Dizziness was the most frequent symptom in large studies of patients with posterior circulation ischemia.1,2 Previous studies have shown that imbalance or gait instability and subtle neurologic findings including positive Romberg test, gait instability, and dysmetria were associated with posterior circulation strokes in patients who present with dizziness/vertigo or isolated dizziness symptoms.3,4 However, no large studies to date have investigated the characteristics of dizziness/vertigo presentation (e.g., the time of onset and duration) in predicting a cerebrovascular event.
We retrospectively reviewed 883 consecutive patients who presented to a tertiary care center in a large city in China with a primary complaint of vertigo or dizziness and identified those who were found to have a cerebrovascular event.
The final diagnosis was a cerebrovascular event in 4.6% (95% CI: 3.3–6.3%). There were 25 ischemic strokes (20 posterior, 5 anterior), 11 transient ischemic attacks, and 4 intracranial hemorrhages. Acute onset (p = 0.001), dysarthria (p = 0.001), gait instability (p = 0.008), dysmetria (p < 0.0001), Babinski’s sign (p = 0.025), numbness (p = 0.008), consciousness disturbance (p = 0.015), smoking (p = 0.042), and previous transient ischemic attack (p = 0.02) were positively associated with a cerebrovascular event, while isolation (p = 0.001) and intermittent frequency (p = 0.059) of dizziness had a negative association (Table 1). On multivariate analysis, acute onset (hazard ratio, 2.714; 95% CI 1.155–6.378), dysmetria (hazard ratio 3.973; 95% CI 1.658–9.518), and previous transient ischemic attack (hazard ratio 5.107; 95% CI 1.315–19.833) remained statistically significant. Patients with cerebrovascular events had higher ABCD2 and FHS scores than those without. For patients with isolated symptom, acute onset (hazard ratio 10.433; 95% CI 1.198–90.891) and dysmetria (hazard ratio 5.851; 95% CI 1.005–34.065) were significant on multivariate analysis.
Clinical characteristics and cardiovascular risk factors of patients presenting with vertigo or dizziness
Characteristics
Patients with CVE (n = 40)
Patients without CVE (n = 824)
p
Age, median y (IQR)
61.5 (54–74.5)
65 (58–73)
0.272
Male
25 (62.5)
418 (50.7)
0.146
Clinical Features, n (%)
Vertigo
26 (65)
478 (58)
0.381
Isolated
11 (27.5)
455 (55.3)
0.001
Acute onset
30 (75)
394 (47.8)
0.001
Intermermittent frequency
21 (52.5)
547 (67)
0.059
Triggered by position change
3 (7.5)
117 (14.2)
0.231
Worsened by position change
9 (22.5)
259 (31.4)
0.233
Dysarthria
5 (12.5)
12 (1.5)
0.001
Gait instability
24 (60)
320 (39.1)
0.008
Hearing loss
3 (7.5)
58 (7.1)
0.758
Tinnitus
6 (15)
136 (16.6)
0.795
Nystagmus
3 (7.5)
51 (6.2)
0.734
Nausea/Vomiting
25 (62.5)
497 (60.4)
0.79
Headache
4 (10)
157 (19.1)
0.148
Diplopia
2 (5)
21 (2.6)
0.291
Dysmetria
10 (25)
41 (5)
<0.0001
Romberg sign
10 (25)
137 (16.7)
0.174
Babinski's sign
4 (10)
21 (2.5)
0.025
Weakness
9 (22.5)
133 (16.2)
0.298
Numbness
8 (20)
57 (7)
0.008
Visual blurring
3 (7.5)
81 (9.9)
0.789
Consciousness disturbance
5 (12.5)
28 (3.4)
0.015
History of migraine
1 (2.5)
11 (1.3)
0.437
Stroke risk factors, n (%)
SBP, median mmHg (IQR)
142.5 (130.5–160)
134 (120–150)
0.003
Smoker
12 (30)
143 (17.4)
0.042
Alcohol
4 (10)
76 (9.2)
0.781
Hypertension
26 (65)
468 (56.8)
0.306
Diabetes
9 (22.5)
157 (19.1)
0.589
Hyperlipidemia
9 (22.5)
173 (21)
0.823
Previous AF
3 (7.5)
28 (3.4)
0.169
LVH
6 (15)
67 (8.1)
0.14
Previous angina
9 (22.5)
194 (23.5)
0.879
Previous MI
2 (5)
22 (2.7)
0.306
Previous PVD
2 (5)
21 (2.5)
0.289
Previous TIA
4 (10)
16 (1.9)
0.011
Previous stroke
8 (20.0)
152 (18.4)
0.805
ABCD score, median (IQR)
4 (3–5)
4 (3–4)
0.02
Low risk
12 (30)
400 (48.5)
Intermediate risk
24 (60)
361 (43.8)
High risk
4 (10)
63 (7.6)
FHS score, median (IQR)
13.5 (8–17)
10 (6–15)
0.051
Low risk
11 (27.5)
215 (26.1)
Intermediate risk
16 (40)
452 (54.9)
High risk
11 (32.5)
157 (19.1)
Medications, n (%)
Aspirin
5 (26.3)
129 (21.4)
0.576
Antiplatelet
1 (5.3)
38 (6.3)
1
Statin
5 (26.3)
118 (19.5)
0.556
Antihypertensive
10 (52.6)
259 (42.7)
0.391
Imaging, n (%)
Narrowing of vertebral on CTA/MRA
5 (33.3)
115 (50)
0.211
CVE: cerebrovascular event; IQR: interquartile range; SBP: systolic blood pressure; AF: atrial fibrillation; LVH: left ventricular hypertension; MI: myocardial infarction; PVD: peripheral vascular disease; TIA: transient ischemic attack; FHS: Long-term cerebrovascular risk categories from the Framingham Study cohort; CTA: computer tomography angiography; MRA: magnetic resonance angiography.
Patients who present with acute, sustained dizziness/vertigo and positive findings on neurological examination targeted at cerebellar and brainstem function are more likely to have a cerebrovascular event. This holds true even for patients with isolated dizziness/vertigo only.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Sheng Hua Yu Ying Experts Project of Central South University, China granted to LY, Natural Science Foundation of China (grant number 81301988) to LY, and China Ministry of Education Doctoral Program Spot Foundation (grant number 20130162120061) to LY.
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