Dizziness In A Tertiary Neurological Department： A Retrospective Study


 Background

Dizziness is a common and challenging condition among population. There is little published study which surveys the characteristics of dizziness of inpatients in the department of neurology.
Objective

This study was to investigate the inpatients with dizziness as the chief complaint in a neurology department.
Materials and Methods

We conducted a retrospective study of inpatients with dizziness attending a tertiary neurological department in Beijing. We audited 211 patients with dizziness as the chief complaint from 1841 patients discharged from our tertiary neurological department.
Results

The inpatients with dizziness as the chief complaint accounted for 11.5% of all inpatients. Dizziness was more common in women than in men (p=0.004). There were more patients presenting with vertigo (40.8%) and light-headedness (39.8%) than disequilibrium (17.1%) and pre-syncope (2.4%). Nausea (48.3%), vomiting (34.1%), headache (13.3%), walk unsteadily (13.3%) and ear symptoms (12.8%) were the most common accompanying symptoms. Hypertension, diabetes, cerebrovascular diseases, dyslipidemia, and coronary heart disease were the most common diseases in past medical history. Dix-Hallpike test (24.6%) and Romberg’s sign (11.4%) were positive in dizziness patients. Nystagmus (2.4%), vision changes (1.4%) and hearing disorders (8.5%) were relatively rare symptoms. MRI (60.2%), CT (31.8%), carotid duplex ultrasound (30.8%), echocardiography (28.0%) were common auxiliary examination. Benign paroxysmal positional vertigo (24.2%) and stroke/transient ischemic attack (19.0%) were common causes of dizziness. 97.2% of inpatients with dizziness can be improving after treatment.
Conclusion

Dizziness was a common and challenging condition. Vertigo and light-headedness were the most common dizziness types. Benign paroxysmal positional vertigo and stroke/transient ischemic attack were the common dizziness disorders. The prognosis of most patients with dizziness was good.


Introduction
Dizziness is the third major complaint among individuals who mentioned any health problems after fever and headache. [1] Dizziness (including vertigo) affects about 15% to over 20% of adults yearly in large population-based studies. [2] Also, dizziness is a common and challenging condition seen in outpatients, emergency patients and inpatients. More than one-third of Americans see a health physician for dizziness during their lifetime. [3] Although most dizziness is due to benign causes, life-threatening causes also need to be excluded. There are some rare life-threatening diseases in patients with dizziness (with cerebrovascular disease accounting for 6%, cardiac arrythmia for 1.5% and brain tumor for <1%). [4,5] Additionally, dizziness usually leads to some other complications such as falls and some other accidents, which signi cantly affect the patient's quality of life. However, clinicians are still unable to correctly diagnose and treat many patients with dizziness at present. In addition to emergency departments and otolaryngology departments, our neurologists often see patients with dizziness as the chief complaint. To date, there are very few investigations of patients with dizziness in neurology. Based on above-mentioned, this study was to investigate the inpatients with dizziness in a neurology department from the aspects of demographic characteristics, characteristics of symptoms, past medical history, physical examination and auxiliary examination, clinical diagnosis, and treatment effect.

Methods
In this 16-month retrospective study, the pro les of all dizziness inpatients referred to the department of neurology of a tertiary hospital, from September 2019 to December 2020, were evaluated. All inpatients with dizziness as the chief complaint referred to our neurological department during this time were included. We excluded patients who had symptoms of dizziness but did not have dizziness as their chief complaint. Demographic data, baseline characteristics of the patients (dizziness type, past medical history, accompanied symptoms), physical examination and auxiliary examination, clinical diagnosis, and treatment effect were recorded using a checklist. Patients were diagnosed based on the ndings of symptoms, past history, auxiliary examination, and clinical examination such as presence or absence of headache, tinnitus, hearing loss, nystagmus characteristics, signs of sympathetic release, focal neurologic ndings, etc. The diagnosis of dizziness conformed to the latest international diagnostic standards. The nal decision on the diagnosis of dizziness was made based on the results of brain imaging or para-clinical ndings and the opinion of an expert neurologist. The researchers adhered to the principles of Helsinki Declaration and con dentiality of patient information over the course of the study.

