Acute dizziness with potential life-threatening event: A case series from single ICU

Abstract

BACKGROUND:

Whether the acute dizziness would be associated with potentially life-threatening event, which was previously unknown.

METHODS:

Between Jan 2014 and Dec 2016, We performed a retrospective survey to investigate the clinical data of patients with acute dizziness from an intensive care unit (ICU) in China. Inclusion criteria for all cases were presented with acute dizziness at onset, and then with a potentially life-threatening event. Baseline data and 30-days outcomes were collected.

RESULTS:

Approximately 1.0% of ICU patients had an acute dizziness with potentially life-threatening events. The median age of patients was 60 years (range 23 to 81 years), male: female ratio was 1.8:1. The causes of acute dizziness included focal cerebral hemorrhage in 15 cases (60%), shock in 7cases (28%), and cerebral infarction in 3 cases (12%). The most frequent potentially life-threatening event was acute brain failure (24/25), and the most common cause leading to brain failure was the lesion enlarged (54.2%, including hematoma enlargement in 8 cases, large area infarction or new infarction in 3 cases, and intraventricular hemorrhage in 2 cases). The second potentially life-threatening event was septic shock/secondary sepsis (45.8%). The fatality rate for all life- threatening events was in 64%. Compared with the survival group, the patients with lesion enlarged (56.3% vs. 11.1%, p < 0.05), acute respiratory failure (93.8% vs. 55.6% p < 0.05), lactate level (5.3 mmol/l vs. 1.3 mmol/l, p < 0.05), and Sequential Organ Failure Assessment (SOFA) score (6.9 vs. 3.4, p < 0.0001) in the non-survival group were significantly higher, while late mean arterial blood pressure (84.6 mmHg vs.124 mmHg, p < 0.0001), GCS score (5.0 score vs. 15 score, p < 0.0001) in the non-survival group were significantly lower.

CONCLUSION:

Acute dizziness with potentially life-threatening events accounts for about 1% of adult ICU patients. Acute dizziness in ICU patients is associated with a high risk of death within 30 days of onset.

Keywords

Acute dizziness or vertigo;life-threatening event organ dysfunction prognosis

1 Introduction

About 40 to 80 thousand dizziness or vertigo patients visit in emergency department every year in the United States [1]. In a three grade hospital in North China, dizziness or vertigo accounted for 30% of ischemic stroke patients in neurology clinic [2]. Clinically, the origin of acute dizziness or vertigo are usually divided into two categories: [1 , 4] peripheral and central. The peripheral cause of acute dizziness is usually considered benign, such as Meniere’s disease, vestibular neuritis, and benign paroxysmal positional vertigo (BPPV). But the central cause of acute dizziness may have poor prognosis. The most common central cause of acute dizziness is cerebrovascular disease. The prognosis may be related to the central vestibular pathway. Besides, acute dizziness is still a considerable number of patients with serious disease [5]. More importantly, the central pathway of acute dizziness is not absolutely isolated, when a damage is extended to the other neural structure or pathway, the initial isolated dizziness can often develop to the clinical manifestation of “non isolated” dizziness, even including the neurologic symptoms and signs of life-threatening. Therefore, our aim was to report the prevalence for acute dizziness in patients with potentially life-threatening causes in the ICU, so as to arouse the attention of clinical workers.

2 Methods

2.1 Research design

From January 2014 to December 2016, all the acute dizziness’ patients who had been staying in our hospital ICU were selected into the current retrospective study. The inclusion criteria for acute dizziness in adult ICU patients with potentially life-threatening events were as follows: (1) acute onset of dizziness or vertigo as the first symptom and lasting over 10 minutes, (2) following an elevated Sequential Organ Failure Assessment (SOFA) score ≥2, or having a diagnosis of life-threatening organ dysfunction event. Exclusion criteria: (1) less than 3 hours of hospitalization, namely, automatic discharge, (2) patients with acute dizziness/vertigo at the first time with headache or other focal neurological symptoms. This research was approved by the Ethical Committee on Clinical Research of the affiliated Shuyang hospital (2017-3), Xuzhou Medical University. Informed consents were obtained from patients or their families.

