https://orcid.org/0009-0000-4292-5691
Figures
Abstract
Background
Dizziness is a frequent emergency department (ED) presentation, and a subset of patients, especially those with isolated dizziness without focal neurological deficits, have stroke but are prone to misdiagnosis and adverse outcomes. Reported stroke prevalence in ED dizziness cohorts is highly heterogeneous, and comprehensive assessments of isolated dizziness remain limited.
Methods
Following PRISMA guidelines, we systematically searched PubMed, Web of Science, Embase, and the Cochrane Library for relevant studies. We included cross-sectional studies reporting stroke prevalence among all ED patients with dizziness or isolated dizziness. A random-effects model was used for meta-analysis to calculate pooled prevalence. Subgroup analyses and Egger’s test were employed to explore heterogeneity and publication bias. The diagnostic accuracy of bedside diagnostic tools was also systematically reviewed.
Results
Twenty-nine studies involving 161,013 ED patients presenting with dizziness were included. The pooled stroke prevalence among all ED dizziness patients (n = 158,583) was 5.5% (95% CI: 4.1–7.1). Among patients with isolated dizziness (n = 2,559), the pooled prevalence was 13.9% (95% CI: 8.2–20.9), substantially higher than in the overall dizziness cohort. Subgroup analyses indicated diagnostic methods and hospital level as major contributors to heterogeneity. Summary analysis of bedside diagnostic tools showed that HINTS and STANDING examinations have high diagnostic accuracy overall, while the TriAGe+ score can be applied flexibly for screening or confirmation based on different cut-off points.
Citation: Lin H, Zhu M, Zhang X, Tang Y (2026) Dizziness in the emergency department and risk of stroke: A systematic review and meta-analysis. PLoS One 21(4): e0346556. https://doi.org/10.1371/journal.pone.0346556
Editor: Aldobrando Broccolini, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, ITALY
Received: January 13, 2026; Accepted: March 20, 2026; Published: April 8, 2026
Copyright: © 2026 Lin et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data are included in this manuscript and supplementary materials.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Dizziness is among the most frequent reasons for emergency department (ED) presentation, accounting for roughly 3–4% of all visits [1–3]. The core challenge for clinicians is to identify patients with life-threatening central etiologies, particularly acute ischemic or hemorrhagic stroke [4,5]. A substantial proportion of posterior circulation (vertebrobasilar system) strokes present with dizziness, vertigo, or imbalance as the primary or even sole symptom [6–8]. Given that stroke remains a leading cause of disability and mortality worldwide [9], and that its management is highly time-sensitive, encapsulated by the concept “time is brain”, rapid and accurate ED triage is essential.
Missed or misdiagnosed strokes remain significant problems in ED practice [10,11]. The risk of error is markedly increased in patients presenting with only isolated dizziness – defined as dizziness without accompanying focal neurological deficits such as limb weakness, facial asymmetry, or slurred speech. These patients are easily misclassified as having benign peripheral vestibular disorders (e.g., benign paroxysmal positional vertigo or vestibular neuritis) [6,12]. Such misdiagnoses can delay revascularization therapies like thrombolysis or thrombectomy, with consequences that include catastrophic neurological injury or death and substantial healthcare costs [13,14]. Therefore, precisely quantifying the risk of stroke among ED patients with dizziness, particularly those with isolated dizziness, is crucial for developing effective clinical screening strategies, optimizing healthcare resource allocation, and improving the quality and safety of ED care.
Numerous studies have investigated stroke prevalence among ED patients presenting with dizziness, yet the existing evidence shows marked heterogeneity and inconsistency. Reported prevalence rates vary widely, from less than 1% to over 10% [15–17]. This variation likely stems from multiple factors, including study design, population definitions, the diagnostic reference standard for stroke confirmation, and the level of the participating healthcare institutions. Furthermore, many studies also have limited sample sizes and do not systematically assess these potential sources of variability. Although prior systematic reviews exist, several are outdated or do not comprehensively incorporated recent evidence [18–20]. Rigorous quantitative analysis focused on the high-risk isolated dizziness subgroup remains insufficient.