Statistical analysis
Data analyses were carried out using Statistical Package for the Social Sciences (SPSS) (version 25: SPSS, Inc, an IBM Company, Chicago, Illinois). Normally distributed continuous variables were reported as mean value±standard deviation; differences were assessed by a two tailed t test. Categorical variables were introduced as frequency and percentage; a chi square test or Fisher's exact test was performed to establish differences between groups. Signi cance level was considered p<0.05.

Demographic characteristics
In our study, 211 inpatients with initial diagnosis of dizziness were referred to our department of neurology. During the same period, 1841 inpatients were referred to our department of neurology. The 211 inpatients with the mean age of 58.76±14.817 years (minimum 17 and maximum 89) were enrolled (44.1% male and 55.9% female). The 1841 inpatients with the mean age of 65.92±18.612 years (minimum 7 and maximum 95) were enrolled (54.6% male and 45.4% female). Table 1 shows the number of dizziness inpatients and total inpatients in the department of neurology. It reveals that the incidence of dizziness was higher in women than in men. There was signi cant difference in dizziness incidence (p=0.004). Table 2 shows the number of dizziness inpatients in different age groups. There was no sex different in dizziness incidence of different age groups (p=0.549).

Past medical history
The past medical history of 211 inpatients with dizziness as the chief complaint was described in Table  5. 40.8% of patients had past history of hypertension. Besides, diabetes (17.1%), cerebrovascular disease (stroke or transient ischemic attack) (16.6%), dyslipidemia (15.2%), and coronary heart disease (11.4%) were the most common diseases in past medical history of 211 inpatients with dizziness. However, past history of 30.3% of patients was nothing special.

Physical examination and auxiliary examination
Physical examination and auxiliary examination of 211 inpatients with dizziness were described in Table   6. In terms of physical examination, 29.4% of patients with dizziness as the chief complaint in our department of neurology had neurological defect symptoms. Dix-Hallpike test was positive in 24.6% of patients. Romberg's sign was positive in 11.4% of patients. Nystagmus (2.4%), vision changes (1.4%) and hearing disorders (8.5%) were relatively rare symptoms. Unfortunately, there was no record of HINTS test in all 211 patients. In terms of auxiliary examination, 60.2% of patients underwent a brain MRI examination. In addition, brain CT (31.8%), carotid duplex ultrasound (30.8%), echocardiography (28.0%) were common auxiliary examination in dizziness patients, whereas vestibular function tests (2.4%) and head-up tilt test (1.4%) were less used in dizziness patients.

Treatment effect
Treatment effect of 211 patients with dizziness as the chief complaint was described in Table 8. The most common outcome was improving and it accounted for 97.2% of all 211 patients. Two patients were healing and 3 patients were untreated. Only 1 patient was dying.

