Separating stroke and acute unilateral vestibulopathy using history, examination and vestibular tests: a machine learning approach

BACKGROUND: Acute unilateral vestibulopathy (AUVP) and posterior circulation stroke (PCS) are the two common causes of the acute vestibular syndrome. We developed and evaluated machine learning models to differentiate AUVP and PCS using combinations of patient history, examination, and vestibular tests. METHODS: We recruited 294 patients presenting to the Emergency Room (ER) with acute vestibular syndrome (AUVP: n = 163, PCS: n = 131). Data from history, bedside examination and vestibular tests (video-nystagmography (VNG), video head-impulse test (VHIT), vestibular-evoked myogenic potentials (VEMP) and subjective visual horizontal) were used for machine learning model development. Different subsets of data simulated three scenarios hierarchically reflecting different levels of clinical expertise and resources: Tier 1 represented an ER with neuro-otology support (history, neuro-otological examination, VNG, VHIT, ocular VEMP), Tier 2 an ER with VHIT (history, basic examination, VHIT) and Tier 3 an ER reliant on history and basic examination only. Model performance was also compared against the HINTS test (head impulse, nystagmus, test-of-skew). RESULTS: Our best-performing models used the CatBoost or XGBoost algorithms and identified PCS with accuracies of 96.6% (95% CI: 93.3-99.9%), 94.6% (95% CI: 90.5-98.6%) and 88.8% (95% CI: 86.0-91.6%) for Tiers 1, 2 and 3. HINTS by experts achieved 94.6% accuracy. The most important variables were the bedside head-impulse test, presence of focal neurological symptoms and spontaneous nystagmus slow phase velocity in Tier 1; focal neurological symptoms in Tier 2; and age in Tier 3. CONCLUSION: Machine learning models can accurately separate PCS and AUVP and hold promise as diagnostic aids for frontline clinicians.