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Pitfalls and Rewards for Implementing Ocular Motor Testing in Acute Vestibular Syndrome: A Pilot Project.

Abstract Isolated acute vestibular syndrome (iAVS) presentations to the emergency department (ED) pose management challenges, given the concerns for posterior circulation strokes. False-negative brain imaging may erroneously reassure clinicians, whereas HINTS-plus examination outperforms imaging to screen for strokes in iAVS. We studied the feasibility of implementing HINTS-plus testing in the ED, aiming to reduce neuroimaging in patients with iAVS.
PMID
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Authors

Mayor MeshTerms

Eye Movement Measurements

Magnetic Resonance Imaging

Keywords
Journal Title the neurologist
Publication Year Start




PMID- 28248913
OWN - NLM
STAT- MEDLINE
DA  - 20170301
DCOM- 20170314
LR  - 20170314
IS  - 2331-2637 (Electronic)
IS  - 1074-7931 (Linking)
VI  - 22
IP  - 2
DP  - 2017 Mar
TI  - Pitfalls and Rewards for Implementing Ocular Motor Testing in Acute Vestibular
      Syndrome: A Pilot Project.
PG  - 44-47
LID - 10.1097/NRL.0000000000000106 [doi]
AB  - OBJECTIVES: Isolated acute vestibular syndrome (iAVS) presentations to the
      emergency department (ED) pose management challenges, given the concerns for
      posterior circulation strokes. False-negative brain imaging may erroneously
      reassure clinicians, whereas HINTS-plus examination outperforms imaging to screen
      for strokes in iAVS. We studied the feasibility of implementing HINTS-plus
      testing in the ED, aiming to reduce neuroimaging in patients with iAVS. METHODS: 
      We launched an institutional Quality Improvement initiative, using DMAIC
      methodology. The outcome measures [proportion of iAVS subjects who had HINTS-plus
      examinations and underwent neuroimaging by computed tomography/magnetic resonance
      imaging (CT/MRI)] were compared before and after the established intervention.
      The intervention consisted of formal training for neurologists and emergency
      physicians on how to perform, document, and interpret HINTS-plus and
      implementation of novel iAVS management algorithm. Neuroimaging was not
      recommended if HINTS-plus suggested peripheral vestibular etiology. If a central 
      process was suspected, brain MRI/MR angiogram was performed. Head CT was reserved
      only for thrombolytic time-window cases. RESULTS: In the first 2 months
      postimplementation, HINTS-plus testing performance by neurologists increased from
      0% to 80% (P=0.007), and by ED providers from 0% to 9.09% (P=0.367). Head CT
      scans were reduced from 18.5% to 6.25%. Brain MRI use was reduced from 51.8% to
      31.2%. About 60% of the iAVS subjects were discharged from the ED; none were
      readmitted or had another ED presentation in the ensuing 30 days. CONCLUSIONS:
      Implementation of HINTS-plus evaluation in the ED is valuable and feasible for
      neurologists, but challenging for emergency physicians. Future studies should
      determine the "dose-response" curve of educational interventions.
FAU - Dumitrascu, Oana M
AU  - Dumitrascu OM
AD  - Departments of *Neurology daggerEmergency Medicine double daggerBiostatistics and
      Bioinformatics, Cedars-Sinai Medical Center, Los Angeles, CA section
      signDepartments of Neurology and Otolaryngology, The Johns Hopkins University
      School of Medicine, Baltimore, MD.
FAU - Torbati, Sam
AU  - Torbati S
FAU - Tighiouart, Mourad
AU  - Tighiouart M
FAU - Newman-Toker, David E
AU  - Newman-Toker DE
FAU - Song, Shlee S
AU  - Song SS
LA  - eng
GR  - U01 DC013778/DC/NIDCD NIH HHS/United States
PT  - Journal Article
PL  - United States
TA  - Neurologist
JT  - The neurologist
JID - 9503763
SB  - IM
MH  - *Eye Movement Measurements
MH  - Female
MH  - Humans
MH  - *Magnetic Resonance Imaging
MH  - Male
MH  - Neuroimaging
MH  - Pilot Projects
MH  - Stroke/complications/*diagnostic imaging
MH  - Tomography, X-Ray Computed
MH  - Vertigo/*diagnostic imaging/etiology
PMC - PMC5334787
MID - NIHMS818809
EDAT- 2017/03/02 06:00
MHDA- 2017/03/16 06:00
CRDT- 2017/03/02 06:00
PMCR- 2018/03/01
AID - 10.1097/NRL.0000000000000106 [doi]
AID - 00127893-201703000-00002 [pii]
PST - ppublish
SO  - Neurologist. 2017 Mar;22(2):44-47. doi: 10.1097/NRL.0000000000000106.

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