Diagnosis Of Peripheral Vertigo Research Articles

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

The temporal characteristics of stroke risks were evaluated in emergency department patients who had a diagnosis of peripheral vertigo. It was also attempted to reveal the stroke risk factor amongst those with peripheral vertigo. This is a parallel-group cohort study in a tertiary referral hospital. After assigning each of 4367 matched patients to the comparative set of peripheral vertigo and appendicitis-ureterolithiasis groups and each of 4911 matched patients to the comparative set of peripheral vertigo and ischaemic stroke groups, the relative stroke risk was evaluated. In addition, to predict the individual stroke risk in patients with peripheral vertigo, any association between the demographic factors and stroke events was evaluated in the peripheral vertigo group. The peripheral vertigo group had a higher stroke risk than the appendicitis-ureterolithiasis group (hazard ratio 1.73, 95% confidence interval 1.18-2.55) but a lower risk than the ischaemic stroke group (hazard ratio 0.30, 95% confidence interval 0.24-0.37). The stroke risk of the peripheral vertigo group was just below that of small vessel stroke. The stroke risk of the peripheral vertigo group differed markedly by time: higher within 7 days, moderate between 7 days and 1 year, and diminished thereafter. Old age (>65 years), male gender and diabetes mellitus were the risk factors for stroke in the peripheral vertigo group. Patients with a diagnosis of peripheral vertigo in the emergency department showed a moderate future stroke risk and so a stroke preventive strategy tailored to the timing of symptom onset and individual risk is required.

Meta-Analysis of the Use of Head Impulse Test and Head Impulse Test with Direction Changing Nystagmus and Test of Skew Deviation in the Diagnosis of Peripheral Vertigo and Stroke

Introduction: The head impulse test (HIT) and HIT combined with direction-changing Nystagmus-Test of Skew deviation (HINTS) have been proposed as bedside tests to differentiate between peripheral and central causes of vertigo in the emergency department (ED). We conducted a meta-analysis of the HIT and HINTS tests to diagnose peripheral vertigo (PV) and central vertigo. Methods: Pubmed, Google Scholar, EmBase, and articles references published in English up to July 2021 were searched for keywords “vertigo” or “acute vestibular syndrome” or “dizziness” and “head impulse” and “stroke.” The bivariate method for meta-analysis was used to calculate positive (PLR) and negative likelihood ratios (NLR) and summary receiver operating characteristics area under the curve (AUC). Results: A total of 11 studies were included analysing both HIT (8 studies, N = 417) and HINTS (6 studies, N = 405). HIT and HINTS were performed within 24 h in 4 of 11 studies. PLR and NLR for HIT in PV was 4.85 (95% CI: 2.83–8.08) and 0.19 (95% CI: 0.12–0.29, I² 63.25%), respectively. The AUC for HIT the diagnosis of PV and stroke was 0.90 and 0.92, respectively. PLR and NLR for a negative HIT in stroke was 5.85 (95% CI: 3.07–10.6) and 0.17 (95% CI: 0.08–0.30), respectively. PLR and NLR for peripheral HINTS pattern for PV was 17.3 (95% CI: 8.38–32.1) and 0.15 (95% CI: 0.07–0.26), respectively. PLR and NLR for central HINTS pattern for stroke: 5.61 (95% CI: 4.19–7.7) and 0.06 (95% CI: 0.03–0.12). In all included studies, HIT and HINTS exams were administered by neurology residents or neurology specialists with additional neuro-otology or neuro-ophthalmology subspeciality experience, and two studies included ED physicians. Raters reported high degree of bias and high concern regarding applicability in most domains of the quality assessment of diagnostic accuracy studies (QUADAS-2) tool. Meta-regression did not demonstrate a statistically significant effect of publication year, time to test, and type of assessor on sensitivity or false positive rate. Conclusion: The HIT and HINTS exams appear to be moderately good discriminators of central and PV. However, in most papers, the tests were administered by neurologists and were evaluated beyond 24 h, which may limit utility in the ED setting.

