The management of acute isolated vertigo in the emergency department: a mini review

MRI outcomes in patients with acute-onset vertigo in the emergency department – A prospective study

134 Diagnostic Accuracy of the Physical Exam in Patients With Vertigo or Dizziness Presenting to the Emergency Department: A Systematic Review and Meta Analysis Supporting the Guidelines for Reasonable and Appropriate Care in Emergency Medicine

Diagnosing stroke in dizzy patients remains a challenge in emergency medicine. The accuracy of the neuroophthalmologic examination HINTS performed by emergency physicians (EPs) is unknown. Our objective was to determine the accuracy of the HINTS examination performed by trained EPs for diagnosing central cause of acute vertigo and unsteadiness and to compare it with another bedside clinical tool, STANDING, and with the history-based score ABCD2. This was a prospective diagnostic cohort study among patients with isolated vertigo and unsteadiness seen in a single emergency department (ED). Trained EPs performed HINTS and STANDING tests blinded to attending physicians. ABCD2≥4 was used as the threshold and was calculated retrospectively. The criterion standard was diffusion-weighted brain magnetic resonance imaging (MRI). Peripheral diagnoses were established by a normal MRI, and etiologies were further refined by an otologic examination. We included 300 patients of whom 62 had a central lesion on neuroimaging including 49 strokes (79%). Of the 238 peripheral diagnoses, 159 were vestibulopathies, mainly benign paroxysmal positional vertigo (40%). HINTS and STANDING tests reached high sensitivities at 97% and 94% and NPVs at 99% and 98%, respectively. The ABCD2 score failed to predict half of central vertigo cases and had a sensitivity of 55% and a NPV of 87%. The STANDING test was more specific and had a better positive predictive value (PPV; 75% and 49%, respectively; positive likelihood ratio [LR+]= 3.71, negative likelihood ratio [LR-]= 0.09) than the HINTS test (67% and 44%, respectively; LR+= 2.96, LR-= 0.04). The ABCD2 score was specific (82%, LR+= 3.04, LR-= 0.56) but had a very low PPV (44%). In the hands of EPs, HINTS and STANDING tests outperformed ABCD2 in identifying central causes of vertigo. For diagnosing peripheral disorders, the STANDING algorithm is more specific than the HINTS test. HINTS and STANDING could be useful tools saving both time and costs related to unnecessary neuroimaging use.

347 Patient Crossover Rates Vary by Disease in a Health Information Exchange

Differentiating between peripheral and central causes of vertigo

Differentiating between peripheral and central causes of vertigo

Vertigo is a common presenting complaint resulting from central or peripheral etiologies. Because central causes may be life-threatening, ascertaining the nature of the vertigo is crucial in the emergency department (ED). With a broad range of potential etiologies, distinguishing central causes from benign peripheral causes is a diagnostic challenge. Cranial magnetic resonance imaging (MRI) is the recommended neuroimaging method when clinical findings are ambiguous. However, MRI scanning for every patient with an uncertain diagnosis may not be efficient or possible. Therefore, to improve ED resource utilization for patients with vertigo, there is a need to identify the subset most likely to have MRI abnormalities. It has previously been shown that S100B protein provides a useful serum marker of stroke, subarachnoid hemorrhage, and traumatic brain injury. This study evaluated whether S100B levels could predict central causes of vertigo as identified by cranial MRI in the ED. This prospective, observational study was conducted with adult patients with acute-onset vertigo (within 6 hours) in the ED of a teaching hospital in Kocaeli, Turkey. Patients with nausea or dizziness complaints without previously known vertigo or cranial pathology, and who agreed to participate in the study, were included. Patients with trauma or with neurologic findings that developed concurrent with their symptoms were excluded. Serum levels of S100B were measured with an electrochemiluminescence immunoassay kit. All subjects underwent cranial MRI. The predictors of positive MRI results were evaluated using logistic regression analysis. Sensitivity and specificity of S100B​ levels for identifying subjects with central causes of vertigo on MRI were calculated with receiver operating characteristic (ROC) curve. Of the 82 subjects included in the study, 48 (58.5%) were female, and the mean (±SD) age was 51 (±16) years. Thirty-one (37.8%) subjects had positive MRI results. Median (with interquartile range [IQR]) serum S100B levels were significantly different between MRI-negative and MRI-positive groups (median = 27.00 pg/mL, IQR = 10.00 to 44.60 vs. median = 60.94 pg/mL, IQR = 38.25 to 77.95, respectively; p = 0.04). In logistic regression analysis, subjective "he or she is spinning" (p = 0.030, odds ratio [OR] = 1.63, 95% confidence interval [CI] = 1.38 to 2.49), systolic blood pressure (sBP; p = 0.045, OR = 1.044, 95% CI = 1.021 to 1.080), and serum S100B level (p = 0.042, OR = 1.22, 95% CI = 1.018 to 1.445) were found to be independent predictors of MRI abnormalities. In the ROC analysis, S100B > 30 pg/mL predicted the clinical outcome with 83.9% sensitivity (95% CI = 66.3% to 94.5%) and 51.0% specificity (95% CI = 36.6% to 65.2%). The area under the ROC curve was 0.774 (95% CI = 0.666 to 0.881). To the best of our knowledge this is the first study assessing the utility of serum S100B levels for diagnosis of acute-onset vertigo. Serum S100B levels are associated with the presence of central causes of vertigo on cranial MRI. However, serum S100B levels are not sufficiently sensitive to exclude candidates from cranial MRI.