To address these knowledge gaps, we conducted a systematic review and meta-analysis with the following objectives: (1) to comprehensively update and pool estimates of the prevalence of acute stroke among adult ED patients presenting with dizziness globally; (2) to specifically focus on the isolated dizziness subgroup and more precisely calculate their stroke prevalence; (3) to investigate potential sources of heterogeneity through detailed subgroup analysis and meta-regression; and (4) to systematically evaluate the diagnostic performance of commonly used bedside tools. This study aims to provide a comprehensive overview of the available epidemiological evidence on stroke risk among ED patients presenting with dizziness.
Materials and methods
Study protocol
This systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines (see PRISMA 2020 Checklist). The pre designed protocol for this study was registered on the Open Science Framework (OSF): https://doi.org/10.17605/OSF.IO/JY3UV.
Literature search
We systematically searched PubMed (from inception to July 30, 2025), Web of Science, Embase, and the Cochrane Library (from inception to July 31, 2025). Our goal was to identify studies reporting stroke prevalence among all ED patients with dizziness or the subgroup with isolated dizziness. A combination of Medical Subject Headings (MeSH) and keywords was used to search the databases. The detailed search strategies are provided in S1 Table. To ensure inclusion of the most recent evidence, we performed an additional PubMed search on September 15, 2025, which identified one additional eligible study that was incorporated into the meta-analysis. We also performed a meticulous manual search of the reference lists of identified studies and relevant reviews to ensure that no pertinent articles were missed.
Inclusion and exclusion criteria
Literature was screened based on the following criteria. Inclusion criteria: Population: All ED patients with dizziness, or patients with isolated dizziness; participants aged ≥16 years. Study populations were consecutively and without selection bias. Outcome: The study reported quantitative outcomes (number of dizzy patients, number or incidence of stroke). Language: No restrictions. Article Type: Cross-sectional studies. Publication Year: No restrictions. Region/Country: No restrictions.
Exclusion criteria: (1) Reviews, case reports, conference abstracts, editorials, and letters to the editor. (2) Duplicate publications or studies focusing on the same cohort of subjects. (3) Studies limited to specific populations, e.g., only elderly patients, only those undergoing MRI, or studies that excluded patients with peripheral vertigo. (4) Studies lacking clear information on their methods or outcomes relevant to the interest of this review.
Definitions: Dizziness patients were defined as those presenting to the ED with dizziness, vertigo, or unsteadiness as the primary complaint. We use dizziness as an umbrella term throughout the manuscript. Isolated dizziness patients were defined as those experiencing dizziness, vertigo, or imbalance in the absence of impaired consciousness and focal neurological deficits, including visual field defects, facial asymmetry, sensory loss, dysarthria, dysphagia, aphasia, diplopia, or unilateral limb weakness.
Study selection and data extraction
Literature was managed using EndNote software. Two researchers independently screened studies according to the inclusion and exclusion criteria. Discrepancies were resolved by discussion and consensus. Non-English articles were translated using Google Translate if necessary. If studies involved overlapping patient populations, the study with the most detailed information was selected. A pre designed Excel form was used for data extraction. Two researchers independently extracted required data from the articles into the form. Data included: first author, publication year, study location (country), study period, data source (hospital type/level), sample size, number of stroke cases, participant age, gender, diagnostic method, imaging coverage rate, diagnostic efficiency of tools, etc. When the original article did not directly provide the number of male patients, we calculated it based on the total sample size and the number (or proportion) of female patients. For imaging coverage rate, we derived them from the total sample size and the number of examinations performed. Studies were categorized by the primary method used to confirm stroke outcomes: (1) MRI with or without follow-up (all patients underwent MRI); (2) clinical follow-up/composite assessment, which encompasses any combination of medical record review, post-discharge follow-up, linkage to registries, and adjudication of outcomes without mandatory MRI in all patients; and (3) coding/discharge summary only, in which stroke diagnosis was based solely on administrative data or ED discharge codes without further verification.
