Continuous Dizziness Research Articles

A case of cerebellopontine angle meningioma presenting as neurovascular compression syndrome of the 8th cranial nerve

A 54-year-old female patient presented with paroxysmal tinnitus and vertigo for 2 years, which have repeatedly occurred while rotating her neck, and lasted about 10 seconds. An anticonvulsant medication was prescribed with a diagnosis of microvascular compression syndrome on the 8th cranial nerve and audiovestibular evaluation and magnetic resonance imaging (MRI) scan were appointed a week later. In her next visit, she reported the disappearance of paroxysmal audiovestibular symptoms after medication. In the left ear, canal paresis and abnormal auditory brainstem response were observed. In MRI, a large meningioma in the cerebellopontine angle in the vicinity of the internal auditory canal orifice was detected, that was surgically resected by a neurosurgeon. After surgical removal of the tumor, she reported continuous dizziness due to vestibular nerve injury, but the paroxysmal attack of tinnitus and vertigo disappeared without anticonvulsant medication. This case suggests that an imaging study is mandatory when diagnosing microvascular compression syndrome on the 8th cranial nerve.

Pearls for the Emergency Clinician: Posterior Circulation Stroke

BackgroundPosterior circulation (PC) stroke in adults is a rare, frequently misdiagnosed, serious condition that carries a high rate of morbidity. Objective of the ReviewThis review evaluates the presentation, diagnosis, and management of PC stroke in the emergency department (ED) based on current evidence. DiscussionPC stroke presents most commonly with dizziness or vertigo and must be distinguished from more benign diagnoses. Emergency clinicians should consider this condition in patients with dizziness, even in younger patients and those who do not have traditional stroke risk factors. Neurologic examination for focal neurologic deficit, dysmetria, dysarthria, ataxia, and truncal ataxia is essential, as is the differentiation of acute vestibular syndrome vs. spontaneous episodic vestibular syndrome vs. triggered episodic vestibular syndrome. The HINTS (head impulse, nystagmus, and test of skew) examination can be useful for identifying dizziness presentations concerning for stroke when performed by those with appropriate training. However, it should only be used in patients with continuous dizziness who have ongoing nystagmus. Contrast tomography (CT), CT angiography, and CT perfusion have limited sensitivity for identifying PC strokes, and although magnetic resonance imaging is the gold standard, it may miss some PC strokes early in their course. Thrombolysis is recommended in patients presenting within the appropriate time window for thrombolytic therapy, and although some data suggest endovascular therapy for basilar artery and posterior cerebral artery infarcts is beneficial, its applicability for all PC strokes remains to be determined. ConclusionsAn understanding of PC stroke can assist emergency clinicians in diagnosing and managing this disease.

A Case of Vertigo with TORP in Inner Ear.

This is a case of a patient with history of ear surgery who visited ENT outdoor, for continuous vertigo which used to get aggravated with loud noise, associated with hearing loss, persistent sensations of right-sided aural fullness/pressure and otalgia for last 2years. He had history of tympanoplasty with ossiculoplasty using a TORP. On exploration under local anesthesia there was a displaced prosthesis into inner ear, upon removal of which symptoms and severity subsided exponentially.

Our Experience on Tug Test as Diagnostic Marker in Peripheral Vestibular Diseases

