Value of Magnetic Resonance Imaging and Audiology in the Emergency Department in Differential Diagnosis of Peripheral and Central Vertigo

Özakın, Engin; Çoşkun, Figen; Saraç, Sarp; Oğuz, Kader K.; Bozkurt, Şebnem

doi:10.5336/medsci.2010-20673

Cited by 4 publications

(17 citation statements)

References 11 publications

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“…Four studies evaluated 1135 patients for dysmetria, two used fingerto-nose, one used unspecified dysmetria, and one used a combination of dysmetria and/or dysdiadochokinesia. 17,40,48,49 The pooled estimates for sensitivity were 24.6% (95% CI 15.6%-36.5%, moderate certainty) and specificity 97.8% (95% CI 94.4%-99.2%, moderate certainty; Figure S1).…”

Section: Dysmetriamentioning

confidence: 99%

“…Five studies with a total of 869 patients evaluated the diagnostic accuracy of the general neurologic examination, defined as abnormal when having a focal neurologic deficit [49][50][51][52] or more than one neurologic finding on examination. 53 In a meta-analysis, sensitivity was 46.8% (95% CI 32.3%-61.9%, moderate certainty) and specificity was 92.8% (95% CI 75.7%-98.1%, low certainty) for identifying all central causes.…”

Section: General Neurologic Examinationmentioning

confidence: 99%

“…Six studies evaluated 621 patients for the presence of spontaneous nystagmus and its ability to differentiate between central and peripheral causes of dizziness/vertigo. 11,12,44,49,55,56 A true positive was defined as the presence of spontaneous nystagmus in a patient with a central cause of dizziness. Pooled estimates revealed a sensitivity of 52.3% (95% CI 29.8%-74.0%, low certainty; Figure 2A).…”

Section: Spontaneous Nystagmusmentioning

confidence: 99%

“…f Four of 10 studies were at high risk of bias. 48,53,59,60 g Three of four studies were at moderate risk of bias, 17,40,49 one study was at high risk of bias. The 95% CI for sensitivity fell below the predetermined threshold of 70% for specificity.…”

Section: Truncal/gait Ataxiamentioning

confidence: 99%

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Diagnostic accuracy of the physical examination in emergency department patients with acute vertigo or dizziness: A systematic review and meta‐analysis for GRACE‐3

Shah

Silva

Farah

et al. 2023

Academic Emergency Medicine

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Background History and physical examination are key features to narrow the differential diagnosis of central versus peripheral causes in patients presenting with acute vertigo. We conducted a systematic review and meta‐analysis of the diagnostic test accuracy of physical examination findings. Methods This study involved a patient–intervention–control–outcome (PICO) question: (P) adult ED patients with vertigo/dizziness; (I) presence/absence of specific physical examination findings; and (O) central (ischemic stroke, hemorrhage, others) versus peripheral etiology. Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) was assessed. Results From 6309 titles, 460 articles were retrieved, and 43 met the inclusion criteria: general neurologic examination—five studies, 869 patients, pooled sensitivity 46.8% (95% confidence interval [CI] 32.3%–61.9%, moderate certainty) and specificity 92.8% (95% CI 75.7%–98.1%, low certainty); limb weakness/hemiparesis—four studies, 893 patients, sensitivity 11.4% (95% CI 5.1%–23.6%, high) and specificity 98.5% (95% CI 97.1%–99.2%, high); truncal/gait ataxia—10 studies, 1810 patients (increasing severity of truncal ataxia had an increasing sensitivity for central etiology, sensitivity 69.7% [43.3%–87.9%, low] and specificity 83.7% [95% CI 52.1%–96.0%, low]); dysmetria signs—four studies, 1135 patients, sensitivity 24.6% (95% CI 15.6%–36.5%, high) and specificity 97.8% (94.4%–99.2%, high); head impulse test (HIT)—17 studies, 1366 patients, sensitivity 76.8% (64.4%–85.8%, low) and specificity 89.1% (95% CI 75.8%–95.6%, moderate); spontaneous nystagmus—six studies, 621 patients, sensitivity 52.3% (29.8%–74.0%, moderate) and specificity 42.0% (95% CI 15.5%–74.1%, moderate); nystagmus type—16 studies, 1366 patients (bidirectional, vertical, direction changing, or pure torsional nystagmus are consistent with a central cause of vertigo, sensitivity 50.7% [95% CI 41.1%–60.2%, moderate] and specificity 98.5% [95% CI 91.7%–99.7%, moderate]); test of skew—15 studies, 1150 patients (skew deviation is abnormal and consistent with central etiology, sensitivity was 23.7% [95% CI 15%–35.4%, moderate] and specificity 97.6% [95% CI 96%–98.6%, moderate]); HINTS (head impulse, nystagmus, test of skew)—14 studies, 1781 patients, sensitivity 92.9% (95% CI 79.1%–97.9%, high) and specificity 83.4% (95% CI 69.6%–91.7%, moderate); and HINTS+ (HINTS with hearing component)—five studies, 342 patients, sensitivity 99.0% (95% CI 73.6%–100%, high) and specificity 84.8% (95% CI 70.1%–93.0%, high). Conclusions Most neurologic examination findings have low sensitivity and high specificity for a central cause in patients with acute vertigo or dizziness. In acute vestibular syndrome (monophasic, continuous, persistent dizziness), HINTS and HINTS+ have high sensitivity when performed by trained clinicians.

