HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness
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...The one patient in this series missed by HINTS would have been captured by the recently described HINTS “plus” approach that identifies hearing loss as a sign of anterior inferior cerebellar artery infarction in patients with AVS.(9) In the hands of subspecialists, HINTS “plus” has an estimated sensitivity of 99% and specificity of 97% for identifying central causes of AVS, whether isolated or not....
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...In fact, when cerebrovascular patients present vestibular symptoms, they are isolated much more often than nonisolated at initial presentation,1,13 and isolated vertigo or dizziness is the most common initial manifestation of vertebrobasilar ischemia.13 While isolated transient vertigo still presents substantial diagnostic challenges, ample evidence now indicates that bedside oculomotor examinations reliably distinguish central from peripheral causes in those with persistent, continuous symptoms (i.e., AVS).1,2,8,9,14 The one patient in this series missed by HINTS would have been captured by the recently described HINTS “plus” approach that identifies hearing loss as a sign of anterior inferior cerebellar artery infarction in patients with AVS.9 In the hands of subspecialists, HINTS “plus” has an estimated sensitivity of 99% and specificity of 97% for identifying central causes of AVS, whether isolated or not.9 Similar results, however, can probably be achieved by general neurologists after modest amounts of training.15 Relying on immediate MRI to exclude patients with stroke AVS is probably not sufficient....
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...Optimal, evidence-based neuroimaging protocols in AVS await further study, although we recently proposed one possible strategy (figure e-1).(9) The prognosis and impact of early treatment for these specific patients remain largely unknown, but Table 1 Clinicoradiographic case descriptions, listed from caudal to rostral, based on anatomical lesion location...
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...Small strokes involving vestibular projections within the brainstem or cerebellum can produce AVS....
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..., AVS).(1,2,8,9,14) The one patient in this series missed by HINTS would have been captured by the recently described HINTS “plus” approach that identifies hearing loss as a sign of anterior inferior cerebellar artery infarction in patients with AVS....
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...temic or local (otitis or mastoiditis) infection, however, this presentation should be viewed suspiciously, because inner ear strokes typically present this way(54,106,129) and may often be the cause of s-AVS with hearing loss in the ED.(101) The prevalence of stroke in ED dizziness is 3% to 5%(1,2,12,16,130,131) and probably less for those with isolated dizziness....
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...Patients typically present with a combination of dizziness, headaches, fatigue, and minor cognitive impairments, with dizziness the most common symptom in the first 2 weeks after injury.89 Anticonvulsant side effects or toxicity is a frequent cause of dizziness and vertigo in the ED and may present with an acute clinical picture.90 Carbon monoxide intoxication is an uncommon but important cause to consider.91 Aminoglycoside toxicity is a wellknown cause of acute bilateral vestibular failure.92,93 Gentamicin produces profound, permanent loss of vestibular function with relatively spared hearing, and toxicity may occur after even a single antibiotic dose.93 Although this problem is often discovered during the course of an inpatient admission, patients may develop symptoms later and present to the ED....
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...Less well known is that even MRI with diffusion-weighted imaging (DWI) misses 10% to 20% of strokes in s-AVS during the first 24 to 48 hours.(95,101) When smaller strokes (<1 cm in diameter) present with s-AVS, early MRI sensitivity is only approximately 50%....
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...Strong evidence95 suggests that a physical examination clinical decision rule using 3 bedside eye examination findings (HINTS—head impulse test, nystagmus type, and skew deviation; see Table 4) rules out stroke more accurately than early MRI.90,100,101 Importantly, the mere presence of nystagmus (found in both neuritis and stroke) is not as useful as the nystagmus attributes, which help differentiate the 2 (see Table 3)....
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...This benign presentation must be differentiated from bacterial labyrinthitis, a dangerous disorder resulting from spread of middle ear or systemic infection that may lead to meningitis if left untreated.128 Even in the absence of systemic or local (otitis or mastoiditis) infection, however, this presentation should be viewed suspiciously, because inner ear strokes typically present this way54,106,129 and may often be the cause of s-AVS with hearing loss in the ED.101 The prevalence of stroke in ED dizziness is 3% to 5%1,2,12,16,130,131 and probably less for those with isolated dizziness.12 Among ED dizzy patients, those with AVS Evidence-Based Diagnosis of Dizziness 591 are a high-risk subgroup for stroke (approximately 25% of s-AVS cases).95 Posterior circulation stroke typically presents with s-AVS, sometimes after a series of spontaneous episodes in the preceding weeks or months (ie, TIAs, usually from posterior circulation stenosis, culminating in stroke).95 Almost all of these strokes (96...
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