hospitalized patients presenting acutely to ED with isolated vertigo or dizziness.…”

Section: Discussionmentioning

confidence: 99%

“…A retrospective analysis reviewed 907 case of dizziness visited in emergency department (ED) and found 37 cases (4%) were vascular origin. The vascular dizziness were associated with age >60 years old, accompanying imbalance and focal neurological deficits (Navi et al., 2012). Researches also suggested that vertebral artery hypoplasia, posterior circulation stenosis, and diabetes were correlated with stroke (Mosarrezai, Toghae, Majed, & Aloosh, 2012; Zhang et al., 2017).…”

Section: Introductionmentioning

confidence: 99%

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Clinical and laboratory factors related to acute isolated vertigo or dizziness and cerebral infarction

et al. 2018

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ObjectiveTo clarify the relationship of clinical factors with isolated vertigo or dizziness of cerebrovascular origin.MethodsClinical data of patients admitted in East Hospital from Jan. 2015 to Apr. 2016, whose complaint were acute vertigo or dizziness were retrospectively collected. All patients arrived at the emergency department within 24 hr of symptom onset, had no acute ischemic lesion first CT and NIHSS score of 0. Patients were divided into cerebral infarction group and noncerebral infarction group according to subsequent cerebral imaging results and clinical and laboratory factors related to cerebral infarction were analyzed.Result51.6% of patients were female (n = 141). 46 patients (16.8%) were diagnosed with acute cerebral infarction. Baseline demographic data of the two groups was not significantly different. Univariate analysis found that history of smoking (p = 0.009), headache (p = 0.028), unsteadiness (p = 0.009), neuron specific enolase (p = 0.001), and vertebral artery abnormalities found on imaging (p = 0.009) were the significant difference between two groups. Increased neuron specific enolase (p = 0.005) and an abnormal vertebral artery (p = 0.044) were significant on multivariate analysis.Conclusions16.8% of acute isolated vertigo or dizziness presentations were diagnosed with acute cerebral infarction. Increased serum neuron specific enolase and vertebral artery abnormalities were the strongest indicators of acute cerebral infarction.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Clinical and laboratory factors related to acute isolated vertigo or dizziness and cerebral infarction

et al. 2018

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“…[2][3][4][5][6] Rapid, accurate diagnosis of stroke is important to initiate acute treatments and monitor patients to prevent complications. 7 For example, missed cerebellar stroke at the initial ED visit may confer up to an eightfold increased risk of death.…”

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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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“…SBP ²150 and DBP ²85 were entered into the multivariate logistic regression analysis because they were derived by the ROC curve analysis in the present study, and age ²60 years because it has been shown to be a predictive of stroke in other studies. 15 Ikeda brain structures relate to a system-mediating pressor response close to the cerebellum. 17 It may therefore be possible to assume that DBP in stroke cases is higher than in non-stroke cases; indeed, all our stroke cases included a cerebellar lesion.…”

Section: Discussionmentioning

confidence: 99%

Using Diastolic Blood Pressure to Diagnose Acute Stroke in Isolated Acute Vestibular Syndrome

Matsumoto

Kishikawa

Okuyama

et al. 2016

J of Gen and Family Med

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Background: Although diagnosis of isolated acute vestibular syndrome (AVS) via physical examination has been reported, a great deal of experience is needed to interpret the results. Patients with AVS often cannot participate in a physical examination, and not every emergency department (ED) is equipped with a magnetic resonance imaging machine. Therefore, in isolated AVS, clinical factors other than those used by general physicians and/or residents are required to identify strokes in these patients. The aim of this study was to determine those clinical factors useful in differentiating stroke patients from isolated AVS patients in the ED setting. Methods:We examined the records of 116 consecutive patients who presented to the ED between May 2010 and April 2013 with AVS (acute vertigo or dizziness, nystagmus, nausea/vomiting, head-motion intolerance, unsteady gait) and without auditory symptoms, head and/or neck pain, or neurological findings. Patients underwent diagnostic neuroimaging. Clinical characteristics and vital signs measured in the ambulance were assessed. Multivariate logistic regression analysis was performed to evaluate the associations of systolic blood pressure (SBP) ²150 mmHg, diastolic blood pressure (DBP) ²85 mmHg, heart rate, age ²60 years, and dyslipidemia with stroke.Results: Stroke was diagnosed in eight of the 116 (6.9%) patients with isolated AVS. DBP ²85 mmHg (odds ratio 29.0; 95% confidence interval 3.38-249) was the only significant and independent factor associated with stroke among patients with isolated AVS. Journal of General and Family Medicine 2016, vol. 17, no. 3, p. 218-224. Original Articles -218 -Conclusion: This study identified DBP ²85 mmHg to be a simple and useful clinical factor differentiating stroke from non-stroke isolated AVS.

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Rate and Predictors of Serious Neurologic Causes of Dizziness in the Emergency Department

Cited by 113 publications

References 19 publications

Clinical and laboratory factors related to acute isolated vertigo or dizziness and cerebral infarction

Clinical and laboratory factors related to acute isolated vertigo or dizziness and cerebral infarction

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

Using Diastolic Blood Pressure to Diagnose Acute Stroke in Isolated Acute Vestibular Syndrome

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