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• W2980868121 abstract "HomeStrokeVol. 50, No. 11TeleVertigo Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBTeleVertigoDiagnosing Stroke in Acute Dizziness: A Telemedicine-Supported Approach Peter Müller-Barna, MD, Nikolai Dominik Hubert, MSc, Christina Bergner, MD, Nina Schütt-Becker, Holger Rambold, MD, Roman Ludwig Haberl, MD and Gordian Jan Hubert, MD Peter Müller-BarnaPeter Müller-Barna Correspondence to Peter Müller-Barna, MD, Department of Neurology and Neurological Intensive Care, TEMPiS–Telemedical Stroke Center, München Klinik Harlaching–Academic Teaching Hospital of the Ludwig-Maximilians-Universität München, Sanatoriumsplatz 2, München 81545, Germany. Email E-mail Address: [email protected] From the Department of Neurology and Neurological Intensive Care, München Klinik Harlaching–Academic Teaching Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany (P.M.-B., N.D.H., C.B., N.S.-B., R.L.H., G.J.H.) Search for more papers by this author , Nikolai Dominik HubertNikolai Dominik Hubert From the Department of Neurology and Neurological Intensive Care, München Klinik Harlaching–Academic Teaching Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany (P.M.-B., N.D.H., C.B., N.S.-B., R.L.H., G.J.H.) Search for more papers by this author , Christina BergnerChristina Bergner From the Department of Neurology and Neurological Intensive Care, München Klinik Harlaching–Academic Teaching Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany (P.M.-B., N.D.H., C.B., N.S.-B., R.L.H., G.J.H.) Search for more papers by this author , Nina Schütt-BeckerNina Schütt-Becker From the Department of Neurology and Neurological Intensive Care, München Klinik Harlaching–Academic Teaching Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany (P.M.-B., N.D.H., C.B., N.S.-B., R.L.H., G.J.H.) Search for more papers by this author , Holger RamboldHolger Rambold Department of Neurology, County Hospitals of Altötting and Burghausen, Germany (H.R.) Department of Neurology, University of Regensburg, Germany (H.R.) MVZ Kliniken Mühldorf, Mühldorf am Inn, Germany (H.R.). Search for more papers by this author , Roman Ludwig HaberlRoman Ludwig Haberl From the Department of Neurology and Neurological Intensive Care, München Klinik Harlaching–Academic Teaching Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany (P.M.-B., N.D.H., C.B., N.S.-B., R.L.H., G.J.H.) Search for more papers by this author and Gordian Jan HubertGordian Jan Hubert From the Department of Neurology and Neurological Intensive Care, München Klinik Harlaching–Academic Teaching Hospital of the Ludwig-Maximilians-Universität München, Munich, Germany (P.M.-B., N.D.H., C.B., N.S.-B., R.L.H., G.J.H.) Search for more papers by this author Originally published14 Oct 2019https://doi.org/10.1161/STROKEAHA.119.026505Stroke. 2019;50:3293–3298Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: October 14, 2019: Ahead of Print Acute dizziness and vertigo are frequent symptoms in the emergency department (ED),1 yet difficult to turn into a diagnosis.2–6 In about 5% of patients presented with vertigo and dizziness in EDs, stroke is identified as the cause.7–9 In these cases, immediate treatment is essential, for example, with systemic intravenous thrombolysis or even mechanical revascularization therapy as to prevent poor clinical outcome.10,11 However, to date, 35% of those patients are misdiagnosed with peripheral vestibular failure.7The primary approach to identify stroke in dizziness and vertigo is a clinical one.12–14 The best known test battery is the HINTS test (Head Impulse, Nystagmus, and Test of Skew), which includes the horizontal head impulse test, gaze-evoked nystagmus, and tonic skew.15,16 This clinical approach is more reliable, faster, and cheaper than standard magnetic resonance imaging,17,18 which is less sensitive and specific in the first 48 hours after symptom onset.19 Indeed some improvement may also be achieved by adding coronal and sagittal diffusion-weighted magnetic resonance imaging sequences.20,21 Yet, to apply these clinical tests, the neuro-otologic expertise of the consultant, which is rare in rural hospitals or during off hours, is essential.22Nowadays, oculomotor symptoms can be captured and stored in video-oculography systems. Moreover, for some oculomotor tests, data can be analyzed and converted into quantitative results.23 In particular, the quantitative horizontal video head impulse test (vHIT) has a much higher sensitivity and specificity compared with the bedside head impulse test.24 In acute vestibular syndrome, sensitivity of 88% and specificity of 92% of normal vestibulo-ocular reflex on