Background: Vestibular dysfunction in elderly screened with Timed Up and Go (TUG) test, is fast, simple way to assess fall risk, lower limb mobility, and function in clinical settings. This study was initiated to assess improvement of patient symptoms and postural control after performing Epley's maneuver using the Timed Up and test. Incorporation of the TUG test in this study provided a comprehensive evaluation of the effects of Epley's maneuver on both symptom relief and functional mobility. It allowed for objective measurements and quantifiable data to assess the effectiveness of the intervention, providing valuable insights for clinical decision-making and patient management. Methods: Prospective observational study was carried out on 100 patients aged 65 years and above suffering with peripheral vertigo were performed with "timed up and go" (TUG) test. We Propose Cutoff point of 13.5 seconds proposed as standard for identifying at risk of falling after particle repositioning maneuver. This decision was based on several factors and considerations specific to our study population and objectives. By setting a cut-off value of 13.7 seconds, we tried to achieve better balance between sensitivity and specificity, ensuring a more accurate identification of the target parameter in our study population. Results: In our study we observed from the results that the mean age of the patients in study was 69.6 years. A study population of 62 (62.0%) males and a number of 38(38.0%) females were considered for the study. Clinical findings of the study revealed that for patients suffering with dizziness it was observed that 29(29.0%) of patients had dizziness of less than 6 months, 24(24.0%) of the patients had dizziness for 6-12 months, 23(23.0%) patients had dizziness for >2 years, and 22(22.0%) of patients had dizziness for 1-2 years. Based on frequency of dizziness attacks it was observed that 53(53.0%) of study population had dizziness every day and 47(47.0%) had dizziness every week. Based on the duration of dizziness in the study population 29(6.0%6) of them had dizziness for few seconds only, 25(25.0%) of them had dizziness lasting for few minutes to hours, and 23(23.0%) of study population had continuous dizziness. In the study population 28(28.0%) had dizziness on lying down, 24(24.0%) had dizziness on turning, and 22(22.0%) had dizziness on lying down and turning. Also 84(84.0%) of these population had body instability, 73(73.0%) had vomiting during dizziness, 71(71.0%) had anxiety related to dizziness, 67(67.0%) had associated symptoms of nausea during attacks, 65(65.0%) of study population had associated tinnitus, 61(61.0%) among the study population had disordered sleep. Also it was observed that 59(59.0%) had headache, 56(56.0%) had sensation of fainting, 39(39.0%) had pallor & hearing loss, 38(38.0%) had sensation of pressure, and 29(29.0%) had sweating as associated clinical symptoms during the attacks of dizziness. Re-assessment after Epley’s maneuver reveals reduction in majority clinical findings. TUG test findings show mean initial assessment score of 15.3 + 3.02, after Epley’s maneuver was 12.3 + 3.34 with mean difference of 3.01 with p-value (<0.001). Discussion and Conclusion: Epley’s maneuver is useful to reduce clinical symptoms with peripheral vestibular disorders as assessed by TUG test in elderly

Role of bedside video-oculography in selecting neuroimaging in patients with acute vertigo and ataxia posterior fossa mass lesions

The acute vestibular syndrome ((AVS) is the sudden onset of continuous vertigo, nausea, vomiting and head motion intolerance [1]. The most common peripheral cause is a vestibular neuritis [2], and the most frequent central lesion associated with an AVS is an ischemic stroke in about 10 to 15% of cases [3–5]; less frequently demyelinating plaques (multiple sclerosis (MS) and neuromyelitis optica (NMO)) [6], and inflammatory lesions associated with infectious and paraneoplastic disorders may be responsible.

The Spectrum of Vestibular Disorders Presenting With Acute Continuous Vertigo.

ObjectiveTo explore the composition of vestibular disorders presenting with the acute vestibular syndrome (AVS).MethodsWe performed a case analysis of 209 AVS patients between January 2016 and December 2020. These patients were grouped into different disorder categories according to the relevant diagnostic criteria.ResultsWe classified the 209 patients into 14 disorder categories, including 110 cases of vestibular neuritis, 30 of idiopathic sudden sensorineural hearing loss with vertigo, 17 of the first attack of continuous vertigo with migraine, 15 of Ramsay Hunt syndrome, 11 of acute labyrinthitis secondary to chronic otitis media, 8 of vestibular schwannoma, 6 of posterior circulation infarction and/or ischemia, 3 of cerebellar abscess secondary to chronic otitis media, 3 of AVS caused by trauma or surgery, 2 of AVS with down-beating nystagmus, 1 of multiple sclerosis of the medulla oblongata, 1 of epidermoid cyst of the posterior cranial fossa, 1 of a probable acute otolithic lesion, and 1 of AVS without measurable vestibular dysfunction.ConclusionWhen a group of disorders present with AVS, characteristic clinical manifestations and imaging help with an accurate diagnosis.

Can “HINTS” aid the Diagnosis of Posterior Circulation Stroke among patients with Acute Vestibular Syndrome?

