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Risk of stroke is low after transient ischemic attack presentation with isolated dizziness

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Canadian Journal of Emergency Medicine Aims and scope Submit manuscript

Abstract

Objective

Stroke presenting as dizziness is a diagnostic challenge in frontline settings, given the multitude of benign conditions that present similarly. The risk of stroke after episodic dizziness is unknown, leading to divergent guidance on optimal workup and management. Prior TIA risk scores have shown a history of dizziness is a negative predictor of subsequent stroke. Our objective was to assess the subsequent stroke risk within 90 days following emergency department assessment (ED) for isolated dizziness diagnosed as TIA during the index visit.

Methods

We conducted prospective, multicenter cohort studies at 13 Canadian EDs over 11 years. We enrolled patients diagnosed with TIA and compared patients with isolated dizziness to those with other neurological deficits. Our primary outcome was subsequent stroke within 90 days. Secondary outcomes were subsequent stroke within 2, 7, and 30 days, respectively, as well as subsequent TIA within 90 days.

Results

Only 4/483 (0.8%) patients with isolated dizziness had a stroke within 90 days compared to 320/11024 (2.9%) of those with any focal neurological sign or symptom (RR 0.29, 95% CI 0.11–0.76). Over the first 90 days, the two groups differ significantly in their probability of stroke (p = 0.007). Subsequent TIA was also significantly less common in the isolated dizziness group (1.7% vs. 5.6%, p = 0.001) with a relative risk of 0.30 (95% CI 0.15–0.60).

Conclusion

The risk of subsequent stroke following ED presentation for TIA is low when the presenting symptoms are isolated dizziness.

Résumé

Objectif

Les accidents vasculaires cérébraux (AVC) se présentant sous forme de vertiges constituent un défi diagnostique en première ligne, étant donné la multitude d'affections bénignes qui se présentent de la même manière. Le risque d'accident vasculaire cérébral (AVC) après des vertiges épisodiques est inconnu, ce qui donne lieu à des conseils divergents sur le bilan et la prise en charge optimaux. Des scores de risque d'AIT antérieurs ont montré que des antécédents de vertiges sont un facteur prédictif négatif d'accident vasculaire cérébral ultérieur. Notre objectif était d'évaluer le risque ultérieur d'accident vasculaire cérébral (AVC) dans les 90 jours suivant l'évaluation aux urgences d'un étourdissement isolé diagnostiqué comme un AIT lors de la visite de référence.

Méthodes

Nous avons mené des études de cohorte prospectives multicentriques dans 13 services d'urgence canadiens pendant 11 ans. Nous avons recruté des patients ayant reçu un diagnostic d'AIT et avons comparé les patients présentant des vertiges isolés à ceux présentant d'autres déficits neurologiques. Nous avons inscrit des patients ayant reçu un diagnostic d’AIT et comparé des patients ayant des étourdissements isolés à ceux présentant d’autres déficits neurologiques. Notre résultat primaire était l'AVC subséquent dans les 90 jours. Les résultats secondaires étaient l'AVC subséquent dans les 2, 7 et 30 jours, respectivement, ainsi que l'AIT subséquent dans les 90 jours.

Résultats

Seuls 4/483 (0,8 %) des patients présentant des vertiges isolés ont eu un AVC dans les 90 jours, contre 320/11 024 (2,9 %) de ceux présentant un signe ou symptôme neurologique focal (RR 0,29, IC 95 % 0,11-0,76). Au cours des 90 premiers jours, les deux groupes diffèrent significativement en termes de probabilité d'AVC (p = 0,007). L'AIT ultérieur était également significativement moins fréquent dans le groupe des vertiges isolés (1,7 % contre 5,6 %, p = 0,001) avec un risque relatif de 0,30 (IC 95 % 0,15-0,60).

Conclusions

Le risque d'AVC ultérieur après une présentation aux urgences pour un AIT est faible lorsque les symptômes présentés sont des étourdissements isolés.

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Acknowledgements

The authors thank the hundreds of physicians who completed our data collection forms and all the emergency department nurses, and clerks at the 13 study sites for their cooperation with the study. We also thank the following research personnel at the study hospitals: Ottawa Hospital–Civic Campus and General Campus, Ottawa, Ontario (Rebecca Briscoe, Renée Labreche, Natalie Bilodeau, Tara Leach, Sarai Cohn-Kalter, Jane Sutherland, Juanita Wilzer, Ruth Glenwright, Carly O’Brien, Kathryn Madill, Alana Mistry, Kelly Smith, Connor Sheehan); Kingston General Hospital and Hotel Dieu Hospital, Kingston, Ontario (Jane Reid, Vlad Latiu, Jessica Montagner, Nicole O’Callaghan); Hôpital de L’Enfant-Jésus, Quebec City, Quebec (Suzy Lavoie); Hamilton Health Sciences Centre (General, and Henderson Sites), Hamilton, Ontario (Natasha Clayton); Montfort Hospital, Ottawa, Ontario (Christine Nadia Compas); Vancouver General Hospital, Vancouver, British Columbia (Vi Ho); Sacré Coeur Hospital, Montreal, Quebec (Chantal Lanthier); Sunnybrook Health Sciences Centre, Toronto, Ontario (Joanna Yeung); Queensway Carleton Hospital, Ottawa, Ontario (Karen Lemay, Katie Girimonte). We thank our colleagues at the Ottawa Hospital Research Institute (Sheryl Domingo, My-Linh Tran and Angela Marcantonio) for their assistance with this project. We thank David Newman-Toker for his thoughtful input and helpful discussions.

