This study seeks to improve clinical care for peripheral and central vestibular disorders by translating recent advances in vestibular physiology to clinical practice. Vertigo and dizziness lead to 4 million US emergency department (ED) visits annually at a cost of $4 billion. Most of the ~1 million patients with peripheral vestibular causes for their symptoms are over-tested, misdiagnosed, and undertreated. Hundreds of millions of dollars are spent on neuroimaging (~$500M CT, ~$100M MRI) trying to detect the ~5% of patients who have life-threatening posterior fossa strokes causing their vertigo - yet one-third of these vestibular strokes are missed. Accurate and efficient diagnosis will save lives and reduce costs through prompt and appropriate treatments. Our team has studied dizziness in the ED for more than a decade. We have developed a new approach to differentiate benign peripheral causes from dangerous central ones by careful assessment of three vestibular eye movements (HINTS: Head Impulse, Nystagmus, Test of Skew) and hearing. Our approach enables rapid physiologic diagnosis at the bedside with greater accuracy than MRI brain scans in the first two days after the onset of acute, continuous vertigo or dizziness. This approach has been validated in over 200 patients. Similar, well-established bedside techniques (e.g., Dix-Hallpike test) work to diagnose intermittent, position-provoked vertigo. Unfortunately, these eye movement tests are unfamiliar to most ED physicians, and even to many specialists. A new video-oculography (VOG) device that measures these eye movements quantitatively at the bedside has the potential to transform diagnosis for ED patients with dizziness and vertigo. The device is easy to use, measures eye movements accurately, and requires no more patient cooperation than a bedside exam of the cranial nerves. We have shown initial proof that the device correctly diagnoses acute vestibular strokes. We propose the AVERT trial (Acute Video-oculography for Vertigo in Emergency Rooms for Rapid Triage), a multicenter, randomized, Phase II clinical trial of VOG-guided vs. standard care to improve diagnosis and initial management for patients with a chief symptom of vertigo or dizziness suspected to be of vestibular cause. We will recruit 226 adults from 3 EDs. We will perform bedside VOG and portable audiometry on all subjects, who will then be randomized to VOG-guided vs. standard care. In the VOG arm, patients will be diagnosed and treated according to a standard, predefined protocol guided by VOG results using automated, evidence-based decision rules. We will compare the impact of this VOG-guided care pathway relative to standard care on ED diagnoses, diagnostic resource utilization, costs of diagnosis, treatments applied, and short-term outcomes. We hypothesize that VOG-guided diagnosis and management of acute vertigo or dizziness in the ED will (1) improve diagnostic accuracy and increase correct treatment for vestibular disorders, (2) reduce diagnostic costs, and (3) offer the potential to improve patient health outcomes. Results from this study could transform care for millions of ED patients with vertigo, offering a higher-quality, lower-cost alternative to current practice.

Public Health Relevance

Despite being over-tested, patients with inner ear diseases who present to the emergency room with symptoms of vertigo or dizziness are frequently misdiagnosed, resulting in incorrect treatments. Better diagnostic tools would improve clinical care for patients with inner ear balance disorders and for those with more dangerous diseases causing vertigo or dizziness, such as stroke. This project seeks to prove that a new, non-invasive device measuring abnormal eye movements can assist physicians in accurately diagnosing patients with vertigo or dizziness, leading to better outcomes at lower cost.

National Institute of Health (NIH)
National Institute on Deafness and Other Communication Disorders (NIDCD)
Research Project--Cooperative Agreements (U01)
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Special Emphasis Panel (ZDC1-SRB-L (49))
Program Officer
Platt, Christopher
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Johns Hopkins University
Schools of Medicine
United States
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Chang, Tzu-Pu; Wang, Zheyu; Winnick, Ariel A et al. (2018) Sudden Hearing Loss with Vertigo Portends Greater Stroke Risk Than Sudden Hearing Loss or Vertigo Alone. J Stroke Cerebrovasc Dis 27:472-478
Liberman, Ava L; Newman-Toker, David E (2018) Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data. BMJ Qual Saf 27:557-566
Saber Tehrani, Ali S; Kattah, Jorge C; Kerber, Kevin A et al. (2018) Diagnosing Stroke in Acute Dizziness and Vertigo: Pitfalls and Pearls. Stroke 49:788-795
Edlow, Jonathan A; Gurley, Kiersten L; Newman-Toker, David E (2018) A New Diagnostic Approach to the Adult Patient with Acute Dizziness. J Emerg Med 54:469-483
Tarnutzer, Alexander Andrea; Lee, Seung-Han; Robinson, Karen A et al. (2017) ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis. Neurology 88:1468-1477
Dumitrascu, Oana M; Torbati, Sam; Tighiouart, Mourad et al. (2017) Pitfalls and Rewards for Implementing Ocular Motor Testing in Acute Vestibular Syndrome: A Pilot Project. Neurologist 22:44-47
Saber Tehrani, Ali S; DeSanto, Jeffrey R; Kattah, Jorge C (2017) Neuroimaging ""HINTS"" of the Lateral Medullary Syndrome. J Neuroophthalmol 37:403-404
Newman-Toker, David E (2016) Missed stroke in acute vertigo and dizziness: It is time for action, not debate. Ann Neurol 79:27-31
Mantokoudis, Georgios; Saber Tehrani, Ali S; Wozniak, Amy et al. (2016) Impact of artifacts on VOR gain measures by video-oculography in the acute vestibular syndrome. J Vestib Res 26:375-385
Thomas, Dana B; Newman-Toker, David E (2016) Diagnosis is a team sport - partnering with allied health professionals to reduce diagnostic errors: A case study on the role of a vestibular therapist in diagnosing dizziness. Diagnosis (Berl) 3:49-59

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