ORIGINAL ARTICLE
A Prospective Pilot Study of Predictors of Acute Stroke in Emergency Department Patients With Dizziness Maureen Chase, MD, MPH; Joshua N. Goldstein, MD, PhD; Magdy H. Selim, MD, PhD; Daniel J. Pallin, MD, MPH; Marc A. Camacho, MD; Jennifer L. O’Connor, MPH; Long Ngo, PhD; and Jonathan A. Edlow, MD Abstract Objective: To prospectively examine undifferentiated emergency department (ED) patients with dizziness to identify clinical features associated with acute stroke. Patients and Methods: We conducted a pilot study from November 1, 2009, through October 30, 2010, of adult patients with dizziness presenting to 3 urban academic EDs. Data collected included demographic characteristics, medical history, presenting symptoms, examination findings, clinician pretest probability of stroke, and neuroimaging results. Logistic regression was used to identify variables with a significant association with acute stroke (P.99
106 57 184 148 52 35 47 23 63 3 56
1 2 11 9 4 2 2 1 3 0 0
.21 .69 .005 .02 .07 .30 .65 .52 .43 >.99 .39
a
RESULTS We enrolled 473 patients. Table 1 lists the demographic characteristics of the population. Mean SD age was 56.719.3 years, 60% were female, 71% were white, 16% were African American, and 6% were Hispanic. We found 30 acute, serious diagnoses (6.3%) in our undifferentiated ED population with dizziness. Overall, there were 14 patients (3.0%) with acute ischemic stroke. Patients with stroke were a mean SD of 68.517 years old. Table 2 gives the distribution of clinical variables among patients with and without stroke. In addition to the 14 stroke diagnoses, there were 2 subarachnoid hemorrhages, 7 new mass lesions, 2 new demyelinating lesions, 2 cases of severe vertebral artery stenosis, 2 cases of acute coronary syndrome, and 1 case of hydrocephalus and meningitis in our dizzy population. We identified several variables associated with the primary outcome: age (OR, 1.04; 95% CI, 1.0-1.07), hyperlipidemia (OR, 3.62; 95% CI, 1.24-10.6), hypertension (OR, 4.91; 95% CI, 1.46-16.5), coronary artery disease (OR, 3.33; 95% CI, 1.06-10.5), and abnormal tandem gait test result (OR, 3.13; 95% CI, 1.10-8.89). Emergency physician pretest probability when assessed as high (n¼8) or medium (n¼4) compared with low (n¼2) Mayo Clin Proc. n February 2014;89(2):173-180 www.mayoclinicproceedings.org
n
Data are presented as No. of patients unless otherwise indicated.
also reliably predicted stroke (OR, 18.8; 95% CI, 4.72-74.5) (Table 3). No presenting symptoms were significantly associated with the primary outcome, although 12 of our 14 stroke patients experienced feeling off balance or unsteady with walking (OR, 3.7; 95% CI, 0.93-14.5). However, neither ataxia nor a positive Romberg test result predicted acute stroke in our sample. Three patients with an acute stroke had documented ataxia, whereas 8 did not have ataxia and 3 were not tested compared with 70 nonstroke patients with ataxia of 344 tested (104 patients not tested) (OR, 1.06; 95% CI, 0.58-1.9). Similarly, 3 of 9 tested patients in the stroke group had a positive Romberg test result, whereas 28 of 247 tested nonstroke patients had a positive Romberg test result (OR, 0.97; 95% CI, 0.57-1.7). Ninety-three percent of our patients were tested for nystagmus, and 93 patients had positive findings (71 horizontal, 12 vertical, and 10 direction-changing), 5 of whom were stroke patients (3 horizontal and 2 directionchanging). Eight of our patients with stroke had no nystagmus noted on examination, and 1 patient was not included (P¼.17).