15 - Dizziness and Vertigo

Background: Despite a reduction in morbidity and mortality associated with the use of disease modifying therapies, sickle cell disease (SCD) remains associated with high healthcare resource utilization (HRU), primarily attributed to vaso-occlusive crisis (VOC). (1, 2) There are limited national estimates on HRU, cost of medical care, and treatment expenditures for patients with SCD in Lebanon. A better understanding of these estimates may provide new perspectives to improve access to high-quality cost-effective health care services. Aims: We aimed to evaluate patterns of HRU and related cost in a cohort of patients with SCD receiving care in a Comprehensive SCD referral center at NINI hospital in North Lebanon. Methods: A retrospective non-interventional observational study was conducted among 136 patients (54.4% females) with confirmed diagnosis of SCD in North Lebanon. Data on HRU including emergency department (ED) visits, ambulatory visits and hospitalizations collected in a patient health information (PHI)-anonymized format during the period 01 May2018 - 30 Apr 2020 were obtained from patients’ paper and electronic medical files, as well as hospital and ED files. Uncomplicated VOCs were defined as pain crises, whereas complicated VOCs were defined as acute chest syndrome, acute splenic sequestration, acute hepatic sequestration or priapism. The annual rate of HRU visits was calculated as a ratio of the total number of visits to the total number of years of follow-up across all patients. The average annual cost was similarly calculated as the ratio of total cost of these visits to the total number of years of follow-up, based on available data. Results: In the present study, the median age of patients at the time of study was 10.8 years (IQR 5.3 to 19.6 years). Majority of patients were diagnosed with SS (72.1%) and Sβ0 (21.3%) genotype across all age groups. Pain crisis (90.4%), fever (43.4%), acute chest syndrome (33.1%), and acute splenic sequestration (22.8%) were the most common SCD-related complications. The annual rate of HRU visits (per patient) was 5.7. Uncomplicated VOCs led to majority of hospitalizations, ICU and ED visits in adult patients (age >16 years). The average annual costs of HRU were 8,270,920 Lebanese pounds (LBP) amounting to 5,514 USD (per patient per year) of which 92.1% was for hospitalizations, 4% for ED visits and 3.9% for ambulatory visits. Annual costs for ED, ICU and hospitalizations were highest for uncomplicated VOC. Costs related to medications, diagnostics, non-hematologist medical consults, uncompensated care and lost productivity are not included in this analysis. Analgesics, folic acid and hydroxyurea were the most frequently administered medications across all age groups with 84% of patients being treated with hydroxyurea. Conclusion: This real world study reveals that SCD and its related complications resulted in significant acute HRU. VOCs remain the primary factor for resource use, ICU admission and costs with the largest proportion of annual cost being attributed to hospitalizations. Despite the high HRU rate in this relatively young SCD cohort, the cost of HRU in a comprehensive setting with effective outpatient management as that in North Lebanon appears affordable for the health care system. However when additional SCD related and non SCD related costs of care are included, the economic burden of SCD care is likely to be significantly higher than the figures reported.