2.2 Research methods

The risk of death in project critical care patients at the ICU was a survey based on the population of Shuyang county. The critical illness survey has been published in previous [6]. Briefly, from 2014 to 2016 years, we performed a retrospective study of 2466 cases of critical illness and the risk of death in ICU for 3 years in the affiliated Shuyang hospital. The ICU was the only referral center in the county. Almost all the critical illness in this county has been sent to our ICU. We examined the ICU dataset and the corresponding electronic medical records, which was associated with the data of critically ill patients with acute dizziness as the first symptoms.

We used R40.2, I46.9, R57.9 and J96 as the main codes to identify life-threatening events, according to the main code of the tenth edition of the WHO International Classification of disease classification (ICD-10-CM). In order to evaluate the existence of life-threatening events after acute dizziness, we referred to the diagnostic criteria of Sequential Organ Failure Assessment (SOFA) score (0–4 points for individual organ score, more than 2 points in organ failure, 4 points in severe failure), for example, GCS <12 as brain failure, and serum creatinine more than 171 umol/L as a renal function failure, total bilirubin more than 33 umol/L to show liver failure, blood pressure decreased 40 mmHg or need vasoactive drugs to maintain blood pressure indicating cardiovascular failure, arterial oxygen pressure <300 mmHg or need mechanical respiration is equal to pulmonary failure, platelet <100×10⁹/L hints coagulation and blood failure [7]. In order to compare the risk of life-threatening events, we divided the acute dizziness patients who met the inclusion criteria into two groups: the survival group and the non survival group.

2.3 The vestibular pathway lesion, leading to acute dizziness

The peripheral vestibular pathway includes the inner ear, cerebellum, and the vestibule nucleus of the brainstem; the central vestibular pathway mainly present in the thalamus and the vestibule cortex in the each cortex [8]. These vestibule centers are not only important organs for maintaining and dealing with human balance, but also very sensitive to the pathological stimuli from the vestibular pathway and quickly respond to dizziness or vertigo. However, when the lesion expands to the other neural structure or pathway, it often produces the clinical manifestations of the so-called “non isolated dizziness", even potentially life-threatening event. In this study, significant lesion enlargement was defined as lesion growth of 1/3 on the initial area of cerebral hematoma or new infarction, or the combination of acute brain failure.

2.4 Data collection and assessment

We registered and evaluated the following data: age, sex, time from onset to admission, body temperature, blood pressure, heart rate, respiratory rate, and basic characteristics of acute dizziness. Laboratory data were recorded: including GCS score, PaO2, creatinine, bilirubin, serum glucose, white blood cell count, platelet count, bacteriological results, electrocardiogram, and brain scans. At the same time, we also recorded the discovery of CT, the location, reason, and size of the lesion.

SOFA scores or new organ failure after acute dizziness were recorded. We calculated the worst SOFA scores during the period of hospitalization. Finally, we recorded the days of stay and hospitalization in the ICU, and the prognosis of 30 days follow-up. Evaluation of survival and functional prognosis was based on a GOS score.

2.5 Statistical method

The Kolmogorov-Smirnow method was used to test the normality of the measurement data. The measurement data of normal distribution were expressed in the mean number of standard deviation (±s). The data were represented by median (IQR) and N (%).Continuous variables were compared using a t test. Chi-squared tests were used to explore the relationships between the baseline variables. The single factor variance analysis was used in the groups. The independent predictors of survival are derived from a Cox logistic regression model. All P values were bidirectional, with a significant setting at P < 0.05. The data were analyzed by SPSS17.0 Version (SPSS company, Chicago, IL, USA).

3 Results

During the 3 years continuous research period, 25 patients met the inclusion criteria. The prevalence of acute dizziness with potentially life-threatening events accounted for about 1% of ICU patients in the same period. Their age ranged from 23 to 81 years, with an average age of 59 years and a median age of 60 years. Male: female ratio was 1.8:1. The median time from onset to admission was 2 hours (0.5–260.0). Dizziness/vertigo was the first symptom in all 25 patients. The basic characteristics of 25 patients with acute dizziness were shown in Table 1.