Introduction:
 Identifying posterior circulation stroke in patients with AVS without obvious focal neurological deficits poses a difficult diagnostic challenge. It is estimated that about 10% to 20% of patients who present with acute dizziness to the Emergency department have AVS7. Most AVS patients have a benign peripheral vestibular cause (vestibular neuritis or nonbacterial labyrinthitis), but about 25% have brainstem or cerebellar strokes7, 9-10. Rapid, accurate diagnosis of posterior stroke is important for early management as well as prevention of devastating complications. HINTS is a clinical three-step bedside oculomotor exam, that has been suggested of high diagnostic accuracy in identifying posterior circulation stroke in patients with isolated continuous vertigo.
 Methods:
 A comprehensive systematic search of literature was done using the NHS Evidence healthcare databases Medline, EMBASE, CLINIL, Google scholar and Cochrane.
 Results:
 10 relevant articles were identified, combining the results of all six prospective studies showed a total of 338 patients on which Clinical HINTS exam was performed. The overall Hints exam sensitivity was 96.86% 95%CI (92.8-99), specificity 96.09% 95%CI (92.1-98.4) and negative predictive value was 0.03 95%CI (0.01-0.08). ROC analysis was done in which area under curve was found to be 0.965.
 Conclusion:
 Delay in diagnosis of posterior stroke can result in 8-fold increase in mortality7. HINTS is a useful clinical bed side oculomotor exam, which if done appropriately by trained ED doctors, could aid in the early recognition of a subtly presenting posterior stroke with “acute isolated continuous vertigo”. Hence, will improve the overall diagnostic evaluation of acute vestibular syndrome.

Paradigm shift in acute dizziness: is caloric testing obsolete?

ObjectiveCold and warm water ear irrigation, also known as bithermal caloric testing, has been considered for over 100 years the ‘Gold Standard’ for the detection of peripheral vestibular hypofunction. Its discovery was awarded a Nobel Prize. We aimed to investigate the diagnostic accuracy of Caloric Testing when compared to the video head impulse test (vHIT) in differentiating between vestibular neuritis and vestibular strokes in acute dizziness.DesignProspective cross-sectional study (convenience sample).SettingAll patients presenting with signs of an acute vestibular syndrome at the emergency department of a tertiary referral center.ParticipantsOne thousand, six hundred seventy-seven patients were screened between February 2015 and May 2020 for Acute Vestibular Syndrome (AVS), of which 152 met the inclusion criteria and were enrolled. Inclusion criteria consisted of a state of continuous dizziness, associated with nausea or vomiting, head-motion intolerance, new gait or balance disturbance and nystagmus. Patients were excluded if they were younger than 18 years, if symptoms lasted < 24 h or if the index ED visit was > 72 h after symptom onset. Of the 152 included patients 85 completed testing. We assessed 58 vestibular neuritis and 27 stroke patients.Main outcome measuresAll patients underwent calorics and vHIT followed by a delayed MRI which served as a gold standard for vestibular stroke confirmation.ResultsThe overall sensitivity and specificity for detecting stroke with a caloric asymmetry cut-off of 30.9% was 75% and 86.8%, respectively [negative likelihood ratio (NLR) 0.29] compared to 91.7% and 88.7% for vHIT (NLR 0.094). Best VOR gain cut-off was 0.685. Twenty-five percent of vestibular strokes were misclassified by calorics, 8% by vHIT.ConclusionsCaloric testing proved to be less accurate than vHIT in discriminating stroke from vestibular neuritis in acute dizziness. Contrary to classic teaching, asymmetric caloric responses can also occur with vestibular strokes and might put the patient at risk for misdiagnosis. We, therefore, recommend to abandon caloric testing in current practice and to replace it with vHIT in the acute setting. Caloric testing has still its place as a diagnostic tool in an outpatient setting.

Acute Vestibular Syndrome.

