From the, Division of Clinical Sciences, Northern Ontario School of Medicine, Health Science Northern Research Institute, Sudbury, Ontario.
the, Faculty of Science, Laurentian University, Sudbury, Ontario.
Acad Emerg Med. 2020 Sep;27(9):887-896. doi: 10.1111/acem.13960. Epub 2020 Apr 8.
Dizziness is a common complaint presented in the emergency department (ED). A subset of these patients will present with acute vestibular syndrome (AVS). AVS is a clinical syndrome defined by the presence of vertigo, nystagmus, head motion intolerance, ataxia, and nausea/vomiting. These symptoms are most often due to benign vestibular neuritis; however, they can be a sign of a dangerous central cause, i.e., vertebrobasilar stroke. The Head Impulse test, Nystagmus, Test of Skew (HINTS) examination has been proposed as a bedside test for frontline clinicians to rule out stroke in those presenting with AVS. Our objective was to assess the diagnostic accuracy of the HINTS examination to rule out a central cause of vertigo in an adult population presenting to the ED with AVS. Our aim was to assess the diagnostic accuracy when performed by emergency physicians versus neurologists.
We searched PubMed, Medline, Embase, the Cochrane database, and relevant conference abstracts from 2009 to September 2019 and performed hand searches. No restrictions for language or study type were imposed. Prospective studies with patients presenting with AVS using criterion standard of computed tomography and/or magnetic resonance imaging were selected for review. Two independent reviewers extracted data from relevant studies. Studies were combined if low clinical and statistical heterogeneity was present. Study quality was assessed using the QUADAS-2 tool. Random effects meta-analysis was performed using RevMan 5 and SAS 9.3.
A total of five studies with 617 participants met the inclusion criteria. The mean (±SD) study length was 5.3 (±3.3) years. Prevalence of vertebrobasilar stroke ranged 9.3% to 44% (mean ± SD = 39.1% ± 17.1%). The most common diagnoses were vertebrobasilar stroke (mean ± SD = 34.8% ± 17.1%), peripheral cause (mean ± SD = 30.9% ± 16%), and intracerebral hemorrhage (mean ± SD = 2.2% ± 0.5%). The HINTS examination, when performed by neurologists, had a sensitivity of 96.7% (95% CI = 93.1% to 98.5%, I = 0%) and specificity of 94.8% (95% CI = 91% to 97.1%, I = 0%). When performed by a cohort of physicians including both emergency physicians (board certified) and neurologists (fellowship trained in neurootology or vascular neurology) the sensitivity was 83% (95% CI = 63% to 95%) and specificity was 44% (95% CI = 36% to 51%).
The HINTS examination, when used in isolation by emergency physicians, has not been shown to be sufficiently accurate to rule out a stroke in those presenting with AVS.
头晕是急诊科（ED）常见的主诉。这些患者中有一部分会出现急性前庭综合征（AVS）。AVS 是一种以眩晕、眼球震颤、头部运动不耐受、共济失调和恶心/呕吐为特征的临床综合征。这些症状最常见于良性前庭神经炎；然而，它们也可能是危险的中枢原因的迹象，即椎基底动脉卒中。头脉冲试验、眼球震颤、偏斜试验（HINTS）检查已被提议作为一线临床医生床边检查，以排除出现 AVS 的患者中风。我们的目的是评估 HINTS 检查排除以头晕为主要表现的成年人群中前庭神经病变中枢病因的诊断准确性。我们的目的是评估由急诊医师和神经科医师进行检查时的诊断准确性。
我们检索了 2009 年至 2019 年 9 月期间的 PubMed、Medline、Embase、Cochrane 数据库和相关会议摘要，并进行了手工搜索。未对语言或研究类型施加任何限制。选择了使用计算机断层扫描和/或磁共振成像的标准对出现 AVS 的患者进行前瞻性研究进行综述。两名独立的审查员从相关研究中提取数据。如果存在低临床和统计学异质性，则合并研究。使用 QUADAS-2 工具评估研究质量。使用 RevMan 5 和 SAS 9.3 进行随机效应荟萃分析。
共有五项研究纳入了 617 名参与者，符合纳入标准。平均（±SD）研究长度为 5.3（±3.3）年。椎基底动脉卒中的患病率为 9.3%至 44%（平均值±SD=39.1%±17.1%）。最常见的诊断是椎基底动脉卒中（平均值±SD=34.8%±17.1%）、周围性病因（平均值±SD=30.9%±16%）和颅内出血（平均值±SD=2.2%±0.5%）。当由神经科医师进行 HINTS 检查时，其敏感性为 96.7%（95%CI=93.1%至 98.5%，I=0%），特异性为 94.8%（95%CI=91%至 97.1%，I=0%）。当由包括急诊医师（有执照的）和神经科医师（神经耳科或血管神经病学专业培训的研究员）在内的医师小组进行检查时，敏感性为 83%（95%CI=63%至 95%），特异性为 44%（95%CI=36%至 51%）。
当由急诊医师单独使用 HINTS 检查时，尚未证明其在排除以头晕为主要表现的患者中出现 AVS 的卒中方面具有足够的准确性。
