TiTrATE

Abstract

Diagnosing dizziness can be challenging, and the consequences of missing dangerous causes such as stroke can be substantial. Most physicians use a diagnostic paradigm developed over 40 years ago that focuses on the type of dizziness (e.g., vertigo vs. non-vertigo), but this approach is flawed. In this article we propose a new paradigm based on symptom timing, triggers, and targeted bedside eye examinations (‘TiTrATE’). Using timing and triggers, patients with recent-onset dizziness will fall into one of four major ‘syndrome’ categories (triggered episodic, spontaneous episodic, post-exposure acute, and spontaneous acute), each with its own differential diagnosis and set of targeted examination techniques that help clinicians make a specific diagnosis. Following an evidence-based approach such as this could help reduce the frequency of misdiagnosis of serious causes of dizziness.

A New Diagnostic Approach to the Adult Patient with Acute Dizziness

“…We believe that this new method allows one to confidently make an accurate diagnosis more frequently than the traditional paradigm. Although other acronyms have been used, here we use the mnemonic: ATTEST (associated symptoms, timing and triggers, bedside examination signs, and additional testing as needed) (7). …”

“…Spontaneous acute vestibular syndrome (AVS) is defined as the acute onset of persistent dizziness associated with nausea or vomiting, gait instability, nystagmus, and head-motion intolerance lasting days to weeks (7,17,46). Patients are usually symptomatic at presentation and focused physical examination is often diagnostic.…”

“…Patients with an AVS typically experience worse dizziness with head movement (exacerbation), such as when performing the Dix-Hallpike maneuver, but this is not a sign of BPPV. Confusion on this point contributes to difficulty differentiating BPPV from vestibular neuritis or stroke (6,7,23). Occasionally, BPPV patients may endorse mild, persistent symptoms of malaise or unsteadiness between triggered, brief bouts of vertigo; this may be due to repeated symptoms triggered by small, inadvertent head movements or anticipatory anxiety about moving, and is more common among older patients.…”

“…The prevalence of cerebrovascular disease in patients presenting to the ED with dizziness is 3–5%, but among those with the AVS, it is estimated at ~25% (7,46). Almost all (96%) of these strokes are ischemic (46,49).…”

“…Taking a history from a dizzy patient should be no different than taking a history in other patients. The timing, triggers, and evolution over time; associated symptoms; and context (and not the descriptor used) best inform the differential diagnosis (7). Bedside examination can frequently establish a specific diagnosis (8).…”