Skip to main content

Advertisement

SpringerLink
Log in

Capturing vertigo in the emergency room: three tools to double the rate of diagnosis

  • Original Communication
  • Published:
Journal of Neurology Aims and scope Submit manuscript

Abstract

Objective

Many patients attending the emergency room (ER) with vertigo, leave without a diagnosis. We assessed whether the three tools could improve ER diagnosis of vertigo.

Methods

A prospective observational study was undertaken on 539 patients presenting to ER with vertigo. We used three tools: a structured-history and examination, nystagmus video-oculography (VOG) in all patients, additional video head-impulse testing (vHIT) for acute-vestibular-syndrome (AVS).

Results

In the intervention-group (n = 424), case-history classified AVS in 34.9%, episodic spontaneous-vertigo (ESV 32.1%), and episodic positional-vertigo (EPV 22.6%). In AVS, we employed “Quantitative-HINTS plus” (Head-Impulse, Nystagmus and Test-of-Skew quantified by vHIT and VOG, audiometry) to identify vestibular-neuritis (VN) and stroke (41.2 and 31.1%). vHIT gain ≤ 0.72, catch-up saccade amplitude > 1.4○, saccade-frequency > 154%, and unidirectional horizontal-nystagmus, separated stroke from VN with 93.1% sensitivity and 88.5% specificity. In ESV, 66.2 and 14% were diagnosed with vestibular migraine and Meniere’s Disease by using history and audiometry. Horizontal-nystagmus velocity was lower in migraine 0.4 ± 1.6○/s than Meniere’s 5.7 ± 5.5○/s (p < 0.01). In EPV, benign positional vertigo (BPV) was identified in 82.3% using VOG. Paroxysmal positional-nystagmus lasting < 60 s separated BPV from non-BPV with 90% sensitivity and 100% specificity. In the control group of ER patients undergoing management-as-usual (n = 115), diagnoses included BPV (38.3%) and non-specific vertigo (41.7%). Unblinded assessors reached a final diagnosis in 90.6 and 30.4% of the intervention and control groups. Blinded assessors provided with the data gathered from each group reached a diagnosis in 86.3 and 41.1%.

Conclusion

Three tools: a structured-assessment, vHIT and VOG doubled the rate of diagnosis in the ER.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Data availability

Data not published within the article will be available in a public repository and anonymized data will be shared by request from any qualified investigator.

References

  1. Neuhauser HK, von Brevern M, Radtke A, Lezius F, Feldmann M, Ziese T et al (2005) Epidemiology of vestibular vertigo: a neurotologic survey of the general population. Neurology 65(6):898–904

    CAS  PubMed  Google Scholar 

  2. Murdin L, Schilder AG (2015) Epidemiology of balance symptoms and disorders in the community: a systematic review. Otol Neurotol 36(3):387–392

    PubMed  Google Scholar 

  3. Gopinath B, McMahon CM, Rochtchina E, Mitchell P (2009) Dizziness and vertigo in an older population: the Blue Mountains prospective cross-sectional study. Clin Otolaryngol 34(6):552–556

    CAS  PubMed  Google Scholar 

  4. Kerber KAMW, West BT, Fendrick AM (2008) Dizziness presentations in U.S. emergency departments, 1995–2004. Acad Emerg Med 15(8):744–750

    PubMed  Google Scholar 

  5. Chase MGJ, Selim MH, Pallin DJ, Camacho MA, O’Connor JL, Ngo L, Edlow JA (2014) A prospective pilot study of predictors of acute stroke in emergency department patients with dizziness. Mayo Clin Proc 89(2):173–180

    PubMed  Google Scholar 

  6. Ljunggren MPJ, Salzer J (2018) Dizziness and the acute vestibular syndrome at the emergency department: a population-based descriptive study. Eur Neurol 79(1–2):5–12

    PubMed  Google Scholar 

  7. Arch AEWD, Coca S et al (2016) Missed ischemic stroke diagnosis in the emergency department by emergency medicine and neurology services. Stroke 47:668–673

    PubMed  Google Scholar 

  8. Kerber KAZD, Brown DL, Meurer WJ, Burke JF, Smith MA, Lisabeth LD, Fendrick AM, McLaughlin T, Morgenstern LB (2014) Stroke risk after nonstroke emergency department dizziness presentations: a population-based cohort study. Ann Neurol 75(6):899–907

