ED patients with vertigo: can we identify clinical factors associated with acute stroke?

doi:10.1016/j.ajem.2011.02.002

The American Journal of Emergency Medicine

Volume 30, Issue 4, May 2012, Pages 587-591

https://doi.org/10.1016/j.ajem.2011.02.002 Get rights and content

Abstract

Background

Vertigo is a common emergency department (ED) complaint with benign and serious etiologies with overlapping features. Misdiagnosis of acute stroke may result in significant morbidity and mortality. Magnetic resonance imaging (MRI) is superior to computer tomography (CT) for diagnosis of acute stroke but is costly with limited availability.

Objective

The aim of this study was to identify clinical characteristics associated with a cerebrovascular cause for vertigo.

Methods

We performed a retrospective chart review on patients with an MRI for vertigo, with or without additional historical or physical examination findings, over 18 months. Study patients were seen in the ED for vertigo within 2 weeks of MRI. Data collected included medical history, physical findings, and imaging results. Fisher's exact test was used to identify factors associated with the primary outcome, an acute stroke.

Results

There were 325 eligible patients; 131 were ED patients. Patients were 57 (±18) years, and 53% were women. There were 12 ED patients with a new stroke (9.2%). Two variables were associated with acute stroke: a presenting complaint of gait instability (odds ratio, 9.3; 95% confidence interval, 2.6-33.9) or a subtle neurologic finding (odds ratio, 8.7; 95% confidence interval, 2.3-33.1). One patient with a new stroke had a prior stroke, 3 were age >65 years, and none had coronary artery disease or dysrhythmia. Among patients with acute stroke, 5 also had head CT, and none detected the stroke.

Conclusions

This study identified 2 variables associated with acute stroke that should be considered in the evaluation of ED patients with vertigo. Head CT was inadequate for diagnosing acute stroke in this patient population.

Introduction

Dizziness and vertigo are common complaints, accounting for approximately 7.5 million visits to ambulatory care settings annually [1]. Dizziness has historically been classified into 4 categories: vertigo, lightheadedness, presyncope, and disequilibrium. Of these 4, vertigo is the most common and is believed to represent roughly 54% of dizziness complaints [2]. Although the large majority of patients with dizziness have benign processes that are not life or brain threatening, a small percentage is due to serious central nervous system pathology including space occupying lesions, infarction, and other processes. Clinically, there is significant overlap in the presentation of patients with peripheral and central causes; symptoms of dizziness, vertigo, nausea, vomiting, imbalance, and headache are all common and nonspecific; and stroke is equally likely to be associated with vertigo as nonvertiginous dizziness [1], [3].

For the emergency physician facing a broad range of potential etiologies, there is little research to guide risk stratification for our undifferentiated patient population, and recent data suggest that even neurologists may have difficulty in identifying cerebrovascular disease in the vertebrobasilar system [4]. Distinguishing patients with central processes from those with benign peripheral causes is crucial because patients with a misdiagnosed central nervous system etiology of dizziness have a propensity for bad outcomes. In one case series, half of the patients with missed cerebellar infarctions were less than 50 years, the mortality rate was 40%, and half of all survivors had disabling deficits [5].

As a consequence of this uncertainty and the cost of a missed stroke, patients with dizziness tend to consume greater health care resources than nondizzy emergency department (ED) patients, including longer lengths of stay in the ED and higher rates of admission, cardiac monitoring, and diagnostic imaging [6], [7]. Although head computed tomography (CT) is used widely in the ED setting, it has poor sensitivity for brain ischemia or infarction, especially in the posterior fossa. Magnetic resonance imaging (MRI) is the imaging test of choice, but it has several practical limitations, including its poor real-time availability in the emergent setting [8].

At present, there are wide variations in clinical management of ED patients with vertigo because very little focused data exist in the emergency medicine literature to improve both our understanding and risk stratification of this patient population. We performed this study as an initial step toward this end. We retrospectively reviewed charts of all patients who received an MRI for the indication of vertigo either emergently or within 2 weeks of an ED visit for vertigo. Our goal was to determine the feasibility of creating a risk profile for ED patients with vertigo at risk for acute stroke at time of initial presentation.

