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Stroke Among Patients With Dizziness, Vertigo, and

Imbalance in the Emergency Department


A Population-Based Study
Kevin A. Kerber, MD; Devin L. Brown, MD; Lynda D. Lisabeth, PhD; Melinda A. Smith, MPH;
Lewis B. Morgenstern, MD

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Background and PurposeDizziness, vertigo, and imbalance are common presenting symptoms in the emergency
department. Stroke is a leading concern even when these symptoms occur in isolation. The objective of the present study
was to determine the real-world proportion of stroke among patients presenting to the emergency department with
these dizziness symptoms (DS).
MethodsFrom a population-based study, patients 44 years of age presenting with DS to the emergency department, or
directly admitted to the hospital, were identified. Demographics, the frequency of new cerebrovascular events, and the
frequency of isolated DS (ie DS with no other stroke screening term or accompanying neurologic signs or symptoms)
were assessed. Multivariable logistic regression was used to evaluate the association of age, gender, ethnicity, and
isolated DS with stroke/transient ischemic attack (TIA). The association of the presenting symptoms with stroke/TIA
was also assessed.
ResultsStroke/TIA was diagnosed in 3.2% (53 of 1666) of all patients with DS. Only 0.7% (9 of 1297) of those with
isolated DS had a stroke/TIA. Patients with stroke/TIA were slightly older than those without stroke/TIA (69.311.7
vs 65.312.9, P0.02). Male gender was associated with stroke/TIA, whereas isolated DS was negatively associated
with stroke/TIA. Patients with imbalance (dizziness as referent) were more likely to have stroke/TIA.
ConclusionsThe proportion of cerebrovascular events in patients presenting with dizziness, vertigo, or imbalance is very
low. Isolated dizziness, vertigo, or imbalance strongly predicts a noncerebrovascular cause. The symptom of imbalance
is a predictor of stroke/TIA. (Stroke. 2006;37:2484-2487.)
Key Words: cerebrovascular accident dizziness gait disorders population surveillance vertigo

n estimated 7.5 million patients with dizziness are seen


each year in ambulatory care settings in the United
States, making it one of the most common principal complaints in the emergency department (ED).1
The term dizziness is very nonspecific but may refer to
vertigo, lightheadedness, presyncope, anxiety, or just not
feeling well.2 6 Although some physicians consider imbalance to be a more serious symptom of neurologic disease, it
is also considered by many authors to be a type of dizziness.2 6 Some patients have difficulty describing their specific type of dizziness and oftentimes physicians do not
attempt to differentiate among these types.7 Although the
most common causes are benign,2,4 the differential diagnosis
includes potentially life-threatening stroke. In the acute setting, cerebellar or brain stem infarction must be a leading
concern because hydrocephalus or recurrent stroke could
follow.8,9 Although other focal neurologic symptoms may

accompany dizziness,10,11 case reports and small series have


shown that dizziness can also be the principal or only
complaint in patients with stroke.1219 However, to date, no
large population-based study has investigated the frequency
of stroke among patients presenting to the ED with dizziness.
From a large population-based study, the Brain Attack
Surveillance in Corpus Christi (BASIC) project, we sought to
determine the real-world proportion of stroke/transient
ischemic attack (TIA) in patients presenting to the ED with a
primary complaint of dizziness or specific types of dizziness
(ie vertigo and imbalance).2 6

Methods
The methods of the BASIC project were previously reported.20 This
population-based study is an ongoing stroke surveillance study in
Nueces County, Texas. All but 5% of the 313 645 residents of
Nueces County live in the city of Corpus Christi and the next closest
metropolitan areas (San Antonio and Houston, Texas) are more than

Received June 22, 2006; final revision received July 25, 2006; accepted August 1, 2006.
From the Stroke Program (D.L.B., L.D.L., M.A.S., L.B.M.) and the Departments of Neurology and Otolaryngology (K.A.K.), University of Michigan
Health System, Ann Arbor, Mich; and the Department of Epidemiology (L.D.L., L.B.M.), University of Michigan School of Public Health, Ann Arbor,
Mich.
Correspondence to Lewis B. Morgenstern, MD, Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Dr TC 1920/0316,
Ann Arbor, MI 48109-0316. E-mail LMorgens@umich.edu
2006 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org

