Differential diagnosis of stroke and vestibular neuritis in emergency neurology

Abstract

Introduction. The differential diagnosis of vertebrobasilar stroke (VBS) and vestibular neuritis (VN) is important challenge for a neurologist when a patient presents to the emergency department with acute vertigo. Current approaches and algorithms of management need to be modified, taking into account clinical practice. The aim of the study was to identify the clinical features of acute vestibular syndrome that are the most helpful in the differential diagnosis of VBS and VN. Materials and methods. We examined 80 emergency admissions to the neurological ward with suspected stroke. A detailed otoneurological examination (including the STANDING and HINTS+ algorithms) and brain imaging (DWI MRI) were performed. Results. Out of 80 patients, 26 were diagnosed with VBS, 30 with VN, 11 with vestibular migraine and 2 with Meniere's disease, while the cause of vertigo could not be determined in 11 patients. The most powerful indicator of VBS in the differential diagnosis was gaze-evoked nystagmus, which had a 15.9-fold association with VBS. An increased likelihood of VBS was also associated with unsteadiness (6.3 times), age over 58 years (4.1 times), dysmetria in the finger-to-nose test (3.7 times), adiadochokinesia (3.1 times), and trunk ataxia (3 times). An increased likelihood of VN was associated with a positive unilateral head impulse test (6 times), nystagmus that followed Alexander's law (3.7 times), and presence of nausea (2.5 times). A model was developed for the differential diagnosis of VBS and VNin patients presenting with acute vertigo. The model accuracy was 100% in the validation sample. Conclusions. Clinical approach remains crucial when differentiating between VBS and VN. The most useful criteria for a differential diagnosis in emergency neurology were the patient's age, the type of nystagmus, head impulse test, and cerebellar dysfunction.