Diagnostic Accuracy of the Physical Exam in Patients With Vertigo or Dizziness Presenting to the Emergency Department: A Systematic Review and Meta Analysis Supporting the Guidelines for Reasonable and Appropriate Care in Emergency Medicine

Study ObjectivesHistory and physical exam are key features to narrow the differential and help establish a diagnosis of central versus peripheral causes in patients presenting to the ED with acute vertigo. We conducted a systematic review and meta-analysis of the diagnostic test accuracy of physical exam findings.MethodsAn electronic search was designed following patient-intervention-control-outcome (PICO) question, (P) adult patients with vertigo presenting to the ED; (I) presence of specific physical exam or history findings; (O) central (ischemic stroke, hemorrhage, tumor, others) versus peripheral cause of symptoms. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Each report was assessed by 2 independent reviewers.ResultsFrom 6,309 titles, 458 articles were retrieved, and 44 met the inclusion criteria. We included studies that reported diagnostic test accuracy to differentiate central from peripheral causes of vertigo. General Neurologic Exam: 5 studies, 869 patients, pooled sensitivity 46.8% (CI 32.3%, 61.9%) and specificity 92.8% (CI 75.7%, 98.1%). Peripheral weakness: 4 studies, 893 patients, sensitivity 11.4% (CI 5.1%, 23.6%) and specificity 98.5% (CI 97.1%, 99.2%). Spontaneous Nystagmus: 6 studies, 621 patients, sensitivity 52.3% (CI 29.8%, 74.0%) and specificity 42.0% (CI 15.5%, 74.1%). Truncal/Gait Ataxia: 10 studies, 1,810 patients. Increasing severity of truncal ataxia had an increasing sensitivity for central etiology. Sensitivity 69.7% (CI 43.3%, 87.9%) and specificity 83.7% (CI 52.1%, 96.0%). Cerebellar signs: 4 studies, 1,135 patients, sensitivity 24.6% (CI 15.6%, 36.5%) and specificity 97.8% (CI 94.4%, 99.2%). Head Impulse Test: 17 studies, 1,366 patients, sensitivity 76.8% (CI 64.4%, 85.8%) and specificity 89.1% (CI 75.8%, 95.6%). Nystagmus Type: 16 studies, 1,366 patients. Bidirectional, vertical, direction- changing, or pure torsional nystagmus are consistent with a central cause of vertigo. Sensitivity was 50.7% (CI 41.1%, 60.2%) and specificity 98.5% (CI 91.7%, 99.7%). Test of Skew: 15 studies, 1,150 patients. Skew deviation is considered abnormal and consistent with central etiology. Sensitivity was 23.7% (CI 15%, 35.4%) and specificity 97.6% (CI 96%, 98.6%). HINTS (Head Impulse, Nystagmus, Test of Skew): 14 studies, 1,781 patients, sensitivity 92.9% (CI 79.1%, 97.9%), specificity 83.4% (CI 69.6%, 91.7%). HINTS+: 5 studies, 342 patients, sensitivity 99.0% (CI 73.6%, 100%) and specificity was 84.8% (CI 70.1%, 93.0%).ConclusionA complete neurological exam including gait evaluation can help determine etiology in patients with vertigo or dizziness. HINTS is the most sensitive exam finding to differentiate central vs peripheral cause of symptoms.No, authors do not have interests to disclose Study ObjectivesHistory and physical exam are key features to narrow the differential and help establish a diagnosis of central versus peripheral causes in patients presenting to the ED with acute vertigo. We conducted a systematic review and meta-analysis of the diagnostic test accuracy of physical exam findings. History and physical exam are key features to narrow the differential and help establish a diagnosis of central versus peripheral causes in patients presenting to the ED with acute vertigo. We conducted a systematic review and meta-analysis of the diagnostic test accuracy of physical exam findings. MethodsAn electronic search was designed following patient-intervention-control-outcome (PICO) question, (P) adult patients with vertigo presenting to the ED; (I) presence of specific physical exam or history findings; (O) central (ischemic stroke, hemorrhage, tumor, others) versus peripheral cause of symptoms. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Each report was assessed by 2 independent reviewers. An electronic search was designed following patient-intervention-control-outcome (PICO) question, (P) adult patients with vertigo presenting to the ED; (I) presence of specific physical exam or history findings; (O) central (ischemic stroke, hemorrhage, tumor, others) versus peripheral cause of symptoms. