Category: Updates

Background

Vertigo can be difficult to diagnose correctly with BPPV being common and stroke / central vertigo much less common with intervention due to stroke even rarer. Confounding the prevalence issues are stroke mimics (benign etiology presenting as stroke) and chameleons (stroke presenting as benign etiology). The HINTs exam can be quite sensitive but can be difficult to perform correctly and is very user dependent. The neverending search for a better screening tool for further stroke evlauation lead the authors of the Sudbury Risk Score to near simultaneously publish their derivation and validation manuscripts.

Bottom line / Clinical Implications

The study authors tout the potential utility of the Sudbury Vertigo Risk, but do not suggest it is ready for clinical implementation. From the validation study manuscript:

If this score is prospectively validated in centers not included in the derivation cohort, the next step will be a consensus meeting. This meeting will need to include neurologists, radiologists, ED physicians, ENT surgeons, and patients. The goal would be to establish the most appropriate investigations and treatments at each serious outcome probability level.

It seems reasonable to incorporate this score in your thinking about your patient with vertigo, but there is no specific guidance that incorporates this score from hospital systems or EM clinical societies.

Limitations

• Both validation and derivation studies were conducted at large urban tertiary centers in Canada. This may not generalize well to your small community hospital in another country.
• There is no external validation — the validation study was a retrospective review of 6 years of patient information at the same institutions that performed the derivation. The authors mention this limitation.
• This score remains operator dependent — accurate scoring depends on a focused neurological exam; motor, sensory, and cerebellar deficits must be actively sought, or risk will be underestimated.

Study Inclusion/Exclusion

• Adults (≥18 yr) who present to an ED or urgent-care setting
• Within 14 days of onset of acute vertigo, dizziness, or imbalance.
• Patient is alert (GCS = 15)
• Patient is hemodynamically stable (SBP ≥90 mmHg)
• No recent head/neck trauma, syncope, or active cancer.

Risk Score Points Calculation

Variable	Description	Points
Male	Patient’s sex is male	+1
Age >65 years	Patient is older than 65 years	+1
Diabetes	Patient has a diagnosis of diabetes	+1
Hypertension	Patient has a history of hypertension	+3
Motor or sensory deficit	Patient has either motor or sensory neurological deficits	+5
Cerebellar deficit	Includes diplopia, dysarthria, dysphagia, dysmetria, or ataxia	+6
BPPV diagnosis (protective)	A clinical diagnosis of benign paroxysmal positional vertigo (BPPV) is present	−5

Interpretation

Sudbury Vertigo Risk Score	Risk of Serious Diagnosis	Clinical Implication
<5	0%	Low risk – no further testing needed
5–8	~2–4%	Moderate risk – further investigation if unclear
>8	Up to 41% or higher	High risk – urgent evaluation and neuroimaging

References

1. Kerber KA, Sangha N, Burke JF, Jancis MO, Baecker A, Shen E, Nguyen H, Monjazeb S, Manthena P, Park S, Sharp AL, Meurer WJ. Cumulative Incidence of Stroke Disability and Mortality Following Emergency Department Discharge for Dizziness: A Cohort Study. Ann Emerg Med. 2025 Nov 18:S0196-0644(25)01244-2.
2. MDCalc Sudbury Vertigo Risk Calculator