Validation of a comprehensive diagnostic algorithm for patients with acute vertigo and dizziness

Abstract

Background and purpose Vertigo and dizziness are common complaints in emergency departments and primary care, and pose major diagnostic challenges due to their various underlying etiologies. Most supportive diagnostic algorithms concentrate on either identifying cerebrovascular events (CVEs) or diagnosing specific vestibular disorders or are restricted to specific patient subgroups. The aim of the present study was to develop and validate a comprehenisve algorithm for identifying patients with CVE and classifying the most common vestibular disorders. Methods The study was conducted within the scope of the “PoiSe” project (Prevention, Online feedback, and Interdisciplinary Therapy of Acute Vestibular Syndromes by e‐health). A three‐level algorithm was developed according to international guidelines and scientific evidence, addressing both the detection of CVEs and the classification of non‐vascular vestibular disorders (unilateral vestibulopathy, benign paroxysmal positional vertigo, vestibular paroxysmia, Menière's disease, vestibular migraine, functional dizziness). The algorithm was validated in a prospectively collected dataset of 407 patients with acute vertigo and dizziness presenting to the Emergency Department at the Ludwig‐Maximilian University of Munich. Results The algorithm assigned 287 of 407 patients to the correct diagnosis, corresponding to an overall accuracy of 71%. CVEs were identified with high sensitivity of 94%. The six most common vestibular disorders were classified with high specificity, above 95%. Random forest identified presence of a paresis, sensory loss, central ocular motor and vestibular signs (HINTS [head impulse test, nystagmus assessment, and test of skew deviation]), and older age as the most important variables indicating a cerebrovascular event. Conclusions The proposed diagnostic algorithm can correctly classify the most common vestibular disorders based on a comprehensive set of key questions and clinical examinations. It is easily applied, not limited to subgroups, and might therefore be transferred to broad clinical settings such as primary healthcare.

Risk of future stroke in patients with a diagnosis of peripheral vertigo in the emergency department

“…Studies based on clinical specifics in the evaluation of ED patients with acute vertigo are expected to provide a clear answer [29,30].…”

“…Since MR could not fully elucidate central lesions in the acute setting, misdiagnosed patients may have increased stroke risk in the peripheral vertigo group. Studies based on clinical specifics in the evaluation of ED patients with acute vertigo are expected to provide a clear answer [29, 30]. Thirdly, the ischaemic stroke group had undergone systematic risk evaluation and secondary prevention, but the other groups would probably have not.…”

Needs and supporting tools for primary care physicians to improve care of patients with vertigo and dizziness: a national survey

“…However, with sensitivity values as low as 34.7% for vestibular migraine, its use can only be considered complementary. Novel app-based diagnostic algorithms are currently under development for application in general practice, which have proven to have a high sensitivity for detecting vestibular stroke and a high specificity to correctly diagnose the most frequent non-vascular vestibular disorders in the hospital setting of acute vertigo or dizziness ( 20 ).…”

Akutes zentrales vestibuläres Syndrom

“…Der diagnostische Goldstandard besteht in einer genauen anamnestischen Erfassung des zeitlichen Beginns, der Trigger, nicht vestibulären Begleitsymptome, der strukturierten klinischen Untersuchung der vestibulären und okulomotorischen Systeme, der quantitativen Erfassung des Kopfimpulstests mittels Videookulografie (VOG) und der zielgerichteten Durchführung einer zerebralen Bild-gebung [4,[14][15][16]. Aufgrund der Vielfältigkeit symptomatischer Präsentationen beruht die finale Diagnose eines akuten zentralen vestibulären Syndroms in der Regel auf der Kombination verschiedener Befunde.…”

“…Mögliche Begleitsymptome des akuten Schwindels wie eine Parese, Sensibilitätsstörung, Doppelbilder, Extremitäten-/Rumpfataxie oder Dysarthrie haben eine hohe Sensitivität für einen zugrun-de liegenden Schlaganfall [16]. Allerdings können diese Symptome und Zeichen insbesondere bei zerebellären Schlaganfällen auch fehlen (z.…”