Section snippets

Setting

The study was performed at an urban academic medical center with an annual ED census of 53 000 patients and Accreditation Council for Graduate Medical Education (ACGME)-accredited Emergency Medicine and Neurology residency programs. Magnetic resonance imaging is available 24 hours a day for emergency cases. Informed consent was waived via expedited review of the institutional review board at our institution.

Study design

Patients were identified via an electronic query of the MRI patient database for the

Results

There were 325 patients who had an MRI for the indication of vertigo during the study period, of whom 131 (40%) were seen in the ED; 118 of these patients had an MRI during the index hospitalization, and 13 had an MRI within 2 weeks of the ED visit. Non-ED patients (60%) were referred from primary care, neurology, and oncology clinics primarily. Patients were 57 (±18) years, and 53% were women (Table 1). Overall, there were 27 patients (8.3%) with a new MRI finding including 12 strokes, 1

Discussion

Although a finding of multiple sclerosis or a new mass is of obvious importance in the evaluation of ED patients with acute vertigo, we focused our investigation on acute stroke because there are clear data that if these patients are not diagnosed, monitored, and treated properly, they may have worse outcomes [3], [5].

In our small patient sample, we did not find that traditional cardiovascular risk factors were associated with a higher risk for stroke. In fact, the average age of our patients

Conclusion

Acute posterior circulation infarction can present with common, nonspecific clinical findings and a normal head CT. Despite the limitations of our retrospective study, we were able to identify 2 clinical features in our patient population associated with acute stroke. These findings underscore that a thorough history and physical examination focused on cerebellar and posterior circulation functions performed in real time at the bedside are keys to the diagnostic workup for patients with

References (12)

J.A. Edlow et al.
Diagnosis and initial management of cerebellar infarction
Lancet Neurol
(2008)
D.E. Newman-Toker et al.
Spectrum of dizziness visits to US emergency departments: cross-sectional analysis from a nationally representative sample
Mayo Clin Proc
(2008)
J.A. Chalela et al.
Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison
Lancet
(2007)
E.H. Gilbert et al.
Chart reviews in emergency medicine research: where are the methods?
Ann Emerg Med
(1996)
A. Worster et al.
Reassessing the methods of medical record review studies in emergency medicine research
Ann Emerg Med
(2005)
K.A. Kerber et al.
Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study
Stroke
(2006)

There are more references available in the full text version of this article.

Cited by (39)