Quality assessment
Study quality was independently assessed by two researchers using the Joanna Briggs Institute (JBI) Critical Appraisal tool for prevalence studies. A third researcher arbitrated disagreements. The JBI tool comprises nine criteria: (1) Was the sample frame appropriate to address the target population? (2) Were study participants sampled in an appropriate way? (3) Was the sample size adequate? (4) Were the study subjects and the setting described in detail? (5) Was the data analysis conducted with sufficient coverage of the identified sample? (6) Was the condition measured in a standard, reliable way for all participants? (7) Were valid methods used for the identification of the condition? (8) Was there appropriate statistical analysis? (9) Was the response rate adequate, and if not, was the low response rate managed appropriately? Each criterion was assigned a score of 1 for “Yes” and 0 for “No”. Based on the total score, each article was rated as high quality (≥8 points), moderate quality (6–7 points), or low quality (≤5 points).
Statistical analysis
Continuous variables were presented as mean with standard deviations, while categorical variables were presented as counts and percentages. Pooled analysis of extracted data was performed using Stata software. Heterogeneity between studies was assessed using Cochran’s Q statistic and the I² statistic. Due to anticipated heterogeneity, a random-effects model was used for meta-analysis. Publication bias was examined using funnel plots and Egger’s test, with a P value less than 0.05 indicating statistical significance. Furthermore, subgroup analyses were conducted based on various factors, including publication year (≤ 2015 vs > 2015), geographic region (Europe, Asia, Oceania, North America), sample size (≥ 500 vs < 500; ≥ 300 vs < 300), study design (prospective vs retrospective), diagnostic method (MRI with/without follow-up; clinical follow-up/composite assessment; coding/discharge summary only), imaging coverage rate (100% vs < 100%/unspecified), and patient source (tertiary/teaching hospitals; stroke centers; community hospitals). A P value < 0.05 for between-subgroup differences was considered statistically significant.
Results
Study selection
Out of 1794 citations identified by the search strategy, 149 articles were considered relevant based on title and abstract screening. After full-text assessment, 29 manuscripts met the inclusion criteria [21–49]. The study selection process and reasons for exclusion are shown in Fig 1.
Study characteristics
Baseline characteristics of the 29 included studies, encompassing 161,013 ED patients with dizziness, are summarized in Table 1. Publication dates ranged from 2006 to 2025. Among the included studies, 20 reported stroke prevalence in all ED dizziness patients, 9 reported stroke prevalence in isolated dizziness patients, and 1 study reported both cohorts. Geographically, most reports were conducted in Asia (12 studies) and North America (9 studies), followed by Europe (7 studies) and Oceania (1 study). Regarding patient source, most studies involved patients from tertiary/teaching hospitals (22 studies), followed by community hospitals (4 studies) and stroke centers (2 studies). Regarding diagnostic methods, most studies relied on clinical follow-up/composite assessment (19 studies), followed by MRI with or without follow-up (6 studies) and coding/discharge summary only (4 studies). Overall, 16 studies were of high quality, and 13 were of moderate quality (S2 Table).
Stroke prevalence in all ED dizziness patients
Analysis of 21 studies involving 158,583 individuals showed that the overall pooled prevalence of stroke among all ED dizziness patients was 5.5% (95% CI, 4.1–7.1; I² = 99.14) (Fig 2). The funnel plot appeared asymmetric (S1A Fig). Egger’s test indicated significant publication bias among the 21 included studies (P = 0.088). Sensitivity analysis using the leave-one-out method did not reveal any single study whose exclusion caused a directional change in the results (S1B Fig).
Among these 21 studies, 12 reported the number of ischemic and hemorrhagic strokes separately. The pooled prevalence of ischemic stroke in all ED dizziness patients was 6.9% (95% CI, 4.9–9.1; I² = 98.91) (S2A Fig), while hemorrhagic stroke prevalence was 0.3% (95% CI, 0.1–0.4; I² = 78.88) (S2B Fig). Additionally, 12 studies reported the number of TIAs, yielding a pooled TIA prevalence of 2.2% (95% CI, 1.3–3.4; I² = 96.83) (S2C Fig).