Discussion
Dizziness is seen frequently in patients in department of neurology. Because dizziness is a vague term that include a wide array of medical disorders, it is important to master the characteristics of dizziness diseases from the aspects of demographic characteristics, characteristics of symptoms, past medical history, physical examination and auxiliary examination, clinical diagnosis, and treatment effect. A striking nding from this study was that the inpatients with dizziness as the chief complaint accounted for 11.5% of all inpatients in the department of neurology. Dizziness was more common in women than in men. These ndings is in accordance with the data from other studies. [6,7] However, our study shows that there was no sex different in dizziness incidence of different age groups (p=0.549).
The patient history can generally classify dizziness into one of four categories: vertigo, disequilibrium, pre-syncope, or lightheadedness. [8] However, symptom types might substantially overlap in individual patients. Kevin A Kerber etc. found that substantial overlap of dizziness types exists among US adults with dizziness. [9] Usually, vertigo symptom lasts for a short time. People having features of traditionally vertigo symptom also typically report multiple dizziness types. In our study, the primary type of dizziness was used as the classi cation criterion. Vertigo and light-headedness were the most common dizziness types in our department of neurology. Disequilibrium was relatively less common dizziness type. Presyncope was the primary dizziness symptom in only three patients. Our ndings suggest that the traditionally emphasis on dizziness types may have limited clinical utility.
Accompanying symptoms may indicate certain diseases. Some common dizziness diseases are also based on symptoms as diagnostic criteria. Therefore, it is important to ask detailed questions about accompanying symptoms in patients with dizziness. However, some accompanying symptoms are relatively speci c for diagnosis of dizziness diseases. Headache symptoms in patients with dizziness may suggest a possible diagnosis of vestibular migraine. Tinnitus, hearing loss and aural fullness in patients with dizziness may suggest Meniere's disease or other ear diseases. In our study, nausea and vomiting were the most common accompanying symptoms in patients with dizziness, but these symptoms were non-speci c and appeared in many diseases. Reversely, speci c accompanying symptoms (such as headache for vestibular migraine, symptoms of nervous system defect for cerebrovascular disease, tinnitus, hearing loss and aural fullness for ear diseases) were common in patients with dizziness.
Past medical history is another important aspect in diagnosing patients with dizziness. Hypertension was the most common past history in dizziness inpatients in the department of neurology. Diabetes, dyslipidemia, coronary heart disease and stroke/transient ischemic attack were also relatively common diseases in the past medical history of dizziness patients. On the contrary, headache, ear diseases, headache trauma, anxiety and depression were less common. There are two possible reasons. Dizziness patients with ear symptoms may referred to the department of otology. Secondly, some patients with headache, head trauma, anxiety and depression unwilling to be hospitalized for further diagnosis and treatment. This was different from otolaryngology and the emergency department. [10][11][12] Some signs can often be found in physical examination and auxiliary examination in patients with dizziness. Neurological defect symptoms were most common positive sign in patients with dizziness. Dix-Hallpike test was simple and important for diagnosis of benign paroxysmal positional vertigo. In our study, Dix-Hallpike test was used for 24.6% patients. Acute vestibular syndrome (AVS) is common in department of neurology. Generally, physicians use the HINTS (head impulse, nystagmus, test of skew) test to make a differential diagnosis of acute vestibular syndrome. Physicians can use the HINTS test to differentiate vestibular neuritis(the most common cause of an AVS) from ischemic stroke involving the cerebellum or the brainstem (the second most common cause of an AVS). [13] In our study, there was no record in the inpatients with dizziness. There are several possible reasons for no record of HINTS test. Firstly, our neurologist didn't know what the HINTS mean or how to do the HINTS test. Then, physicians relied too heavily on imaging tests like CT and MRI. Thirdly, physicians didn't understand the speci city and sensitivity of HINTS test in diagnosis of stroke. Conversely, 31.8% patients had a brain CT scan and 60.2% patients underwent a brain MRI test. Carotid duplex ultrasound and echocardiography were also common auxiliary examination in patients with dizziness.
Benign paroxysmal positional vertigo was the most common disease in patients with dizziness in our study. Stroke/Transient ischemic attack was the second most common dizziness disorder. Only 6 patients was diagnosed with vestibular migraine, 2 patients were diagnosed with Meniere's disease. Two patients was diagnosed with persistent postural-perceptual dizziness. Only 1 patient was diagnosed with sudden deafness with vertigo, or syncope, or postural hypotension. Our results were different from K Hanley's study in general practice. [14] Unfortunately, up to 44.1% of patients were discharged without a de nite diagnosis.
Like any other study, our study showed that 97.2% of inpatients with dizziness can be improving after treatment. It illustrated that most dizziness diseases were benign. However, only 2 patients were healing and only 1 patient was dying. Based on this fact, we should rule out some malignant diseases as soon as possible and let these patients get the right treatment in time.
It was a retrospective study based on past medical records, so the results were objective. Inevitably, our study has some limitations. Because our study was conducted among hospitalized patients in the department of neurology, the results can only re ect the characteristics of dizziness of inpatients in the department of neurology. The study was different from population-based studies and other studies from otolaryngology department or emergency department. On the other hand, because there was no standardized design in advance, the quality of medical records was uneven. Therefore, we plan to conduct a Randomized Controlled Trial in the near future.

Conclusion
Dizziness was a common clinical symptom. The inpatients with dizziness as the chief complaint accounted for 11.5% of all inpatients in the department of neurology. Dizziness was more common in women than in men. Vertigo and light-headedness were the most common dizziness types in the department of neurology. Some accompanying symptoms (such as headache, ear symptoms) and previous history were critical to the diagnosis of dizziness. Usually, some signs can be found in physical examination and auxiliary examination in patients with dizziness. Therefore, it was necessary to master some simple beside physical examination (such as HINTS, Dix-Hallpike) to differentiate dizziness diseases. Benign paroxysmal positional vertigo was the most common disease in patients with dizziness in our study and stroke/transient ischemic attack was the second most common dizziness disorder.