This article provides a practical approach to acute vestibular syndrome while highlighting recent research advances. Acute vestibular syndrome is defined as sudden-onset, continuous vertigo lasting longer than 24 hours with associated nausea and vomiting, all of which are worsened with head movement. Acute vestibular syndrome is provoked by a variety of central and peripheral causes, the most common of which are vestibular neuritis and acute stroke (posterior circulation). A clinical approach focusing on timing, associated history, and ocular motor findings can improve diagnostic accuracy and is more sensitive and specific than early neuroimaging. Because of the shared neurovascular supply, both peripheral and central vestibular disorders can manifest overlapping signs previously considered solely peripheral or central, including vertical skew, nystagmus, abnormal vestibular ocular reflex, hearing loss, and gait instability. Although acute vestibular syndrome is typically benign, stroke should be considered in every person with acute vestibular syndrome because it can act as a harbinger of stroke or impending cerebellar herniation. Treatment is focused on physical therapy because the evidence is minimal for the long-term use of medication. The diagnosis of acute vestibular syndrome first requires the elimination of common medical causes for dizziness. Next, underlying pathology must be determined by distinguishing between the most common causes of acute vestibular syndrome: central and peripheral vestibular disorders. Central vestibular disorders are most often the result of ischemic stroke affecting the cerebellar arteries. Peripheral vestibular disorders are assumed to be caused mostly by inflammatory sources, but ischemia of the peripheral vestibular apparatus may be underappreciated. By using the HINTS Plus (Head Impulse test, Nystagmus, Test of Skew with Plus referring to hearing loss assessment) examination in addition to a comprehensive neurologic examination, strokes are unlikely to be missed. For nearly all acute vestibular disorders, vestibular physical therapy contributes to recovery.

Clinical features of BPPV and their influence on the choice of the doctor’s tactics

BPPV is the most common cause of recurrent vertigo. Except vertigo attacks main clinical symptoms of BPPV can include autonomic symptoms and imbalance, which sometimes complicate the diagnosis of BPPV. A total of 640 patients (504 (78.8%) women) aged from 20 to 86 years old, mean age 56.43±0.54 years with BPPV were included and diagnosed by roll and Dix-Hallpike tests. Among them 144 (22.5%) patients were inpatient and 496 (77.5%) patients were outpatient. The detailed patient intake comprised the disease onset, the type of dizziness, vertigo triggers, autonomic symptoms, similar attacks in the past and previously made definite diagnosis of BPPV. The period from the appearance of the first symptoms to the correct diagnosis was assessed. The majority of patients (75.3%) consult a neurologist at the initial visit. Only 30.6% of patients had a correct diagnosis within a week of the onset of the disease. Initial BPPV symptoms included persistent dizziness that increased with head turns (38.8%), nausea and vomiting (21.6%), significant increase in blood pressure (13.4%), persistent imbalance while walking (73.4%). Inpatients more frequently had constant continuous dizziness, high blood pressure, severe nausea and vomiting, and the onset of symptoms in the morning when getting out of bed (p<0.05). Initial BPPV symptoms may be similar to other diseases. Focusing on medical history and complaints leads to frequent diagnostic errors, unnecessary hospitalization and prolonged treatment of patients. Positional tests are necessary for the correct diagnosis of BPPV.

Diagnostic Accuracy of the HINTS Exam in an Emergency Department: A Retrospective Chart Review.

The HINTS exam is a series of bedside ocular motor tests designed to distinguish between central and peripheral causes of dizziness in patients with continuous dizziness, nystagmus, and gait unsteadiness. Previous studies, where the HINTS exam was performed by trained specialists, have shown excellent diagnostic accuracy. Our objective was to assess the diagnostic accuracy of the HINTS exam as performed by emergency physicians on patients presenting to the emergency department (ED) with a primary complaint of vertigo or dizziness. A retrospective cohort study was performed using data from patients who presented to a tertiary care ED between September 2014 and March 2018 with a primary complaint of vertigo or dizziness. Patient characteristics of those who received the HINTS exam were assessed along with sensitivity and specificity of the test to rule out a central cause of stroke. A total of 2,309 patients met criteria for inclusion in the study. Physician uptake of the HINTS exam was high, with 450 (19.5%) dizzy patients receiving all or part of the HINTS. A large majority of patients (96.9%) did not meet criteria for receiving the test as described in validation studies; most often this was because patients lacked documentation of nystagmus or described their symptoms as intermittent. In addition, many patients received both HINTS and Dix-Hallpike exams, which are intended for use in mutually exclusive patient populations. In no case was dizziness due to a central cause identified using the HINTS exam. Our results suggest that despite widespread use of the HINTS exam in our ED, its diagnostic value in that setting was limited. The test was frequently used in patients who did not meet criteria to receive the HINTS exam (i.e., continuous vertigo, nystagmus, and unsteady gait). Additional training of emergency physicians may be required to improve test sensitivity and specificity.

