Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome

Tarnutzer, Alexander A.; Berkowitz, Aaron L.; Robinson, Karen A.; Hsieh, Yu Hsiang; Newman‐Toker, David E.

doi:10.1503/cmaj.100174

Cited by 364 publications

(466 citation statements)

References 116 publications

(204 reference statements)

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“…Recent evidence suggests that, counter to traditional teaching, the presence of such hearing loss more often indicates a vascular (labyrinthine or lateral pontine infarction) rather than viral (labyrinthitis) cause of the AVS presentation. 8,18,19 †In the current study, there was only a single peripheral H.I.N.T.S. pattern-unilaterally abnormal head impulse test; plus direction-fixed, horizontal or horizontal > torsional nystagmus obeying Alexander's law 20 (i.e., increased intensity in gaze toward the fast phase) with the fast phase beating away from the side of the abnormal impulse; plus absent skew deviation by the alternate cover test.…”

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confidence: 65%

“…7 For example, missed cerebellar stroke at the initial ED visit may confer up to an eightfold increased risk of death. 8 Preventable adverse outcomes 9 result from missed opportunities for thrombolysis, 10 early surgical intervention for posterior fossa edema, 7 and averting major vertebrobasilar stroke after initially minor infarction. 11,12 Identifying these posterior circulation stroke patients presents an important clinical challenge for emergency physicians (EPs), because symptoms are frequently isolated, 13 and contrary to conventional wisdom, obvious focal neurologic signs are usually absent.…”

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confidence: 99%

“…11,12 Identifying these posterior circulation stroke patients presents an important clinical challenge for emergency physicians (EPs), because symptoms are frequently isolated, 13 and contrary to conventional wisdom, obvious focal neurologic signs are usually absent. 8 When vestibular symptoms are of cerebrovascular cause, over 90% are ischemic strokes in the vertebrobasilar (posterior) circulation. 8 Although patients with brainstem or cerebellar (posterior fossa) hemorrhages also present with vertigo or dizziness, these rarely mimic benign dizziness presentations.…”

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confidence: 99%

“…8 When vestibular symptoms are of cerebrovascular cause, over 90% are ischemic strokes in the vertebrobasilar (posterior) circulation. 8 Although patients with brainstem or cerebellar (posterior fossa) hemorrhages also present with vertigo or dizziness, these rarely mimic benign dizziness presentations. 14 Brain computed tomography (CT) scans are very sensitive for detecting acute intracranial hemorrhages (93% 15 ), but cannot "rule out" ischemic stroke, as CTs detect only about 16% 15 to 42% 16 of early ischemic strokes.…”

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confidence: 99%

“…Brain magnetic resonance imaging (MRI) scans are costly, not always available, and in the first 24 hours after posterior fossa stroke symptom onset may be falsely negative in up to 20%. 8 So it is not surprising that EPs rate the development of a clinical decision rule for identifying central vertigo a top priority. 17 Although originally designed to predict future stroke in patients with transient ischemic attacks, a recent retrospective study suggested that a risk stratification approach ('ABCD2' score [ Table 1] 18-20 ) might help identify strokes acutely in ED patients with dizziness.…”

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confidence: 99%

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HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Newman‐Toker

Kerber

Hsieh

et al. 2013

Academic Emergency Medicine

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351

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ObjectivesDizziness 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 [ABCD2]).MethodsThis 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. ABCD2 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.ResultsA 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 ABCD2 was 4.0 (range = 2 to 7; IQR = 3.0 to 4.0). ABCD2 ≥ 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 MRIs 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.ConclusionsHINTS substantially outperforms ABCD2 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 (EPs) to leverage this approach for stroke screening in dizziness should be investigated.

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confidence: 65%

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confidence: 99%

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confidence: 99%

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confidence: 99%

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confidence: 99%

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HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Newman‐Toker

Kerber

Hsieh

et al. 2013

Academic Emergency Medicine

Self Cite

314

351

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High-Stakes Diagnostic Decision Rules for Serious Disorders

Newman‐Toker

Edlow

2013

JAMA

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Diagnostic errors lead to death or disability for an estimated 150 000 patients in the United States each year. 1 The emergency department is a known high-risk location for misdiagnosis. 2 Missed ischemic stroke and brain hemorrhage are recognized sources of diagnostic error, with approximately 9% of cerebrovascular events missed at first emergency department contact, 3 including an estimated 20% of subarachnoid hemorrhages in patients presenting with normal mental status. 4 Because effective treatments are available, diagnostic delays increase morbidity and mortality 3-to 8-fold, 4,5 so accurate early diagnosis is important.Rates of missed subarachnoid hemorrhage in the 1980s and 1990s were estimated at 32%, 6 although more recent estimates suggest the rate is approximately 12%, with about half occurring in the emergency department. 7 Some improvement is probably from newergeneration computed tomography (CT), 7,8 but most is not. 9 The current recommended standard of care is to obtain cranial CT for patients with new, rapid-onset, severe headaches and, for those with nondiagnostic CTs who are still suspected of having possible subarachnoid hemorrhages, to follow with diagnostic lumbar puncture. 10 This "CT-LP" rule is a proven method, with sensitivity for subarachnoid hemorrhage close to 100% when performed correctly. 11 However, because the real-world emergency department miss rate for subarachnoid hemorrhage is approximately 6%, 7 the CT-LP rule either is not applied to all at-risk patients or is used incorrectly (eg, lumbar puncture is obtained too early or too late, when spinal fluid findings may be misleading).In this issue of JAMA, Perry and colleagues 12 seek to enhance the clinical capabilities for diagnosing subarachnoid hemorrhage through validation and refinement of the Ottawa SAH Rule. The authors present the results of a prospective, cross-sectional study involving 2131 patients with acute headache and demonstrate that their best bedside decision rule identified all cases of subarachnoid hemorrhage (n = 132) among emergency department patients presenting with new, isolated headaches. The final rule relies on the presence of any 1 of 6 findings (age ≥40 years; neck pain or stiffness; witnessed loss of consciousness; onset during exertion; thunderclap headache [instantly peaking pain]; limited neck flexion on examination) and has an estimated sensitivity of 100% for detecting atraumatic subarachnoid hemorrhage. This rule offers the potential to reduce missed subarachnoid hemor-

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Neuro‐otology

Kerber¹

2016

International Neurology

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Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome

Cited by 364 publications

References 116 publications

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

High-Stakes Diagnostic Decision Rules for Serious Disorders

Neuro‐otology

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