Risk of acute brain lesions in dizzy patients presenting to the emergency room: who needs imaging and who does not?

Abstract

The usefulness of brain imaging studies in dizzy patients presenting to the emergency department (ED) is controversial. We aimed to assess the 'real-world' probability of ischemic stroke and other acute brain lesions (ABLs) in these patients to create an algorithm that helps decision-making on whether which and when brain imaging is needed. By reviewing medical records, we identified 610 patients presenting with dizziness, vertigo or imbalance to our university hospital's ED and receiving neurological workup. We collected timing/triggers of symptoms, ABCD 2 score, focal neurological abnormalities, HINTS (head impulse, nystagmus, test-of-skew) and other central oculomotor signs. ABLs were extracted from CT/MRI reports. Uni-/multivariate logistic regression analyses investigated associations between clinical parameters and ABLs. Finally, the likelihood of ABLs was assessed for different clinically defined subgroups ('dizziness syndromes'). Early CT (day 1) was performed in 539 (88%) and delayed MR imaging (median: day 4) in 299 (49%) patients. ABLs (89% ischemic stroke) were revealed in 75 (24%) of 318 patients with adequate imaging (MRI or lesion-positive CT). The risk for ABLs increased with the presence of central oculomotor signs (odds ratio 2.8, 95% confidence interval 1.5-5.2) or focal abnormalities (OR 3.3, 95% CI 1.8-6.2). The likelihood of ABLs differed between dizziness syndromes, e.g., HINTS-negative acute vestibular syndrome: 0%, acute imbalance syndrome with ABCD 2-score ≥ 4: 50%. We propose a clinical pathway, according to which patients with HINTS-negative acute vestibular syndrome should not receive brain imaging, whereas imaging is suggested in dizzy patients with acute imbalance, central oculomotor signs or focal abnormalities.

What guides decision-making on intravenous thrombolysis in acute vestibular syndrome and suspected ischemic stroke in the posterior circulation?

“…This retrospective study is based on data from an in-house register of dizzy patients that was compiled by reviewing medical records of adult patients who presented with dizziness, vertigo or imbalance to the emergency department (ED) of our University Medical Center (Lübeck, Germany) between January 1, 2016 and December 31, 2018 and who received neurological work-up after exclusion of general medical causes [21]. The 610 cases in the original database were amended by 4 more patients presenting with acute dizziness to our hospital in 2019 who were identified via search for the procedure code of 'IVT' in the hospital's medical controlling database.…”

“…Due to the retrospective character and real-world setting in which the data for this study were acquired [21], there are implicit limitations. First, the use of imaging methods (NCCT, CTP, and MRI) did not follow a uniform protocol but depended on the individual decision of the responsible clinician.…”

“…Dizziness is the most common symptom in PCS, being reported by 47% of the patients [34]. Hence, PCS patients may primarily present with an acute vestibular syndrome (AVS: vertigo, nystagmus, nausea/vomiting) or acute imbalance (AIS: dizziness, sudden unsteadiness of stance and/ or gait, no nystagmus) [12,18,21,36,42]. On the other hand, only 3-4% of all patients presenting with dizziness to the emergency department (ED) really suffer from a stroke while the majority have peripheral vestibular or non-vestibular causes [13,22].…”

“…Making the diagnosis of PCS in AVS/AIS patients can be supported by brain imaging studies; however, their diagnostic value, particularly of the widely used non-contrast computed tomography (NCCT), is low for detecting acute ischemic strokes in the posterior fossa [21,28]. CT perfusion (CTP) has additional diagnostic value to NCCT for detecting acute PCS [35,39] and CTP was previously shown to guide IVT in ACS patients in extended time windows [20].…”

“…Given the lack of prospective clinical trials, we used a single-center register [21] to retrospectively evaluate the diagnostic management and acute treatment (IVT) as well as the short-term outcome of AVS/AIS patients with suspected PCS presenting to the ED. We were especially interested in clinical and/or imaging parameters that may have guided decision-making in favor of IVT in this subgroup of acute dizzy patients.…”