Capturing vertigo in the emergency room: three tools to double the rate of diagnosis

Nham, Benjamin; Reid, Nicole; Bein, Kendall J; Bradshaw, Andrew P.; McGarvie, Leigh A.; Argaet, Emma C; Young, Allison S.; Watson, Shaun; Halmagyi, G. Michael; Black, Deborah; Welgampola, Miriam S.

doi:10.1007/s00415-021-10627-1

Cited by 32 publications

(78 citation statements)

References 45 publications

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“…V-HIT can be performed using portable and relatively inexpensive equipment at the bedside. There is increasing evidence to support the use of v-HIT alongside expert clinical assessment for diagnosis of vestibular disorders in the ED 11. There are also ongoing clinical trials12 investigating the use of v-HIT in the acute clinical setting.…”

Section: Introductionmentioning

confidence: 99%

Video head impulse testing to differentiate vestibular neuritis from posterior circulation stroke in the emergency department: a prospective observational study

et al. 2022

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Background and aimsVertigo is a common presentation to the emergency department (ED) with 5% of presentations due to posterior circulation stroke (PCS). Bedside investigations such as the head impulse test (HIT) are used to risk stratify patients, but interpretation is operator dependent. The video HIT (v-HIT) provides objective measurement of the vestibular-ocular-reflex (VOR) and may improve diagnostic accuracy in acute vestibular syndrome (AVS). We aimed to evaluate the use of v-HIT as an adjunct to clinical assessment to acutely differentiate vestibular neuritis (VN) from PCS.Methods133 patients with AVS were consecutively enrolled from the ED of our comprehensive stroke centre between 2018 and 2021. Patient assessment included a targeted vestibular history, HINTs examination (Head Impulse, Nystagmus and Test of Skew), v-HIT and MRI>48 hours after symptom onset. The HINTS/v-HIT findings were analysed and compared between VN, PCS and other cause AVS. Clinical course, v-HIT and MRI findings were used to determine diagnosis.ResultsFinal diagnosis was VN in 40%, PCS 15%, migraine 16% and other cause AVS 29%. PCS patients were older than VN patients (mean age 68.5±10.6 vs 60.1±14.2 years, p=0.14) and had more cardiovascular risk factors (3 vs 2, p=0.002). Mean VOR gain was reduced (<0.8) in ipsilateral horizontal and (<0.7) anterior canals in VN but was normal in PCS, migraine and other cause AVS. V-HIT combined with HINTs was 89% sensitive and 96% specific for a diagnosis of VN.ConclusionsV-HIT combined with HINTs is a reliable tool to exclude PCS in the ED.

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Section: Introductionmentioning

confidence: 99%

Video head impulse testing to differentiate vestibular neuritis from posterior circulation stroke in the emergency department: a prospective observational study

et al. 2022

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“…This direction preponderance is thought to be due to the involvement of the medial vestibular nucleus in PICAc strokes and the caudal lateral vestibular nucleus in PICAb strokes [27,28]. Med PICA medial VNc [10], ICP [12,23], tonsil [12,23], nodulus [12,23], uvula [12,23] Nodulus (bilateral) [28] Superior VNc [25,26] ICP [12,23] Lat PICA Lateral medulla [8,33], Caudal lateral VNc [24,26] Caudal medulla [23] Lateral medulla [32] Lateral medulla [32] Lateral medulla [32] AICA Vestibular root entry zone [11,12] Inner ear [11], flocculus (unilateral) [29], pontine tegmentum [12,23] Dorsal pontine tegmentum [14,30], Flocculus (bilateral) [27] MCP [33] MCP [33] Vestibular root entry zone [11,12], Inner ear [11], MCP [33] SCA Superior vermis [13], rostral anterior cerebellum [13] BC [26,28] Basilar perf NPH [12,…”

Section: Discussionmentioning

confidence: 99%

Capturing nystagmus in the emergency room: posterior circulation stroke versus acute vestibular neuritis