    PubMed  PubMed Central  Google Scholar 

  9. Renner V, Geißler K, Boeger D, Buentzel J, Esser D, Hoffmann K et al (2017) Inpatient treatment of patients admitted for dizziness: a population-based healthcare research study on epidemiology, diagnosis, treatment, and outcome. Otol Neurotol 38(10):e460–e469

    PubMed  Google Scholar 

  10. Mármol-Szombathy I, Domínguez-Durán E, Calero-Ramos L, Sánchez-Gómez S (2018) Identification of dizzy patients who will develop an acute cerebrovascular syndrome: a descriptive study among emergency department patients. Eur Arch Otorhinolaryngol 275:1709–1713

    PubMed  Google Scholar 

  11. Atzema CLGK, Lu H et al (2016) Outcomes among patients discharged from the emergency department with a diagnosis of peripheral vertigo. Ann Neurol 79:32–41

    PubMed  Google Scholar 

  12. Tarnutzer AALBMP, Robinson KA, Yu-Hsiang H, Newman-Toker DE (2011) Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome. CMAJ 183(9):E571–E592

    PubMed  PubMed Central  Google Scholar 

  13. Choi J, Park MG, Choi SY, Park KP, Baik SK, Kim JS, Choi KD (2017) Acute transient vestibular syndrome: prevalence of stroke and efficacy of bedside evaluation. Stroke 48:556–562

    PubMed  Google Scholar 

  14. Bohmer A, Straumann D, Fetter M (1997) Three-dimensional analysis of spontaneous nystagmus in peripheral vestibular lesions. Ann Otol Rhinol Laryngol 106(1):61–67

    CAS  PubMed  Google Scholar 

  15. Kheradmand A, Colpak AI, Zee DS (2016) Eye movements in vestibular disorders. Handb Clin Neurol 137:104–117

    Google Scholar 

  16. Lee HKH (2013) Nystagmus in SCA territory cerebellar infarction: pattern and a possible mechanism. J Neurol Neurosurg Psychiatry 84(4):446–451

    PubMed  Google Scholar 

  17. Lee HKJ, Chung EJ, Yi HA, Chung IS, Lee SR, Shin JY (2009) Infarction in the territory of anterior inferior cerebellar artery spectrum of audiovestibular loss. Stroke 40(12):3745–3751

    PubMed  Google Scholar 

  18. Huh YE, Kim JS (2011) Patterns of spontaneous and head-shaking nystagmus in cerebellar infarction: imaging correlations. Brain 134(Pt 12):3662–3671

    PubMed  Google Scholar 

  19. Lee H, Sohn SI, Cho YW, Lee SR, Ahn BH, Park BR et al (2006) Cerebellar infarction presenting isolated vertigo: frequency and vascular topographical patterns. Neurology 67(7):1178–1183

    CAS  PubMed  Google Scholar 

  20. MacDougall HG, Weber KP, McGarvie LA, Halmagyi GM, Curthoys IS (2009) The video head impulse test: diagnostic accuracy in peripheral vestibulopathy. Neurology 73(14):1134–1141

    CAS  PubMed  PubMed Central  Google Scholar 

  21. Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE (2009) HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke 40(11):3504–3510

    PubMed  PubMed Central  Google Scholar 

  22. Young ASLC, Bradshaw AP, MacDougall HG, Black DA, Halmagyi GM, Welgampola MS (2019) Capturing acute vertigo: a vestibular event monitor. Neurology 92:e1–e11

    Google Scholar 

  23. Calic Z, Nham B, Bradshaw AP, Young AS, Bhaskar S, D’Souza M et al (2020) Separating posterior-circulation stroke from vestibular neuritis with quantitative vestibular testing. Clin Neurophysiol 131:2047–2055

    PubMed  Google Scholar 

  24. Pogson JMTR, McGarvie L, Bradshaw AP, D’Souza M, Halmagyi GM, Welgampola MS (2019) The human vestibulo-ocular reflex and saccades: normal subjects and the effect of age. J Neurophysiol. https://doi.org/10.1152/jn.00847.2018