Funding

Canadian Institutes of Health Research. The funder had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. Researchers are independent from funders and all authors, external and internal, had full access to all of the data (including statistical reports and tables) in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Author information

Authors and Affiliations

  1. Division of Neurology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada

    Anand K. Bery, Daniel A. Lelli & Grant Stotts

  2. Division of Neurology, McMaster University, Hamilton, ON, Canada

    Mukul Sharma, Wieslaw J. Oczkowski & Demetrios J. Sahlas

  3. Ottawa Hospital Research Institute, Ottawa, ON, Canada

    Marie-Joe Nemnom, Ian G. Stiell, George A. Wells & Jeffrey J. Perry

  4. Department of Emergency Medicine, University of Ottawa, The Ottawa Hospital Epidemiology Program, F6, The Ottawa Hospital, Ottawa, ON, Canada

    Peter Johns, Ian G. Stiell & Jeffrey J. Perry

  5. Department of Emergency Medicine, Queen’s University, Kingston, ON, Canada

    Marco L. A. Sivilotti & Heather E. Murray

  6. CHU de Québec, Hôpital de L’Enfant-Jésus, Québec City, Québec, Canada

    Marcel Émond, Ariane Mackey, Steve Verreault & Marie-Christine Camden

  7. Division of Family and Emergency Medicine, Université Laval, Québec City, Québec, Canada

    Marcel Émond

  8. Schwartz\Reisman Emergency Medicine Institute, Mount Sinai Hospital, Toronto, ON, Canada

    Jacques Lee

  9. Department of Emergency Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

    Jacques Lee & Clare Atzema

  10. Division of Emergency Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada

    Andrew Worster

  11. Hôpital du Sacré-Cœur de Montréal, Université de Montréal, Montréal, Québec, Canada

    Judy Morris, Tarik Slaoui & Jeanne Teitelbaum

  12. Department of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada

    Ka Wai Cheung

  13. Division of Neurology, Queen’s University, Kingston, ON, Canada

    Albert Y. Jin

  14. Division of Neurology, Laval University, Quebec City, QC, Canada

    Ariane Mackey, Steve Verreault & Marie-Christine Camden

  15. Division of Neurology, University of British Columbia, Vancouver, BC, Canada

    Samuel Yip & Philip Teal

  16. Sunnybrook Research Institute and Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada

    David J. Gladstone & Mark I. Boulos

  17. Department of Emergency Medicine, Montfort Hospital and University of Ottawa, Ottawa, ON, Canada

    Nicolas Chagnon

  18. Queensway Carleton Hospital and University of Ottawa, Ottawa, ON, Canada

    Elizabeth Shouldice

Authors
  1. Anand K. Bery
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  2. Mukul Sharma
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  3. Marie-Joe Nemnom
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  4. Peter Johns
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  5. Daniel A. Lelli
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  6. Marco L. A. Sivilotti
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  7. Marcel Émond
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  8. Ian G. Stiell
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  9. Grant Stotts
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  10. Jacques Lee
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  11. Andrew Worster
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  12. Judy Morris
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  13. Ka Wai Cheung
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  14. Albert Y. Jin
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  15. Wieslaw J. Oczkowski
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  16. Demetrios J. Sahlas
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  17. Heather E. Murray
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  18. Ariane Mackey
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  19. Steve Verreault
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  20. Marie-Christine Camden
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  21. Samuel Yip
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  22. Philip Teal
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  23. David J. Gladstone
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  24. Mark I. Boulos
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  25. Nicolas Chagnon
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  26. Elizabeth Shouldice
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  27. Clare Atzema
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  28. Tarik Slaoui
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  29. Jeanne Teitelbaum
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  30. George A. Wells
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  31. Jeffrey J. Perry
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Contributions

The author contributions were as follows: JP conceived the idea and AB prepared the manuscript. M-JN assisted with the statistical analysis. All co-authors contributed to revising the manuscript.

Corresponding author

Correspondence to Jeffrey J. Perry.

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Conflict of interest

Dr. Perry is supported by a mid-career award from the Heart and Stroke Foundation of Ontario. Dr. Lee is supported by the Schwartz/Reisman Emergency Medicine Institute Inaugural Research Chair in Geriatric Emergency Medicine. No other relationships or activities appear to have influenced the submitted work.

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Bery, A.K., Sharma, M., Nemnom, MJ. et al. Risk of stroke is low after transient ischemic attack presentation with isolated dizziness. Can J Emerg Med 24, 844–852 (2022). https://doi.org/10.1007/s43678-022-00391-0

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  • DOI: https://doi.org/10.1007/s43678-022-00391-0

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