Tarnutzer Alexander A, Koohi Nehzat, Lee Sun-Uk, Kaski Diego
Neurology, Cantonal Hospital of Baden, 5404 Baden, Switzerland.
Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland.
Brain Sci. 2025 Jan 9;15(1):55. doi: 10.3390/brainsci15010055.
Acute vertigo or dizziness is a frequent presentation to the emergency department (ED), making up between 2.1% and 4.4% of all consultations. Given the nature of the ED where the priority is triage, diagnostic delays and misdiagnoses are common, with as many as a third of vertebrobasilar strokes presenting with acute vertigo or dizziness being missed. Here, we review diagnostic errors identified in the evaluation and treatment of the acutely dizzy patient and discuss strategies to overcome them. Lessons learned include focusing on structured history taking, asking about timing and triggers to inform a targeted examination, assessing subtle ocular motor findings (e.g., by use of HINTS(+)), and avoiding overreliance on brain imaging (including early magnetic resonance imaging including diffusion-weighted sequences [DWI-MRI]). Importantly, up to 20% of DWI-MRI may be false negatives if obtained within the first 24-48 h after symptom onset. Likewise, overreliance on focal neurologic findings to confirm a stroke diagnosis should be avoided because isolated dizziness, vertigo, or even unsteadiness may be the only symptoms in some patients with vertebrobasilar stroke. Furthermore, in patients with triggered episodic vestibular symptoms provocation maneuvers should be preferred over HINTS(+), and a potential diagnosis of stroke should not be immediately dismissed in younger patients presenting with a headache (where migraine may be more common), but the possibility of a vertebral artery dissection should be further evaluated. Importantly, moderate training of non-experts allows for significant improvement in diagnostic accuracy in the acutely dizzy patient and thus should be prioritized.
急性眩晕或头晕是急诊科常见的就诊症状，占所有会诊病例的2.1%至4.4%。鉴于急诊科的性质，其首要任务是分诊，诊断延迟和误诊很常见，多达三分之一的椎基底动脉卒中患者表现为急性眩晕或头晕，但被漏诊。在此，我们回顾了在急性头晕患者评估和治疗中发现的诊断错误，并讨论了克服这些错误的策略。吸取的经验教训包括注重结构化病史采集，询问发作时间和诱因以指导有针对性的检查，评估细微的眼动表现（例如，通过使用HINTS(+)），以及避免过度依赖脑部成像（包括早期磁共振成像，包括弥散加权序列[DWI-MRI]）。重要的是，如果在症状发作后的最初24至48小时内进行DWI-MRI检查，高达20%的结果可能为假阴性。同样，应避免过度依赖局灶性神经系统表现来确诊卒中，因为在一些椎基底动脉卒中患者中，孤立的头晕、眩晕甚至不稳可能是唯一的症状。此外，对于有诱发性发作性前庭症状的患者，应优先进行激发试验而非HINTS(+)检查，对于出现头痛的年轻患者（偏头痛可能更常见），不应立即排除卒中的潜在诊断，而应进一步评估椎动脉夹层的可能性。重要的是，对非专家进行适度培训可显著提高急性头晕患者的诊断准确性，因此应优先考虑。