Meclizine prescriptions in the Emergency Department and return visits in the elderly population

Background: Meclizine is a commonly prescribed medication for patients discharged from the Emergency Department (ED) with a diagnosis of peripheral vertigo, however it is on the Beers list of medications to avoid in elderly patients. Objectives: This study aims to determine the correlation between use of meclizine and return visits to the ED within 1 week in patients > 65 years old. Methods: This is a retrospective observational study conducted at 2 urban tertiary care EDs over 5 years. Inclusion criteria included patients > 65 years who were given meclizine in the ED or discharged with a prescription. Charts were reviewed for diagnosis, prescriptions and return visits within 7 days. Results: There were a total of 1608 patients over 65 years of age who met inclusion criteria, 669 patients identified as receiving meclizine in the ED and 962 who received no meclizine (ED or ED plus home prescription). Of the meclizine patients, 548 (84.8%) were given home prescriptions, of which there were 36 (6.6%) return visits within 7 days. Patients who were given meclizine while in the ED without home prescriptions (121) had 16 return visits (13.2%). Among the non-meclizine group, 102 patients (10.6%) had a return visit within 7 days. Conclusion: There was no increase in return visits in elderly patients discharged from the ED with a prescription for meclizine after a diagnosis of benign dizziness. Meclizine prescriptions at discharge were associated with fewer return visits to the ED within 1 week. Ongoing dizziness was the most common reason for return visits; there were no documented chief complaints of weakness, syncope/falls, or hypotension.

310 Meclizine Prescriptions in the Emergency Department and Return Visits in an Elderly Population

Vertigo and dizziness are among the most common chief complaints in the elderly emergency department (ED) population. Meclizine, a first-generation antihistamine, is commonly prescribed for treatment of peripheral vertigo. The American Geriatric Society has placed meclizine on the Beers list of potentially inappropriate medications to avoid in patients over 65 years old, due to its anticholinergic properties resulting in an increased risk of confusion, constipation, and overall morbidity. Despite existing recommendations, meclizine is commonly prescribed, likely due to the lack of other suitable medication alternatives for vertigo management and barriers to canalith repositioning therapy. There is a paucity of literature exploring the safety of meclizine in an elderly population. The purpose of this study is to evaluate ED patients age 65 years old or older who received a prescription for meclizine during their ED stay and to determine the correlation between use of meclizine and return visits to the ED within 1 week. This is a retrospective observational study conducted at 2 tertiary care EDs between June 4, 2012 - Dec 31, 2017. Inclusion criteria included all patients age 65 years or older who were either given meclizine in the ED or discharged with a prescription. Charts were reviewed for final diagnosis, disposition, medications prescribed and return visits within 7 days. A control group included patients 65 or older with chief complaints of dizziness and/or vertigo who were discharged without any medications. There were 644 patients age 65 years old or older who were identified as receiving meclizine in the ED during the study period. 430 patients were female (67%) and 214 were male (33%). Most patients (n=353, 55%) were between 65-74 years old, followed by 200 (31%) between 75-84 years old. 90 (14%) patients were 85 years old or older. 548 of these patients were given home prescriptions. Of this group, there were 37 return visits (6.7%) within 7 days. Of those return visits, 12 visits were for ongoing dizziness (32.4%). Four return visits were for abdominal pain/nausea/vomiting (10.8%), and 21 return visits (56.8%) were for other minor complaints deemed unrelated to dizziness/vertigo or meclizine. In the control group, 962 patients were seen for dizziness without meclizine prescribed in the ED or at discharge. Of these, 102 patients (10.6%) had a return ED visit within the week; 12 return visits for dizziness (11.8%), 13 visits for weakness (12.7%), 8 visits for abdominal pain/nausea/vomiting (7.8%), and 61 visits for other (60%). Patients who were only given meclizine while in the ED without home prescriptions (121) had 16 return visits within 7 days (13.2%). There are several situations in which pharmaceutical management as a supplement to canalith repositioning may be needed in the treatment of peripheral vertigo. Options include antihistamines such as meclizine or benzodiazepines, but these medications have been designated as potentially inappropriate in older adults. Although limited by its retrospective design, we found no increased rate of return visits in elderly patients who were discharged from the ED with a prescription for meclizine after a diagnosis of peripheral vertigo or dizziness. Ongoing dizziness was the most common reason for return visits in this group. Further studies are needed to determine the safety of meclizine in an elderly population.

Outcomes among patients discharged from the emergency department with a diagnosis of peripheral vertigo.