DOI: 10.1161/01.STR.0000240329.48263.0d

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Kerber et al

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150 miles away. Seven acute-care hospitals and no academic medical


centers also contribute to making this community ideal for complete
case capture of acute medical conditions while avoiding tertiary
referral center bias.
Both active and passive surveillance are used to capture all cases
of stroke/TIA, including ischemic stroke, nontraumatic intracerebral
hemorrhage, and subarachnoid hemorrhage, in subjects over age 44
years in Nueces County, Texas. Active surveillance involves manually searching ED and hospital logs for a large set of previously
validated stroke screening terms recorded as the patients presenting
complaint.21 Included among these are the following indicators of
dizziness symptoms (DS): dizziness, vertigo, and imbalance.
Passive ascertainment using International Classification of Disease,
9th Revision codes in discharge records is also performed to ensure
complete case capture.
Cases are documented by trained abstractors using the medical
record. Board-certified neurologists validated all stroke cases after
reviewing source documents from the ED and hospital course (if
applicable), blinded to subject age and ethnicity, on the basis of
previously published international criteria.22 Using these criteria, a
diagnosis of TIA was made when symptoms abated within 24 hours.
Source documents include the following: treating physician history
and physical (including impression and plan), triage records, nursing
records, results of any testing ordered, and inpatient hospitalization
records, including discharge summaries (if applicable). Information
entered into the database for all subjects includes the following: log
book screening term, demographics (age, gender, race/ethnicity), focal
motor, sensory, language, and visual signs and symptoms documented
in the medical record, diagnosis by ED or admitting physician, and
discharge disposition. We determined the treating physicians diagnosis
to be stroke/TIA if any mention of stroke/TIA (eg cerebrovascular
accident, TIA, rule out cerebrovascular accident, or rule out
TIA) was recorded in the final impression, a method used previously.23
Stroke risk factors (hypertension, diabetes, atrial fibrillation, coronary
artery disease, history of stroke/TIA, high cholesterol, heavy alcohol
consumption, and smoking status) are recorded only for patients
validated as a stroke/TIA by the study neurologist.
Patients presenting between January 1, 2000, and June 30, 2003,
to the ED or directly admitted to the hospital with the principal
presenting complaint documented in the ED or hospital log of DS,
regardless of final diagnosis are the subject of this analysis. Only
cases of first presentation with DS screening terms during the study
period were included. Isolated DS was defined as dizziness,
vertigo, or imbalance with no other stroke screening term and no
motor, sensory, language, or visual signs or symptoms.

Statistical Analysis
Frequencies and means with standard deviations were calculated for
baseline variables for the stroke/TIA and nonstroke/TIA groups.
Baseline characteristics were compared between groups using t tests
for continuous variables and 2 tests for categorical variables.
Baseline stroke risk factors could not be compared because this
information was not recorded in the nonstroke/TIA patients. Discharge disposition was compared using a 2 test. Using the BASIC
neurologists diagnosis as the gold standard, the proportion of
stroke/TIA cases missed in the ED was calculated. The number of
patients with isolated DS admitted to the hospital from the ED with
a presumed diagnosis of stroke/TIA was also determined.
Multivariable logistic regression was used to identify variables
associated with stroke/TIA in those presenting with DS. The number
of covariates was limited based on the rule of 10, which requires at
least 10 least frequent outcomes for each degree of freedom.24
Variables were prespecified and included age (modeled continuously), gender, ethnicity, and isolated DS. The inclusion of age,
gender, and ethnicity in the model adjusts for these important
potential confounders when testing the association between isolated
DS and stroke.
The associations between the individual DS screening terms and
stroke/TIA were also assessed using multivariable logistic regression
with dizziness as the referent. Because the term dizziness was no
longer used as a screening term after March 14, 2001, only subjects

Patients With Dizziness, Vertigo, and Imbalance

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identified between January 1, 2000, and March 14, 2001, were


available for this specific analysis. Because some patients had two
or, rarely, all three screening terms recorded, a hierarchy was
established a priori, whereby imbalance was selected over vertigo or
dizziness, and vertigo was selected over dizziness when more than
one was listed. This hierarchy provides priority to the terms
determined to have a higher positive predictive value for stroke cases
in this population.21 Statistical analysis was performed using S-plus
7.0 for Windows (Insightful Corp). The Institutional Review Boards
of the University of Michigan, the University of Texas at Houston,
and each of the Nueces County hospitals approved this project.