http://dx.doi.org/10.1016/j.mayocp.2013.10.026
175
MAYO CLINIC PROCEEDINGS
TABLE 2. Clinical Characteristics of Patients With and Without Stroke
Characteristic Symptoms Upper respiratory tract infection Ear pain Tinnitus Fever Headache Palpitations Chest pain Presenting symptom(s) Dizziness Vertigo Lightheaded Imbalance Syncope Gait instability Fall Transient ischemic attack or stroke Visual disturbance Weakness (focal) Weakness (generalized) Nausea Neck pain History of present illness Sudden onset Gradual onset Head movement trigger General movement trigger Worsened by head movement Worsened by general movement Single episode Multiple episodes Physical examination findings Nystagmus (426 patients tested) Dysmetria (383 patients tested) Tandem gait (266 patients tested) Tested and abnormal Too symptomatic to test Tandem gait abnormal or too symptomatic to test Ataxia (355 patients tested) Romberg test (256 patients tested) Positive Dix-Hallpike test result (149 patients tested) Positive head thrust (64 patients tested) Moderate-high pretest probability for acute stroke (448 nonstroke patients [97.6%] and 14 stroke patients [100%] tested)
A total of 149 patients underwent DixHallpike testing, including 3 stroke patients, all of whom had negative test results. Sixty-five nonstroke patients had a positive Dix-Hallpike test result (OR, 0.18; 95% CI, 0.01-3.6). Similarly, 64 patients had head thrust testing, 3 of whom were stroke patients and all of whom had a negative head thrust examination result, 176
Mayo Clin Proc.
n
No. dizzy without acute stroke (n¼459)
No. dizzy with acute stroke (n¼14)
P value
37 50 42 9 160 26 32
2 2 1 0 5 1 0
.32 .66 >.99 >.99 >.99 .54 .61
376 168 245 230 154 191 62 4 93 28 104 205 41
11 7 8 10 4 8 2 0 4 2 1 6 2
.73 .40 >.99 .17 .78 .28 >.99 >.99 .50 .22 .32 >.99 .37
288 92 58 78 74 105 257 164
9 2 2 2 1 3 11 3
>.99 >.99 .69 >.99 .71 >.99 .11 .27
88 15 186 62 73 135 70 28 65 12
5 1 9 4 4 8 3 3 0 0
.17 .43 .001 .12 .26 .04 .80 .11 .26 >.99
94
12
A Prospective Pilot Study of Predictors of Acute Stroke in Emergency Department Patients With Dizziness Maureen Chase, MD, MPH; Joshua N. Goldstein, MD, PhD; Magdy H. Selim, MD, PhD; Daniel J. Pallin, MD, MPH; Marc A. Camacho, MD; Jennifer L. O’Connor, MPH; Long Ngo, PhD; and Jonathan A. Edlow, MD Abstract Objective: To prospectively examine undifferentiated emergency department (ED) patients with dizziness to identify clinical features associated with acute stroke. Patients and Methods: We conducted a pilot study from November 1, 2009, through October 30, 2010, of adult patients with dizziness presenting to 3 urban academic EDs. Data collected included demographic characteristics, medical history, presenting symptoms, examination findings, clinician pretest probability of stroke, and neuroimaging results. Logistic regression was used to identify variables with a significant association with acute stroke (P.99
106 57 184 148 52 35 47 23 63 3 56
1 2 11 9 4 2 2 1 3 0 0
.21 .69 .005 .02 .07 .30 .65 .52 .43 >.99 .39
a
RESULTS We enrolled 473 patients. Table 1 lists the demographic characteristics of the population. Mean SD age was 56.719.3 years, 60% were female, 71% were white, 16% were African American, and 6% were Hispanic. We found 30 acute, serious diagnoses (6.3%) in our undifferentiated ED population with dizziness. Overall, there were 14 patients (3.0%) with acute ischemic stroke. Patients with stroke were a mean SD of 68.517 years old. Table 2 gives the distribution of clinical variables among patients with and without stroke. In addition to the 14 stroke diagnoses, there were 2 subarachnoid hemorrhages, 7 new mass lesions, 2 new demyelinating lesions, 2 cases of severe vertebral artery stenosis, 2 cases of acute coronary syndrome, and 1 case of hydrocephalus and meningitis in our dizzy population. We identified several variables associated with the primary outcome: age (OR, 1.04; 95% CI, 1.0-1.07), hyperlipidemia (OR, 3.62; 95% CI, 1.24-10.6), hypertension (OR, 4.91; 95% CI, 1.46-16.5), coronary artery disease (OR, 3.33; 95% CI, 1.06-10.5), and abnormal tandem gait test result (OR, 3.13; 95% CI, 1.10-8.89). Emergency physician pretest probability when assessed as high (n¼8) or medium (n¼4) compared with low (n¼2) Mayo Clin Proc. n February 2014;89(2):173-180 www.mayoclinicproceedings.org
n
Data are presented as No. of patients unless otherwise indicated.
