European Radiology: What is the clinical value of magnetic resonance imaging for patients with double vision or dizziness in the emergency department?

According to statistics, the proportion of acute vestibular syndrome caused by stroke is about 25%, and 50-70% of posterior circulation stroke patients will experience dizziness
.
Double vision is another important clinical symptom
of posterior circulation stroke.
At this stage, computed tomography (CT) is still the most common imaging test in emergency departments (EDs), but CT has its inherent drawbacks, with acute ischaemic stroke missed in approximately 9% to 14% of patients with ED
。

Diagnostic imaging (CT or magnetic resonance imaging (MRI)) is used for about 40% of dizziness visits, or about 12%
of the total annual cost of dizziness visits.
Regarding diplopia, there are 49,790 ED visits per year in the US, of which 59.
7% have imaging at ED
.
Data on the effect of MRI on ED are scarce and often retrospective
.

The sensitivity of non-contrast CT is only 26% to 42%, 9.
5% in the case of dizziness, and 70% to 94%
for MRI to diagnose stroke.
Therefore, in 2015, the Academic Emergency Medicine Consensus Conference proposed six key areas
for optimizing emergency diagnostic imaging.
Clinical decision rules for emergency diagnostic imaging, patient-centered outcome studies, and effectiveness studies comparing alternatives to traditional CT use have all been preserved, suggesting the importance of
proposing studies on imaging costs and tissue benefits for ED-based diagnostic tests.
Due to the multiple occurrences of dizziness or diplopia and the clinical difficulty of excluding possible underlying vascular lesions, it is necessary to further improve the imaging process and strategy of dizziness or diplopia in ED.

Recently, a study published in the journal European Radiology conducted a cost-benefit analysis of imaging diagnostic examinations for patients with dizziness or diplopia in ED, which provided a reference for further standardizing the imaging examination process of such patients and improving the positive test rate
.

This study was conducted in a prospective observational uncontrolled before-and-after study
in an emergency room of a university hospital in France from 1 July 2018 to 3 January 2020.
All patients
with continuous dizziness or diplopia were included in this review.
The primary outcomes were clinical decision time for ED physicians and total cost
of each strategy.
Results were compared in 2 groups using propensity scores and inverse probability weighting, and incremental cost-benefit ratios (ICER)
were calculated.

112 men (57%) of 199 patients (mean age: 60.
4 years ± 17.
6) during the "before MRI" period and "after MRI" Of the 107 men (59%) of the 181 patients during the period (mean age, 54.
8 years ± 18.
5), the mean cost per patient was €2701 (95% CI 1918; 3704) and €2389 (95% CI: €1627), respectively; 3280）
。 The mean clinical decision time was 9.
8 hours (95% CI: 8.
9 to 10.
7) in the 'before MRI' group and 7.
7 hours (95% CI: 7.
1; 8.
4) in the 'After MRI' group, and ICER: €151 less, Clinical decision time is 1 hour
.
Probabilistic sensitivity analysis estimates that there is a 71% chance that MRI dedicated to ED is dominant (less costly and more effective).

This study found that specialized MRI for patients presenting to the emergency department for dizziness or diplopia is cost-effective, reduces the time and cost of making clinical decisions, and reduces the cost of hospitalization and readmissions for patients
.
In addition, after MRI examination, the number of imaging in the emergency room and during hospitalization is reduced
.
The results of this study suggest that specialized MRI of acute stroke-like symptoms such as vertigo or diplopia in the emergency department should be considered to improve diagnostic management and access to healthcare for emergency room patients while reducing costs
to the healthcare system.

Original source:

Sabrina Kepka,Kevin Zarca,François Lersy,et al.
MRI dedicated to the emergency department for diplopia or dizziness: a cost-effectiveness analysis.
DOI:10.
1007/s00330-022-08791-7