Results
During this study period, 1666 patients were identified with
the principal presenting complaint of dizziness (885), vertigo
(665), imbalance (78), or more than one of these terms (38).
Only 3.2% (53 of 1666) of these patients were validated to
have a stroke/TIA by a BASIC neurologist based on international criteria22 after thorough review of all source documentation. Of those with a validated stroke/TIA, the principal
presenting complaint was dizziness in 23 cases, vertigo in 18
cases, imbalance in 11 cases, and more than one of these
terms in one case. Nearly all (1629 of 1666 [98%]) of the
patients identified in this study presented to the ED. Of the 46
validated stroke/TIA cases evaluated in the ED, the ED
physician did not make a diagnosis of stroke or TIA in 16
cases (35%). Whereas 17% (9 of 53) of those with stroke/TIA
had isolated DS, only 0.7% (9 of 1297) of all patients presenting
with isolated DS had stroke/TIA diagnosed. Of patients with
isolated DS, 15 of 1297 (1%) were admitted to the hospital with
a diagnosis of stroke/TIA by the ED or admitting physician; five
of these were validated as stroke/TIA. Ischemic strokes were
identified in 33 patients, TIA in 17, intracranial hemorrhage in
one, and two were of uncertain type because imaging results
were not available. The demographics and clinical characteristics of those with and without a diagnosis of stroke/TIA are
shown in Table 1. The group with cerebrovascular events were
significantly older (69.311.7) compared with the nonstroke/
TIA group (65.312.9, P0.02). Male gender was more common in the stroke/TIA group compared with the nonstroke/TIA
group. There was no significant difference in race/ethnicity
between the groups.
Most patients without stroke/TIA had isolated DS (80%).
The most common diagnoses in patients without stroke/TIA
were dizziness not otherwise specified, peripheral vestibular
disorders (eg labyrinthitis, benign positional vertigo), metabolic disturbances (eg anemia, hyperglycemia, electrolyte
abnormalities), orthostatic hypotension, anxiety, or dizziness
associated with headache.
Patients with stroke/TIA were more likely than patients
without stroke/TIA to be admitted to the hospital (75% vs 18%,
respectively). Hypertension was the most common stroke risk
factor followed by history of coronary artery disease, diabetes,
previous TIA/stroke, current smoker, hypercholesterolemia, and
atrial fibrillation (Table 1). Most patients with stroke/TIA (72%)
had at least two stroke risk factors.
Table 2 provides the results of multivariable logistic regression analysis for potential predictors of stroke. Male gender
(odds ratio [OR], 2.47; 95% CI, 1.39 4.40) was associated with
stroke/TIA, whereas isolated DS had a strong negative association with stroke/TIA (OR, 0.05; 95% CI, 0.02 0.11). In a

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Stroke

October 2006

TABLE 1. Demographic and Clinical Characteristics of Patients


With and Without Cerebrovascular Cause of Dizziness, Vertigo,
or Imbalance
Characteristic

Stroke/TIA
(n53)

No Stroke
(n1613)

Age (mean)SD

69.311.7

65.312.9

0.02

29 (55%)

574 (36%)

0.01

Male
Race

0.38

Non-Hispanic white (%)

21 (40%)

545 (34%)

Mexican American (%)

31 (58%)

954 (60%)

1 (2%)

95 (6%)

Hypertension

38 (72%)

NA

Coronary artery disease

21 (40%)

NA

Diabetes

17 (32%)

NA

Previous transient ischemic


attack/stroke

15 (28%)

NA

Current smoker

12 (23%)

NA

Hypercholesterolemia

11 (21%)

NA

Atrial fibrillation

3 (6%)

NA

Heavy alcohol consumption

0 (0%)

NA

38 (72%)

NA

9 (17%)

1288 (80%)

0.01

Motor deficit

31 (60%)

55 (4%)

0.01

Sensory deficit

15 (31%)

43 (3%)

0.01

Language disturbance

10 (21%)

20 (1%)

0.01

Visual changes

12 (24%)

42 (3%)

0.01

Admitted to hospital

40 (75%)

292 (18%)

0.01

Other (%)
Stroke risk factors

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Total risk factors 2


Isolated dizziness symptoms*

*Isolated dizziness symptomsdizziness, vertigo, or imbalance without


other stroke screening terms or accompanying neurologic signs or symptoms.
NA indicates not available.

separate regression model, patients with imbalance had almost


four times the odds of having stroke/TIA (OR, 3.71; 95% CI,
1.30 10.65) than those with dizziness. Patients with vertigo did
not have a higher odds of stroke/TIA than those with dizziness
(OR, 0.88; 95% CI, 0.39 1.97).

Discussion
In this population-based study, we found that the proportion
of stroke/TIA in patients presenting to the ED with DS was
low, especially among those with isolated DS. In fact,
isolated DS strongly predicted a nonstroke/TIA diagnosis.
TABLE 2. Multivariable Logistic Regression Model of Predictors
of Stroke Associated With Dizziness, Vertigo, or Imbalance
Covariates

OR (95% CI)

Age

1.02 (1.01.04)

Male gender

2.47 (1.394.40)

Ethnicity
Non-Hispanic white

0.89 (0.481.63)

Other

0.36 (0.052.77)

Isolated dizziness symptoms*

0.05 (0.020.11)

*Isolated dizziness symptomsdizziness, vertigo, or imbalance without


other stroke screening terms or accompanying neurologic signs or symptoms.