also reliably predicted stroke (OR, 18.8; 95% CI, 4.72-74.5) (Table 3). No presenting symptoms were significantly associated with the primary outcome, although 12 of our 14 stroke patients experienced feeling off balance or unsteady with walking (OR, 3.7; 95% CI, 0.93-14.5). However, neither ataxia nor a positive Romberg test result predicted acute stroke in our sample. Three patients with an acute stroke had documented ataxia, whereas 8 did not have ataxia and 3 were not tested compared with 70 nonstroke patients with ataxia of 344 tested (104 patients not tested) (OR, 1.06; 95% CI, 0.58-1.9). Similarly, 3 of 9 tested patients in the stroke group had a positive Romberg test result, whereas 28 of 247 tested nonstroke patients had a positive Romberg test result (OR, 0.97; 95% CI, 0.57-1.7). Ninety-three percent of our patients were tested for nystagmus, and 93 patients had positive findings (71 horizontal, 12 vertical, and 10 direction-changing), 5 of whom were stroke patients (3 horizontal and 2 directionchanging). Eight of our patients with stroke had no nystagmus noted on examination, and 1 patient was not included (P¼.17).
http://dx.doi.org/10.1016/j.mayocp.2013.10.026
175
MAYO CLINIC PROCEEDINGS
TABLE 2. Clinical Characteristics of Patients With and Without Stroke
Characteristic Symptoms Upper respiratory tract infection Ear pain Tinnitus Fever Headache Palpitations Chest pain Presenting symptom(s) Dizziness Vertigo Lightheaded Imbalance Syncope Gait instability Fall Transient ischemic attack or stroke Visual disturbance Weakness (focal) Weakness (generalized) Nausea Neck pain History of present illness Sudden onset Gradual onset Head movement trigger General movement trigger Worsened by head movement Worsened by general movement Single episode Multiple episodes Physical examination findings Nystagmus (426 patients tested) Dysmetria (383 patients tested) Tandem gait (266 patients tested) Tested and abnormal Too symptomatic to test Tandem gait abnormal or too symptomatic to test Ataxia (355 patients tested) Romberg test (256 patients tested) Positive Dix-Hallpike test result (149 patients tested) Positive head thrust (64 patients tested) Moderate-high pretest probability for acute stroke (448 nonstroke patients [97.6%] and 14 stroke patients [100%] tested)
A total of 149 patients underwent DixHallpike testing, including 3 stroke patients, all of whom had negative test results. Sixty-five nonstroke patients had a positive Dix-Hallpike test result (OR, 0.18; 95% CI, 0.01-3.6). Similarly, 64 patients had head thrust testing, 3 of whom were stroke patients and all of whom had a negative head thrust examination result, 176
Mayo Clin Proc.
n
No. dizzy without acute stroke (n¼459)
No. dizzy with acute stroke (n¼14)
P value
37 50 42 9 160 26 32
2 2 1 0 5 1 0
.32 .66 >.99 >.99 >.99 .54 .61
376 168 245 230 154 191 62 4 93 28 104 205 41
11 7 8 10 4 8 2 0 4 2 1 6 2
.73 .40 >.99 .17 .78 .28 >.99 >.99 .50 .22 .32 >.99 .37
288 92 58 78 74 105 257 164
9 2 2 2 1 3 11 3
>.99 >.99 .69 >.99 .71 >.99 .11 .27
88 15 186 62 73 135 70 28 65 12
5 1 9 4 4 8 3 3 0 0
.17 .43 .001 .12 .26 .04 .80 .11 .26 >.99
94
12