We read with interest the paper by Nikles et al. [1], where they present a cohort of patients with stroke-related dizziness but no nystagmus. We were surprised, however, that no reference was made to our data, published in this same journal, on acute truncal ataxia in patients with acute vertigo without nystagmus [2], which may reflect the timing of their original submission. Despite some methodological differences, our data share similarities. Nikles et al. [1] retrospectively analysed 961 head and neck magnetic resonance imaging scans and reviewed notes in the 122 confirmed stroke cases to identify vestibular symptoms and ocular motor signs. We explored the frequency of ataxia without concurrent nystagmus in a cross section of patients with acute vertigo who presented to the emergency department at two centres in Argentina (n = 71) and the UK (n = 24), of whom a total of 30 patients had stroke syndromes [2]. Nikles and colleagues report that nystagmus was present in 50% of their stroke patients. Eighty percent had isolated posterior circulation stroke, and nystagmus was absent in 46% of these patients. In our 30 patients with acute stroke, nystagmus was absent in 40% of patients. We did not report the nystagmus characteristics in our patients with stroke, but the majority had gaze-evoked (“direction-changing”) nystagmus, in keeping with cerebellar involvement [3]. This differs from the findings by Nikles et al., where in all stroke patients with nystagmus this was spontaneous and typically horizontal or "unspecified." In their cohort, 35% of patients with anterior circulation stroke had nystagmus, again all spontaneous. The authors argue that the absence of nystagmus in so many patients with posterior circulation stroke may be because many patients were evaluated by nonspecialists who may have missed subtle abnormalities. This may account for the absence of gaze-evoked nystagmus in their cohort. Considering the high number of patients with stroke in whom no nystagmus was observed, the authors recommend the use of the BE-FAST (balance, eyes, face, arm, speech, time) for evaluation of all patients with acute vertigo, as a number of their patients without nystagmus had facial palsy, dysarthria, and limb ataxia. They further suggest that a more precise examination of ocular motor function (saccades, smooth pursuit, optokinetic nystagmus) may allow detection of subtle signs suggestive of stroke, ideally with video-oculography. Although we observed abnormal smooth pursuit and hypermetric saccades in five patients with acute truncal ataxia without nystagmus, the effects of age on the ocular motor system make it difficult to ascribe such abnormalities to the acute pathology. Therefore, reliance on the ocular motor assessment may be insufficient to identify central causes of vertigo when nystagmus is absent. We emphasize the importance of assessing static balance in patients with acute vertigo, particularly those without nystagmus, where moderate or severe acute truncal ataxia predicts a central (vs. inner ear) pathology [4]. Nikles et al. and others have referred to this as acute imbalance syndrome, but we would argue that such a nomenclature does not reflect the cerebellar dysfunction that underpins the cause of the unsteadiness and perhaps therefore degrades its urgency. We propose that acute truncal ataxia without nystagmus is an important subtype of the acute vestibular syndrome. Diego Kaski: Conceptualization; methodology; formal analysis; writing – original draft; writing – review and editing. Sergio Carmona: Conceptualization; methodology; writing – review and editing. Carlos Martínez: Conceptualization; writing – review and editing. Guillermo Zalazar: Conceptualization; writing – review and editing. Nehzat Koohi: Conceptualization; writing – review and editing. None of the authors has any conflict of interest to disclose. The data that support the findings of this study are available from the corresponding author upon reasonable request.

Summary Introduction: Acute vertigo ranks among the common reasons for visiting the emergency department. The aim of this study was to evaluate the rate of peripheral vestibular syndrome (PVS) in patients with acute vertigo examined at the ENT emergency department and to compare the agreement of physical ENT examination with video-assisted vestibular testing. Methods: Patients eamined at the ENT emergency department from January to December 2019 were evaluated retrospectively. The patients who underwent basic ENT examination without video-assisted vestibular testing form group A. The patients who underwent basic ENT examination which was followed by video head impulse test (vHIT) and videonystagmography in the next four days form group B. Results: A total of 117 patients with acute vertigo were included in group A, PVS was found in 31 patients (27%). In total, 50 patients were included in group B; PVS was found in 15 patients (30%), vestibular neuronitis was dia­gnosed most often (10 patients). The difference in the dia­gnosis of PVS by basic ENT examination (27 patients, 54%) and by video-assisted vestibular testing (15 patients, 30%) was statistically significant (P = 0.0030). The gain of the lateral (P = 0.0101) and superior (P = 0.0043) semicircular canal proved to be statistically significant, while vHIT was lower in PVS in comparison to other causes of vertigo. Conclusion: After basic ENT examination, PVS as a cause of acute vertigo was dia­gnosed in 27%. Video-assisted vestibular testing proved a statistically significant lower incidence of PVS in comparison to basic ENT examination. Accessibility of video- -assisted vestibular testing in the emergency department might allow for higher accuracy in the dia­gnosis of acute vertigo. Key words acute vertigo – vestibular function tests – video head impulse test – videonystagmography