vHIT are reported in the classification of patients with stroke.25 Furthermore, the digitalization of neuro-otologic tests opens the chance for remote assessment. This may overcome lack of expertise outside metropolitan areas.On this ground, we introduce a concept embedded in a telestroke network to remotely diagnose and manage patients with acute vertigo and dizziness.ConceptThe key technical feature of our TeleVertigo concept is a vHIT system (video goggles; for example, ICS Impulse; Otometrics, Natus Medical Denmark ApS, Taastrup, Denmark). These video goggles have been specifically developed to document and quantify the vestibulo-ocular reflex of the head impulse test. In our telemedical setting, we use them additionally as a second camera during videoconferencing (Figure 1). This allows teleconsultants to detect even subtle eye movements, which is not possible with a standard camera. The video goggles are plugged into the videoconferencing system on demand.Download figureDownload PowerPointFigure 1. Schematic views of the first stage of the TeleVertigo scenario, the emergency department (ED) triage. A, Acute dizzy patient in the ED of a spoke hospital. The standard camera of the videoconferencing system captures the survey of patient and emergency physician, the additional camera within the video head impulse test (vHIT) system (video goggles) a magnified image of 1 eye. Both pictures are transmitted simultaneously to the teleconsultant in the hub. B, The teleconsultant is able to see both images and, therefore, even subtle eye movements. With the vHIT system in the spoke hospital, he can assess all parts of the HINTS test (Head Impulse, Nystagmus, and Test of Skew) telemedically (as long as the emergency physician is trained to apply head impulses properly). All necessary investigations are comprised in a precise triage algorithm (Figure 2).Our concept addresses all patients who reach an ED because of acute dizziness, vertigo, or imbalance. It comprises 3 stages with distinct actors and aims (Table 1):Table 1. Stages of the TeleVertigo ConceptStageAimSettingActors in the SpokeActors in the CenterED triageRapid and reliable triage to stroke unit or normal ward; rapid identification of IVT/MT casesED; 24/7; triage algorithmED physiciansTelestroke consultantsElective examinationFinding of causal diagnosisNext working day during regular working hours; reevaluation and VOGStroke experts; technician captures VOGTeleneuro-otologistTreatmentAdequate treatment including vestibular rehabilitation and canalith repositioning proceduresEarly during hospital stayTrained physical therapistsSpecialized physical therapist offers trainingED indicates emergency department; IVT, intravenous thrombolysis; MT, mechanical thrombectomy; and VOG, video-oculography.Triage in the ED: the aim of this stage is the reliable and rapid triage in the ED. It is of absolute priority not to miss a single patient with stroke at this stage, otherwise the necessary stroke unit treatment and in some cases intravenous thrombolysis or even mechanical thrombectomy would be withheld. Almost as important is the prevention of unnecessary stroke unit treatment in cases without stroke. Our concept takes into account that in a typical rural hospital, (1) resources in the ED are scarce, and (2) most of the addressed patients stay in hospital and get further elective diagnostics anyhow. The clinical pathway at this stage should be simple and precise and, therefore, easy to teach and easy to apply.Elective examination and diagnosis: the aim of this second stage is to reliably find the correct diagnosis. Therefore, all test results done in the ED have to be verified, additional examinations have to be performed, and the patient’s history has to be complemented. For this stage, a limited number of physicians (eg, neurologist, head of the telestroke unit) is required to be trained, telemedically assisted, and supervised by a neuro-otologist based in the network center. This allows, therefore, the expansion of the complexity of the procedures and standards.Treatment: the aim of this stage is to offer adequate pharmacological and physical therapy to all patients with dizziness/vertigo during their hospital stay. In addition, recommendations for adequate further treatment should be established.Stage 1: ED TriageFigure 2 shows the algorithm developed for the triage of all patients with acute dizziness/vertigo in EDs. All of the following criteria must be fulfilled to enter the algorithm:Download figureDownload PowerPointFigure 2. Emergency department (ED) triage algorithm for all ED cases with dizziness/vertigo or imbalance with acute onset within the last 3 d and symptoms of