Table 1
Basic characteristics of acute dizziness with potential life-threatening events in the ICU (n = 25)

Basic characteristics Value

Male. n. (%) 16(64.0)

Middle age, y (range) 60(23–81)

Time from onset to hospitalization, median h (range) 2(0.5–260)

Risk factors

Hypertension,n(%) 14(56.0)

Hypertension,n(%) 7(28.0)

Heart disease, n(%) 2(8.0)

Moyamoya, n(%) 1(4.0)

Leukemia, n(%) 1(4.0)

First symptom, alternatively

Dizziness, n(%) 14(56.0)

Vertigo, n(%) 11(44.0)

Accompanying symptoms

Nausea or vomiting, n(%) 21(84.0)

Balance disorders, n(%) 14(56.0)

Nystagmus, n(%) 1(0.4)

Vascular involvement site

Anterior circulation, n(%) 9(36.0)

Posterior circulation, n(%) 9(36.0)

Global cerebral, n(%) 7(28.0)

Middle time of stay in ICU, d(range) 2(1–16)

Middle time of hospitalization, d(range) 10(3–59)

Basic characteristics	Value
Male. n. (%)	16(64.0)
Middle age, y (range)	60(23–81)
Time from onset to hospitalization, median h (range)	2(0.5–260)
Risk factors
Hypertension,n(%)	14(56.0)
Hypertension,n(%)	7(28.0)
Heart disease, n(%)	2(8.0)
Moyamoya, n(%)	1(4.0)
Leukemia, n(%)	1(4.0)
First symptom, alternatively
Dizziness, n(%)	14(56.0)
Vertigo, n(%)	11(44.0)
Accompanying symptoms
Nausea or vomiting, n(%)	21(84.0)
Balance disorders, n(%)	14(56.0)
Nystagmus, n(%)	1(0.4)
Vascular involvement site
Anterior circulation, n(%)	9(36.0)
Posterior circulation, n(%)	9(36.0)
Global cerebral, n(%)	7(28.0)
Middle time of stay in ICU, d(range)	2(1–16)
Middle time of hospitalization, d(range)	10(3–59)

ICU = intensive care unit.

The most common cause of acute dizziness with potentially life-threatening event in our series of patients was spontaneous intracerebral hemorrhage (60%, 15/25), followed by septic shock in 7 cases (28%), arteriosclerosis or cardiogenic cerebral infarction in 3 cases (12%).

Clinical features of acute dizziness with potentially life- threatening causes see in the Table 2.

Table 2

Clinical features of acute dizziness with potentially life-threatening causes(N = 25)

Causes or Lesion site	Cases (n)	Lesion size (Mean volume, ml)	Lesion enlarge (n)	Organ dysfunction	death (n)
Insula hemorrhage	4	27.0	1	Lethargy, coma, ARF	0
Thalamus hemorrhage	3	10.5	2	Lethargy, coma, ARF	2
Brainstem hemorrhage	4	11.5	3	Coma, ARF	3
Ventricular hemorrhage	2	Whole Ventricle	2	Lethargy, coma	2
Occipital hemorrhage	1	120.0	1	Lethargy⟶coma, ARF	1
Cerebellar hemorrhage	1	20.0	1	Lethargy	0
Septic shock	7	GCI	1	Multiple organ failure	6
Hemorrhagic shock	1	GCI	0	Lethargy, ARF	0
Temporal lobe infarction	1	200.0	1	Coma, ARF	1
Thalamic infarction	1	4.0	1	Coma, ARF	1
All	25	–	13	–	16

ARF = acute respiratory failure; GCI = Global cerebral ischemia.

In the current series, the median time from acute dizziness onset to life-threatening events was 3 hours (0.1–336). The most frequent life-threatening event after acute dizziness was acute brain failure (24/25, including severe lethargy and coma). Focus growth was the most common cause of brain failure (13/25), including enlargement of early hematoma, new infarction or large area infarction (Fig. 1), followed by septic shock/secondary sepsis in 11 cases.

Fig. 1

Imaging scan in patient with acute dizziness with potentially life threatening event. A 63-year-old woman with recurrent dizziness for 8 days was admitted to hospital. Admission blood pressure was 200 /120mmHg, electrocardiogram showed rapid atrial fibrillation, and cerebral MRI-FLAIR scan showed recent infarction of left insula (Fig. 1A, arrows). After eleventh days of hospitalization, she was suddenly unconscious, and a repeated brain CT scan show a large hemorrhagic infarction in the left basal ganglia area(Fig. 1 B, arrows). A decompressive craniectomy was performed on this day, but the patient died.

