Diagnostic Errors in the Acutely Dizzy Patient—Lessons Learned
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 pre...
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2025-01-01
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| author | Alexander A. Tarnutzer Nehzat Koohi Sun-Uk Lee Diego Kaski |
| author_facet | Alexander A. Tarnutzer Nehzat Koohi Sun-Uk Lee Diego Kaski |
| author_sort | Alexander A. Tarnutzer |
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| description | 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. |
| format | Article |
| id | doaj-art-91070ab5b25c4bcf86367618995e820d |
| institution | Kabale University |
| issn | 2076-3425 |
| language | English |
| publishDate | 2025-01-01 |
| publisher | MDPI AG |
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| series | Brain Sciences |
| spelling | doaj-art-91070ab5b25c4bcf86367618995e820d2025-01-24T13:25:49ZengMDPI AGBrain Sciences2076-34252025-01-011515510.3390/brainsci15010055Diagnostic Errors in the Acutely Dizzy Patient—Lessons LearnedAlexander A. Tarnutzer0Nehzat Koohi1Sun-Uk Lee2Diego Kaski3Neurology, Cantonal Hospital of Baden, 5404 Baden, SwitzerlandDepartment of Neurology, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UKNeurotology and Neuro-Ophthalmology Laboratory, Korea University Medical Center, Seoul 02841, Republic of KoreaDepartment of Neurology, National Hospital for Neurology and Neurosurgery, London WC1N 3BG, UKAcute 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.https://www.mdpi.com/2076-3425/15/1/55acute vestibular syndromedizzinessheadachevertigodiagnostic errormigraine |
| spellingShingle | Alexander A. Tarnutzer Nehzat Koohi Sun-Uk Lee Diego Kaski Diagnostic Errors in the Acutely Dizzy Patient—Lessons Learned Brain Sciences acute vestibular syndrome dizziness headache vertigo diagnostic error migraine |
| title | Diagnostic Errors in the Acutely Dizzy Patient—Lessons Learned |
| title_full | Diagnostic Errors in the Acutely Dizzy Patient—Lessons Learned |
| title_fullStr | Diagnostic Errors in the Acutely Dizzy Patient—Lessons Learned |
| title_full_unstemmed | Diagnostic Errors in the Acutely Dizzy Patient—Lessons Learned |
| title_short | Diagnostic Errors in the Acutely Dizzy Patient—Lessons Learned |
| title_sort | diagnostic errors in the acutely dizzy patient lessons learned |
| topic | acute vestibular syndrome dizziness headache vertigo diagnostic error migraine |
| url | https://www.mdpi.com/2076-3425/15/1/55 |
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