Rising Annual Costs of Dizziness Presentations to U.S. Emergency Departments

Tehrani, Ali S. Saber; Coughlan, Diarmuid; Hsieh, Yu Hsiang; Mantokoudis, Georgios; Korley, Fredrick K.; Kerber, Kevin A.; Frick, Kevin D.; Newman‐Toker, David E.

doi:10.1111/acem.12168

Cited by 234 publications

(246 citation statements)

References 23 publications

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“…§Most of the patients were examined within 24 hours of symptom onset and almost all within 72 hours. ‖In the 14 with early false-negative MRI (<48 hours), follow-up ("final") MRI-DWI an average of about 3 days after symptom onset (range = 2-10 days) revealed infarctions located in the lateral medulla (11, one extending to the pons and one associated with a cerebellar infarction), middle cerebellar peduncle (2), and pontomesencephalic junction (1). Two of these false-negative initial MRI patients deteriorated substantially and one died.…”

Section: Discussionmentioning

confidence: 99%

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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314

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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Section: Discussionmentioning

confidence: 99%

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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“…It has been observed that increasing number of patients reporting dizziness has been admitted to hospital. At the same time, the frequency of doing the imaging tests has also increased (Saber Tehrani et al 2013).…”

Section: Epidemiologymentioning

confidence: 99%

Dizziness — Pathogenesis, Diagnosis and Treatment

Tomaszewski

Banakiewicz

Jajko

et al. 2015

hpc

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“…Despite extensive emergency department (ED) workups, the diagnostic accuracy of a central cause of AVS is low (approximately 35% of strokes are missed). 3,4 If patients who present with AVS have focal neurologic signs, stroke will be diagnosed relatively easily. However, only around 20% do present with focal signs, and the remainder have isolated AVS.…”

Section: Introductionmentioning

confidence: 99%

“…Furthermore, although the prevalence of stroke in isolated AVS is low (approximately 1%), 9 neuroimaging is overused to exclude stroke because of an absence of rules for determining appropriate use. 3 For instance, an international survey of emergency physicians found that the top adult emergency medicine priority for clinical decision procedures was a rule for when to image patients with vertigo. 10 The aim of the present study was to investigate predictive factors of stroke that can easily be used by a range of clinical staff in patients with isolated AVS.…”

Section: Introductionmentioning

confidence: 99%

Using Diastolic Blood Pressure to Diagnose Acute Stroke in Isolated Acute Vestibular Syndrome

Matsumoto

Kishikawa

Okuyama

et al. 2016

J of Gen and Family Med

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Background: Although diagnosis of isolated acute vestibular syndrome (AVS) via physical examination has been reported, a great deal of experience is needed to interpret the results. Patients with AVS often cannot participate in a physical examination, and not every emergency department (ED) is equipped with a magnetic resonance imaging machine. Therefore, in isolated AVS, clinical factors other than those used by general physicians and/or residents are required to identify strokes in these patients. The aim of this study was to determine those clinical factors useful in differentiating stroke patients from isolated AVS patients in the ED setting. Methods:We examined the records of 116 consecutive patients who presented to the ED between May 2010 and April 2013 with AVS (acute vertigo or dizziness, nystagmus, nausea/vomiting, head-motion intolerance, unsteady gait) and without auditory symptoms, head and/or neck pain, or neurological findings. Patients underwent diagnostic neuroimaging. Clinical characteristics and vital signs measured in the ambulance were assessed. Multivariate logistic regression analysis was performed to evaluate the associations of systolic blood pressure (SBP) ²150 mmHg, diastolic blood pressure (DBP) ²85 mmHg, heart rate, age ²60 years, and dyslipidemia with stroke.Results: Stroke was diagnosed in eight of the 116 (6.9%) patients with isolated AVS. DBP ²85 mmHg (odds ratio 29.0; 95% confidence interval 3.38-249) was the only significant and independent factor associated with stroke among patients with isolated AVS. Journal of General and Family Medicine 2016, vol. 17, no. 3, p. 218-224. Original Articles -218 -Conclusion: This study identified DBP ²85 mmHg to be a simple and useful clinical factor differentiating stroke from non-stroke isolated AVS.

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Rising Annual Costs of Dizziness Presentations to U.S. Emergency Departments

Abstract: Objectives: Dizziness and vertigo account for roughly 4% of chief symptoms in the emergency department (ED). Little is known about the aggregate costs of ED evaluations for these patients. The authors sought to estimate the annual national costs associated with ED visits for dizziness.

Cited by 234 publications

References 23 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

Dizziness — Pathogenesis, Diagnosis and Treatment

Using Diastolic Blood Pressure to Diagnose Acute Stroke in Isolated Acute Vestibular Syndrome

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