How to Detect Central Vertigo on Examination in ED without neuroimaging?

Diagnosing stroke in dizzy patients remains a challenge in emergency medicine. The accuracy of the neuroophthalmological examination HINTS performed by emergency physicians (EPs) is unknown.

Differentiating posterior circulation stroke from peripheral vertigo is difficult, and 10-30% of these strokes are overlooked in the emergency department.

Studies in the past have revealed that while evaluating patients with vertigo, Emergency Physicians (EPs) commonly abuse or misunderstand key methods such as the HINTS test.

Researchers have found in a new study study published in the Journal of Academic Emergency Medicine on 10 July 2021 established that HINTS and STANDING might be valuable aids for saving time and money on needless neuroimaging. Further STANDING algorithm is more precise than the HINTS test for identifying peripheral diseases.

This study by Dr. Stephen Huff, was aimed to evaluate the accuracy of the HINTS examination conducted by trained EPs for identifying central causes of acute vertigo and unsteadiness to another bedside clinical instrument, STANDING, and the history-based score ABCD2.

This single-centre research looked at 300 prospectively recruited Emergency Department (ED) patients who had vertigo. All were subjected to HINTS and STANDING tests in ED, as well as a confirming brain MRI. Members of the research team gave the HINTS and STANDING tests after 6 hours of intensive instruction on both approaches.

The HINTS and STANDING tests showed high sensitivities of 97 percent and 94 percent, respectively, and NPVs of 99 percent and 98 percent.

The ABCD2 score failed to predict half of all central vertigo cases, with a sensitivity of 55% and an NPV of 87%.

The STANDING test was more accurate and showed a better positive predictive value than HINT test.

The Frenzel glasses used by STANDING test to detect nystagmus showed higher sensitivity as 75%.

The researchers concluded that in the hands of emergency physicians, HINTS and STANDING tests outperformed ABCD2 in identifying central causes of vertigo. For diagnosing peripheral disorders, the STANDING algorithm was found to be more specific than the HINTS test. HINTS and STANDING could be useful tools saving both time and costs related to unnecessary neuroimaging use.

The data showed that formal training in the HINTS test can considerably enhance ability of Emergency physician to rule out posterior circulation stroke without an MRI or a specialist consult. Including Frenzel glasses in the ED toolbox may help increase nystagmus detection and minimize false positive HINTS findings.

Source

Wiley Online Library – Academic Emergency Medicine, 10 July 2021

Gerlier, C., Hoarau, M., Fels, A., Vitaux, H., Mousset, C., Farhat, W., Firmin, M., Pouyet, V., Paoli, A., Chatellier, G., & Ganansia, O. (2021). Differentiating central from peripheral causes of acute vertigo in an emergency setting with the HINTS, STANDING, and ABCD2 tests: A diagnostic cohort study. Academic Emergency Medicine. https://doi.org/10.1111/acem.14337