HINTS Outperforms ABCD 2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Objectives Dizziness 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 [ ABCD 2]). Methods This 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. ABCD 2 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. Results A 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 ABCD 2 was 4.0 (range = 2 to 7; IQR  = 3.0 to 4.0). ABCD 2 ≥ 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 MRI s 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 . Conclusions HINTS substantially outperforms ABCD 2 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 ( EP s) to leverage this approach for stroke screening in dizziness should be investigated. Resumen Objetivos El mareo y el vértigo contabilizan aproximadamente 4 millones de visitas anuales a los servicios de urgencias ( SU ) en Estados Unidos, y de 160.000 a 240.000 (4% al 6%) tienen un origen cerebrovascular. El diagnóstico de ictus en los pacientes con vértigo o mareo es complejo debido a que la mayoría no tienen signos de focalidad neurológica evidentes en la atención inicial. Los autores comparan la certeza de dos aproximaciones previamente publicadas que resultaron ser de utilidad en el cribaje a pie de cama del posible ictus en el mareo: una regla de decisión clínica [ HINTS : Head Impulse (impulso de la cabeza), Nystagmus (nistagmo), Test of Skew (test de la desviación)], y una regla de estratificación del riesgo [ ABCD 2: Age (edad), Blood pressure (presión arterial), Clinical features (hallazgos clínicos), Duration of symptoms (duración de los síntomas), Diabetes (diabetes)]. Metodología Estudio transversal de pacientes de alto riesgo (más de un factor de riesgo de ictus) con síndrome vestibular agudo ( SVA ) (mareo o vértigo agudo persistente con nistagmo, más náuseas o vómitos; intolerancia a la movilización de la cabeza; e inestabilidad de la marcha aparecidos de novo ) realizado en un único centro universitario. Se llevó a cabo en todos los pacientes una exploración neurootológica, de neuroimagen (97,4% mediante resonancia magnética [ RM ]) y de seguimiento. Las puntuaciones de riesgo ABCD 2 (0–7 puntos), usando el punto de corte recomendado ≥ 4 para ictus, se compararon con una batería de movimiento ocular de tres componentes ( HINTS ). Se evaluaron la sensibilidad, la especificidad y las razones de probabilidad positiva y negativa ( RPP y RPN ) para ictus y otras causas centrales, y los resultados se estratificaron por edad. También se evaluaron los falsos negativos iniciales de la neuroimagen (RM). Resultados Se evaluaron 190 pacientes adultos con SVA (1999–2012). La mediana de edad fue de 60,5 años (rango 18 a 92 años; RIC 52,0 a 70,0 años); un 60,5% fueron hombres. Los diagnósticos finales fueron neuritis vestibular (34,7%), ictus de fosa posterior (59,5% [105 infartos, 8 hemorragias]) y otras causas centrales (5,8%). La mediana de ABCD 2 fue 4,0 (rango 2 a 7; RIC 3,0 a 4,0). ABCD 2 ≥4 para ictus tuvo una sensibilidad de un 61,1%, una especificidad de un 62,3%, una RPP de 1,62, y una RPN de 0,62; la sensibilidad fue menor para aquéllos que eran más jóvenes de 60 años (28,9%). La sensibilidad para el ictus del HINTS fue de un 96,5%, la especificidad de un 84,4%, la RPP de 6,19 y la RPN de 0,04, y no se modificó por la edad. Para cualquier lesión central, la sensibilidad fue de un 96,8%, la especificidad de un 98,5%, la RPP de 63,9 y la RPN de 0,03 para el HINTS ; y la sensibilidad de un 99,2%, la especificidad de un 97,0%, la RPP de 32,7 y la RPN de 0,01 para HINTS + (cualquier nueva pérdida de audición añadida al HINTS ). Las RM iniciales fueron falsamente negativas en 15 de 105 (14,3%) infartos, todas salvo una fueron hechas antes de las 48 horas del inicio de la clínica, y todos fueron confirmados por una RM diferida. Conclusiones El HINTS mejora sustancialmente el ABCD 2 para el diagnóstico de ictus en los pacientes con SVA en el SU . También supera a la RM obtenida en los primeros dos días tras el inicio de los síntomas. Dado que el test de HINTS se ha realizado tradicionalmente por especialistas, se deberían investigar métodos que permitan a los urgenciólogos hacer uso de esta aproximación para el cribado de ictus en el mareo.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/100264/1/acem12223.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/100264/2/acem12223-sup-0001-DataSupplementS1.pd