Clinical Application of Video Head Impulse Test in Acute Vestibular Syndrome

Acute unilateral vestibulopathy (AUV) is the recommended term [rather than the more widely used ‘vestibular neuritis (VN)’] for all pathologies involving sudden impairment of the unilateral peripheral vestibular function regardless of the exact location of the lesion. Acute vestibular syndrome (AVS) is an upper-level entity of AUV, which is the most common cause of AVS, and includes acute central vertigo. AVS typically presents with the symptoms of new onset continuous vertigo, gait instability, and nausea/vomiting lasting several days to weeks. The video head impulse test (vHIT) was recently developed and has been widely adopted at clinics and emergency centers. In this study, we will review the differential diagnosis of AVS using vHIT. In addition, we will describe the subtypes of VN and the use of vHIT for follow-up testing in AVS. Key words: Acute unilateral vestibulopathy ㆍ Acute vestibular syndrome ㆍ Vestibular neuritis ㆍ Video head impulse test

Recovery Phase Spontaneous Nystagmus, Its Existence and Clinical Implication.

Background and ObjectivesDetermination of the lesion side based on the direction of the nystagmus could result in confusions to the clinicians due to mismatch between the vestibular function tests and also between vestibular and audiologic features. To minimize these mistakes, we elucidated the clinical manifestation and vestibular function test results in cases with recovery spontaneous nystagmus (rSN).Subjects and MethodsPatients who visited ENT clinic of tertiary referral hospital for acute onset continuous vertigo from January 2008 to December 2011 were enrolled. In these patients, we assessed onset time of vertigo, time point of paralytic spontaneous nystagmus (SN) and time point of rSN. At each time point of SN, vestibular function tests and hearing function tests were performed.ResultsWe confirmed the rSN among patients with unilateral vestibulopathy and demonstrated that high gain of the rotatory chair test (slow harmonic acceleration) and/or mismatch of the SN direction and contralateral caloric weakness could indicate the recovery state of patients and nystagmus observed in this stage is recovery phase nystagmus.ConclusionsIn acute vestibulopathy patients, recovery phase nystagmus was observed and on this stage of disease vestibular function tests shows several features that could predict recovery state.

Asking about dizziness when turning in bed predicts examination findings for benign paroxysmal positional vertigo.

Benign paroxysmal positional vertigo (BPPV) is the single most common cause of vestibular vertigo and is characterised by short episodes of rotational vertigo precipitated by changes in head positions like lying down or turning in bed. This study aims to assess useful questions when suspecting benign paroxysmal positional vertigo (BPPV) caused dizziness as well as identifying if a single question can be useful in identify or distinguish patients with BPPV from other dizziness aetiology. A total of 149 patients admitted due to dizziness were included. Patients answered a questionnaire and were investigated for BPPV with diagnostic manoeuvres. Two of the 15 questions were of diagnostic importance. Dizziness when laying down or turning in bed, increased likelihood of BPPV by an odds ratio (95% confidence interval) of 60 (7.47-481.70). Continuous dizziness duration as opposed to lasting seconds decreased likelihood of BPPV with an odds ratio of 0.06 (0.01-0.27). Vertiginous attacks by turning or laying down in bed together with dizziness <1 minute, are important questions and strongly related to BPPV. Such questions are important when taking a medical history and may help to early identify BPPV, also for non-medical staff, as well as reduce the need of further investigations.

The value of brain magnetic resonance imaging in the early diagnosis of neuropsychiatric systemic lupus erythematosus

