Diagnostic yield and impact of MRI for acute ischaemic stroke in patients presenting with dizziness and vertigo

Kabra, Rajesh; Robbie, Hasti; Connor, Steve

doi:10.1016/j.crad.2015.01.016

Cited by 27 publications

(27 citation statements)

References 36 publications

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“…When looking at improving the clinical criteria to identify vertigo patients who should be undergo urgent neuroimaging test, we found that our algorithm alone, based on a PPV of 48%, could allow reaching a “number needed to image” of one positive every two to three neuroimaging tests. Previous studies reported very high-neuroimaging study rate among patients with vertigo ( 27 ), with diagnostic yield for MRI around 20% ( 28 ). This suggests that the STANDING algorithm could significantly reduce unnecessary neuroimaging tests.…”

Section: Discussionmentioning

confidence: 99%

Differential Diagnosis of Vertigo in the Emergency Department: A Prospective Validation Study of the STANDING Algorithm

et al. 2017

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ObjectiveWe investigated the reliability and accuracy of a bedside diagnostic algorithm for patients presenting with vertigo/unsteadiness to the emergency department.MethodsWe enrolled consecutive adult patients presenting with vertigo/unsteadiness at a tertiary hospital. STANDING, the acronym for the four-step algorithm we have previously described, based on nystagmus observation and well-known diagnostic maneuvers includes (1) the discrimination between SponTAneous and positional nystagmus, (2) the evaluation of the Nystagmus Direction, (3) the head Impulse test, and (4) the evaluation of equilibrium (staNdinG). Reliability of each step was analyzed by Fleiss’ K calculation. The reference standard (central vertigo) was a composite of brain disease including stroke, demyelinating disease, neoplasm, or other brain disease diagnosed by initial imaging or during 3-month follow-up.ResultsThree hundred and fifty-two patients were included. The incidence of central vertigo was 11.4% [95% confidence interval (CI) 8.2–15.2%]. The leading cause was ischemic stroke (70%). The STANDING showed a good reliability (overall Fleiss K 0.83), the second step showing the highest (0.95), and the third step the lowest (0.74) agreement. The overall accuracy of the algorithm was 88% (95% CI 85–88%), showing high sensitivity (95%, 95% CI 83–99%) and specificity (87%, 95% CI 85–87%), very high-negative predictive value (99%, 95% CI 97–100%), and a positive predictive value of 48% (95% CI 41–50%) for central vertigo.ConclusionUsing the STANDING algorithm, non-sub-specialists achieved good reliability and high accuracy in excluding stroke and other threatening causes of vertigo/unsteadiness.

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Section: Discussionmentioning

confidence: 99%

Differential Diagnosis of Vertigo in the Emergency Department: A Prospective Validation Study of the STANDING Algorithm

et al. 2017

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“…As the manoeuvre is such a simple bedside test, it should perhaps be used more in clinical practice to differentiate between aetiology rather than relying solely on 'diagnostic' scans [4]. In conclusion, this study suggests that clinical examination findings should be used to determine appropriateness of MRI scans rather than relying purely on patients' reported symptoms of dizziness and vertigo.…”

Section: Resultsmentioning

confidence: 99%

“…Kabra et al, came to an alternative conclusion where the yield was 21% with diagnostic impact of MRI on management being 22% [4] meaning clinicians should have a low threshold for requesting MRI if patients exhibit these features. However, this research study would suggest that vestibular symptoms are non-specific for diagnosing posterior Fossa infarct given the low percentage of positive results amongst the large cohort in this study.…”

Section: Resultsmentioning

confidence: 99%

“…However, only 17% of patients with confirmed PICA strokes had symptoms of vestibular neuritis [3]. Manoeuvres such as Dix-Hallpike can help distinguish between peripheral or central aetiology since none of the patients who had symptoms of vestibular neuritis due to ischaemic stroke had a positive head thrust [4]. Nevertheless, it has been argued that MRI plays an important role in differentiating between peripheral and central aetiology when clinical diagnosis fails [5].…”

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confidence: 99%

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MRI Yield of Posterior Fossa Strokes in ‘Dizzy’ Patients

