Vestibular syndromes, diagnosis and diagnostic errors in patients with dizziness presenting to the emergency department: a cross-sectional study

Abstract

ObjectivesWe aimed to determine the frequency of vestibular syndromes, diagnoses, diagnostic errors and resources used in patients with dizziness in the emergency department (ED).DesignRetrospective cross-sectional study.SettingTertiary referral hospital.ParticipantsAdult patients presenting with dizziness.Primary and secondary outcome measuresWe collected clinical data from the initial ED report from July 2015 to August 2020 and compared them with the follow-up report if available. We calculated the prevalence of vestibular syndromes and stroke prevalence in patients with dizziness. Vestibular syndromes are differentiated in acute (AVS) (eg, stroke, vestibular neuritis), episodic (EVS) (eg, benign paroxysmal positional vertigo, transient ischaemic attack) and chronic (CVS) (eg, persistent postural-perceptual dizziness) vestibular syndrome. We reported the rate of diagnostic errors using the follow-up diagnosis as the reference standard.ResultsWe included 1535 patients with dizziness. 19.7% (303) of the patients presented with AVS, 34.7% (533) with EVS, 4.6% (71) with CVS and 40.9% (628) with no or unclassifiable vestibular syndrome. The three most frequent diagnoses were stroke/minor stroke (10.1%, 155), benign paroxysmal positional vertigo (9.8%, 150) and vestibular neuritis (9.6%, 148). Among patients with AVS, 25.4% (77) had stroke. The cause of the dizziness remained unknown in 45.0% (692) and 18.0% received a false diagnosis. There was a follow-up in 662 cases (43.1%) and 58.2% with an initially unknown diagnoses received a final diagnosis. Overall, 69.9% of all 1535 patients with dizziness received neuroimaging (MRI 58.2%, CT 11.6%) in the ED.ConclusionsOne-fourth of patients with dizziness in the ED presented with AVS with a high prevalence (10%) of vestibular strokes. EVS was more frequent; however, the rate of undiagnosed patients with dizziness and the number of patients receiving neuroimaging were high. Almost half of them still remained without diagnosis and among those diagnosed were often misclassified. Many unclear cases of vertigo could be diagnostically clarified after a follow-up visit.

Digital biomarkers from gaze tests for classification of central and peripheral lesions in acute vestibular syndrome

“…In conclusion, these results are highly encouraging and strongly motivate further investigation into nystagmus biomarkers, such as vertical nystagmus, up and down gaze tests, and wave-shapes which are known to be diagnostically relevant ( 8 , 22 , 23 ). While acknowledging the limitations of our small sample size, these preliminary findings suggest significant potential, with the biomarkers surpassing the performance of features conventionally used in nystagmus analysis, and a baseline machine learning model.…”

Do monosymptomatic stroke patients with dizziness present a vestibular syndrome without nystagmus? An underestimated entity

“…All patients were classified into one of three categories of vestibular syndromes based on predefined criteria [16]: (i) AVS (state of continuous dizziness and additional symptoms and signs such as nausea, vomiting, SN, head motion intolerance, or new gait/balance disturbance); (ii) episodic vestibular syndrome (EVS; short duration of <24 h or repeated episodes of vertigo); and (iii) acute imbalance syndrome (AIS) if patients did not fulfill all the criteria of a vestibular syndrome (e.g., acute vestibular symptoms such as vertigo, dizziness, postural symptoms, vestibulovisual symptoms with no recorded nystagmus). Thus, patients with acute onset of vestibular symptoms and no recorded nystagmus who could therefore not be classified as having AVS were classified as AIS [17].…”

“…The diagnosis remained unknown in 45% of the cases. A recent retrospective analysis of all screened patients showed a total of 26 missed strokes at the follow-up [17].…”

Different clinical course of BPPV according to the medical conditions

“…In some cases, the symptoms may be mild and do not require a hospital visit, but in others, patients may experience severe dizziness and require a visit to the emergency room. According to a recent report, 9.8% of patients who visited the emergency room with dizziness had BPPV 7 .…”