Screening and diagnosis

Classification and risk stratification

Perioperative care

Quality improvement

Patient education

Nonpharmacologic interventions

Therapeutic procedures

Respiratory support

Follow-up and surveillance

Specific circumstances

Preventative measures

Medical management

Surgical interventions

Inpatient care

Diagnostic procedures

Diagnostic investigations

Insufficient evidence to make a recommendation.

Strongly favor this test or intervention.

The ROSIER scale helps in the recognition of stroke in an emergency setting by evaluating several clinical symptoms and assigning them corresponding scores. This assessment involves a set of inputs based on observed conditions including loss of consciousness or syncope, seizure activity, asymmetric facial weakness, asymmetric arm weakness, asymmetric leg weakness, speech disturbance, and visual field defect.

Each of these inputs is binary (i.e., true/false) and corresponds to specific clinical features that may be present or absent in the patient. When performing the computation, each positive symptom (true) contributes 1 point toward the total score:

- Loss of consciousness or syncope = 1 point if true
- Seizure activity = 1 point if true
- Asymmetric facial weakness = 1 point if true
- Asymmetric arm weakness = 1 point if true
- Asymmetric leg weakness = 1 point if true
- Speech disturbance = 1 point if true
- Visual field defect = 1 point if true

The total score is the summation of points for all "true" responses. The score ranges from 0 to 7, where each additional point indicates a higher likelihood of a stroke occurring. Based on the total score, the following interpretations can be made:

- If the score is 0 or less, the interpretation is "Stroke is unlikely," implying that the combination of symptoms does not strongly suggest a stroke.
- If the score is greater than 0, the interpretation is "Stroke is likely," indicating that the observed symptoms align more closely with stroke indicators.

The Recognition of Stroke in the Emergency Room (ROSIER) scale is a clinical calculator used in the emergency department setting to identify patients who are likely to have had a stroke. It is specifically designed for patients presenting with acute neurological symptoms. The ROSIER scale includes seven items: loss of consciousness or syncope, seizure activity, facial weakness, arm weakness, leg weakness, speech disturbance, and visual field defects. 

The clinical utility of the ROSIER scale is to aid in the early recognition of stroke, allowing for prompt initiation of appropriate treatment and referral to specialist care if needed. It is particularly useful in distinguishing stroke from other conditions that can mimic its symptoms, such as seizures or migraines.

There are no specific exclusion criteria for the use of the ROSIER scale, but it should be noted that it is less reliable in patients with pre-existing neurological deficits or in those with non-stroke causes of acute neurological symptoms. It is also not designed to differentiate between ischemic and hemorrhagic stroke.

Recognition of Stroke in the Emergency Room scale (ROSIER scale)

The tool designed for assessing Ménière's disease criteria evaluates specific clinical inputs to determine if a person meets either the definite or probable criteria for the condition. Here's how the evaluation process unfolds:

The user needs to provide responses to four sets of criteria:

- **Episodes Duration**: This consists of two options, where a user selects whether they have experienced:
  - At least 2 spontaneous episodes of vertigo, each lasting from 20 minutes to 12 hours.
  - At least 2 episodes of vertigo or dizziness, each lasting from 20 minutes to 24 hours.

- **Aural Symptoms**: The user confirms the presence of fluctuating aural symptoms, such as changes in hearing, tinnitus, or ear fullness, in the affected ear.

- **Audiometry Findings**: The user verifies audiometric documentation showing low-to-medium-frequency sensorineural hearing loss in one ear. This loss should be recorded at least once before, during, or after a vertigo episode.

- **Differential Diagnosis**: The user ensures that the symptoms are not better explained by another vestibular diagnosis.

The tool processes these inputs with a decision-making strategy:

- If a user reports having at least 2 spontaneous vertigo episodes with specific durations (20 minutes to 12 hours), confirms fluctuating aural symptoms, presents with audiometrically documented hearing loss, and rules out other vestibular diagnoses, their case is classified as "Meets criteria for definite MD."

- If a user indicates a broader timeframe for vertigo or dizziness episodes (20 minutes to 24 hours), confirms fluctuating aural symptoms, and rules out other vestibular issues with no additional auditory conditions, their case is delineated as "Meets criteria for probable MD."