Bedside differentiation of vestibular neuritis from central "vestibular pseudoneuritis".

Acute unilateral peripheral and central vestibular lesions can cause similar signs and symptoms, but they require different diagnostics and management. We therefore correlated clinical signs to differentiate vestibular neuritis (40 patients) from central ‘‘vestibular pseudoneuritis’’ (43 patients) in the acute situation with the final diagnosis assessed by neuroimaging. Skew deviation was the only specific but non-sensitive (40%) sign for pseudoneuritis. None of the other isolated signs (head thrust test, saccadic pursuit, gaze evoked nystagmus, subjective visual vertical) were reliable; however, multivariate logistic regression increased their sensitivity and specificity to 92%

Stroke risk after nonstroke emergency department dizziness presentations

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/107576/1/ana24172.pd

DIAGNOSING DIZZINESS IN THE EMERGENCY DEPARTMENT: Why “What do you mean by ‘dizzy’?” Should Not Be the First Question You Ask

Dizziness is a complex neurologic symptom reflecting a perturbation of normal balance perception and spatial orientation. It is one of the most common symptoms encountered in general medical practice. Considering the dual impact of symptom-related morbidity (e.g., falls with hip fractures) and direct medical expenses for diagnosis and treatment, dizziness represents a major healthcare burden for society. However, perhaps the dearest price is paid by those individuals who are misdiagnosed, with devastating consequences. Dizziness can be caused by numerous diseases, some of which are dangerous and manifest symptoms almost indistinguishable from benign causes. The risk appears highest among patients with new or severe symptoms, particularly those seeking medical attention in acute-care settings such as the emergency department. Nevertheless, even acute dizziness is more often caused by benign inner ear or cardiovascular disorders. Thus, a major challenge faced by frontline providers is to efficiently identify those patients at high risk of harboring a dangerous underlying disorder. Unfortunately, diagnostic performance in the assessment of dizzy patients is poor. In part, this simply reflects the generally high rates of medical misdiagnosis encountered in frontline settings. However, misdiagnosis of dizziness is disproportionately frequent. Although possible explanations are myriad, I propose that an important cause stems from the pervasive use of an antiquated, oversimplified clinical heuristic to drive diagnostic reasoning in the assessment of dizzy patients. In this dissertation, I contend that the commonly-applied bedside rule that dizziness symptom quality, when grouped into one of four dizziness “types” (vertigo, presyncope, disequilibrium, or ill-defined dizziness), predicts the underlying cause, is false and potentially misleading. The argument supporting this theory is developed in the chapters that follow. Chapter 1 focuses on why dizziness diagnosis presents a significant challenge worthy of our concerted attention. Chapter 2 describes a multi-institutional survey of emergency physicians confirming that the “quality-of-symptoms” approach to dizziness is the dominant paradigm for diagnosis. Chapter 3 describes a cross-sectional study of emergency department dizzy patients demonstrating how this approach is fundamentally flawed. Chapter 4 concludes with a discussion of why this flawed paradigm might have garnered and maintained such widespread acceptance for over three decades

Patient centred diagnosis: sharing diagnostic decisions with patients in clinical practice.