Patients with cerebrovascular events were older, more often


male, and most had two or more stroke risk factors. Overall,
patients with stroke/TIA identified in the current study had a
stroke risk factor profile similar to a previously reported
unselected BASIC study stroke population.25
Only a few studies have looked at the proportion of
stroke/TIA among patients with DS presenting to the
ED.13,26 29 However, all of these are single-center studies
with small sample sizes (range, 24 125 patients). Populationbased studies facilitate the ability to generalize results beyond
individual tertiary referral centers. Proportion of cerebrovascular events varied in previous studies from 2 to 25%. The
higher proportion found in some studies is particularly
alarming because the presentation of DS is so common. The
study reporting the highest proportion of stroke/TIA focused
only on subjects with acute-onset vertigo.13 Some physicians
may be more concerned about stroke when the specific
complaint is vertigo rather than nonspecific dizziness, but
previous stroke predictive models did not separate vertigo
from dizziness.30 We found vertigo to be no more predictive
of stroke/TIA than the less specific term of dizziness, which
emphasizes the importance of research into the presentation
of dizziness.
Although age was significantly greater in those with
stroke/TIA, the absolute difference was only 4 years. This
small difference may be the result of our inclusion criterion of
age 44 years. If younger subjects were included, this
difference may increase because stroke is rare at younger ages
whereas dizziness is not.31 Including younger ages would also
likely further reduce the already low overall proportion of
stroke found among subjects presenting with DS. The difference in gender is consistent with both the established higher
age-adjusted risk of stroke among males and the higher
frequency of peripheral dizziness among females.31,32
It was not surprising that imbalance was associated with
stroke/TIA compared with dizziness, whereas vertigo was
not. The most common causes of vertigo and dizziness are
benign peripheral vestibular disorders, whereas acute imbalance without vertigo or dizziness is usually caused by a
cerebellar stroke, particularly within the superior cerebellar
artery distribution33 and not the result of a peripheral vestibular disorder. Vertigo and dizziness can be caused by acute
brain stem or cerebellar stroke, but the statistical association
of these symptoms with stroke is less than the association of
imbalance with stroke as a result of the relative infrequency
of stroke causing vertigo or dizziness compared with nonstroke causes (ie peripheral vestibular disorders).
The limitations to this study must be addressed. Like with
any observational study, potential for misclassification exists.
Most patients were not examined by a neurologist in the ED,
and this study was not designed to collect specific features
sought by neuro-otology specialists, but rather to report the
real-world ED experience with this type of acute neurological presentation. As a result, subtle neurologic findings
indicating central nervous system dysfunction may have been
missed in some patients.34 In addition, brain MRI was not
ordered in most patients, and some recent reports have shown
small brainstem or cerebellar strokes identified by MRI in
patients with clinical presentations closely resembling periph-

Kerber et al

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eral vestibular disorders.16 18 Therefore, it is possible that


some patients classified as no stroke may have had small
strokes that went unidentified clinically. We categorized
patients based on the screening terms that were entered into
the ED or hospital log at the time of evaluation. Because no
standardized definitions for symptom terminology were used
by the hospital employees entering principal complaints at the
various sites, caution must be taken when interpreting differences among dizzy terms. Also, symptom onset, duration,
aggravating/alleviating factors, and associated auditory
symptoms or headache were not systematically collected.
Thus, these important clinical features could not be compared
between groups. We were unable to adjust for stroke risk
factors in assessing associations with stroke/TIA because this
information was not collected in the nonstroke/TIA patients.
Inclusion of these potential confounders may have altered our
results. This patient population, including a large proportion
of nonimmigrant Hispanic Americans, the United States
largest minority population, may not be generalizable to all
populations.
The strengths of this study are its population-based design
and stroke/TIA diagnosis validations by neurologists using
standardized criteria and source documentation. Furthermore,
this study provides information on real-world experience
with terminology and clinical presentations in a representative community.
Although the percentage of patients presenting with DS
ultimately determined to be caused by stroke is low, when
considering how commonly patients with DS present for
evaluation,1 the absolute number of these patients with stroke
etiologies may be high. More detailed population-based
studies and prospective clinical studies on the relationship of
stroke and DS are critically needed so that stroke can be
rapidly identified. Establishing clinical predictors of stroke is
also crucial to reducing health expenditures and ED waiting
times related to this common ED presentation. This study
suggests that of the patients presenting with DS, those with
other neurologic symptoms, who are older and male, are at
the highest risk for a cerebrovascular etiology.

Source of Funding
The study was funded by National Institutes of Health grant RO1
NS38916.

Disclosures
None.

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Stroke Among Patients With Dizziness, Vertigo, and Imbalance in the Emergency
Department: A Population-Based Study
Kevin A. Kerber, Devin L. Brown, Lynda D. Lisabeth, Melinda A. Smith and Lewis B.
Morgenstern
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Stroke. 2006;37:2484-2487; originally published online August 31, 2006;


doi: 10.1161/01.STR.0000240329.48263.0d
Stroke is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 2006 American Heart Association, Inc. All rights reserved.
Print ISSN: 0039-2499. Online ISSN: 1524-4628

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