new quality. For steps 3 to 5, video goggles are used. PC indicates posterior canal; PPN, positional nystagmus; and vHIT, video head impulse test.dizziness, vertigo, or imbalance as main complaint;acute symptom onset within hours or closer;symptom onset in the last 3 days (symptoms may be recurrent since the first occurrence);symptoms are of new quality, and there is, therefore, no recurrence of previously known dizziness, vertigo, or imbalance.Cases with known, slow evolving, and persistent symptoms are considered less urgent. Those patients are diagnosed and treated on a normal ward and seen by the neurologist on regular hours, unless an indication for hospital admission exists. Importantly, patients not fulfilling the criteria for acute vestibular syndrome and even with paroxysmal and completely resolved symptoms are here included. Although a wider approach is here envisaged compared with the decision rule of the HINTS family,18 the HINTS rule is nevertheless incorporated through slight adaptation.Step 1: internal medicine causes of dizziness, for example, medication, hyponatremia, or cardiac arrhythmia, are identified. Step 2: a remote clinical neurological examination focused on stroke symptoms is performed. This is well established in telestroke networks. Step 3: clinical testing of oculomotor functions: smooth pursuit eye movements and skew deviation by the alternating cover test. Eye movements are assessed by the teleconsultant via the camera of the video goggles. Step 4: quantitative recording of eye movements: nystagmus and vHIT. Step 5: clinical testing for benign paroxysmal positional vertigo applying the Dix-Hallpike test, again using the camera of the video goggles.After each step, a decision can be made whether to admit the patient to the stroke unit, to the normal ward, or to continue with the next step as shown in Figure 2. All cases that are not identified by step 1 are admitted to the stroke unit with 2 important exceptions: proof of acute unilateral vestibular hypofunction or benign paroxysmal positional vertigo, in case of no focal neurological signs.This algorithm is an extension of the normal remote examination in telestroke networks. New introductions are (1) video goggles giving the teleconsultant a more accurate picture of the eye, (2) vHIT performed by the teleconsultant with on-site help from the emergency doctor, and (3) Dix-Hallpike maneuver performed by the emergency doctor under remote supervision of the teleconsultant and interpreted by the teleconsultant through the video goggles.Stage 2: Elective Examination and DiagnosisThe European telestroke unit concept26 requires a stroke expert on site at least once every working day. In our concept, this expert is trained thoroughly in diagnostics of dizziness/vertigo. He reexamines the patient in more detail the following day and performs an elective video-oculography with the video goggles with the help of specially trained technicians or physical therapists. They are required to call the neuro-otologist of the network center whenever in doubt concerning examinations and diagnosis. The neuro-otologist has remote access to the video-oculography and may even perform a second videoconference to speak with patients themselves and perform advanced examinations. In case a final diagnosis cannot be made in this setting, the TeleVertigo center hospital offers an appointment for further investigations.Stage 3: TreatmentPatients with ongoing dizziness and vertigo benefit from vestibular rehabilitation, which is recommended to start already in the first days after onset.27,28 Expertise in these treatments is usually scarce in rural spoke hospitals. TeleVertigo comprises knowledge transfer and trainings for spoke physicians, nurses, and physical therapists addressing treatment options. The same applies to canalith repositioning procedures, which offer an effective and underused treatment in benign paroxysmal positional vertigo.29,30Structural FeaturesAs acute dizziness/vertigo is a possible symptom of acute stroke, it seems natural to expand existing telestroke networks for this indication. To this aim, the main features of telestroke can be extended, regarding specific treatment standards, teleconsultation workflow, training, and quality management.26To achieve an effective cooperation within a network, a consented and accepted network-wide treatment standard is needed. This is also the basis for training programs and quality assurance measures. Our concept comprises standards for the ED triage, elective diagnostics, and physical treatment. Importantly, standards have to take into account limited resources and lack of neuro-otologic expertise in rural