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Each report was assessed by 2 independent reviewers. ResultsFrom 6,309 titles, 458 articles were retrieved, and 44 met the inclusion criteria. We included studies that reported diagnostic test accuracy to differentiate central from peripheral causes of vertigo. General Neurologic Exam: 5 studies, 869 patients, pooled sensitivity 46.8% (CI 32.3%, 61.9%) and specificity 92.8% (CI 75.7%, 98.1%). Peripheral weakness: 4 studies, 893 patients, sensitivity 11.4% (CI 5.1%, 23.6%) and specificity 98.5% (CI 97.1%, 99.2%). Spontaneous Nystagmus: 6 studies, 621 patients, sensitivity 52.3% (CI 29.8%, 74.0%) and specificity 42.0% (CI 15.5%, 74.1%). Truncal/Gait Ataxia: 10 studies, 1,810 patients. Increasing severity of truncal ataxia had an increasing sensitivity for central etiology. Sensitivity 69.7% (CI 43.3%, 87.9%) and specificity 83.7% (CI 52.1%, 96.0%). Cerebellar signs: 4 studies, 1,135 patients, sensitivity 24.6% (CI 15.6%, 36.5%) and specificity 97.8% (CI 94.4%, 99.2%). Head Impulse Test: 17 studies, 1,366 patients, sensitivity 76.8% (CI 64.4%, 85.8%) and specificity 89.1% (CI 75.8%, 95.6%). Nystagmus Type: 16 studies, 1,366 patients. Bidirectional, vertical, direction- changing, or pure torsional nystagmus are consistent with a central cause of vertigo. Sensitivity was 50.7% (CI 41.1%, 60.2%) and specificity 98.5% (CI 91.7%, 99.7%). Test of Skew: 15 studies, 1,150 patients. Skew deviation is considered abnormal and consistent with central etiology. Sensitivity was 23.7% (CI 15%, 35.4%) and specificity 97.6% (CI 96%, 98.6%). HINTS (Head Impulse, Nystagmus, Test of Skew): 14 studies, 1,781 patients, sensitivity 92.9% (CI 79.1%, 97.9%), specificity 83.4% (CI 69.6%, 91.7%). HINTS+: 5 studies, 342 patients, sensitivity 99.0% (CI 73.6%, 100%) and specificity was 84.8% (CI 70.1%, 93.0%). From 6,309 titles, 458 articles were retrieved, and 44 met the inclusion criteria. We included studies that reported diagnostic test accuracy to differentiate central from peripheral causes of vertigo. General Neurologic Exam: 5 studies, 869 patients, pooled sensitivity 46.8% (CI 32.3%, 61.9%) and specificity 92.8% (CI 75.7%, 98.1%). Peripheral weakness: 4 studies, 893 patients, sensitivity 11.4% (CI 5.1%, 23.6%) and specificity 98.5% (CI 97.1%, 99.2%). Spontaneous Nystagmus: 6 studies, 621 patients, sensitivity 52.3% (CI 29.8%, 74.0%) and specificity 42.0% (CI 15.5%, 74.1%). Truncal/Gait Ataxia: 10 studies, 1,810 patients. Increasing severity of truncal ataxia had an increasing sensitivity for central etiology. Sensitivity 69.7% (CI 43.3%, 87.9%) and specificity 83.7% (CI 52.1%, 96.0%). Cerebellar signs: 4 studies, 1,135 patients, sensitivity 24.6% (CI 15.6%, 36.5%) and specificity 97.8% (CI 94.4%, 99.2%). Head Impulse Test: 17 studies, 1,366 patients, sensitivity 76.8% (CI 64.4%, 85.8%) and specificity 89.1% (CI 75.8%, 95.6%). Nystagmus Type: 16 studies, 1,366 patients. Bidirectional, vertical, direction- changing, or pure torsional nystagmus are consistent with a central cause of vertigo. Sensitivity was 50.7% (CI 41.1%, 60.2%) and specificity 98.5% (CI 91.7%, 99.7%). Test of Skew: 15 studies, 1,150 patients. Skew deviation is considered abnormal and consistent with central etiology. Sensitivity was 23.7% (CI 15%, 35.4%) and specificity 97.6% (CI 96%, 98.6%). HINTS (Head Impulse, Nystagmus, Test of Skew): 14 studies, 1,781 patients, sensitivity 92.9% (CI 79.1%, 97.9%), specificity 83.4% (CI 69.6%, 91.7%). HINTS+: 5 studies, 342 patients, sensitivity 99.0% (CI 73.6%, 100%) and specificity was 84.8% (CI 70.1%, 93.0%). ConclusionA complete neurological exam including gait evaluation can help determine etiology in patients with vertigo or dizziness. HINTS is the most sensitive exam finding to differentiate central vs peripheral cause of symptoms.No, authors do not have interests to disclose A complete neurological exam including gait evaluation can help determine etiology in patients with vertigo or dizziness. HINTS is the most sensitive exam finding to differentiate central vs peripheral cause of symptoms.