Bahan vertigohttp://www.ncbi.nlm.nih.gov/pubmed/25297477Peripheral vertigo versus central vertigo. Application of the HINTS protocol].[Article in Spanish]Batuecas-Caletro 1, Yez-Gonzlez R, Snchez-Blanco C, Gonzlez-Snchez E, Benito J, Gmez JC, Santa Cruz-Ruiz S.Author informationAbstractin English, SpanishINTRODUCTION: One of the most important dilemmas concerning vertigo in emergency departments is its differential diagnosis. There are highly sensitive warning signs in the examination that can put us on the path towards finding ourselves before a case of central vertigo.AIM: To determine how effective the application of the HINTS protocol is in the diagnosis of cerebrovascular accidents that mimics peripheral vertigo.PATIENTS AND METHODS: We conducted a descriptive observation-based study on patients admitted to hospital with a diagnosis of acute vestibular syndrome in the emergency department. All the patients were monitored on a day-to-day basis until their symptoms improved, with information about nystagmus, the oculocephalic manoeuvre and the skew test. The results from the magnetic resonance imaging study were compared with the alteration of any of those three signs during the time the patient was hospitalised.RESULTS: Altogether 91 patients were examined, with a mean age of 55.8 years. A cerebrovascular accident was observed in eight cases. Of these (mean age: 71 years), in seven of them there were alterations in some of the HINTS signs, and in one case the study was normal (sensitivity: 0.88; specificity: 0.96). All of them had some vascular risk factor.CONCLUSIONS: Faced with a patient who visits the emergency department with an acute vestibular syndrome, a suitably directed examination is essential to be able to establish the differential diagnosis between peripheral and central pathology, since some cerebrovascular accidents can present with the appearance of acute vertigo. Applying a protocol like HINTS makes it possible to suspect the central pathology with a high degree of sensitivity and specificity.HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness.Newman-Toker DE1, Kerber KA, Hsieh YH, Pula JH, Omron R, Saber Tehrani AS, Mantokoudis G, Hanley DF, Zee DS, Kattah JC.Author informationAbstractOBJECTIVES: Dizziness and vertigo account for about 4 million emergency department (ED) visits annually in the United States, and some 160,000 to 240,000 (4% to 6%) have cerebrovascular causes. Stroke diagnosis in ED patients with vertigo/dizziness is challenging because the majority have no obvious focal neurologic signs at initial presentation. The authors sought to compare the accuracy of two previously published approaches purported to be useful in bedside screening for possible stroke in dizziness: a clinical decision rule (head impulse, nystagmus type, test of skew [HINTS]) and a risk stratification rule (age, blood pressure, clinical features, duration of symptoms, diabetes [ABCD2]).METHODS: This was a cross-sectional study of high-risk patients (more than one stroke risk factor) with acute vestibular syndrome (AVS; acute, persistent vertigo or dizziness with nystagmus, plus nausea or vomiting, head motion intolerance, and new gait unsteadiness) at a single academic center. All underwent neurootologic examination, neuroimaging (97.4% by magnetic resonance imaging [MRI]), and follow-up. ABCD2 risk scores (0-7 points), using the recommended cutoff of 4 for stroke, were compared to a three-component eye movement battery (HINTS). Sensitivity, specificity, and positive and negative likelihood ratios (LR+, LR-) were assessed for stroke and other central causes, and the results were stratified by age. False-negative initial neuroimaging was also assessed.RESULTS: A total of 190 adult AVS patients were assessed (1999-2012). Median age was 60.5years (range=18 to 92years; interquartile range [IQR]=52.0 to 70.0years); 60.5% were men. Final diagnoses were vestibular neuritis (34.7%), posterior fossa stroke (59.5% [105 infarctions, eight hemorrhages]), and other central causes (5.8%). Median ABCD2 was 4.0 (range=2 to 7; IQR=3.0 to 4.0). ABCD2 4 for stroke had sensitivity of 61.1%, specificity of 62.3%, LR+ of 1.62, and LR- of 0.62; sensitivity was lower for those younger than 60years old (28.9%). HINTS stroke sensitivity was 96.5%, specificity was 84.4%, LR+ was 6.19, and LR- was 0.04 and did not vary by age. For any central lesion, sensitivity was 96.8%, specificity was 98.5%, LR+ was 63.9, and LR- was 0.03 for HINTS, and sensitivity was 99.2%, specificity was 97.0%, LR+ was 32.7, and LR- was 0.01 for HINTS "plus" (any new hearing loss added to HINTS). Initial MRIs were falsely negative in 15 of 105 (14.3%) infarctions; all but one was obtained before 48hours after onset, and all were confirmed by delayed MRI.CONCLUSIONS: HINTS substantially outperforms ABCD2 for stroke diagnosis in ED patients with AVS. It also outperforms MRI obtained within the first 2days after symptom onset. While HINTS testing has traditionally been performed by specialists, methods for empowering emergency physicians (EPs) to leverage this approach for stroke screening in dizziness should be investigated. 2013 by the Society for Academic Emergency Medicine. Original ContributionsHINTS to Diagnose Stroke in the Acute Vestibular SyndromeThree-Step Bedside Oculomotor Examination More Sensitive Than Early MRI Diffusion-Weighted Imaging1. Jorge C. Kattah, MD; 2. Arun V. Talkad, MD; 3. David Z. Wang, DO; 4. Yu-Hsiang Hsieh, PhD, MS; 5. David E. Newman-Toker, MD, PhD+ Author Affiliations1. From the Department of Neurology (J.C.K., A.V.T., D.Z.W.), The University of Illinois College of Medicine at Peoria and the Illinois Neurological Institute at OSF Saint Francis Medical Center, Peoria, Ill; and the Department of Neurology (D.E.N.-T.), and Department of Emergency Medicine (Y.H.H.), The Johns Hopkins University School of Medicine, Baltimore, Md. 1. Correspondence to David E. Newman-Toker, MD, PhD, Assistant Professor, Department of Neurology, The Johns Hopkins Hospital, Pathology Building 2-210, 600 North Wolfe Street, Baltimore, MD 21287. E-mail toker@jhu.eduNext SectionAbstractBackground and Purpose Acute vestibular syndrome (AVS) is often due to vestibular neuritis but can result from vertebrobasilar strokes. Misdiagnosis of posterior fossa infarcts in emergency care settings is frequent. Bedside oculomotor findings may reliably identify stroke in AVS, but prospective studies have been lacking. Methods The authors conducted a prospective, cross-sectional study at an academic hospital. Consecutive patients with AVS (vertigo, nystagmus, nausea/vomiting, head-motion intolerance, unsteady gait) with 1 stroke risk factor underwent structured examination, including horizontal head impulse test of vestibulo-ocular reflex function, observation of nystagmus in different gaze positions, and prism cross-cover test of ocular alignment. All underwent neuroimaging and admission (generally