Risk of future stroke in patients with a diagnosis of peripheral vertigo in the emergency department

Abstract

Vertigo is one of the most common symptoms of patients in the emergency department (ED), being reported in approximately 2.5%-4% of all ED patients [1,2]. Amongst the various neurological or nonneurological medical disorders causing vertigo, stroke is reported in approximately 3%-4% [3,4], but its prevalence could vary from 0.7% to 27% depending on the population studied [4-6]. Individualized risk assessment, detailed oculomotor examination and the progress of modern neuroimaging techniques have substantially improved the diagnostic accuracy for stroke-related vertigo [7][8][9][10][11][12].Despite advances in current diagnostics, patients discharged from the ED with a diagnosis of peripheral vertigo are known to have an unignorable stroke risk [13][14][15][16]]. There may be three possible explanations for this risk. First, stroke after ED discharge may be due to a missed diagnosis of stroke that has already occurred [17,18].

Characteristics and risk of stroke in emergency department patients with acute dizziness

“…The risk was approximately 6 times higher at 7 days and gradually declined with increasing time from discharge. Similar results have been shown in several prior studies [ 11 , 20 , 38 , 39 ].…”

“…However, an overemphasis on this approach may lead to a missed stroke diagnosis [ 36 , 37 ], posing a diagnostic challenge to ED physicians. This study, in line with previous ones [ 11 , 17 , 20 ], found that ED patients presenting with acute dizziness have a non-negligible risk of stroke even after being discharged from the ED without a stroke diagnosis. Several new observations that may extend current knowledge regarding this issue are discussed as follows.…”

“…After the early post-ED discharge period, patients with dizziness still had a more than two-fold risk of stroke within 365 days after ED discharge, compared to those with abdominal or flank pain. Consistent with previous studies [ 11 , 20 ], the increased risk of stroke in dizzy patients gradually decreased over time. According to a prior study [ 20 ], the heightened stroke risk appeared to disappear after one year.…”

“…Consistent with previous studies [ 11 , 20 ], the increased risk of stroke in dizzy patients gradually decreased over time. According to a prior study [ 20 ], the heightened stroke risk appeared to disappear after one year. However, based on the landmark analysis, the increased stroke risk became insignificant for patients who remained stroke-free 90 days after ED discharge.…”

“…Following the ideas of previous studies [ 13 , 20 ], patients aged 20 years or older presenting with abdominal or flank pain were chosen as the comparison cohort because they are common in the emergency setting, often discharged home from the ED, and generally not associated with poor outcomes. Similarly, only the first ED visit was considered if they had repeat ED visits for abdominal or flank pain.…”