Stroke risk stratification in acute dizziness presentations: A prospective imaging-based study.
OBJECTIVE
To estimate the ability of bedside information to risk stratify stroke in acute dizziness presentations.


METHODS
Surveillance methods were used to identify patients with acute dizziness and nystagmus or imbalance, excluding those with benign paroxysmal positional vertigo, medical causes, or moderate to severe neurologic deficits. Stroke was defined as acute infarction or intracerebral hemorrhage on a clinical or research MRI performed within 14 days of dizziness onset. Bedside information comprised history of stroke, the ABCD(2) score (age, blood pressure, clinical features, duration, and diabetes), an ocular motor (OM)-based assessment (head impulse test, nystagmus pattern [central vs other], test of skew), and a general neurologic examination for other CNS features. Multivariable logistic regression was used to determine the association of the bedside information with stroke. Model calibration was assessed using low (<5%), intermediate (5% to <10%), and high (≥10%) predicted probability risk categories.


RESULTS
Acute stroke was identified in 29 of 272 patients (10.7%). Associations with stroke were as follows: ABCD(2) score (continuous) (odds ratio [OR] 1.74; 95% confidence interval [CI] 1.20-2.51), any other CNS features (OR 2.54; 95% CI 1.06-6.08), OM assessment (OR 2.82; 95% CI 0.96-8.30), and prior stroke (OR 0.48; 95% CI 0.05-4.57). No stroke cases were in the model's low-risk probability category (0/86, 0%), whereas 9 were in the moderate-risk category (9/94, 9.6%) and 20 were in the high-risk category (20/92, 21.7%).


CONCLUSIONS
In acute dizziness presentations, the combination of ABCD(2) score, general neurologic examination, and a specialized OM examination has the capacity to risk-stratify acute stroke on MRI.
From the Stroke Program (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.) and Departments of Neurology (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.), Emergency Medicine (W.J.M.), Internal Medicine (T.P.H., A.M.F.), and Radiology (E.G.H.), University of Michigan Health System, Ann Arbor; and Department of Biostatistics (A.T.), University of Michigan School of Public Health, Ann Arbor. kakerber@umich.edu.
Kevin A
KA
Kerber
From the Stroke Program (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.) and Departments of Neurology (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.), Emergency Medicine (W.J.M.), Internal Medicine (T.P.H., A.M.F.), and Radiology (E.G.H.), University of Michigan Health System, Ann Arbor; and Department of Biostatistics (A.T.), University of Michigan School of Public Health, Ann Arbor.
William J
WJ
Meurer
From the Stroke Program (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.) and Departments of Neurology (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.), Emergency Medicine (W.J.M.), Internal Medicine (T.P.H., A.M.F.), and Radiology (E.G.H.), University of Michigan Health System, Ann Arbor; and Department of Biostatistics (A.T.), University of Michigan School of Public Health, Ann Arbor.
Devin L
DL
Brown
From the Stroke Program (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.) and Departments of Neurology (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.), Emergency Medicine (W.J.M.), Internal Medicine (T.P.H., A.M.F.), and Radiology (E.G.H.), University of Michigan Health System, Ann Arbor; and Department of Biostatistics (A.T.), University of Michigan School of Public Health, Ann Arbor.
James F
JF
Burke
From the Stroke Program (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.) and Departments of Neurology (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.), Emergency Medicine (W.J.M.), Internal Medicine (T.P.H., A.M.F.), and Radiology (E.G.H.), University of Michigan Health System, Ann Arbor; and Department of Biostatistics (A.T.), University of Michigan School of Public Health, Ann Arbor.
Timothy P
TP
Hofer
From the Stroke Program (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.) and Departments of Neurology (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.), Emergency Medicine (W.J.M.), Internal Medicine (T.P.H., A.M.F.), and Radiology (E.G.H.), University of Michigan Health System, Ann Arbor; and Department of Biostatistics (A.T.), University of Michigan School of Public Health, Ann Arbor.
Alexander
A
Tsodikov
From the Stroke Program (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.) and Departments of Neurology (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.), Emergency Medicine (W.J.M.), Internal Medicine (T.P.H., A.M.F.), and Radiology (E.G.H.), University of Michigan Health System, Ann Arbor; and Department of Biostatistics (A.T.), University of Michigan School of Public Health, Ann Arbor.
Ellen G
EG
Hoeffner
From the Stroke Program (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.) and Departments of Neurology (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.), Emergency Medicine (W.J.M.), Internal Medicine (T.P.H., A.M.F.), and Radiology (E.G.H.), University of Michigan Health System, Ann Arbor; and Department of Biostatistics (A.T.), University of Michigan School of Public Health, Ann Arbor.
A M
AM
Fendrick
From the Stroke Program (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.) and Departments of Neurology (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.), Emergency Medicine (W.J.M.), Internal Medicine (T.P.H., A.M.F.), and Radiology (E.G.H.), University of Michigan Health System, Ann Arbor; and Department of Biostatistics (A.T.), University of Michigan School of Public Health, Ann Arbor.
Eric E
EE
Adelman
From the Stroke Program (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.) and Departments of Neurology (K.A.K., W.J.M., D.L.B., J.F.B., E.E.A., L.B.M.), Emergency Medicine (W.J.M.), Internal Medicine (T.P.H., A.M.F.), and Radiology (E.G.H.), University of Michigan Health System, Ann Arbor; and Department of Biostatistics (A.T.), University of Michigan School of Public Health, Ann Arbor.
Lewis B
LB
Morgenstern
D000208:Acute Disease; D000328:Adult; D000368:Aged; D004244:Dizziness / Q000175:diagnosis* / Q000209:etiology* / Q000378:metabolism; D004636:Emergency Service, Hospital / Q000639:trends; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging / Q000379:methods; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D012307:Risk Factors; D020521:Stroke / Q000150:complications* / Q000175:diagnosis* / Q000378:metabolism