The diagnosis of central vestibular disorders based on the complementary examination of the vestibulospinal reflex
2022, Journal of Otology
Stance and gait unsteadiness along with vertigo contribute to a central vestibular disorder. For objective analysis ultrasound-computer-craniocorpography (US-COMP-CCG) can be used. Aim of the study was to characterize the unsteadiness in central vestibular disorders and discuss the possible diagnostic usage of US-COMP-CCG.
Hundred-and-ninety patients (70 male and 120 female, mean age ± SD, 58.94 ± 15.27) suffering from central vestibular disorder and 230 healthy control patients (78 male and 152 female, mean age ± SD, 50.94 ± 15.27) were enrolled. Stance and gait analysis was according to vestibulospinal tests of US-COMPCCG. IBM SPSS V24 software was used for statistical analysis. Mann-WhitneyU test and Chi-square test were used, along with sensitivity and specificity categorization. The significance level was p < 0.05. According to schematic and statistical analysis instability and postural sway were increased in the vertigo population and statistically significant difference was shown. Upon categorical analysis significant correlation was detected [standing test: longitudinal sway (p < 0.00001), lateral sway (p < 0.00001), forehead covering area parameters (p = 0.0001); stepping test: longitudinal deviation (p = 0.05), lateral sway (p = 0.011) parameters].
Clinicians should consider that postural instability is prominently present in this population and might be of a diagnostic importance.
Effectiveness of Clinical Risk Factors in the Detection of Central Pathology in Patients With Isolated Vertigo
2021, Journal of Emergency Medicine
Citation Excerpt :
It was reported that about 15–33% of posterior circulatory strokes were misclassified as acute peripheral vertigo in the ED (7). Cases of missed cerebellar infarction are at high risk for complications, and mortality was found to be 40% in this group (8). Therefore, determination of the central etiologies in patients presenting with vertigo or dizziness is critical in terms of reducing morbidity and mortality.
There is no clinical guidance for the indications of neuroimaging in patients with isolated vertigo. The differential diagnosis of isolated vertigo can be challenging for emergency physicians.
The aim of this study was to identify the risk factors that increase the likelihood of detecting a central pathology in patients who present with isolated vertigo and in whom peripheral vertigo is considered.
Patients imaged using neuroimaging, including diffusion-weighted magnetic resonance imaging (DW-MRI) with head computed tomography (CT), for isolated vertigo over a 3-year period were identified retrospectively. The patients were divided into two groups—a positive neuroimaging group and a negative neuroimaging group—according to the abnormal lesions in the head CT and DW-MRI results. We reviewed the medical records to identify presenting symptoms and signs, vascular risk factors, history of vertigo, medical comorbidities, and diagnostic imaging results (i.e., head CT and DW-MRI).
Two hundred and seventy-nine patients were included: 231 in the negative neuroimaging group (82.8%) and 48 in the positive neuroimaging group (17.2%). Univariate and multivariate logistic regression analyses were performed. It was found in the regression analysis that being 65 years or older (odds ratio [OR] 2.53; 95% confidence interval [CI] 1.29–4.96; p = 0.006), having two or more vascular risk factors (OR 2.45; 95% CI 1.10–5.46; p = 0.028), and not responding to the treatment (OR 2.57; 95% CI 1.08–6.14; p = 0.033) increased the likelihood of detecting a pathology in neuroimaging.
We suggest that patients unresponsive to ED treatment, 65 years or older, and with two or more vascular risk factors, should alert physicians for central causes and increase the yield of neuroimaging.
A New Diagnostic Approach to the Adult Patient with Acute Dizziness
2018, Journal of Emergency Medicine
Dizziness, a common chief complaint, has an extensive differential diagnosis that includes both benign and serious conditions. Emergency physicians must distinguish the majority of patients with self-limiting conditions from those with serious illnesses that require acute treatment.
This article presents a new approach to diagnosis of the acutely dizzy patient that emphasizes different aspects of the history to guide a focused physical examination with the goal of differentiating benign peripheral vestibular conditions from dangerous posterior circulation strokes in the emergency department.
Currently, misdiagnoses are frequent and diagnostic testing costs are high. This relates in part to use of an outdated, prevalent, diagnostic paradigm. The traditional approach, which relies on dizziness symptom quality or type (i.e., vertigo, presyncope, or disequilibrium) to guide inquiry, does not distinguish benign from dangerous causes, and is inconsistent with current best evidence. A new approach divides patients into three key categories using timing and triggers, guiding a differential diagnosis and targeted bedside examination protocol: 1) acute vestibular syndrome, where bedside physical examination differentiates vestibular neuritis from stroke; 2) spontaneous episodic vestibular syndrome, where associated symptoms help differentiate vestibular migraine from transient ischemic attack; and 3) triggered episodic vestibular syndrome, where the Dix-Hallpike and supine roll test help differentiate benign paroxysmal positional vertigo from posterior fossa structural lesions.
