The diagnostic strategy, procedure and pathway for acute vestibular syndrome SCD

Acute vestibular syndrome（AVS） accounts for about 5% of walk clinic, and 20% of neurology consultations in the emergency department. A central acute vestibular syndrome is of high-risk vertigo disorders or potentially life-threaten disorders. Some of the central vestibular vertigo, especially brainstem or cerebellar ischemic infarction, can be misdiagnosed due to the absence of focal neurological symptoms and signs. In the past decade, the diagnosis mode and diagnosis pathway of vestibular syndrome have been made great progress. The HINTS examination battery reported by Kattah et al. （2009）, the STANDING examination battery reported by Vanni et al. （2014） as well as the "Big five" step examination procedure reported by Brandt et al. （2017） have been used widely to identify stroke in clinic. The TiTrATE proposed by Newman Toker and Edlow（2015） as well as the ATTEST proposed by Gurley and Edlow（2019） have promoted the accuracy for AVS diagnosis. However, only about 50% of patients with cerebellar ischemic infarction have spontaneous nystagmus. The sensitivity of direction-changing nystagmus in diagnostic predicting stroke in acute vestibular syndrome was only 38%. The diagnostic predictive sensitivity of AICA stroke was only 62% when the horizontal head pulse test were normal. Therefore, the bed-side test battery for differentiating acute isolated vertigo as well as the diagnosis approach of AVS need to be further improved. Based on the SCD diagnosis strategy and the differentiating pathway for vestibular disorders proposed by the author, I propose further in this paper the step-rised SCD strategy for the acute vestibular syndrome, and the ABC mode for differentiating central vestibular vertigo[A: Associated neurological deficit（or: with headache=HAND）; B: Eye（E³） GAP examination battery; C: Combined warning battery of A³B²C²D²E³], as well as the differential diagnosis pathway of acute vestibular diseases. The history questioning of associated neurological deficit and the examining batteries for acute central vestibular disorders can be summarized as an illogical English phrase "HAND-Eye（E³） GAP" for memory.