Videooculography “HINTS” in Acute Vestibular Syndrome: A Prospective Study

Korda, Athanasia; Wimmer, Wilhelm; Zamaro, Ewa; Wagner, Franca; Sauter, Thomas; Caversaccio, Marco; Mantokoudis, Georgios

doi:10.3389/fneur.2022.920357

Cited by 13 publications

(9 citation statements)

References 30 publications

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“…Future work should focus on education and training of ED providers on appropriate application and interpretation of Dix–Hallpike test and treatment of BPPV. In addition, as providers become more familiar with pc‐BPPV and if subsequent data confirm recent studies suggesting that hc‐BPPV is more common in an early‐presenting population than previously thought, 3,61,181,182,237 learning about other variants, especially geotropic and apogeotropic hc‐BPPV, will allow correct management of a much larger proportion of BPPV patients (and thus, of all patients with acute dizziness).…”

Section: Methodsmentioning

confidence: 70%

“…178 Although routine ED use of VOG may seem far off, it was not that long ago that cardiologists routinely overread all electrocardiograms performed in the ED, a skill that is now firmly within the scope of emergency medicine. Early feasibility studies of VOG in the ED show promise 61,[179][180][181][182] and could become standard over time.…”

Section: Conclusion and Research Needsmentioning

confidence: 99%

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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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Section: Methodsmentioning

confidence: 70%

Section: Conclusion and Research Needsmentioning

confidence: 99%

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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“…In addition, we did not analyze other tests such as nystagmus and test of skew. We expect that the combination of several tests (which is reflected in the three steps “HINTS” exam), would further improve AI sensitivity ( 32 ). AVS patients suffer from imbalance and gait disturbance.…”

Section: Discussionmentioning

confidence: 99%

Artificial intelligence for early stroke diagnosis in acute vestibular syndrome

et al. 2022

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ObjectiveMeasuring the Vestibular-Ocular-Reflex (VOR) gains with the video head impulse test (vHIT) allows for accurate discrimination between peripheral and central causes of acute vestibular syndrome (AVS). In this study, we sought to investigate whether the accuracy of artificial intelligence (AI) based vestibular stroke classification applied in unprocessed vHIT data is comparable to VOR gain classification.MethodsWe performed a prospective study from July 2015 until April 2020 on all patients presenting at the emergency department (ED) with signs of an AVS. The patients underwent vHIT followed by a delayed MRI, which served as a gold standard for stroke confirmation. The MRI ground truth labels were then applied to train a recurrent neural network (long short-term memory architecture) that used eye- and head velocity time series extracted from the vHIT examinations.ResultsWe assessed 57 AVS patients, 39 acute unilateral vestibulopathy patients (AUVP) and 18 stroke patients. The overall sensitivity, specificity and accuracy for detecting stroke with a VOR gain cut-off of 0.57 was 88.8, 92.3, and 91.2%, respectively. The trained neural network was able to classify strokes with a sensitivity of 87.7%, a specificity of 88.4%, and an accuracy of 87.9% based on the unprocessed vHIT data. The accuracy of these two methods was not significantly different (p = 0.09).ConclusionAI can accurately diagnose a vestibular stroke by using unprocessed vHIT time series. The quantification of eye- and head movements with the use of machine learning and AI can serve in the future for an automated diagnosis in ED patients with acute dizziness. The application of different neural network architectures can potentially further improve performance and enable direct inference from raw video recordings.

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“…Hier sind nur größere vertikale Deviationswinkel, also klinisch deutliche Vertikaldeviationen spezifisch für eine zentrale Läsion 35 . Die diagnostische Sensitivität der HINTS-Trias für die Differenzierung peripherer und zentraler Ursachen eines AVS liegt in verschiedenen Studien bei 95–100 % 17, 30 , 36 . Beim Kriterium einer Suppression eines Spontannystagmus durch visuelle Fixation gilt, dass ein Nystagmus sicher zentral ist, falls dieser nicht supprimiert wird.…”

Section: Klinische Untersuchungunclassified

“…Eine herausgehobene Stellung nimmt dabei die Testung des Video-Kopfimpulstest (vHIT) ein. In mehreren Arbeiten wurde die Überlegenheit des vHIT gegenüber dem klinischen Kopfimpulstest (bHIT) insbesondere in der sensitiven Erfassung akuter zentraler Schwindelursachen gezeigt 32 , 33 , 36 . Von mehreren Autoren wurde dabei als zentraler Parameter der Verstärkungsfaktor des horizontalen vestibulo-okulären Reflexes („VOR-Gain“) mit einem Schwellenwert von 0,7 für die Differenzierung peripheren und zentraler Ursachen eines AVS vorgeschlagen 17 , 21 , 33 , 42 , 43 .…”

Section: Apparative Neurootologische Diagnostikunclassified

Akutes zentrales vestibuläres Syndrom

Zwergal¹,

Filippopulos²,

Huppert³

et al. 2023

Nervenheilkunde

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ZUSAMMENFASSUNGEinem akuten Schwindelsyndrom liegt in 4–15 % der Fälle ein akutes zentrales vestibuläres Syndrom in Folge eines Schlaganfalls im Bereich des Hirnstamms und/oder Kleinhirns zugrunde. Bei der differenzialdiagnostischen Einordnung helfen insbesondere die gezielte Anamnese, klinische und apparative Untersuchung der vestibulären und okulomotorischen Systeme und der bedarfsweise Einsatz geeigneter zerebraler Bildgebung weiter. Die Anamnese sollte folgende Aspekte umfassen: Akuität des Symptombeginns, schwindelspezifische Trigger, Begleitsymptome und Vorgeschichte von Schwindelattacken. Die Schwindelqualität, -intensität und -dauer helfen hingegen nicht bei der Differenzierung zu peripher-vestibulären Ursachen. Die zielgerichtete klinische vestibuläre und okulomotorische Untersuchung umfasst 4 Tests: Untersuchung auf Spontan-/Provokations-/Blickrichtungs-/Lagerungs-/Lagenystagmus, Kopfimpulstest, Abdecktest zur Erfassung einer Vertikaldeviation und Romberg-Stehversuch mit Frage nach posturaler Instabilität. Eine videookulografiegestützte Testung des Kopfimpulstests (vHIT) erhöht die Genauigkeit für die Erfassung einer zentralen Ursache (Schwellenwert für Verstärkungsfaktor: 0,7). Bildgebende Diagnostik sollte bei klinischem Verdacht auf eine zentrale Ursache durchgeführt werden. Der MRT-basierte Nachweis eines Schlaganfalls gelingt am besten 3–5 Tage nach Symptombeginn, während Diffusionsstörungen < 10 mm in der Akutphase nur in ca. 50 % der Fälle erfasst werden. Für die Therapie des akuten zentralen vestibulären Syndroms mittels intravenöser Thrombolyse gibt es keine hochwertigen und kontrollierten Untersuchungen. Die Nachbehandlung des akuten zentralen vestibulären Syndroms umfasst ein multimodales Gleichgewichtstraining zur Förderung der vestibulären Kompensation. Die Prognose ist in der Regel günstig. Einflussfaktoren sind die Symptomintensität im Akutstadium, die Infarktgröße, weibliches Geschlecht in Kombination mit einer Ängstlichkeit der Patienten und das Vorhandensein einer Extremitäten- oder Gangataxie.

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Videooculography “HINTS” in Acute Vestibular Syndrome: A Prospective Study

Cited by 13 publications

References 30 publications

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

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

Artificial intelligence for early stroke diagnosis in acute vestibular syndrome

Akutes zentrales vestibuläres Syndrom

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