The timing and triggers diagnostic approach for the acutely dizzy patient derives from current best evidence and offers the potential to reduce misdiagnosis while simultaneously decreases diagnostic test overuse, unnecessary hospitalization, and incorrect treatments.
Predictors of false negative diffusion-weighted MRI in clinically suspected central cause of vertigo
2018, American Journal of Emergency Medicine
Vertigo is classified as peripheral and central. Differentiation of stroke mimics is the most important diagnostic challenge. There is no clinical guidance for the indications of neuroimaging in isolated vertigo patients. The primary aim of this study is to test the diagnostic value of a DWI-MRI protocol to rule-out a central cause in patients with acute isolated vertigo in the ED.
We prospectively enrolled 144 patients who were presented with isolated vertigo to the ED. A detailed neurological examination and maneuvers were performed for differential diagnosis. All patients underwent CT and/or DW-MRI either during ED visit or at the follow-up, if necessary. Out-patient follow-up exams and evaluations were repeated until all patients had a definitive diagnosis.
In the study, 137 of the 144 patients completed the follow-up period, and 34 of 137 patients were diagnosed with central vertigo. Six of 34 central vertigo patients had normal DW-MRI findings. One was diagnosed with migraine headache and five with vertebra-basilar insufficiency during the out-patient follow-up. One of the 28 patients with a pathological MRI was diagnosed with mass and the rest was stroke. The utility of DW-MRI in vertigo patients was moderately high (sensitivity: 82%, specificity: 100%). We found that age, history of HT, history of CAD and vertigo unresponsive to ED treatment were significantly associated with a central cause of vertigo.
We suggest that unresponsiveness to ED treatment, especially in patients with a history of HT and CAD, should alert physicians for central causes and warrant DW-MRI imaging.
A Posterior Circulation Ischemia Risk Score System to Assist the Diagnosis of Dizziness
2018, Journal of Stroke and Cerebrovascular Diseases
Citation Excerpt :
Only .74% of the dizzy patients evaluated by computerized tomography who showed clinically significant pathology required intervention. However, several guidelines and studies have made specific recommendations against neuroimaging, stating that computerized tomography and MRI are largely insensitive to such a serious condition as PCI, and their costs are high.13-16 Because no criterion or protocol is available in evaluating the potential risk, how to distinguish PCI has become a clinical as well as a public concern.
We aimed to establish a risk score system without radio-image examination, which could help clinicians to differentiate patients with vertigo and posterior circulation ischemia (PCI) rapidly from the other dizzy patients.
We analyzed 304 patients with vertigo (50% PCI). The attributes with more significant contributions were selected as the risk factors for the PCI risk score system, and every one of them was assigned a value according to their respective odds ratio values. We also compared the respective receiver operating characteristic curves of the 3 diagnostic methods (PCI score system, ABCD², and Essen score systems) to evaluate their prediction effectiveness.
Nine risk factors were ultimately selected for PCI score system, including high blood pressure (1′), diabetes mellitus (1′), ischemic stroke (1′), rotating and rocking (−1′), difficulty in speech (5′), tinnitus (−5′), limb and sensory deficit (5′), gait ataxia (1′), and limb ataxia (5′). According to their respective PCI risk scores, the patients were divided into 3 subgroups: low risk (≤0′, risk <37.4%), medium risk (1′-5′), and high risk (≥6′, risk >95.0%). When 0′ was selected as a cutoff point for differentiating the patients with PCI from patients without PCI, the sensitivity was 94.1%, with a specificity of 41.4%. The areas under the receiver operator curve value of PCI score system was .82 (P = .000), much higher than the areas under the receiver operator curve value of ABCD² (.69, P = .000) and that of the Essen system (.67, P = .000)
The PCI score system could help clinicians to differentiate patients with vertigo and PCI rapidly from the other dizzy patients.
A New Approach to the Diagnosis of Acute Dizziness in Adult Patients
2016, Emergency Medicine Clinics of North America
Citation Excerpt :
Various studies have tried to identify risk factors for ED dizzy patients with CNS causes.1,15,17–20 One ED study of dizzy patients found that abnormal gait and subtle neurologic deficits on neurologic examination were associated with a CNS cause.17 Overall, the risk factors include increasing age, vascular risk factors, history of previous stroke, complaint of “instability,” and focal neurologic findings (Table 1).

View all citing articles on Scopus

^☆: Presented at: Society for Academic Emergency Medicine National Conference, 2009.

View full text

Brief ReportED patients with vertigo: can we identify clinical factors associated with acute stroke?☆

Abstract

Background

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Setting

Study design

Results

Discussion

Conclusion

Lancet Neurol

Mayo Clin Proc

Lancet

Ann Emerg Med

Ann Emerg Med

Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study

Stroke

Brief Report
ED patients with vertigo: can we identify clinical factors associated with acute stroke?☆