To investigate the value of brain magnetic resonance imaging (MRI) in evaluating the intracranial injuries in patients with juvenile onset systemic lupus erythematosus (SLE). Data of brain MRI, CT, electroencephalogram (EEG), cerebrospinal fluids analysis and clinical features of the central nervous system of 44 patients from March 2007 to March 2015 with juvenile onset SLE who were not treated with glucocorticoids (Gcs) and immunosuppressive agents (Is) were retrospectively analyzed and compared. Twenty-seven out of 44 patients demonstrated abnormal signs on brain MRI, including encephalatrophy, cerebral infarction, demyelination, encephalorrhagia, vertebral arteriostenosis and abnormal signals on the brain diffusion-weighted imaging (DWI). Sixteen patients had clinical features of the central nervous system involvement, fifteen had continuous headache, nine had continuous dizziness, seven had convulsions, three had hemiplegia, one had blurred vision. Physical examination of the nervous system: ten patients had abnormal signs, all had cervical rigidity, five showed pyramidal sign, three showed loss of muscle tone, two with cranial neuropathies and one had paresthesia. EEG: Ten patients showed abnormal waves on EEG, all showed diffused slow-waves, and five showed sharp waves and spikes. Cerebrospinal fluids analysis: six patients had abnormal results, five of them had cell count elevation and one had cell count and protein elevation, while there was glucose and chloride degression. Brain CT: Eight patients received CT scan, two showed cerebral infarction. χ(2) test was used to compare the differences among head MRI, EEG, cerebrospinal fluid analysis, physical examination of the nervous system, clinical features of the nervous system, the difference was significant(χ(2)=12.055, P=0.001; χ(2)=19.627, P=0.001; χ(2)=3.859, P=0.049; χ(2)=12.055, P=0.001). Brain MRI may be a better method in early diagnosis of intracranial injuries than CT, EEG, cerebrospinal fluid analysis and physical examination of the nervous system. Patients with juvenile onset SLE should receive brain MRI after diagnosis in order to investigate the intracranial injuries. Abnormal signals on the DWI are the signs of active disease.

Comment: Diagnosing stroke in acute dizziness-Do the "eyes" still have it?

In this issue of Neurology ®, Kerber et al.1 describe 272 emergency department patients with acute, continuous dizziness and nystagmus or gait unsteadiness, 29 (11%) with strokes by MRI neuroimaging. Their population is similar to those described previously as the acute vestibular syndrome (AVS).2 The authors compare clinical features (ABCD2 [age, blood pressure, clinical features, duration, and diabetes] risk score, general neurologic examination, and head impulse, nystagmus pattern, test of skew [HINTS]2 eye movement tests) in stroke and nonstroke patients. They contend that no single examination “can identify a sufficiently low-risk group” to rule out stroke in AVS. They suggest instead a mathematical modeling approach combining all of these factors to identify a very low-risk population (86 [32%] without stroke).

Graphic representation of the burden of suffering in dizziness patients.

BackgroundDizziness adversely affects an individual’s well-being. However, its impact is not only influenced by its physical manifestations, but also by its subjective importance to the patient. Appropriately assessing the subjective burden of dizziness is difficult. The Pictorial-Representation of Illness- and Self-Measure (PRISM), on which patients illustrate the distance between their ‘self’ and their illness, has been documented to indicate the perception of suffering in several different illnesses. Our study objectives were (1) to assess how useful the PRISM is in patients with dizziness; and (2) to determine which clinical, emotional and sociodemographic factors contribute to their burden of suffering.MethodsA total of 177 outpatients with dizziness completed this cross-sectional study, in which the following measures were assessed of suffering rated using the PRISM tool; dizziness-related variables, like emotional distress (Hospital Anxiety and Depression-Scale, HADS); self-perceived severity of dizziness (Dizziness Handicap Inventory, DHI); and sociodemographic variables.ResultsRegression analyses identified the strongest association between PRISM-rated suffering and DHI (p < 0.001), explaining 34% of the variance in PRISM-rated suffering. The HADS score and having continuous dizziness versus transient attacks each explained roughly 2% of the variance in suffering. No significant associations with PRISM-rated suffering were found for sociodemographic variables or other dizziness characteristics.ConclusionsThe PRISM is applicable to patients suffering from dizziness, demonstrating a significant association with the severity of dizziness and reliably distinguishing between those with low and high intensities of dizziness. The PRISM also reflects the multi-factorial aspects of suffering. Due to its immediate, timesaving and economical use, the PRISM could enable clinicians to identify vulnerable patients at risk for chronic symptoms and distress. Whether the PRISM can detect improvements and worsening of symptoms during treatment warrants further research.