The comparison of the life-threatening causes between the survival and non survival group are showed in the Table 3. Our results showed that the lesion growth (68.8% vs. 22.2%, p < 0.05), respiratory failure (93.8% vs. 55.6%, p < 0.05), blood lactate level (5.3 vs. 1.3, p < 0.05), and SOFA score (6.9 vs. 3.4, p < 0.0001) in the non survival group was significantly higher than that in the survival group. The subsequent mean arterial pressure (84 vs. 124, p < 0.0001), GCS (5.0 vs. 15.0, p < 0.0001), and GOS score (1.3 vs. 3.4, p < 0.0001) were significantly lower in the non survival group than in the survival group.

Table 3

Comparison of acute dizziness with potentially life threatening causes between the survival and non survival groups

Variable	Survival group (N = 9)	Non-survival group (N = 16)	P value
Male, n (%)	7(63.6)	9(64.3)	1.000
Age (y, mean±SD)	58.5±11.7	59.9±14	0.805
Dizziness with potential life-threatening causes
Cerebral failure, n(%)	8(88.9)	16(100.0)	0.360
Focus growth, n(%)	2(22.2)	11(68.8)	0.041
Sepsis/septic shock, n(%)	4(44.4)	7(43.8)	1.000
Respiratory failure, n(%)	5(55.6)	15(93.8)	0.040
Initial arterial pressure, mmHg (±SD)	127.8±33.9	109.1±40.6	0.256
Sequential arterial pressure, mmHg (±SD)	124.0±32.6	84.6±28.3	0.005
Lactic acid (mmol/l, mean±SD)	1.3±0.4	5.3±4.5	0.016
Blood sugar (mmol/l, mean±SD)	7.8±2.4	11.9±6.5	0.085
SOFA score,(mean±SD)	3.4±1.8	6.9±1.7	0.000
GCS score,(mean±SD)	15.0±0.0	4.9±2.7	0.000
GOS score,(mean±SD)	3.4±1.5	1.3±0.9	0.000
ICU days, median(range)	2(1–16)	1.6(1–9)	0.148
Days of hospitalization, median(range)	29(2–54)	2(1–142)	0.388

SOFA = Sequential Organ Failure Assessment (solo organ score range 0–4), ≥2 score indicate organ failure, 4 score indicate severe organ failure); GCS = Glasgow Coma Scale; GOS = Glasgow outcome Scale.

During the 30 day follow-up period, 64% (16/25) patients with acute dizziness with potentially life-threatening event died, of which 13 died in the ICU and 3 died within 1-2 days after discharge. 10 cases died because of the enlargement of lesion (including early hematoma growth and infarction progression) and 6 died due to septic shock. The GOS score (no patients lost visit) in good recovery accounted for 20%, moderate to severe disability accounted for 16%, and death accounted for 64%. Multivariate Cox regression analysis confirmed that only the low GCS score was closely related to the risk of death (RR = 0.784, 95% CI, 0.670–0.918, P < 0.005).

4 Discussion

Although most abundant vestibular structure is in two hemispheres [8, 9], at any area along the vestibular pathway from the inner ear to two hemispheres or cerebellum, acute dizziness may occur. However, our mainly finding showed that acute dizziness with potentially life-threatening events accounted for about 1% of adult ICU patients, and with 64% risk of death.

In our current series, 12 patients with cerebral hemorrhage and 3 patients with cerebral infarction caused an acute dizziness at initial, which was confirmed by CT or MRI, indicating that acute stroke was a common cause of acute dizziness with potentially life-threatening events.

Although the brain failure was no significant difference in the current two groups, our study confirmed that the growth of the lesions (including the growth of the early hematoma or the new infarction) were potentially life-threatening events in the non survival group. This has been confirmed by some previous studies [10 –13].

Among 7 patients with initial acute dizziness due to septic shock, although only 3 patients with imaging were confirmed the focal ischemic lesion in the vestibular pathway, we believe that the vestibular damaged pathology is associated with infection and sepsis associated encephalopathy (SAE) [10].