Background:Since hepatitis C virus therapy is typically prioritized for patients with more advanced disease, predicting which patients will progress could help direct scarce resources to those likely to benefit most. This study aims to identify demographics and clinical characteristics associated with high healthcare resource utilization (HRU) and liver disease progression among CHC patients.Methods:Using health insurance claims (January 2001–March 2013), adult patients with ≥2 CHC claims (ICD-9-CM: 070.44 or 070.54), and ≥6 months of continuous insurance coverage before and ≥36 months after the first CHC diagnosis were included. Patients with human immunodeficiency virus were excluded. Generalized estimating equations were used to identify the demographic and clinical characteristics of being in the 20% of patients with the highest HRU. Factors predicting liver disease progression were also identified.Results:In the study population (n = 4898), liver disease severity and both CHC- and non–CHC-related comorbidities and conditions were strong predictors of high healthcare costs, with odds ratios (ORs; 95% confidence interval [CI]) for ≥2 CHC-related and ≥2 non-CHC-related comorbidities/conditions of 2.78 (2.48–3.12) and 2.19 (1.76–2.72), respectively. CHC- and non-CHC-related comorbidities and conditions were also strong predictors of liver disease progression with ORs (95% CI) for ≥2 CHC-related and ≥2 non-CHC-related comorbidities and conditions of 2.18 (1.83–2.60) and 1.50 (1.14–1.97), respectively.Limitations:Potential inaccuracies in claims data, information or classification bias, and findings based on a privately insured population.Conclusion:This study suggests that CHC patients with high healthcare resource utilization have a high level of comorbidity at baseline and also that non-CHC comorbidities and conditions are strong predictors of high HRU. Non-cirrhotic CHC patients with one or more comorbidities are at high risk of progressing to cirrhosis or end-stage liver disease.

Acute vertigo is defined as the perception of movement of oneself or the surroundings in the absence of actual motion and it is a frequent cause for emergency department admissions. The utilization of medical resources and the duration of hospital stay for this kind of symptom is high. Furthermore, the efficiency of brain imaging in the acute phase is low, considering the limited sensitivity of both CT and MRI for diagnosing diseases that are the causes of central type of vertigo. Relying on imaging tests can provide false reassurance in the event of negative results or prolong the in-hospital work-up improperly. On the other hand, clinical examinations, notably the assessment of nystagmus’ features, have proven to be highly accurate and efficient when performed by experts. Literature data point out that emergency physicians often do not employ these skills or use them incorrectly. Several clinical algorithms have been introduced in recent years with the aim of enhancing the diagnostic accuracy of emergency physicians when evaluating this specific pathology. Both the ‘HINTS and ‘STANDING’ algorithms have undergone external validation in emergency physician hands, showing good diagnostic accuracy. The objective of this consensus document is to provide scientific evidence supporting the clinical decisions made by physicians assessing adult patients with acute vertigo in the emergency department, particularly in cases without clear associated neurological signs. The document aims to offer a straightforward and multidisciplinary approach. At the same time, it tries to delineate benchmarks for the formulation of local diagnostic and therapeutic pathways, as well as provide a base for the development of training and research initiatives.