Subgroup analysis of stroke in all dizziness patients
The estimated stroke prevalence in all ED dizziness patients according to different subgroups was summarized (Table 2). Based on subgroup analysis, diagnostic method and imaging coverage rate were the most important sources of heterogeneity (P < 0.001). Studies using MRI (with or without follow-up) as the diagnostic method had the highest stroke prevalence about 24.0%. In contrast, studies relying on clinical follow-up/composite assessment and those using only coding/discharge summary had prevalence rates of only 5.5% and 2.4%, respectively. Similarly, studies with 100% imaging coverage had a significantly higher prevalence (24.0%) than those with inadequate or unspecified coverage (4.6%). Studies with smaller sample sizes (<500 participants) reported a significantly higher stroke prevalence (14.9%) than larger sample studies (≥500; 3.0%), with a between group difference P = 0.002. Studies published after 2015 reported higher stroke prevalence (6.9%) than those published in 2015 or earlier (3.1%; P = 0.003). Differences were observed between studies from different continents (P = 0.016). European studies had the highest prevalence (10.5%), followed by Asia (6.8%), with North America having the lowest (3.0%). Prospective designs showed higher prevalence (9.4%) than retrospective studies (4.5%; P = 0.035). Studies from tertiary/teaching hospitals reported higher prevalence (6.1%) than community hospitals (2.8%), but the between group difference was not statistically significant (P = 0.086). Overall, these findings indicate that diagnostic intensity and study rigor significantly impact stroke detection rates and may partially explain the high heterogeneity observed between studies.
Stroke prevalence in ED isolated dizziness patients
Pooled analysis of 9 studies involving 2,559 individuals showed that the overall pooled stroke prevalence among ED patients with isolated dizziness was 13.9% (95% CI, 8.2–20.9; I² = 95.23) (Fig 3). The funnel plot appeared asymmetric (S3A Fig), but Egger’s test did not indicate significant publication bias among the 9 included studies (P = 0.369). Sensitivity analysis using the leave-one-out method did not reveal any study the exclusion of which caused a directional change in the results (S3B Fig).
All 9 studies reported the number of ischemic and hemorrhagic strokes separately. The pooled prevalence of ischemic stroke in ED isolated dizziness patients was 13.2% (95% CI, 7.5–20.2; I² = 95.46) (S4A Fig), whereas hemorrhagic stroke prevalence was 0.5% (95% CI, 0.2–0.9; I² = 0.0) (S4B Fig). Additionally, 5 studies reported the number of TIA cases, yielding a pooled prevalence in ED isolated dizziness patients was 2.6% (95% CI, 0.1–7.9; I² = 94.93) (S4C Fig).
Subgroup analysis of stroke in isolated dizziness patients
Subgroup analysis of 9 studies (n = 2,559) showed highly significant differences between studies from different location (P < 0.001). For ED isolated dizziness patients, Asia showed the highest stroke prevalence (22.9%), followed by Oceania (15.0%), Europe (8.4%), and North America (3.4%). There were also extremely significant differences based on the level of the medical center (P < 0.001). Stroke centers (15.7%) and tertiary/teaching hospitals (15.5%) had similar and relatively high prevalence rates, while community hospitals had a significantly lower rate (4.8%). In terms of study design, retrospective designs reported a significantly higher prevalence (19.7%) than prospective studies (11.8%), with a between-group difference P = 0.045. Regarding diagnostic methods and imaging coverage, although not statistically significant, studies using MRI (with or without follow-up) had a stroke prevalence (19.5%) almost double that of studies relying on clinical follow up/composite assessment (10.0%). Similarly, studies with 100% imaging coverage had a higher prevalence (19.8%) than those with inadequate or unspecified coverage (11.3%), but the between group difference was not significant (P = 0.136). Furthermore, there were no significant differences in prevalence based on sample size or publication year (Table 3).
