A comparison of benign positional vertigo and stroke patients presenting to the emergency department with vertigo or dizziness,
Author links open overlay panelJonathanHannaaAjayMalhotrabPhilip R.BraueraAlexanderLuryicEliasMichaelidesc
a
Yale University School of Medicine, New Haven, CT, United States of America
b
Department of Radiology and Biomedical Imaging, Yale University School of Medicine, Yale-New Haven Hospital, Yale Cancer Center, New Haven, CT, United States of America
c
Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, Yale-New Haven Hospital, Yale Cancer Center, New Haven, CT, United States of America
Received 15 May 2019, Available online 8 July 2019.
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Abstract
Purpose
To compare imaging utilization between patients presenting to the emergency department (ED) with vertigo and dizziness (VDS) who are diagnosed with stroke and benign paroxysmal positional vertigo (BPPV).
Methods
All patients presenting to the ED with VDS (January 2014–June 2018) were identified. Those with a discharge diagnosis of stroke and BPPV were analyzed.
Results
17,884 patients presented to with VDS. 452 were diagnosed with BPPV and 174 with acute stroke. 55.7% of stroke patients had at least one neurologic symptom beyond VDS, 63.8% had a positive neurologic exam, and 80.5% had either; 90.2% had at least one stroke risk factor (RF). 42.0% of BPPV patients received imaging, of which 24.7% had neurologic symptoms beyond VDS, 16.3% had neurologic exam findings, and 34.2% had either (P < 0.001, as compared to stroke). 43 patients (22.6%) lacked neurologic symptoms, exam findings, and stroke RFs; 40 had an adequate HINTS (head impulse, nystagmus, skew) exam. The most common imaging modality received by BPPV patients was plain CT Head (54.2%), followed by CT/CTA (43.7%), and MRI brain (26.3%). CT head was the initial imaging of choice in 44.7% and CT/CTA in 42.6%.
Conclusions
Imaging utilization in BPPV patients presenting with VDS is high. The profile of patients with BPPV that received imaging was substantially more benign than that of stroke patients (a quarter had no neurologic symptoms, exam findings, or stroke RFs). The HINTS exam was underutilized, and computed tomography was heavily utilized despite well-established limitations in diagnosing posterior circulation strokes. This study highlights the need for increased training in the HINTS exam, narrowing of the scope for computed tomography, and a higher threshold for imaging patients with isolated VDS.
Keywords
Benign positional vertigoStrokeComputed tomographyVertigoDizzinessEmergency department
Author links open overlay panelJonathanHannaaAjayMalhotrabPhilip R.BraueraAlexanderLuryicEliasMichaelidesc
a
Yale University School of Medicine, New Haven, CT, United States of America
b
Department of Radiology and Biomedical Imaging, Yale University School of Medicine, Yale-New Haven Hospital, Yale Cancer Center, New Haven, CT, United States of America
c
Department of Surgery, Section of Otolaryngology, Yale University School of Medicine, Yale-New Haven Hospital, Yale Cancer Center, New Haven, CT, United States of America
Received 15 May 2019, Available online 8 July 2019.
Show less
https://doi.org/10.1016/j.amjoto.2019.07.007Get rights and content
Abstract
Purpose
To compare imaging utilization between patients presenting to the emergency department (ED) with vertigo and dizziness (VDS) who are diagnosed with stroke and benign paroxysmal positional vertigo (BPPV).
Methods
All patients presenting to the ED with VDS (January 2014–June 2018) were identified. Those with a discharge diagnosis of stroke and BPPV were analyzed.
Results
17,884 patients presented to with VDS. 452 were diagnosed with BPPV and 174 with acute stroke. 55.7% of stroke patients had at least one neurologic symptom beyond VDS, 63.8% had a positive neurologic exam, and 80.5% had either; 90.2% had at least one stroke risk factor (RF). 42.0% of BPPV patients received imaging, of which 24.7% had neurologic symptoms beyond VDS, 16.3% had neurologic exam findings, and 34.2% had either (P < 0.001, as compared to stroke). 43 patients (22.6%) lacked neurologic symptoms, exam findings, and stroke RFs; 40 had an adequate HINTS (head impulse, nystagmus, skew) exam. The most common imaging modality received by BPPV patients was plain CT Head (54.2%), followed by CT/CTA (43.7%), and MRI brain (26.3%). CT head was the initial imaging of choice in 44.7% and CT/CTA in 42.6%.
Conclusions
Imaging utilization in BPPV patients presenting with VDS is high. The profile of patients with BPPV that received imaging was substantially more benign than that of stroke patients (a quarter had no neurologic symptoms, exam findings, or stroke RFs). The HINTS exam was underutilized, and computed tomography was heavily utilized despite well-established limitations in diagnosing posterior circulation strokes. This study highlights the need for increased training in the HINTS exam, narrowing of the scope for computed tomography, and a higher threshold for imaging patients with isolated VDS.
Keywords
Benign positional vertigoStrokeComputed tomographyVertigoDizzinessEmergency department
American Journal of Otolaryngology
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