    Article  PubMed  Google Scholar 

  25. Yeung JC, Heley S, Beauregard Y, Champagne S, Bromwich MA (2015) Self-administered hearing loss screening using an interactive, tablet play audiometer with ear bud headphones. Int J Pediatr Otorhinolaryngol 79(8):1248–1252

    PubMed  Google Scholar 

  26. Margolis RH, Saly GL (2008) Asymmetric hearing loss: definition, validation, and prevalence. Otol Neurotol 29(4):422–431

    PubMed  Google Scholar 

  27. Lempert T, Olesen J, Furman J, Waterston J, Seemungal B, Carey J et al (2012) Vestibular migraine: diagnostic criteria. J Vestib Res 22(4):167–172

    PubMed  Google Scholar 

  28. Lopez-Escamez JA, Carey J, Chung WH, Goebel JA, Magnusson M, Mandala M et al (2015) Diagnostic criteria for Meniere’s disease. J Vestib Res 25(1):1–7

    PubMed  Google Scholar 

  29. von Brevern M, Bertholon P, Brandt T, Fife T, Imai T, Nuti D et al (2015) Benign paroxysmal positional vertigo: diagnostic criteria. J Vestib Res 25(3–4):105–117

    Google Scholar 

  30. Vibert DHR, Safran AB, Koerner F (1996) Diplopia from skew deviation in unilateral peripheral vestibular lesions. Acta Otolaryngol 116(2):170–176

    CAS  PubMed  Google Scholar 

  31. Brodsky MC, Donahue SP, Vaphiades M, Brandt T (2006) Skew deviation revisited. Surv Ophthalmol 51(2):105–128

    PubMed  Google Scholar 

  32. Geser R, Straumann D (2012) Referral and final diagnoses of patients assessed in an academic vertigo center. Front Neurol 3:169

    PubMed  PubMed Central  Google Scholar 

  33. Parker IG, Hartel G, Paratz J, Choy NL, Rahmann A (2019) A Systematic review of the reported proportions of diagnoses for dizziness and vertigo. Otol Neurotol 40(1):6–15

    PubMed  Google Scholar 

  34. Neuhauser HK (2016) The epidemiology of dizziness and vertigo. Handb Clin Neurol 137:67–82

    CAS  PubMed  Google Scholar 

  35. Vanni S, Pecci R, Casati C, Moroni F, Risso M, Ottaviani M et al (2014) STANDING, a four-step bedside algorithm for differential diagnosis of acute vertigo in the Emergency Department. Acta Otorhinolaryngol Ital 34(6):419–426

    CAS  PubMed  PubMed Central  Google Scholar 

  36. Cheung CSKMP, Manley KV, Lam JMY, Tsang AYL, Chan HMS, Rainer TH, Graham CA (2009) Predictors of important neurological causes of dizziness among patients presenting to the emergency department. Emerg Med J 27:517–521

    Google Scholar 

  37. Ozono YKT, Fukushima M, Michiba T, Imai R, Tomiyama Y, Nishiike S, Inohara H, Morita H (2014) Differential diagnosis of vertigo and dizziness in the emergency department. Acta Otolaryngol 134(2):140–145

    PubMed  Google Scholar 

  38. Felgueiras R, Magalhães R, Correia M, Silva MC (2014) Long-term prognosis of patients presenting first-ever vestibular symptoms in a community-based study. J Stroke Cerebrovasc Dis 23(8):2190–2198

    PubMed  Google Scholar 

  39. Kim MBBS, Ban JH (2013) Nystagmus-based approach to vertebrobasilar stroke presenting as vertigo without initial neurologic signs. Eur Neurol 70:322–328

    PubMed  Google Scholar 

  40. Pavlin-Premrl D, Waterston J, McGuigan S, Infeld B, Sultana R, O’Sullivan R et al (2015) Importance of spontaneous nystagmus detection in the differential diagnosis of acute vertigo. J Clin Neurosci 22(3):504–507

    PubMed  Google Scholar 

  41. Chen LTM, Halmagyi GM, Aw S (2014) Head impulse gain and saccade analysis in pontine-cerebellar stroke and vestibular neuritis. Neurology 83(17):1513–1522

