ED patients with vertigo: can we identify clinical factors associated with acute stroke?

Maureen Chase, Nina R Joyce, Erin Carney, Justin D Salciccioli, Deborah Vinton, Michael W Donnino, Jonathan A Edlow
American Journal of Emergency Medicine 2012, 30 (4): 587-91

BACKGROUND: Vertigo is a common emergency department (ED) complaint with benign and serious etiologies with overlapping features. Misdiagnosis of acute stroke may result in significant morbidity and mortality. Magnetic resonance imaging (MRI) is superior to computer tomography (CT) for diagnosis of acute stroke but is costly with limited availability.

OBJECTIVE: The aim of this study was to identify clinical characteristics associated with a cerebrovascular cause for vertigo.

METHODS: We performed a retrospective chart review on patients with an MRI for vertigo, with or without additional historical or physical examination findings, over 18 months. Study patients were seen in the ED for vertigo within 2 weeks of MRI. Data collected included medical history, physical findings, and imaging results. Fisher's exact test was used to identify factors associated with the primary outcome, an acute stroke.

RESULTS: There were 325 eligible patients; 131 were ED patients. Patients were 57 (± 18) years, and 53% were women. There were 12 ED patients with a new stroke (9.2%). Two variables were associated with acute stroke: a presenting complaint of gait instability (odds ratio, 9.3; 95% confidence interval, 2.6-33.9) or a subtle neurologic finding (odds ratio, 8.7; 95% confidence interval, 2.3-33.1). One patient with a new stroke had a prior stroke, 3 were age >65 years, and none had coronary artery disease or dysrhythmia. Among patients with acute stroke, 5 also had head CT, and none detected the stroke.

CONCLUSIONS: This study identified 2 variables associated with acute stroke that should be considered in the evaluation of ED patients with vertigo. Head CT was inadequate for diagnosing acute stroke in this patient population.

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