hospitals. Different training programs are needed to cover all requirements within this concept for ED staff (doctors and nurses), physicians and nurses in charge of the dizziness/vertigo patients, and physical therapists. Because there is no prior experience with the network-based system of care suggested by this concept, quality assessment is essential to monitor the adherence to the defined standards and quality of care.Additional resources of the TeleVertigo concept exceeding a telestroke network are summarized in Table 2.Table 2. Additional Resources of the TeleVertigo Concept Exceeding a Telestroke NetworkPersonnel1 expert teleneuro-otologist (center)1 physical therapist specialized on vestibular rehabilitation (center)1 quality manager for additional quality assessmentTechnologyvHIT systems in all spokesSystem integration of vHIT system in videoconferencing systemTrainingsFor teleconsultantsFor ED physicians and nursesFor stroke experts in the spokesFor technicians in the spokes capturing the VOGFor physical therapists in the spokesQuality managementSetting up of standard treatment protocolsDefining quality parametersMonitoring of quality parametersED indicates emergency department; vHIT, video head impulse test; and VOG, video-oculography.DiscussionAlready in 1997, Viire et al31 described the potential of telemedicine in the diagnosis of dizzy patients. However, until this day, implementation in routine care is rare. To our knowledge, the sole project set up today is in Baltimore, connecting the ED of the Johns Hopkins Hospital to its specialized neuro-otologic department.32 A clinical trial comparing video-oculography–guided care to standard care in EDs is ongoing (AVERT trial [Acute Video-Oculography for Vertigo in Emergency Rooms for Rapid Triage]).33 Our previous experiences with teleconsultations of dizzy patients in our stroke network have led to the following remarks: first, the assessment of eye movements and nystagmus with standard videoconferencing cameras (with remote steering) is not satisfactory; and, second, the assessment of all relevant findings (all aspects of the patient’s history and physical examination) in ED is difficult and time-consuming. A viable solution to the first problem, in the form of a remote and reliable assessment of eye movements, is provided by a vHIT system like the ICS Impulse goggles. The head mounted camera of these goggles is suitable to gather all relevant eye movements and transfer video information to a remote teleconsultant. In addition, the quantitative vHIT made possible by this system is far more reliable compared with the bedside head impulse test.24The second problem is how to efficiently organize the system of care for dizzy patients with the given resources. Two different aspects need to be taken into account while dealing with acutely dizzy patients: (1) the aspect of urgency while making a decision on whether or not a stroke is the possible reason for the dizziness, and, therefore, whether stroke evaluation and stroke unit treatment are needed; and (2) the elective aspect while making a decisive final diagnosis. With the advent of the eye ECG approach including an extended HINTS rule15,18 and the vHIT in the last years,34 it is now possible to structure the aspect of urgency by means of an easier-to-handle algorithm and ensure adequate management via a vascular teleneurologist. The elective evaluation can then be performed on the next day by the trained on-site stroke expert or by the teleneuro-otologist in the network center or a combination of both.The concept presented here has evolved for the specific demands of a telestroke unit network in Southeast-Bavaria/Germany (TEMPiS [Telemedic Project for Integrative Stroke Care]). It builds on the already established infrastructure of the TEMPiS network, which has 2 hubs and 23 spokes.35,36 In about 400 cases among the 6500 teleconsultations performed annually, the leading symptom was dizziness or vertigo. A comparison of our telemedical diagnosis with the hospital discharge diagnosis revealed that 28% of strokes were missed and 19% were diagnosed incorrectly as strokes by telemedicine (unpublished data). This is in line with data from the United States reporting a percentage as high as 35% of missed strokes in cases with acute dizziness and vertigo.7The integration of TeleVertigo in a telestroke network seems natural. First, in ≈5% of all patients with acute dizziness or vertigo, a stroke is the underlying cause.7–9 These patients need qualified stroke care immediately. Second, on-site stroke experts are already acquainted with central eye movement symptoms. Third, the extension of an already established structure appears