et al. 2022

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Objectives To compare acute nystagmus characteristics of posterior circulation stroke (PCS) and acute vestibular neuritis (AVN) in the emergency room (ER) within 24 h of presentation. Methods ER-based video-nystagmography (VNG) was conducted, recording ictal nystagmus in 101 patients with PCS (on imaging) and 104 patients with AVN, diagnosed on accepted clinical and vestibular test criteria. Results Patients with stroke in the brainstem (38/101, affecting midbrain (n = 7), pons (n = 19), and medulla (n = 12)), cerebellum (31/101), both (15/101) or other locations (17/101) were recruited. Common PCS territories included posterior-inferior-cerebellar-artery (41/101), pontine perforators (18/101), multiple-territories (17/101) and anterior-inferior-cerebellar-artery (7/101). In PCS, 44/101 patients had no spontaneous nystagmus. Remaining PCS patients had primary position horizontal (44/101), vertical (8/101) and torsional (5/101) nystagmus. Horizontal nystagmus was 50% ipsiversive and 50% contraversive in lateralised PCS. Most PCS patients with horizontal nystagmus (28/44) had unidirectional “peripheral-appearing” nystagmus. 32/101 of PCS patients had gaze-evoked nystagmus. AVN affected the superior, inferior or both divisions of the vestibular nerve in 55/104, 4/104 and 45/104. Most (102/104) had primary position horizontal nystagmus; none had gaze-evoked nystagmus. Two inferior VN patients had contraversive torsional-downbeat nystagmus. Horizontal nystagmus with SPV ≥ 5.8 °/s separated AVN from PCS with sensitivity and specificity of 91.2% and 83.0%. Absent nystagmus, gaze-evoked nystagmus, and vertical-torsional nystagmus were highly specific for PCS (100%, 100% and 98.1%). Conclusion Nystagmus is often absent in PCS and always present in AVN. Unidirectional ‘peripheral-appearing’ horizontal nystagmus can be seen in PCS. ER-based VNG nystagmus assessment could provide useful diagnostic information when separating PCS from AVN.

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“…Calculation of slow phase velocity Slow phase velocity is the primary kinematic measure to characterize jerk nystagmus and therefore widely used for its diagnostic classification and monitoring alike 2,6,7,9 . Directional SPV comparisons are routinely used to determine relative asymmetries of caloric excitability of either labyrinth 40,53 .…”

Section: Classification Of Nystagmus Directionmentioning

confidence: 99%

“…Common to VOG methods however is a high degree of resource intensiveness encompassing both monetary and educational aspects, hindering broad use in diverse clinical settings and especially outside of highly specialized laboratories, highresource settings and academic infrastructure. This can be viewed as a significant care gap, since recent clinical investigations convincingly demonstrate clinically relevant benefits of quantitative eye movement recordings for diagnosis 6,[10][11][12] , prognostication 13 and disease monitoring 9,14 . Moreover, yet unknown disease patterns could be identified within the granular kinematic feature space provided by e. g. videooculography, hinting at a largely untapped potential to derive performant physiomarkers to be included in clinical decision making 6,15 .…”

Section: Introductionmentioning

confidence: 99%

“…This can be viewed as a significant care gap, since recent clinical investigations convincingly demonstrate clinically relevant benefits of quantitative eye movement recordings for diagnosis 6,[10][11][12] , prognostication 13 and disease monitoring 9,14 . Moreover, yet unknown disease patterns could be identified within the granular kinematic feature space provided by e. g. videooculography, hinting at a largely untapped potential to derive performant physiomarkers to be included in clinical decision making 6,15 .…”

Section: Introductionmentioning

confidence: 99%

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Convolutional neural networks for quantitative smartphone video nystagmography: ConVNG

Friedrich

Schneider

Buerklein

et al. 2022

Preprint

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Background Eye movement abnormalities are paramount in neurological disorders. However, unaided eye movement assessments lack granularity. Although videooculography (VOG) improves diagnostic accuracy, resource intensiveness preclude its broad use. To bridge this care gap, we here validate a framework for smartphone video-based nystagmography capitalizing on recent computer vision advances. Methods A recurrent convolutional network was fine-tuned for pupil tracking using >550 annotated frames: ConVNG. Slow phase velocity of optokinetic nystagmus was calculated in 10 subjects using both ConVNG and VOG. Equivalence of accuracy and precision was assessed using the two one-sample t-test (TOST) and Bayesian interval-null approaches. Results ConVNG tracking accuracy reached 9-15% of an average pupil diameter. SPV measurement accuracy was equivalent to VOG (p< .017; Bayes factors (BF) > 24). Average precision was 0.30 deg. for ConVNG and 0.12 deg. for VOG. Conclusions ConVNG enables smartphone video nystagmography with an accuracy comparable to VOG and precision approximately one order of magnitude higher than comparable ARKit applications. This serves as a blueprint for highly accessible tools with potential to accelerate progress toward precise and personalized Medicine.

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Capturing vertigo in the emergency room: three tools to double the rate of diagnosis

Cited by 32 publications

References 45 publications

Video head impulse testing to differentiate vestibular neuritis from posterior circulation stroke in the emergency department: a prospective observational study

Video head impulse testing to differentiate vestibular neuritis from posterior circulation stroke in the emergency department: a prospective observational study

Capturing nystagmus in the emergency room: posterior circulation stroke versus acute vestibular neuritis

Convolutional neural networks for quantitative smartphone video nystagmography: ConVNG

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