HINTS Outperforms ABCD2 to Screen for Stroke in Acute Continuous Vertigo and Dizziness

Dizziness and vertigo account for about 4 million emergency department (ED) visits annually in the United States, and some 160,000 to 240,000 (4% to 6%) have cerebrovascular causes. Stroke diagnosis in ED patients with vertigo/dizziness is challenging because the majority have no obvious focal neurologic signs at initial presentation. The authors sought to compare the accuracy of two previously published approaches purported to be useful in bedside screening for possible stroke in dizziness: a clinical decision rule (head impulse, nystagmus type, test of skew [HINTS]) and a risk stratification rule (age, blood pressure, clinical features, duration of symptoms, diabetes [ABCD2]). This was a cross-sectional study of high-risk patients (more than one stroke risk factor) with acute vestibular syndrome (AVS; acute, persistent vertigo or dizziness with nystagmus, plus nausea or vomiting, head motion intolerance, and new gait unsteadiness) at a single academic center. All underwent neurootologic examination, neuroimaging (97.4% by magnetic resonance imaging [MRI]), and follow-up. ABCD2 risk scores (0-7 points), using the recommended cutoff of ≥4 for stroke, were compared to a three-component eye movement battery (HINTS). Sensitivity, specificity, and positive and negative likelihood ratios (LR+, LR-) were assessed for stroke and other central causes, and the results were stratified by age. False-negative initial neuroimaging was also assessed. A total of 190 adult AVS patients were assessed (1999-2012). Median age was 60.5years (range=18 to 92years; interquartile range [IQR]=52.0 to 70.0years); 60.5% were men. Final diagnoses were vestibular neuritis (34.7%), posterior fossa stroke (59.5% [105 infarctions, eight hemorrhages]), and other central causes (5.8%). Median ABCD2 was 4.0 (range=2 to 7; IQR=3.0 to 4.0). ABCD2 ≥ 4 for stroke had sensitivity of 61.1%, specificity of 62.3%, LR+ of 1.62, and LR- of 0.62; sensitivity was lower for those younger than 60years old (28.9%). HINTS stroke sensitivity was 96.5%, specificity was 84.4%, LR+ was 6.19, and LR- was 0.04 and did not vary by age. For any central lesion, sensitivity was 96.8%, specificity was 98.5%, LR+ was 63.9, and LR- was 0.03 for HINTS, and sensitivity was 99.2%, specificity was 97.0%, LR+ was 32.7, and LR- was 0.01 for HINTS "plus" (any new hearing loss added to HINTS). Initial MRIs were falsely negative in 15 of 105 (14.3%) infarctions; all but one was obtained before 48hours after onset, and all were confirmed by delayed MRI. HINTS substantially outperforms ABCD2 for stroke diagnosis in ED patients with AVS. It also outperforms MRI obtained within the first 2days after symptom onset. While HINTS testing has traditionally been performed by specialists, methods for empowering emergency physicians (EPs) to leverage this approach for stroke screening in dizziness should be investigated.

Acute Continuous Vertigo

Acute continuous vertigo presentations are among the most feared presentations in medicine. Although a self-limited disorder is the typical cause, a life-threatening stroke can also occur. Differentiating a self-limited disorder from a life-threatening stroke can be a challenge. Routinely collected information--such as stroke risk factors and findings on the general neurologic examination--is not likely to enable the clinician to discriminate between these causes. A focused oculomotor examination is a necessary component of the assessment, but is underused in routine care. The author describes the challenges to diagnosing stroke in cases of acute continuous vertigo and provides an approach to inform decision making at the bedside. Future research is necessary to validate clinical decision support, assess generalizability, and demonstrate its impact on meaningful outcomes.

A probable cavernoma in the medulla oblongata presenting only as upbeat nystagmus

A cavernoma is a vascular malformation in the central nervous system. Brainstem cavernoma are relatively common and induce variable neurological symptoms. A 19-year-old woman visited our hospital with complaints of continuous dizziness. On a neurological examination, continuous conjugated upbeat nystagmus was observed in the primary position of gaze. A brain CT scan and MRI showed focal hemorrhagic signals in the central caudal medulla caused by a cavernoma. The spontaneous upbeat nystagmus disappeared gradually. To our knowledge, this is the first report of a probable cavernoma in the medulla oblongata presenting with upbeat nystagmus only.