easier to implement than the building up of a new structure. However, the explicit extension of a telestroke network to dizziness needs to address also the frequent nonstroke dizzy cases and, therefore, requires expanded neuro-otologic expertise. This is why this extension can only be recommended in well-established telestroke networks with good neuro-otologic expertise in the center.Based on the cooperation between hospitals of different levels of care, this concept is interdisciplinary, multiprofessional, collaborative, and comprehensive. The advantages of the concept are clear: first, it offers an area-covering approach to acute workup of dizzy patients available 24/7. Second, the implementation of this concept within a telestroke unit network is possible in the short term because all personnel resources in the spokes are already established. Third, early stroke unit treatment in case of underlying stroke is easily applicable within the telestroke network. Furthermore, it also offers a fast and resource-sparing workflow in the ED focusing on the triage between normal ward and stroke unit treatment. This means a relief of the ED compared with the status quo. Additionally, it offers state-of-the-art diagnostics and evidence-based therapies by adequate workup during working hours. It is also important to remark that the network approach enables effective quality assurance measures as demonstrated in telestroke networks. Last but not the least, the deployment of connected technology within a network may promote the development of computerized decision algorithms. Future technologies based on artificial intelligence may then provide further progress.There are nevertheless several limitations to this concept: first, the additional urgent teleconsultations and the additional elective neuro-otologic teleconsultation service, trainings, and quality assessment need additional resources (Table 2). However, a comparable on-site system of care without telemedicine would be far more elaborate and would not be implementable in the short term. Second, establishing the vHIT in the ED 24/7 and training enough ED doctors and nurses to perform the head impulses properly is challenging. The aim is then to achieve an interpretable vHIT in this setting in at least 75% of cases. Third, as the ED triage algorithm is designed not to miss patients with stroke, it may lead to false-positive cases on the stroke unit, that is, dizzy patients with stroke mimics. The low prevalence of stroke in acutely dizzy patients, amounting to about 5% of cases,7–9 accentuates this problem. Even near-perfect screening tools (95% specificity) can achieve correct identification of stroke in 25% to 50% of all identified strokes only. A close analysis of these cases and data from randomized trials like AVERT33 will nevertheless support the evolution of the algorithm in the long term. This is part of the quality assurance system. Additionally, the concept is focused on acute hospital management and does not involve subacute presentations, outpatients, or further treatment after hospital discharge. For these latter cases, different telemedicine systems, for example, independent teledizzy networks, may be appropriate.To summarize, the suggested concept of a telemedical system of care for acute dizziness/vertigo aims to establish state-of-the-art diagnostics and therapies in rural areas and is designed as an add-on to telestroke unit networks.AcknowledgmentsWe thank Dr Tessa Marzotto Caotorta and Dr Iris Jarsch for their careful language editing of the manuscript.Sources of FundingThe efforts of N. Schütt-Becker and Dr Müller-Barna were supported by a grant from the Bavarian Ministry of Health and the German Foundation for Neurology.DisclosuresDr Rambold is β-tester of the Otosuite video head impulse test system but has no financial interest in the product. He received honoraria from GN-Otometrics, Denmark, and Henning-Arzneimittel, Germany. All other authors report grants from the Bavarian Ministry of Health and the German Foundation for Neurology during the conduct of the study.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Presented in part at the European Stroke Organisation Conference, Milan, Italy, May 22–24, 2019.Correspondence to Peter Müller-Barna, MD, Department of Neurology and Neurological Intensive Care, TEMPiS–Telemedical Stroke Center, München Klinik Harlaching–Academic Teaching Hospital of the Ludwig-Maximilians-Universität München, Sanatoriumsplatz 2, München 81545, Germany. Email peter.[email protected]deReferences1. Saber Tehrani AS, Coughlan D, Hsieh YH, Mantokoudis G, Korley FK, Kerber KA, et al. 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