Diagnostic performance of bedside tools
Four studies reported the diagnostic performance of bedside tools for diagnosing stroke in ED dizziness patients, including TriAGe + , ABCD2, HINTS, and STANDING. Table 4 summarizes their performance metrics along with brief descriptions of each tool’s components and clinical application. Due to the limited number of studies and methodological heterogeneity, we provide a qualitative synthesis of the available evidence. Measured by the Area under the curve (AUC) for overall discriminative ability, TriAGe+ and HINTS performed excellently, both with AUCs greater than 0.88, while the ABCD2 score showed relatively poor discriminative ability (AUC = 0.71). The highest sensitivity was observed for the HINTS examination [100% (78.2–100.0)] and the TriAGe+ score at the low cutoff point (>5) [96.4% (87.3–99.5)], indicating an extremely low risk of missing a stroke with these methods. In contrast, both the TriAGe+ at the high cutoff point (>10) and ABCD2 score had sensitivities below 70%. Regarding specificity, the TriAGe+ high cutoff point (>10) performed exceptionally well [99.8% (98.6–100.0)], indicating an extremely low false-positive rate. Likelihood ratio analysis provides more direct clinical utility. The TriAGe+ high cutoff point (>10) produced a very high positive likelihood ratio (+LR) (237.3), suggesting that a patient scoring above 10 has a substantially increased probability of having a stroke. HINTS, STANDING, and the TriAGe + low cutoff point (>5) all had very low negative likelihood ratios (-LR) (0.0–0.1). According to evidence-based medicine principles, a negative result with these tools can significantly reduce the post-test probability, allowing for high confidence rule out of stroke (Table 5).
In summary, HINTS and STANDING demonstrated the best-balanced performance for both rule-out (high sensitivity, low -LR) and rule-in (high specificity, high +LR) stroke. TriAGe+ score can be adapted for different clinical purposes based on the cutoff value: the low cutoff (>5) is suitable for high-sensitivity screening, while the high cutoff (>10) is suitable for high-specificity confirmation. ABCD2 score has limited diagnostic value in this context.
Discussion
This systematic review and meta-analysis comprehensively assessed stroke risk among ED patients presenting with dizziness, particularly those with isolated dizziness. The pooled prevalence of stroke was 5.5% among all ED dizziness patients, while the prevalence in isolated dizziness was markedly higher at 13.9%. Although isolated dizziness is often presumed to be benign, our findings indicate a substantially elevated stroke risk in this subgroup. Further evaluation of bedside diagnostic tools for stroke in dizzy patients indicated that HINTS and STANDING possess strong diagnostic performance and can aid early stroke identification n the ED setting.
The higher stroke prevalence in isolated dizziness patients may be attributed to several factors. First, diagnostic intensity and imaging coverage are pivotal. Subgroup analysis clearly showed that, for both overall dizziness and isolated dizziness patients, studies using MRI as the diagnostic method had substantially higher stroke prevalence rates (all dizziness: 24.0%; isolated dizziness: 17.6%) than those relying on clinical follow-up or coding data, indicating the critical impact of diagnostic intensity on detection rates. Posterior-circulation (vertebrobasilar) strokes often present with isolated dizziness, vertigo, or imbalance as the initial or sole symptom, without typical focal neurological deficits [50]. Such patients are easily misclassified as having benign vestibular disorders, yet the underlying stroke risk remains substantial [51]. Furthermore, atypical presentation of posterior circulation strokes often leads to delays in diagnosis and treatment, resulting in poorer patient outcomes [52]. In our study, most isolated dizziness patients underwent MRI to rule out central causes, thereby enhancing the detection of minor or posterior circulation strokes. Second, patient source and regional differences contributed significant heterogeneity. Subgroup analysis found that the stroke risk in isolated dizziness patients was much higher in stroke centers (15.7%) and tertiary/teaching hospitals (15.5%) than in community hospitals (4.8%). Differences in case complexity, clinical vigilance, and diagnostic capabilities among different levels of healthcare institutions likely account for these variations in stroke confirmation rates [21,30]. Simultaneously, striking regional differences (Asia: 22.9% vs North America: 3.4%) may stem from various complex factors, including the overall burden of stroke, allocation of healthcare resources, prevalence of population risk factors, and differences in clinical practice patterns [53]. Additionally, studies have found that higher education levels are associated with lower stroke risk; higher education may influence stroke occurrence through health literacy and risk factor management, potentially partly explaining the differences in stroke prevalence between low middle income and high income countries [54,55]. The study design itself also influenced prevalence estimates. Retrospective studies reported higher prevalence than prospective studies, possibly because retrospective studies are more likely to include severe cases ultimately diagnosed with stroke, whereas prospective studies more comprehensively cover all consecutive patients presenting with dizziness.