<p class="abstract"><strong>Background:</strong> Vertigo is one of the most distressing symptoms. It is difficult to identify, practically impossible to measure and not easy to treat. Electronystagmography (ENG) objectively records eye movements and thus tests the functional integrity of vestibulo-ocular reflex and its connections from inner ear to the brain. Hence, this present study was taken to evaluate the role of ENG in the diagnosis of vertigo, to know the peripheral, central and other causes of vertigo and to know the side of lesion. The aim of this study was to evaluate the role of ENG in the diagnosis of vertigo, to know the peripheral, central and other causes of vertigo and to know the side of lesion.</p><p class="abstract"><strong>Methods:</strong> This study included 60 patients who presented with primary complaints of vertigo or dizziness. Patients were subjected to ENG under optimal conditions and the results were obtained in the form of a graphical recordings after analysis of the ENG data.</p><p class="abstract"><strong>Results:</strong> Of the 60 patients subjected to ENG, a peripheral cause was seen in 33 patients. 21 patients were diagnosed with benign positional paroxysmal vertigo (BPPV), whereas 06 patients showed a central lesion of the vestibular system.</p><p class="abstract"><strong>Conclusions:</strong> ENG acts as a useful screening tool to differentiate between peripheral cause of vertigo and central cause of vertigo. It has special significance in localizing the side of the lesion. Hence, ENG has proven to be a useful first line investigation in the diagnosis of vertigo.</p>

In reply: We thank Sabour for showing interest in our trial evaluating the diagnostic accuracy and the reliability of the four-step STANDING algorithm performed by emergency seniors and interns in 312 patients with acute vertigo.1 After reading it, we thought it was necessary to clarify the three methodologic issues that seem to have been misunderstood: (1) the clinical significance of this diagnostic cohort study, (2) the accuracy parameters used, and (3) the reliability (agreement) estimate. According to the first point, we agree that diagnosis and prediction are two different research questions requiring two different methodologies. This prospective diagnostic cohort study was designed to assess the diagnostic accuracy of a test—STANDING—compared to criterion standard—brain diffusion-weighted MRI—for the diagnosis of an acute brain process in posterior fossa or in the vestibular cortex. As stated in the sections “Measurements” and “Statistical analysis,” the STANDING algorithm result was classified either positive (i.e., “worrisome,” when indicating a cerebral disease) or negative (i.e., “inconclusive” or “benign,” when not indicating a cerebral disease), while the MRI result was classified either positive (when finding a cerebral disease) or negative (when not finding a cerebral disease). Second, we can only agree that sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios (LRs) are the most appropriate estimates to evaluate validity of the four-step STANDING algorithm compared to the criterion standard. These parameters have been calculated for each step and for the overall STANDING algorithm (Table 5). To compare the accuracy of interns with senior EPs, the method proposed by Roldán-Nofuentes has been used.2 While the overall STANDING algorithm showed good sensitivity (89.3%) and specificity (91.3%), it is important to note that these last are not always associated in a diagnostic test. Thus, these results are useful when considering STANDING as a binary test (positive vs. negative). Moreover, to assess the accuracy, we also calculated respective LR for the three possible results of the STANDING algorithm (Table 5). LR of 0.09 and 0.01 for a benign result means that STANDING is a good exclusion test. As noted in the discussion section, LR of 0.21 and 0.35 for an inconclusive result emphasize that STANDING has one restrictive application in a clinical subgroup frequently encountered in the ED (presenting vestibular symptoms at the time of the clinical examination, without objective worrisome physical criteria). We believe that these results assist EPs in clinical decision and that they should encourage EPs of all levels of experience to learn vestibuloocular examination, especially maneuvers to diagnose the most common benign cause, BPPV. Unlike what Sabour suggested, using receiver operating characteristic (ROC) curves is inappropriate because both STANDING algorithm and MRI are binary tests.3 Third, the author raised that the assessment of reliability (agreement) for qualitative variables should be assessed using appropriate estimate and that kappa coefficient should be used with caution. This is absolutely correct: Feinstein and Cicchetti have already discussed the effect of imbalance and of asymmetry on kappa coefficient.4 They enlightened the fact that one of these cases can lead to a wrong conclusion. As an alternative, Shankar and Bangdiwala recommend using the B-statistic to solved problems of asymmetry and imbalances.5 For these reasons, as explained in the “Statistical analysis” section of the “Methods” part, we used the B-statistic to estimate the agreement between intern and senior. In our article, no mention is made of the kappa coefficient. Finally, from an epidemiologic perspective, we pointed out that an external validation was still needed in a multicenter study to ensure both the accuracy of the algorithm in other emergency settings and the level of training required for EPs worldwide.6 However, we regret that the three methodologic points criticized by the author do not support a risk of misinterpretation, misdiagnosis, or mismanagement, not having already been argued in our article. The authors declare no potential conflict of interest.