Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States of America.
Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, United States of America.
PLoS One. 2023 Mar 9;18(3):e0280752. doi: 10.1371/journal.pone.0280752. eCollection 2023.
Patients presenting to the emergency department (ED) with dizziness may be imaged via CTA head and neck to detect acute vascular pathology including large vessel occlusion. We identify commonly documented clinical variables which could delineate dizzy patients with near zero risk of acute vascular abnormality on CTA.
We performed a cross-sectional analysis of adult ED encounters with chief complaint of dizziness and CTA head and neck imaging at three EDs between 1/1/2014-12/31/2017. A decision rule was derived to exclude acute vascular pathology tested on a separate validation cohort; sensitivity analysis was performed using dizzy "stroke code" presentations.
Testing, validation, and sensitivity analysis cohorts were composed of 1072, 357, and 81 cases with 41, 6, and 12 instances of acute vascular pathology respectively. The decision rule had the following features: no past medical history of stroke, arterial dissection, or transient ischemic attack (including unexplained aphasia, incoordination, or ataxia); no history of coronary artery disease, diabetes, migraines, current/long-term smoker, and current/long-term anti-coagulation or anti-platelet medication use. In the derivation phase, the rule had a sensitivity of 100% (95% CI: 0.91-1.00), specificity of 59% (95% CI: 0.56-0.62), and negative predictive value of 100% (95% CI: 0.99-1.00). In the validation phase, the rule had a sensitivity of 100% (95% CI: 0.61-1.00), specificity of 53% (95% CI: 0.48-0.58), and negative predictive value of 100% (95% CI: 0.98-1.00). The rule performed similarly on dizzy stroke codes and was more sensitive/predictive than all NIHSS cut-offs. CTAs for dizziness might be avoidable in 52% (95% CI: 0.47-0.57) of cases.
A collection of clinical factors may be able to "exclude" acute vascular pathology in up to half of patients imaged by CTA for dizziness. These findings require further development and prospective validation, though could improve the evaluation of dizzy patients in the ED.
因头晕而到急诊就诊的患者，可通过 CTA 头颈部检查来发现急性血管病变，包括大血管闭塞。我们发现了一些常见的记录在案的临床变量，这些变量可以明确头晕患者 CTA 上无急性血管异常的低危风险。
我们对 2014 年 1 月 1 日至 2017 年 12 月 31 日在 3 家急诊就诊的以头晕为主诉且行 CTA 头颈部检查的成年患者进行了横断面分析。在单独的验证队列中，得出了排除急性血管病变的决策规则；使用头晕“中风代码”进行了敏感性分析。
检测、验证和敏感性分析队列分别由 1072、357 和 81 例患者组成，分别有 41、6 和 12 例患者存在急性血管病变。决策规则具有以下特征：无中风、动脉夹层或短暂性脑缺血发作的既往病史（包括不明原因的失语、协调障碍或共济失调）；无冠心病、糖尿病、偏头痛、当前/长期吸烟者，以及当前/长期抗凝或抗血小板药物使用者。在推导阶段，该规则的敏感性为 100%（95%CI：0.91-1.00），特异性为 59%（95%CI：0.56-0.62），阴性预测值为 100%（95%CI：0.99-1.00）。在验证阶段，该规则的敏感性为 100%（95%CI：0.61-1.00），特异性为 53%（95%CI：0.48-0.58），阴性预测值为 100%（95%CI：0.98-1.00）。该规则对头晕性中风代码的效果相似，并且比所有 NIHSS 切点更敏感/预测性。通过 CTA 检查头晕的患者中，约有 52%（95%CI：0.47-0.57）可能可以避免。
一系列临床因素可能能够“排除”多达一半因头晕而行 CTA 检查的患者的急性血管病变。这些发现需要进一步的开发和前瞻性验证，尽管如此，仍可能改善急诊科头晕患者的评估。