Patient centred diagnosis is best practised through shared decision making; an iterative dialogue between doctor and patient, whichrespects a patient’s needs, values, preferences, and circumstances. Shared decision making for diagnostic situations differs fundamentally from that for treatment decisions. This has important implications when considering its practical application. The nature of dialogue should be tailored to the specific diagnostic decision; scenarios with higher stakes or uncertainty usually require more detailed conversation

An unusual stroke-like clinical presentation of Creutzfeldt-Jakob disease: acute vestibular syndrome

INTRODUCTION Vertigo and dizziness are common neurological symptoms in general practice. Most patients have benign peripheral vestibular disorders, but some have dangerous central causes. Recent research has shown that bedside oculomotor examinations accurately discriminate central from peripheral lesions in those with new, acute, continuous vertigo/dizziness with nausea/vomiting, gait unsteadiness, and nystagmus, known as the acute vestibular syndrome. CASE REPORT A 56-year-old man presented to the emergency department with acute vestibular syndrome for 1 week. The patient had no focal neurological symptoms or signs. The presence of direction-fixed, horizontal nystagmus suppressed by visual fixation without vertical ocular misalignment (skew deviation) was consistent with an acute peripheral vestibulopathy, but bilaterally normal vestibuloocular reflexes, confirmed by quantitative horizontal head impulse testing, strongly indicated a central localization. Because of a long delay in care, the patient left the emergency department without treatment. He returned 1 week later with progressive gait disturbance, limb ataxia, myoclonus, and new cognitive deficits. His subsequent course included a rapid neurological decline culminating in home hospice placement and death within 1 month. Magnetic resonance imaging revealed restricted diffusion involving the basal ganglia and cerebral cortex. Spinal fluid 14-3-3 protein was elevated. The rapidly progressive clinical course with dementia, ataxia, and myoclonus plus corroborative neuroimaging and spinal fluid findings confirmed a clinicoradiographic diagnosis of Creutzfeldt-Jacob disease. CONCLUSIONS To our knowledge, this is the first report of an initial presentation of Creutzfeldt-Jacob disease closely mimicking vestibular neuritis, expanding the known clinical spectrum of prion disease presentations. Despite the initial absence of neurological signs, the central lesion location was differentiated from a benign peripheral vestibulopathy at the first visit using simple bedside vestibular tests. Familiarity with these tests could help providers prevent initial misdiagnosis of important central disorders in patients presenting vertigo or dizziness

Dizziness Presentations in U.S. Emergency Departments, 1995–2004

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/71563/1/j.1553-2712.2008.00189.x.pd

Nystagmus Assessments Documented by Emergency Physicians in Acute Dizziness Presentations: A Target for Decision Support?

Objectives:  Dizziness is a common presenting complaint to the emergency department (ED), and emergency physicians (EPs) consider these presentations a priority for decision support. Assessing for nystagmus and defining its features are important steps for any acute dizziness decision algorithm. The authors sought to describe nystagmus documentation in routine ED care to determine if nystagmus assessments might be an important target in decision support efforts. Methods:  Medical records from ED visits for dizziness were captured as part of a surveillance study embedded within an ongoing population‐based cohort study. Visits with documentation of a nystagmus assessment were reviewed and coded for presence or absence of nystagmus, ability to draw a meaningful inference from the description, and coherence with the final EP diagnosis when a peripheral vestibular diagnosis was made. Results:  Of 1,091 visits for dizziness, 887 (81.3%) documented a nystagmus assessment. Nystagmus was present in 185 of 887 (20.9%) visits. When nystagmus was present, no further characteristics were recorded in 48 of the 185 visits (26%). The documentation of nystagmus (including all descriptors recorded) enabled a meaningful inference about the localization or cause in only 10 of the 185 (5.4%) visits. The nystagmus description conflicted with the EP diagnosis in 113 (80.7%) of the 140 visits that received a peripheral vestibular diagnosis. Conclusions:  Nystagmus assessments are frequently documented in acute dizziness presentations, but details do not generally enable a meaningful inference. Recorded descriptions usually conflict with the diagnosis when a peripheral vestibular diagnosis is rendered. Nystagmus assessments might be an important target in developing decision support for dizziness presentations.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/86927/1/j.1553-2712.2011.01093.x.pd