Previous studies suggested that severe hypotension or low cardiac output was the common causes of neurological complications (including watershed infarction or dizziness) [14 –16]. In our current series, 7 patients with acute dizziness with SAE indicated that the occurrence of acute dizziness was related to septic shock [10, 17]. The latest international consensus has been clearly defined: septic shock is a special type of sepsis, which is mainly characterized by deep circulatory failure [17], and has a higher risk of death than sepsis [17, 18].

Our current data also found that 11 patients with acute dizziness, including 7 deaths (64%), were associated with secondary sepsis and septic shock. However, compared with the survival group, acute respiratory failure was also a significant life-threatening organ dysfunction. This has also been confirmed in previous study [19].

Previous studies have also shown that subsequent low mean arterial pressure, increased lactate levels, increased SOFA scores, and reduced GCS scores were the high risk factors for predicting poor prognosis in ICU patients [18 , 20–22]. The mortality rate in our series was up to 64%. However, multiple factor Cox regression analysis shown that only low GCS score was an independent predictor of potentially life-threatening events after acute dizziness. Therefore, we believe that acute dizziness can develop into a deep coma and become a potentially life-threatening event of patients even if the conscious at first is clear.

We acknowledge that there are some limitations in this study, such as the possibility of overestimating the potentially life-threatening events and mortality rates by limiting the inclusion of acute dizziness into the ICU. Besides, small samples also make it difficult to exclude some confounding factors from our research results.

Summary: Acute dizziness with potentially life-threatening events accounts for about 1% of adult ICU patients. Acute dizziness in ICU patients is associated with a high risk of death within 30 days of onset.

References

Tamutzer

A.A.

, Berkowitz

A.L.

, Robinson

K.A.

, Hsieh

Y.H.

and Newman-Toker

D.E.

, Does my dizzy patients have a stroke? A systematic review of bedside dianosis in acute vestibular syndrome, CMAJJ 183 (2011), E571–E592. doi: 10.1503/cmaj.100174

Wang

G.S.

, Tong

D.M.

, Chen

X.D.

, Yang

T.H.

, Zhou

Y.T.

and Ma

X.B.

, Metabolic syndrome is a strong risk factor for minor ischemic stroke and subsequent vascular events, Plos One 18 (2016), 11(8): e0156243. doi: 10.1371/journal.pone.0156243. eCollection 2016

Kim

H.A.

and Lee

, Recent advances in central acute vestibular syndrome of a vascular cause, J Neurol Sci 321 (2012), 17–22.

Saber Tehrani

A.S.

, Kattah

J.C.

, Mantokoudis

, Pula

J.H.

, Nair

, Blitz

, Ying

, Hanley

D.F.

, Zee

D.S.

and Newman-Toker

D.E.

, Small strokes causing severe vertigo: Frequency of false-negative MRIs and nonlacunar mechanisms, Neurology 83 (2014), 169–173.

Navi

B.B.

, Kamel

, Shah

M.P.

, Grossman

A.M.

, Wong

, Poisson

S.N.

, Whetstone

W.D.

, Josephson

S.A.

, Johnston

S.C.

and Kim

A.S.

, Rate and predictors of serious neurologic causes of dizziness in the emergency department, Mayo Clin Proc 87 (2012), 1080–1088. doi: 10.1016/j.mayocp

Zhou

Y.T.

, Tong

D.M.

, Wang

S.D.

, Liu

L.S.

, Ye

and Xu

B.W.

, Comparison of risk of death between older and non-older critical patients in ICU: A retrospective cohort study of consecutive 3 years, Chin Crit Care Med 29 (2017), 448–452.

Vincent

J.L.

, Moreno

, Takala

, Willatts

, De Mendonça

, Bruining

, Reinhart

C.K.

, Suter

P.M.

and Thijs

L.G.

, The SOFA (Sepsis- Related Organ Failure Assessment) score to Describe organ dysfunction/ failure, Intensive Care Med 22 (1996), 707–710.

Duque-Parra

J.E.

, Perspective on the vestibular cortex throughout history, Anat Rec B New Anat 280 (2004), 15–19. DOI: 10.1002/ar.b.20031

Urasaki

and Yokota

, Vertigo and dizziness associated with cerebral hemispheric lesions, J UOEH 25 (2003), 207–215.

10.

Zhou

Y.T.

and Tong

D.M.

, Initial presenting as acute vertigo syndrome in sepsis associated encephalopathy: A retrospective case series, SOJ Neurol 4 (2017), 1–5.