We aimed to determine the risk of short- and long-term stroke, as well as accidental injury, in patients discharged from an emergency department who were given a diagnosis of a peripheral vestibular disorder. In this population-based, retrospective, cohort study, we identified all adult patients who were discharged from an emergency department in Ontario, Canada, between 2006 and 2011, with a primary diagnosis of a peripheral vestibular disorder. We assessed hospitalized strokes at 7, 30, 90, and 365 days, as well as subsequent falls, motor vehicle accidents, fractures, and burns. To provide context, we assessed the same outcomes in propensity score-matched discharged emergency department patients with renal colic. Among 41,794 qualifying patients, 76 (0.18%) had a stroke within 30 days. Accidental injury at 30 days ranged from 0.01% (falls) to 0.15% (fractures). The relative risk (RR) of 30-day stroke was 9.3 (95% confidence interval [CI]: 4.3-20.3) times higher than among matched renal colic controls. The RR was highest at 7 days (50.0; 95% CI, 6.9-362.0) and diminished with duration from the emergency department visit: RR 6.1 (95% CI, 3.5-10.7) at 90 days and 2.5 (95% CI, 1.8-3.5) at 1 year. There was no difference in the risk of accidental injury. The frequency of early stroke after discharge from an emergency department with a diagnosis of a peripheral vestibular disorder was extremely low. However, the relative risk was markedly higher than in matched patients with renal colic, suggesting that some strokes, or sentinel events for strokes, are being misdiagnosed as peripheral vestibular disorders.

Missed strokes using computed tomography imaging in patients with vertigo: population-based cohort study.

The purpose of this study was to determine the proportion of emergency department (ED) patients with a diagnosis of peripheral vertigo who received computed tomography (CT) head imaging in the ED and to examine whether strokes were missed using CT imaging. This population-based retrospective cohort study assessed patients who were discharged from an ED in Ontario, Canada, with a diagnosis of peripheral vertigo, April 2006 to March 2011. Patients who received CT imaging (exposed) were matched by propensity score methods to patients who did not (unexposed). If performed, CT imaging was presumed to be negative for stroke because brain stem/cerebellar stroke would result in hospitalization. We compared the incidence of stroke within 30, 90, and 365 days subsequent to ED discharge between groups, to determine whether the exposed group had a higher frequency of early strokes than the matched unexposed group. Among 41 794 qualifying patients, 8596 (20.6%) received ED head CT imaging, and 99.8% of these patients were able to be matched to a control. Among exposed patients, 25 (0.29%) were hospitalized for stroke within 30 days when compared with 11 (0.13%) among matched nonexposed patients. The relative risk of a 30- and 90-day stroke among exposed versus unexposed patients was 2.27 (95% confidence interval, 1.12-4.62) and 1.94 (95% confidence interval, 1.10-3.43), respectively. There was no difference between groups at 1 year. Strokes occurred at a median of 32.0 days (interquartile range, 4.0-33.0 days) in exposed patients, compared with 105 days (interquartile range, 11.5-204.5) in unexposed patients. One fifth of patients diagnosed with peripheral vertigo in Ontario received imaging that is not recommended in guidelines, and that imaging was associated with missed strokes.

Dissociative Symptoms Secondary to Piracetam: A Case Report

ABSTRACTPiracetam is a cyclic derivative of gamma-aminobutyric acid that is often used in neurology. Piracetam is an antithrombotic, neuroprotective agent which improves cognitive performance. Piracetam is indicated for vertigo in clinical practice. The etiology of dissociation is not precisely defined. In pharmacotherapy studies depersonalization is the basic dissociative symptom. In this article, we have reported a case with the diagnosis of peripheral vertigo where piracetam was used as pari of combination therapy. However dissociative symptom; like depersonalization and derealization occurred aftei piracetam use and these symptoms disappeared afte discontinuation of piracetam.

Bedside diagnosis of vertigo: value of the history and neurological examination.

Vertigo is caused by disturbance of the input or central processing of sensory signals from the vestibular apparatus that provide information regarding the position of the body in space. It is caused either by asymmetric disruption of sensory input from the vestibular organs or asymmetric integration of vestibular input into the central nervous system. Vertigo is readily differentiated from other causes of dizziness by a sensation of motion. A crucial aspect of the management of the emergency department patient with vertigo is the differentiation of vertigo associated with acute stroke syndromes from vertigo due to peripheral causes. Routine computerized axial tomography imaging is insensitive for posterior circulation strokes, so for emergency physicians, the history and neurological examination remain the most useful diagnostic tools. This article emphasizes the history and physical examination in the localization of the lesion in patients with vertigo and offers a rational basis for decisions regarding the need for special neurological imaging and consultation. It also emphasizes subtle findings that may prevent the erroneous diagnosis of peripheral vertigo in the presence of an acute stroke syndrome.