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Section: Dysmetriamentioning

confidence: 99%

Section: General Neurologic Examinationmentioning

confidence: 99%

Section: Spontaneous Nystagmusmentioning

confidence: 99%

Section: Truncal/gait Ataxiamentioning

confidence: 99%

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Diagnostic accuracy of the physical examination in emergency department patients with acute vertigo or dizziness: A systematic review and meta‐analysis for GRACE‐3

Shah

Silva

Farah

et al. 2023

Academic Emergency Medicine

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“…Central vertigo is, while quite uncommon, life threatening. [4] Thus, the distinction must definitely be made in the ED. The aetiology, most of the time, can only be determined through the medical record and physical examination.…”

Section: Amaçmentioning

confidence: 99%

Cost of Neuroimaging of Patients with Vertigo in Emergency Department

Kablan

Karaman

Başol

2019

Journal of Contemporary Medicine

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Introduction: The fact that many diseases cause symptoms of vertigo and that some of them are life-threatening make it difficult to manage vertigo in emergency departments (ED). Parallel to these difficulties, the number of neuroimaging use in diagnosis is increasing. In this study, it is aimed to evaluate the neuroimaging costs of patients with vertigo in ED. Methods: The study was carried out with a retrospective review of the files of the patients with vertigo who were admitted to ED between 01.01.2013 and 31.12.2013. Patients were classified into 6 groups; central, peripheral, cardiac and blood pressure-induced, induced by internal causes, psychogenic, and vertigo related to other causes. Costs and the total cost of these groups were determined and the ratios were analyzed statistically. Results: Of the 381 patients; 31 (8.1%) patients were seen to be in the central, 175 (45.9%) in the peripheral vertigo. 72 of patients were seen to have been examined with computerized tomography (CT) and 35 with magnetic resonance imaging (MRI). Neuroimaging was observed to have been implemented mostly on the central induced group. The highest neuroimaging cost was in the peripheral vertigo group. However, when the cost per patient was calculated, the group with the lowest cost of each patient was the peripheral vertigo group. Discussion and Conclusion: This study is the first study in Turkey for the cost analysis patients with a complaint of vertigo in ED. Avoiding unnecessary costs, along with the algorithms to be developed, can be possible with good and accurate patient management in ED.

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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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Value of Magnetic Resonance Imaging and Audiology in the Emergency Department in Differential Diagnosis of Peripheral and Central Vertigo

Cited by 4 publications

References 11 publications

Diagnostic accuracy of the physical examination in emergency department patients with acute vertigo or dizziness: A systematic review and meta‐analysis for GRACE‐3

Diagnostic accuracy of the physical examination in emergency department patients with acute vertigo or dizziness: A systematic review and meta‐analysis for GRACE‐3

Cost of Neuroimaging of Patients with Vertigo in Emergency Department

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

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