Emergency Physician Attitudes, Preferences, and Risk Tolerance for Stroke as a Potential Cause of Dizziness Symptoms

West J Emerg Med. 2015 Sep;16(5):768-76. doi: 10.5811/westjem.2015.7.26158. Epub 2015 Oct 20.


Introduction: We evaluated emergency physicians' (EP) current perceptions, practice, and attitudes towards evaluating stroke as a cause of dizziness among emergency department patients.

Methods: We administered a survey to all EPs in a large integrated healthcare delivery system. The survey included clinical vignettes, perceived utility of historical and exam elements, attitudes about the value of and requisite post-test probability of a clinical prediction rule for dizziness. We calculated descriptive statistics and post-test probabilities for such a clinical prediction rule.

Results: The response rate was 68% (366/535). Respondents' median practice tenure was eight years (37% female, 92% emergency medicine board certified). Symptom quality and typical vascular risk factors increased suspicion for stroke as a cause of dizziness. Most respondents reported obtaining head computed tomography (CT) (74%). Nearly all respondents used and felt confident using cranial nerve and limb strength testing. A substantial minority of EPs used the Epley maneuver (49%) and HINTS (head-thrust test, gaze-evoked nystagmus, and skew deviation) testing (30%); however, few EPs reported confidence in these tests' bedside application (35% and 16%, respectively). Respondents favorably viewed applying a properly validated clinical prediction rule for assessment of immediate and 30-day stroke risk, but indicated it would have to reduce stroke risk to <0.5% to be clinically useful.

Conclusion: EPs report relying on symptom quality, vascular risk factors, simple physical exam elements, and head CT to diagnose stroke as the cause of dizziness, but would find a validated clinical prediction rule for dizziness helpful. A clinical prediction rule would have to achieve a 0.5% post-test stroke probability for acceptability.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adams-Stokes Syndrome / complications*
  • Adams-Stokes Syndrome / diagnosis
  • Attitude of Health Personnel*
  • California
  • Cross-Sectional Studies
  • Decision Support Techniques
  • Dizziness / etiology*
  • Emergency Medicine / statistics & numerical data*
  • Female
  • Humans
  • Male
  • Physicians / statistics & numerical data
  • Risk Factors
  • Surveys and Questionnaires