Vertigo: Remote Diagnosis by Experts Using Video-oculography Can Help Rule Out Benign Causes of Dizziness and Vertigo

Vertigo can be due to relatively benign conditions like vestibular neuritis or benign paroxysmal positional vertigo (BPPV), but it can also be a symptom of dangerous conditions such as stroke. Being able to accurately diagnose the less dangerous causes in the emergency room may reduce the need for cost-intensive diagnostics like MRI, while helping identify patients who need more careful monitoring and follow-up tests. Video-oculography (VOG), which uses video for detailed measurement of eye movement, is commonly used for diagnosis in specialty clinics but not in emergency departments; in connection with expert telehealth consultations, it could allow for better diagnosis of vertigo in EDs. In this study (the AVERT trial), an expert oto-neurologist reviewed VOG recordings taken from 130 vertigo patients at tertiary-care emergency departments in combination with a brief summary from the ED clinician. The expert consult using VOG was much more accurate than emergency department assessments at diagnosing BPPV (69.8% accuracy vs. 9.3% accuracy) and vestibular neuritis (83.3% accuracy vs. 20.8% accuracy). Although this assessment was not significantly more accurate in detecting stroke, likely due to small numbers, it could prove to be a valuable tool for patient triage in cases of vertigo in the emergency room.

Full abstract, to be presented at the American Neurological Association 2022 Annual Meeting, October 22-25, 2022 in Chicago, and published in Annals of Neurology:

Remote Expert Diagnosis by Video-Oculography is More Accurate Than In-Person ED Diagnosis in Acute Vertigo and Dizziness—Preliminary Results of the AVERT Trial

Shervin Badihian, MD, Johns Hopkins University School of Medicine

Co-authors: David S. Zee, MD, John P. Carey, MD, Ari M. Blitz, MD, Jonathan A. Edlow, MD, Daniel R. Gold, DO, Joshua N. Goldstein, MD, PhD, Joanna C. Jen, MD, PhD, et al.

Introduction: Diagnosis of vertigo/dizziness (hereafter, “vertigo”) is challenging for many emergency department (ED) clinicians. Video-oculography (VOG) is routinely used in specialty clinics but not in EDs. VOG recordings might facilitate correct ED diagnosis of vestibular disorders such as benign paroxysmal positional vertigo (BPPV) and vestibular neuritis, but the accuracy of remote assessment of acute vertigo using VOG is unknown. In the context of a multicenter diagnostic strategy trial, we compared accuracy of ED diagnoses to remote, VOG-based expert diagnoses.

Methods: The AVERT trial (NCT02483429) was performed at six tertiary-care EDs (2/6/2018-3/9/2020). We prospectively recruited adult ED patients with acute vertigo plus ataxia and/or evidence of nystagmus. Potentially eligible patients underwent a structured history and examination, including VOG (ICS Impulse, Schaumberg, IL, USA) and standardized neurologic rating scales. VOG included examination for spontaneous, gaze, and positional nystagmus; head-impulse tests of the horizontal vestibulo-ocular-reflex; and alternate cover testing for skew deviation. We compared real-world ED team primary diagnoses to research diagnoses by a single, experienced oto-neurologist using VOG recordings and a brief clinical summary from the ED charted record, thereby simulating remote, VOG-based, expert teleconsultation. The expert selected their diagnoses from a list of 12 validated diagnoses. Diagnoses were then grouped into prespecified schemas of varying granularity (3/6/12 categories). Gold-standard diagnoses were made by a multi-disciplinary panel using ED charts, structured history and exams (including VOG), plus a one-week oto-neurology evaluation, repeat VOG and MRI, and one-month phone/record review follow-up.

Results: We enrolled 130 patients (52.3% female; 76.9% white, non-Hispanic) with a mean age of 59.2±15 years; 21 with unknown final diagnoses were excluded. Diagnostic accuracy for the oto-neurologist using VOG was much higher than the ED primary diagnosis (3-category schema: 72.5% vs 22.9%, p<0.001; 6-category schema: 63.3% vs 18.3%, p<0.001; 12-category schema: 61.5% vs 17.4%, p<0.001). Even greater differences were identified when comparing diagnostic sensitivity for identifying BPPV (69.8% vs. 9.3%, (p<0.001) and vestibular neuritis (83.3% vs. 20.8%, p=0.003). Stroke sensitivity was not significantly different in this small sample (n=14, 57.1% vs 42.9%; p=0.5).

Conclusion: Remote VOG evaluation by oto-neurologists in ED vertigo presentations could substantially improve diagnostic accuracy, particularly for common inner ear disorders. Limitations were that a single expert determined the VOG-based diagnoses and this individual was a member of the final multi-disciplinary panel.

All abstracts from ANA2022 will be available in Annals of Neurology starting at 3:01 p.m. U.S. Eastern Time on October 14. This research is under embargo until that time. Contact Katherine Pflaumer ([email protected]) for additional highlighted abstracts, full meeting abstracts, and call-in information for the ANA2022 Media Roundtable (Oct. 25, 11 a.m. U.S. Central).