Background: When patients present to the emergency department (ED) with dizziness, it can be difficult to discriminate benign disorders from acute stroke. We sought to describe the clinical details of cases of dizziness discharged home with a benign diagnosis who experienced a subsequent stroke within 14 days.
Methods: From an ongoing population-based dizziness surveillance study, patients ≥45 years of age presenting to the ED in Nueces County, Texas, with dizziness, vertigo, or imbalance were identified by review of ED logs, excluding those with stroke as the initial diagnosis and those admitted to the hospital. Subsequent stroke was determined with rigorous active and passive surveillance methods and neurologist validation using source documentation. Clinical details of those with stroke within 14 days are described.
Results: Over a 2 year period in this population, 1,176 patients presented to the ED with a dizziness symptom and were discharged home with a non-cerebrovascular diagnosis. Five of these cases had a subsequent stroke within 14 days (range 1-3 days) of the index ED presentation. Age of cases was 55, 73, 75, 79, and 88 years. Four of 5 (80%) were female. The symptom was documented as “vertigo” in 1 patient and only “dizziness” in 4 patients. Constant symptoms were reported in 3 patients and episodic symptoms in 2. None had focal abnormalities documented on the neurologic examination, and only 1 had nystagmus. None received a consultation from a neurologist. Vascular risk factors were common. The discharge diagnoses included dizziness, hypertension, vertigo, isolated intermittent nystagmus, and pre-ventricular contractions. A head CT was performed at the index dizziness presentation in 3 of the 5 cases. The subsequent stroke involved the following regions: cerebellum (2), occipital lobe (2), brain stem (1), and peri-ventricular region (1).
Conclusion: Over the 2 year period in this community, 5 patients presenting to the ED with dizziness and discharged home with non-cerebrovascular diagnoses had a stroke within 14 days. Most of these patients were older than 70 years and female. Future efforts to develop decision support for identifying dizziness patients at high risk for subsequent short-term stroke will require large sample sizes.
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