- If neither of these condition sets are met, then the result is "Criteria not met."

This approach integrates user responses with established Ménière's disease diagnostic criteria, using logical assessments to align symptoms with either a definite or probable diagnosis classification.

The International Classification of Vestibular Disorders (ICVD) criteria for Ménière's disease is a diagnostic tool designed to accurately identify and classify cases of Ménière's disease. This clinical tool is particularly useful in distinguishing Ménière's disease from other vestibular disorders, thereby guiding appropriate treatment and management strategies.

The ICVD criteria for Ménière's disease primarily consists of four components: episodes duration, aural symptoms, audiometry findings, and differential diagnosis. The episodes duration component requires either two or more spontaneous episodes of vertigo each lasting 20 minutes to 12 hours, or two or more episodes of vertigo or dizziness each lasting 20 minutes to 24 hours. The aural symptoms component necessitates the presence of fluctuating aural symptoms such as hearing loss, tinnitus, or fullness in the affected ear. The audiometry findings component requires audiometrically documented low-to-medium-frequency sensorineural hearing loss in the affected ear on at least one occasion before, during, or after one of the episodes of vertigo. Lastly, the differential diagnosis component ensures that the symptoms are not better accounted for by another vestibular diagnosis.

The ICVD criteria for Ménière's disease provides a classification of "definite" or "probable" Ménière's disease. A diagnosis of definite Ménière's disease is made if the patient meets criteria A, C, D, and E. A diagnosis of probable Ménière's disease is made if the patient meets criteria B, C, and E. If the patient does not meet these criteria, then a diagnosis of Ménière's disease is not made according to the ICVD criteria.

ICVD criteria for Ménière's disease

In evaluating patients with acute vestibular syndrome to distinguish between a potential stroke and a benign cause such as vestibular neuritis, the HINTS examination relies on three clinical tests to interpret the results in a systematic manner.

The interpretation stems from a combination of:

- Horizontal head impulse test:
  - "Abnormal" indicates a likely benign cause.
  - "Normal/untestable" raises suspicion for a dangerous cause, such as a stroke.

- Observation of nystagmus:
  - "Direction-fixed horizontal nystagmus" aligns with a benign condition.
  - "Direction-changing horizontal nystagmus/untestable" may indicate a dangerous condition.

- Test of skew:
  - "Absent skew deviation" suggests a benign outcome.
  - "Skew deviation/untestable" points towards a dangerous pathology.

For the assessment to conclude with a benign interpretation—the HINTS examination being benign—all three observations must align:
- The head impulse test is "Abnormal."
- The nystagmus is "Direction-fixed horizontal."
- The skew test shows "Absent skew deviation."

If any of the following are observed:
- A "Normal/untestable" response in the horizontal head impulse test,
- "Direction-changing horizontal nystagmus/untestable" during the observation of nystagmus,
- "Skew deviation/untestable" in the test of skew,

The examination concludes with a "HINTS exam is dangerous" result, warranting further investigation to rule out a stroke.

This systematic approach helps clinicians in making prompt decisions based on the combinations of these specifically observed clinical signs.

The HINTS (Head-Impulse, Nystagmus, Test of Skew) examination is a clinical tool used in the evaluation of patients presenting with acute vestibular syndrome (AVS). AVS is characterized by sudden onset of prolonged, continuous vertigo, unsteady gait, nausea or vomiting, nystagmus, and head-motion intolerance. The HINTS examination is used to differentiate between a central cause of AVS, such as a stroke, and a peripheral cause, such as vestibular neuritis.

The HINTS examination consists of three components: the head impulse test, observation for nystagmus, and the test of skew. A "central" pattern on the HINTS examination (normal head impulse test, direction-changing nystagmus, or skew deviation) is highly suggestive of a stroke, while a "peripheral" pattern (abnormal head impulse test, horizontal or horizontal-torsional nystagmus, and no skew deviation) suggests a peripheral cause.

The HINTS examination is particularly useful in the emergency department setting, where rapid differentiation between central and peripheral causes of AVS is critical. It has been shown to be more sensitive than early MRI in detecting strokes in patients with AVS.

Exclusion

Dizziness and vertigo

Guidelines

Key sources

Diagnostic investigations

Medical management

Specific circumstances

Follow-up and surveillance

Quality improvement