AUTHOR=Vanni Simone , Pecci Rudi , Edlow Jonathan A. , Nazerian Peiman , Santimone Rossana , Pepe Giuseppe , Moretti Marco , Pavellini Andrea , Caviglioli Cosimo , Casula Claudia , Bigiarini Sofia , Vannucchi Paolo , Grifoni Stefano 

TITLE=Differential Diagnosis of Vertigo in the Emergency Department: A Prospective Validation Study of the STANDING Algorithm

JOURNAL=Frontiers in Neurology

VOLUME=8

YEAR=2017

URL=https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2017.00590

DOI=10.3389/fneur.2017.00590

ISSN=1664-2295

ABSTRACT=<sec id="ST1"><title>Objective</title><p>We investigated the reliability and accuracy of a bedside diagnostic algorithm for patients presenting with vertigo/unsteadiness to the emergency department.</p></sec><sec id="ST2"><title>Methods</title><p>We enrolled consecutive adult patients presenting with vertigo/unsteadiness at a tertiary hospital. STANDING, the acronym for the four-step algorithm we have previously described, based on nystagmus observation and well-known diagnostic maneuvers includes (1) the discrimination between <bold>S</bold>pon<bold>TA</bold>neous and positional nystagmus, (2) the evaluation of the <bold>N</bold>ystagmus <bold>D</bold>irection, (3) the head <bold>I</bold>mpulse test, and (4) the evaluation of equilibrium (sta<bold>N</bold>din<bold>G</bold>). Reliability of each step was analyzed by Fleiss’ <italic>K</italic> calculation. The reference standard (central vertigo) was a composite of brain disease including stroke, demyelinating disease, neoplasm, or other brain disease diagnosed by initial imaging or during 3-month follow-up.</p></sec><sec id="ST3"><title>Results</title><p>Three hundred and fifty-two patients were included. The incidence of central vertigo was 11.4% [95% confidence interval (CI) 8.2–15.2%]. The leading cause was ischemic stroke (70%). The STANDING showed a good reliability (overall Fleiss <italic>K</italic> 0.83), the second step showing the highest (0.95), and the third step the lowest (0.74) agreement. The overall accuracy of the algorithm was 88% (95% CI 85–88%), showing high sensitivity (95%, 95% CI 83–99%) and specificity (87%, 95% CI 85–87%), very high-negative predictive value (99%, 95% CI 97–100%), and a positive predictive value of 48% (95% CI 41–50%) for central vertigo.</p></sec><sec id="ST4"><title>Conclusion</title><p>Using the STANDING algorithm, non-sub-specialists achieved good reliability and high accuracy in excluding stroke and other threatening causes of vertigo/unsteadiness.</p></sec>