The Diagnostic Accuracy of Truncal Ataxia and HINTS as Cardinal Signs for Acute Vestibular Syndrome

Carmona, Sérgio; Martínez, Carlos; Zalazar, Guillermo; Moro, Marcela; Batuecas‐Caletrío, Ángel; Luis, Leonel; Gordon, Carlos R.

doi:10.3389/fneur.2016.00125

Cited by 93 publications

(133 citation statements)

References 24 publications

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“…Ideally, have the patient walk unassisted, but for severely nauseated patients too symptomatic to walk, test for truncal ataxia by asking the patient to sit upright in the stretcher with arms crossed. Patients who cannot walk or sit up unassisted are unsafe for discharge and are more likely to have a stroke (or other CNS pathology) rather than vestibular neuritis (27,44,77). Although American emergency physicians are uncomfortable using HINTS testing and instead overuse CT, one study reported that specially trained emergency physicians using these bedside examination elements decreased both CT use and hospitalization (62,63,78).…”

Section: A New Diagnostic Paradigmmentioning

confidence: 99%

A New Diagnostic Approach to the Adult Patient with Acute Dizziness

Edlow

Gurley

Newman‐Toker

2018

The Journal of Emergency Medicine

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Background Dizziness, a common chief complaint, has an extensive differential diagnosis that includes both benign and serious conditions. Emergency physicians must distinguish the majority of patients with self-limiting conditions from those with serious illnesses that require acute treatment. Objective of the Review This article presents a new approach to diagnosis of the acutely dizzy patient that emphasizes different aspects of the history to guide a focused physical examination with the goal of differentiating benign peripheral vestibular conditions from dangerous posterior circulation strokes in the emergency department. Discussion Currently, misdiagnoses are frequent and diagnostic testing costs are high. This relates in part to use of an outdated, prevalent, diagnostic paradigm. The traditional approach, which relies on dizziness symptom quality or type (i.e., vertigo, presyncope, or disequilibrium) to guide inquiry, does not distinguish benign from dangerous causes, and is inconsistent with current best evidence. A new approach divides patients into three key categories using timing and triggers, guiding a differential diagnosis and targeted bedside examination protocol: 1) acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke; 2) spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack; and 3) triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions. Conclusions The timing and triggers diagnostic approach for the acutely dizzy patient derives from current best evidence and offers the potential to reduce misdiagnosis while simultaneously decreases diagnostic test overuse, unnecessary hospitalization, and incorrect treatments.

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Section: A New Diagnostic Paradigmmentioning

confidence: 99%

A New Diagnostic Approach to the Adult Patient with Acute Dizziness

Edlow

Gurley

Newman‐Toker

2018

The Journal of Emergency Medicine

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“…In another study of AVS presentations, all of the stroke patients (42/42) had either central nystagmus or severe imbalance defined as inability to walk without support. 42 The head impulse test and test of skew deviation can also inform the likelihood of stroke. In a singlecenter study with two neuro-ophthalmologists performing the bedside examination, the HINTS examination alone had a sensitivity of 97% (109/113: 95% CI, 92-99%) and specificity of 84% (65/77: 95% CI, 75-91%).…”

Section: Approach To the Acute Vestibular Syndrome Presentationmentioning

confidence: 99%

Acute Vestibular Syndrome

Kerber

2020

Semin Neurol

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The acute vestibular syndrome (AVS) is a label for presentations of new-onset severe dizziness, vertigo, or imbalance, with examination findings of nystagmus or gait unsteadiness. The prototypical AVS presentation is the acute unilateral vestibulopathy due to vestibular neuritis. Stroke is also a serious concern in patients with AVS. Most other peripheral vestibular disorders present as episodic or chronic syndromes. In this article, the diagnostic considerations, exam findings, and management of AVS are reviewed.

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“…Patients who cannot walk or sit up unassisted are more likely to have a stroke (or other CNS pathology) rather than vestibular neuritis. 9,32,75 The use of tandem gait testing helps evaluate for midline cerebellar function, but may be impaired in older individuals, or in patients with peripheral causes of dizziness.…”

Section: Acute Vestibular Syndromementioning

confidence: 99%

Acute Dizziness

Edlow

Gurley

2019

Semin Neurol

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Dizziness is a common chief complaint with an extensive differential diagnosis that includes both benign and serious conditions. Physicians must distinguish the majority of patients who suffer from self-limiting conditions from those with serious illnesses that require acute treatment. The preferred approach to the diagnosis of an acutely dizzy patient emphasizes different aspects of the history to guide a focused physical examination, with the goal of differentiating benign peripheral vestibular conditions from dangerous posterior circulation strokes. Currently, misdiagnoses are frequent and diagnostic testing costs are high. This partly relates to use of an outdated diagnostic paradigm. This commonly used traditional approach relies on dizziness “symptom quality” or “type” (vertigo, presyncope, disequilibrium) to guide inquiry. It does not distinguish benign from dangerous causes and is inconsistent with current best evidence. A better approach categorizes patients into three groups based on timing and triggers. Each category has its own differential diagnosis and targeted bedside approach: (1) acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke; (2) spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack; and (3) triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions. The “timing and triggers” diagnostic approach for the acutely dizzy derives from current best evidence and offers the potential to reduce misdiagnosis while simultaneously decreasing diagnostic test overuse, unnecessary hospitalization, and incorrect treatments.

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The Diagnostic Accuracy of Truncal Ataxia and HINTS as Cardinal Signs for Acute Vestibular Syndrome

Cited by 93 publications

References 24 publications

A New Diagnostic Approach to the Adult Patient with Acute Dizziness

A New Diagnostic Approach to the Adult Patient with Acute Dizziness

Acute Vestibular Syndrome

Acute Dizziness

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