    PubMed  PubMed Central  Google Scholar 

  42. Choi KD, Kim JS (2019) Vascular vertigo: updates. J Neurol 266(8):1835–1843

    PubMed  Google Scholar 

  43. Kerber KAMW, Brown DL, Burke JF, Hofer TP, Tsodikov A, Hoeffner EG, Fendrick AM, Adelman EE, Morgenstern LB (2015) Stroke risk stratification in acute dizziness presentations: a prospective imaging-based study. Neurology 85:18691878

    Google Scholar 

  44. Saber Tehrani ASKJ, Mantokoudis G, Pula JH, Nair D, Blitz A, Ying S, Hanley DF, Zee DS, Newman-Toker DE (2014) Small strokes causing severe vertigo: frequency of false-negative MRIs and nonlacunar mechanisms. Neurology 83(2):169–173

    PubMed  PubMed Central  Google Scholar 

  45. Newman-Toker DE, Kerber KA, Hsieh YH, Pula JH, Omron R, Saber Tehrani AS et al (2013) HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med Off J Soc Acad Emerg Med 20(10):986–996

    Google Scholar 

  46. Krishnan K, Bassilious K, Eriksen E, Bath PM, Sprigg N, Brækken SK et al (2019) Posterior circulation stroke diagnosis using HINTS in patients presenting with acute vestibular syndrome: a systematic review. Eur Stroke J 4(3):233–239

    PubMed  PubMed Central  Google Scholar 

Download references

Funding

This research was funded by the Garnett Passe and Rodney Williams Memorial Foundation and the National Health and Medical Research Council of Australia.

Author information

Authors and Affiliations

  1. Institute of Clinical Neurosciences, Central Clinical School, Royal Prince Alfred Hospital, University of Sydney, Sydney, NSW, Australia

    Benjamin Nham, Nicole Reid, Andrew P. Bradshaw, Leigh A. McGarvie, G. Michael Halmagyi & Miriam S. Welgampola

  2. Central Clinical School, University of Sydney, Sydney, NSW, Australia

    Benjamin Nham, Kendall Bein, Andrew P. Bradshaw, Emma C. Argaet, Allison S. Young, G. Michael Halmagyi & Miriam S. Welgampola

  3. Department of Emergency Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia

    Kendall Bein

  4. Prince of Wales Clinical School, University of New South Wales, Sydney, NSW, Australia

    Shaun R. Watson

  5. Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia

    Deborah A. Black

Authors
  1. Benjamin Nham
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nicole Reid
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kendall Bein
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Andrew P. Bradshaw
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Leigh A. McGarvie
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Emma C. Argaet
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Allison S. Young
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Shaun R. Watson
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. G. Michael Halmagyi
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Deborah A. Black
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Miriam S. Welgampola
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Miriam S. Welgampola.

Ethics declarations

Conflicts of interest

B. Nham, N. Reid, K. Bein and A.P. Bradshaw have no disclosures relevant to this manuscript. L.A. McGarvie is an unpaid consultant for Otometrics. E.C. Argaet, A.S. Young and S.R. Watson have no disclosures relevant to this manuscript. G.M. Halmagyi is an unpaid consultant for Otometrics. D.A. Black and M.S. Welgampola have no disclosures relevant to this manuscript.

Ethics approval

This study received local ethics committee approval for the use of human participants (Protocol X13-0425 and HREC/13/RPAH/591) and written informed consent was obtained from all participants in accordance with the Helsinki Declaration of 1964.

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent to publish

The authors affirm that human research participants provided informed consent for publication of the images in the figures and videos of this manuscript.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (DOCX 162 kb)

Supplementary file2 (MP4 6573 kb)

Supplementary file3 (MP4 2486 kb)

Supplementary file4 (MP4 2929 kb)

Supplementary file5 (MP4 1005 kb)

Supplementary file6 (MP4 1138 kb)

Supplementary file7 (MP4 1803 kb)

Supplementary file8 (MP4 3474 kb)

Supplementary file9 (MP4 3577 kb)

Supplementary file10 (MP4 2166 kb)

Supplementary file11 (MP4 7428 kb)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Nham, B., Reid, N., Bein, K. et al. Capturing vertigo in the emergency room: three tools to double the rate of diagnosis. J Neurol 269, 294–306 (2022). https://doi.org/10.1007/s00415-021-10627-1

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00415-021-10627-1

Keywords

Search

Navigation