Diagnosing stroke in acute dizziness and vertigo pitfalls and pearls

Diagnosing cerebrovascular causes of acute dizziness and vertigo is both important and difficult. It is not routinely done well in current clinical ED practice, where misdiagnosis is frequent, patient harms are significant, and costs are high.3 This stems from a focus on dizziness type and overreliance on negative neurological examinations and CT results. Current best evidence suggests an alternative approach emphasizing dizziness timing and triggers, focused ocular motor examinations, and MRI, as needed. This timing, triggers, and targeted examination approach is commonly used by subspecialists in vestibular neurology but is not yet common practice among emergency physicians or neurologists. Because most patients in some settings will never be seen by a neurologist,72 and routine MRI for these patients is untenable, alternative strategies to disseminate this approach may be required. Preliminary studies have found accurate diagnosis using a portable videooculography device that measures eye movements quantitatively. 73,74 This approach has the potential to be broadly scalable in the form of an eye ECG that helps diagnose stroke in acute dizziness via device-based decision support with telemedicine backup.23 An ongoing NIH [NIDCD] phase II clinical trial of this approach (AVERT; URL: http://www. clinicaltrials.gov. Unique identifier: NCT02483429) seeks to develop this general approach going forward.