Acute dizziness in the emergency department: trends, diagnostic challenges and stroke mimics among thrombolysed patients

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Background: Acute dizziness is a frequent cause of emergency department (ED) visits, but differentiating benign vestibular disorders from posterior circulation stroke remains challenging. Neuroimaging has low sensitivity in the acute phase, while bedside tests such as HINTS has shown superior diagnostic accuracy when performed by trained providers. Efforts to reduce door-to-needle times (DNT) in thrombolysis may exacerbate diagnostic variability, increasing the risk of treating stroke mimics. This study aims to evaluate factors contributing to misdiagnosis by analyzing (i) temporal trends in total admissions and triage (ii) quality of clinical assessments and (iii) patterns in IVT use for dizziness presentations. Methods: We conducted a cohort study of all patients admitted with acute dizziness at Stavanger University Hospital from 2016 to 2022. Trends in admissions, triage, bedside clinical assessment, and intravenous thrombolysis (IVT) use were analyzed. Stroke mimics were defined as patients thrombolysed but subsequently discharged with a non-stroke diagnosis after MRI and neurovascular reassessment. Results: A total of 4,594 patients were admitted with acute dizziness, representing 1.9% of all ED admissions. Annual admissions increased from 455 in 2016 to 819 in 2022 (80%), with neurology admissions rising from 33 to 50%. IVT use in isolated dizziness almost doubled (17 in 2016 vs. 32 in 2022), peaking in 2020-2021 (>55 annually), while confirmed stroke cases remained stable (3-7/year). Stroke mimics accounted for most IVT-treated dizziness cases, exceeding 80% in patients with NIHSS 0. On average only 50% of thrombolysed patients had a complete neuro-ophthalmological examination. Conclusion: ED admissions for acute dizziness are rising, with increased IVT use but stable stroke incidence, leading to higher rates of stroke mimics. Incomplete bedside examinations and emphasis on faster DNT may contribute to misclassification. Standardized dizziness protocols, mandatory use of HINTS by trained clinicians, and stronger cross-specialty collaboration are needed to improve diagnostic accuracy while preserving timely stroke treatment.

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