Lam¹

2016

NMRR

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pre-syncope and unsteadiness [1]. The posterior circulation is defined primarily by the vertebro-basilar arterial system, which arises from the subclavian arteries. Infarcts affecting the superior or Posterior Inferior Cerebellar Arteries (PICA) can cause symptoms of vertigo.Many patients with unexplained dizziness ultimately undergo an MRI scan to rule out a posterior circulation ischaemic stroke. Prior research showed that only 3.2% of patients presenting with dizziness, vertigo or imbalance were diagnosed with a stroke or Transient Ischaemic Attack (TIA) [2]. Vestibular symptoms such as vertigo can be attributed to both peripheral causes such as vestibular neuritis or central causes like brainstem/cerebellar stroke. In a study of 240 patients who presented with vertigo lasting more than a day and no other focal neurological deficits, 10% were diagnosed with cerebellar strokes but ischaemia associated with vertigo is often accompanied by other brainstem signs [3]. However, only 17% of patients with confirmed PICA strokes had symptoms of vestibular neuritis [3]. Manoeuvres such as Dix-Hallpike can help distinguish between peripheral or central aetiology since none of the patients who had symptoms of vestibular neuritis due to ischaemic stroke had a positive head thrust [4]. Nevertheless, it has been argued that MRI plays an important role in differentiating between peripheral and central aetiology when clinical diagnosis fails [5].CT scan has been proven to have poor sensitivity in diagnosing posterior Fossa strokes in patients with dizziness and vertigo as it provides suboptimal visualisation of structures secondary to artefact produced by bony structures of the cranial base and therefore early ischaemic events are missed [5,6]. Accordingly, diffusion weighted MRI scans is more commonly used, but even this modality misses up to 20% posterior Fossa infarcts in the first 24-48 hours of presentation [1]. The yield of MRI for stroke in this cohort of patients was only 21%, with a diagnostic impact on management for 22% of these patients [5]. This unreliability of MRI scan is reinforced by a study which showed that diffusion weighted imaging was falsely negative in 12 of patients with acute vestibular symptoms and posterior Fossa strokes [7]. MethodA total of 603 MRI scans were performed for patients presenting with vertigo and dizziness with suspicion of cerebellar or brainstem infarcts during the one year period analysed at Royal Derby Hospital. Prior research showed that there is a low yield of posterior circulation infarcts diagnosed on MRI in this cohort of patients with dizziness [1,5].Data was accumulated for those 603 patients with MRI scans through screening of patients who underwent MRI scan in the last year and key words on the request or report cards included 'cerebellar infarct' , 'cerebellar stroke' , 'brainstem stroke' , 'vertigo' , 'dizziness' , 'ataxia' or 'unsteadiness' . Methods: 588 patients under went MRI within a one-year period. Data was ascertained through requests and results on ICM compute...

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“…Brain magnetic resonance imaging (MRI) is the gold standard for diagnosing acute cerebellar infarction in patients with acute vertigo; however, MRI is not readily available in many EDs and can be costly to patients. [12][13][14] Optic nerve sheath diameter (ONSD) was recently identified as a useful indicator of intracranial pressure (ICP) based on its connection to the dura mater. 15,16 ONSD has been used to predict poor prognosis and mortality after traumatic brain injury (TBI) and ischemic or hemorrhagic stroke.…”

Section: Introductionmentioning

confidence: 99%

Optic nerve sheath diameter as a predictor of acute cerebellar infarction in acute vertigo patients without brain computed tomography abnormalities

You

Lee²,

Yun

et al. 2019

Hong Kong Journal of Emergency Medicine

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Background and objectives: To date, no study has investigated the ability of optic nerve sheath diameter calculated from non-contrast brain computed tomography to predict acute cerebellar infarction in patients with acute vertigo. The aim of our study was to evaluate the predictive utility of optic nerve sheath diameter for diagnosing acute cerebellar infarction in patients with acute vertigo without computed tomography abnormalities. Methods: We retrospectively enrolled patients with acute vertigo without computed tomography abnormalities who underwent magnetic resonance imaging including diffusion-weighted imaging at our emergency department between January 2016 and December 2017. Two emergency physicians independently measured optic nerve sheath diameter at 3 mm (ONSD3) and 10 mm (ONSD10) behind the globe in each patient. Final magnetic resonance imaging reports with clinical progress notes were used as the reference standard. A multivariate logistic regression analysis, receiver operating characteristic curves, and intra-class correlation coefficients were calculated to estimate predictive value. Results: A total of 34 patients (16.1%) were diagnosed with acute infarction and 177 patients (83.9%) were diagnosed with peripheral vertigo. Mean ONSD3 ( p < 0.001) and ONSD10 ( p < 0.001) were independent predictive factors for distinguishing acute infarction and peripheral vertigo. ONSD3 (cut-off = 4.22 mm) had 100% (95% confidence interval = 89.7–100.0) sensitivity and 97.7% (95% confidence interval = 95.1–99.6) specificity with area under the receiver operating characteristic curve of 0.988 (95% confidence interval = 0.978–1.0), while ONSD10 (cut-off = 3.63 mm) had 100% (95% confidence interval = 89.7–100.0) sensitivity and 87.6% (95% confidence interval = 81.8–92.0) specificity with area under the receiver operating characteristic curve of 0.976 (95% confidence interval = 0.959–0.997). There were good inter- and intra-observer agreements for both sides of ONSD3 and ONSD10 (intra-class correlation coefficient range = 0.652–0.773). Conclusion: Optic nerve sheath diameter, in particular OSND3, is a feasible predictive marker for acute infarction in patients with acute vertigo without computed tomography abnormalities. This information can assist decision-making in ordering brain magnetic resonance imaging for the assessment of acute vertigo.

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Diagnostic yield and impact of MRI for acute ischaemic stroke in patients presenting with dizziness and vertigo

Cited by 27 publications

References 36 publications

Differential Diagnosis of Vertigo in the Emergency Department: A Prospective Validation Study of the STANDING Algorithm

Differential Diagnosis of Vertigo in the Emergency Department: A Prospective Validation Study of the STANDING Algorithm

MRI Yield of Posterior Fossa Strokes in ‘Dizzy’ Patients

Optic nerve sheath diameter as a predictor of acute cerebellar infarction in acute vertigo patients without brain computed tomography abnormalities

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