11.

Brott

, Broderick

, Kothari

, Barsan

, Tomsick

, Sauerbeck

, Spilker

, Duldner

and Khoury

, Early hemorrhage growth in patients with intracerebral hemorrhage, Stroke 28 (1997), 1–5.

12.

Rodriguez-Luna

, Rubiera

, Ribo

, Coscojuela

, Piñeiro

, Pagola

, Hernandez-Guillamon

, Ibarra

, Romero

, Alvarez-Sabin

, Montaner

and Molina

C.A.

, Ultraearly hematoma growth predicts poor outcome after acute intracerebral hemorrhage, Neurology 77 (2011), 1599–1604. DOI: 10.1212/WNL.0b013e3182343387

13.

Biffi

, Anderson

C.D.

, Jagiella

J.M.

, Schmidt

, Kissela

, Hansen

B.M.

, Jimenez-Conde

, Pires

C.R.

, Ayres

A.M.

, Schwab

, Cortellini

, Pera

, Urbanik

, Romero

J.M.

, Rost

N.S.

, Goldstein

J.N.

, Viswanathan

, Pichler

, Enzinger

, Rabionet

, Norrving

, Tirschwell

D.L.

, Selim

, Brown

D.L.

, Silliman

S.L.

, Worrall

B.B.

, Meschia

J.F.

, Kidwell

C.S.

, Broderick

J.P.

, Greenberg

S.M.

, Roquer

, Lindgren

, Slowik

, Schmidt

, Woo

and Rosand

, APOE genotype and extent of bleeding and outcome in lobar intracerebral haemorrhage: A genetic association study, Lancet Neurol 10 (2011), 702–709. DOI: 10.1016/S1474-4422(11)70148-X

14.

Arbelaez

, Castillo

and Mukherji

S.K.

, Diffusion- weighted MR imaging of global cerebral anoxia, AJNR Am J Neuroradiol 20 (1999), 999–1007.

15.

Finsterer

and Stöllberger

, Neurological complications of cardiac disease (heart brain disorders), Minerva Med 107 (2016), 14–25.

16.

Verbeet

, Cardiovascular aspects of vertigo, Rev Med Brux 23 (2002), A351–A355.

17.

Singer

, Deutschman

C.S.

, Seymour

C.W.

, Shankar-Hari

, Annane

, Bauer

, Bellomo

, Bernard

G.R.

, Chiche

J.D.

, Coopersmith

C.M.

, Hotchkiss

R.S.

, Levy

M.M.

, Marshall

J.C.

, Martin

G.S.

, Opal

S.M.

, Rubenfeld

G.D.

, van der Poll

, Vincent

J.I.

and Angus

D.C.

, The third international consensus definitions for sepsis and septic shock(Sepsis-3), JAMA 315 (2016), 801–810. doi: 10.1001/jama.2016.0287

18.

Angus

D.C.

, Linde-Zwirble

W.T.

, Lidicker

, Clermont

, Carcillo

and Pinsky

M.R.

, Epidemiology of severe sepsis in the United States: Analysis of incidence, outcome, and associated cost of care, Crit Care Med 29 (2001), 1303–1310.

19.

Khwannimit

and Bhurayanontachai

, The epidemiology of, and risk factors for, mortality from severe sepsis and septic shock in a tertiary-care university hospital setting, Epidemiol Infect 137 (2009), 1333–1341.

20.

Houwink

A.P.

, Rijkenberg

, Bosman

R.J.

and van der Voort

P.H.

, The association between lactate, mean arterial pressure, central venous oxygen saturation and peripheral temperature and mortality in severe sepsis: A retrospective cohort analysis, Crit Care 20 (2016), 56. doi: 10.1186/s13054-016-1243-3

21.

Safari

, Shojaee

, Rahmati

, Barartloo

, Hahshemi

and Mehdi

, Forouzanfar and E. Mohammadi, Accuracy of SOFA score in prediction of 30-day outcome of critically ill patients, Turk J Emerg Med 16 (2016), 146–150.

22.

Leonid

A.E.

, Debby

, Chaim

and Sprung

C.L.

, The spectrum of septic encephalopathy definitions, etiologies, and mortalities, JAMA 275 (1996), 470–473.