Regarding diagnostic tools, HINTS and STANDING demonstrated excellent diagnostic performance in ED dizziness patients, particularly in the isolated dizziness population. The HINTS examination achieved a sensitivity of 100%, and its ability to rule out stroke (extremely low negative likelihood ratio) makes it an ideal screening tool. Multiple studies have confirmed that in patients with acute vestibular syndrome (AVS), HINTS outperforms the ABCD2 score for identifying stroke, even showing higher sensitivity than early MRI diffusion-weighted imaging in some cases [56,57]. The GRACE3 guidelines also recommend the use of HINTS for clinicians trained in its use in patients with nystagmus [58]. This emphasizes the importance of integrating standardized bedside examinations into ED triage process, especially when neuroimaging resources are limited or rapid decision making is required [59,60]. It should be noted that our synthesis of these tools is qualitative rather than a formal diagnostic meta-analysis, owing to the limited number of studies and methodological heterogeneity. Nevertheless, the clinical utility of these bedside tests remains relevant, and our summary provides a practical overview of their performance and applications.
This study has several limitations. First, there was substantial heterogeneity among the included studies, with I² values exceeding 95% in most analyses, indicating that between-study variability far exceeded that expected by chance. Although subgroup analyses identified several important sources of variation (e.g., diagnostic method, region, and patient source), considerable residual heterogeneity remained. Therefore, our findings are more informative for identifying patterns and sources of variation than for providing precise prevalence estimates applicable to specific clinical settings. Second, several studies, particularly the large sample retrospective studies in the all-dizziness group, relied on clinical coding or discharge summaries rather than standardized imaging confirmation, which may lead to an underestimation of the stroke prevalence. Third, the definition of isolated dizziness might have subtle differences across studies, potentially introducing classification bias. Fourth, the diagnostic criteria for TIA were not uniform across the included studies. This heterogeneity in outcome definition likely contributed to the substantial statistical heterogeneity observed in our TIA analysis and may affect the comparability of prevalence estimates across studies. Fifth, the HINTS examination, despite its high sensitivity and specificity, is only applicable to patients presenting with nystagmus and therefore does not cover the full spectrum of ED patients with dizziness, which limits the generalizability of its clinical applicability.
In conclusion, ED patients presenting with isolated dizziness have a relatively high risk of stroke, with risk estimates varying substantially across regions and levels of healthcare institutions. However, given the considerable heterogeneity and publication bias across the included studies, these estimates should be interpreted with appropriate caution. Bedside examination tools such as HINTS and STANDING demonstrate high diagnostic accuracy in appropriate patient subsets and may assist with early risk stratification. Future research should focus on prospective, multicenter designs, standardize the definition of isolated dizziness and the diagnostic gold standard, and further explore the optimal diagnostic pathway integrating bedside examinations with rapid neuroimaging protocols to minimize missed diagnoses and improve patient outcomes.
Supporting information
S1 Fig. Publication bias and sensitivity analysis for the prevalence of stroke.
In all emergency department dizziness patients.
https://doi.org/10.1371/journal.pone.0346556.s001
(DOCX)
S2 Fig. Forest plots for the prevalence of stroke subtypes and TIA among.
All emergency department patients with dizziness.
https://doi.org/10.1371/journal.pone.0346556.s002
(DOCX)
S3 Fig. Publication bias and sensitivity analysis for the prevalence of stroke.
In emergency department patients with isolated dizziness.
https://doi.org/10.1371/journal.pone.0346556.s003
(DOCX)
S4 Fig. Forest plots for the prevalence of stroke subtypes and TIA among.
Emergency department patients with isolated dizziness.
https://doi.org/10.1371/journal.pone.0346556.s004
(DOCX)
S2 Table. Appraisal of papers using Joanna Briggs Institute (JBI) checklist.
https://doi.org/10.1371/journal.pone.0346556.s006
(PDF)
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