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, ABCD2 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 ABCD2-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.
Highlights
Dizziness is one of the most common presenting complaints in emergency departments (EDs) [17, 30]
An magnetic resonance imaging (MRI) was conducted in 299 patients (49.0% of all patients); this usually happened with a delay but always within 18 days after admission
From the 56 patients with an acute brain lesions (ABLs) on MRI, n = 17 already had the lesion revealed on the initial Computed tomography (CT), n = 37 had a normal CT result and n = 2 did not have a CT in the ED
Summary
Dizziness is one of the most common presenting complaints in emergency departments (EDs) [17, 30]. Diagnosing patients with dizziness is challenging and ED physicians often request neurological consultation and brain imaging studies to differentiate non-vestibular medical causes (e.g., orthostatic dizziness) from peripheral (e.g., benign paroxysmal positional vertigo) or central vestibular disorders (e.g., brainstem/cerebellar stroke) [11, 27]. The likelihood of detecting an acute brain lesion (ABL), for instance a stroke, Brain imaging studies can help to differentiate peripheral vestibular and central causes of dizziness [13]. The diagnostic yield of CT brain imaging in the evaluation of non-preselected dizzy patients in the ED is low (~ 2%) [21].
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