The often elderly patient who presents with 'vertigo' can be a diagnostic challenge. Determining whether vertigo has a 'peripheral' versus a 'central' cause can be made easier with the HINTS exam.

Below is a Power Point  and below that a MS Word document summarizing 'vertigo assessment' and the HINTS exam.
Attached below that is an article using the ABCD2 scoring system in addition to the HINTS exam for diagnosing posterior strokes.

Posterior Stroke and HINTS.pptx Posterior Stroke and HINTS.pptx
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Summary HINTS exam.doc Summary HINTS exam.doc
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This article, published in October 2015 shows increases accuracy of diagnosing posterior strokes using the ABCD2 score.

Diagnosing Stroke in Patients with Acute Dizziness
Kerber KA et al. Neurology 2015 Oct 28.
Both the ABCD2 score and ocular motor-based assessment are necessary bedside decision support tools to rule out stroke in these patients.
Dizziness is a common complaint in emergency department (ED) patients and although the etiology can be benign, identifying acute stroke can be a challenge. The ABCD2 (age, blood pressure, clinical features, duration, and diabetes) score and the HINTS (head impulse, nystagmus pattern, test of skew) assessment have previously been described as promising bedside decision support tools to diagnose or rule out acute stroke.
In this single-center prospective observational study, researchers evaluated the accuracy of the ABCD2 score plus an ocular motor-based assessment (head impulse test, nystagmus pattern [central vs. other], test of skew) and a general neurologic examination for predicting acute stroke in ED patients with dizziness.
All patients underwent magnetic resonance imaging (MRI) within 14 days. The researchers enrolled 272 adult patients with acute dizziness and either nystagmus or new imbalance when walking. Of these, 11% had an acute stroke or intracerebral hemorrhage identified on MRI.
The frequency of stroke in patients classified as lowest-risk by the ABCD2 score alone and by ocular motor-based assessment alone was 5.1% and 5.9%, respectively.
In a model combining the two tools, the corresponding frequency was <1%. The authors conclude that both tools are needed to rule out stroke with a 1% risk confidence rate.

Comment by NEJM reviewer Jennifer Wiler.
Patients were selected for enrollment in this single-center study based on physical examinations performed by neurology subspecialty-trained physicians. This study refutes previous reports that either ABCD2 or ocular motor-based assessment alone is a sufficient screening tool for stroke. Although the results are not ready for wide application, if other studies confirm these findings, then recommendations for bedside decision support tools can be updated.

So what is the ABCD2 scoring method?

The ABCD2 Scoring System for Transient Ischemic Attacks: A Review of the Diagnostic Accuracy and Predictive Value

Published on: March 3, 2014  CADTH report

Context
Stroke is currently the third-leading cause of death or disability in Canada, resulting in an estimated associated cost of $3.6 billion per year. In the United States, studies have shown that approximately 23% of strokes are preceded by a transient ischemic attack (TIA). Accurate TIA diagnosis is important so that those who will benefit from medical interventions to lessen the risk of stroke receive the appropriate treatment.

Technology
Because of the increased risk of stroke after a TIA, health care providers have developed tools to calculate the risk of a patient experiencing subsequent ischemic events. The ABCD2 system is used to predict the risk of stroke within seven days post-TIA. The ABCD2 score is a sum of scores for each of five criteria: age, blood pressure, clinical features (unilateral weakness and speech disturbance), duration of symptoms, and diabetes.

Issue
Over the past few years, there have been conflicting reports on the accuracy of predictions made using the ABCD2 system — some indicate the system has a high degree of accuracy, while others suggest the results are comparable to chance. A review of the diagnostic accuracy and predictive value of the ABCD2 scoring system for the identification of TIA and the estimation of future stroke risk will help inform decisions about the use of this tool.

Methods
A limited literature search was conducted of key resources, and titles and abstracts of the retrieved publications were reviewed. Full-text publications were evaluated for final article selection according to predetermined selection criteria (population, intervention, comparator, outcomes, and study designs).

Results
The literature search identified 131 citations, with no additional articles identified from other sources. After screening the abstracts, 39 were deemed potentially relevant, and 12 met the criteria for inclusion in this review — 2 systematic reviews and 10 non-randomized studies.

Key Messages

  • The ABCD2 scoring system can be a valuable tool for predicting stroke risk following a TIA, depending on the clinical setting in which it is used.
  • ABCD2 scoring has a higher predictive value when:
    • performed by a trained neurological expert rather than an emergency room physician
    • determined by a face-to-face assessment rather than a retrospective chart review.

Question

  1. What is the diagnostic accuracy and predictive value of the ABCD2 scoring system for the identification of transient ischemic attacks and estimation of future risk for stroke?

Key Message

Evidence from systematic reviews suggests there is some predictive value to ABCD2 scoring, but results are dependent on setting and method of scoring, with ABCD2 performing more poorly in studies conducted in emergency department settings or when scores are determined by retrospective chart review in place of face-to-face evaluation. This is consistent with individual studies that show low predictive value in emergency department settings and lack of agreement in ABCD2 scores between referring physicians and stroke specialists

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