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Diagnostic Help For Dizziness? The TriAGe+ Score

May 8, 2024

Written by Jason Lesnick

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This retrospective validation study at a single site in Hong Kong found the TriAGe+ score for vertigo or dizziness would have performed reasonably well for risk-stratifying patients who presented to their ED for dizziness or vertigo when evaluating for acute stroke or TIA.

Is the room spinning or is it just me?
The TriAGe+ score is made of 8 clinical parameters and is seen below for reference in the table. It was developed in Japan in 2017, and they categorized patients into low (0-4) points, intermediate (5-7), high (8-9), and very high (10-17) risk. They found incidence of stroke increased significantly as score increased (5.7% in the low risk group vs 57.3% in the very high risk group). They also found at a cutoff of 5 points, sensitivity was 96.6%.

This was a single center retrospective observational cohort study done at the Prince of Wales University Hospital in Hong Kong to validate the TriAGe+ score. The primary outcome was diagnosis of acute CVA (stroke and TIAs included). Secondary outcomes included univariable and multivariable analyses of stroke predictors, 30 day mortality, patient disposition, and final diagnosis.

455 patients aged ≥18 who presented with dizziness or vertigo from 7/19/21-9/30/21 were included. ED charts were reviewed by two EM physicians and categorized into “definite stroke” (54 patients), “indeterminate” (7),  and “definite no stroke” (394). The 7 indeterminate were later categorized expert panel review as “definite no.”

The prevalence of CVA was 11.9%, and median TriAGe+ score was 7 (IQR = 4-9). At a cut off of >5, sensitivity was 96.4% (95%CI: 87.3-99.5); negative LR was 0.09 (95%CI 0.02-0.3). At a cut off of >10, specificity was 99.8% (95%CI: 98.6-100.0) and positive likelihood ratio was 327.6 (95%CI 33.1-1704). On multivariable analyses, atrial fibrillation, blood pressure, gender, dizziness (not vertigo), and no history of dizziness, vertigo or labyrinth/vestibular disease were found to be associated with CVA.

How will this change my practice?
As of now, this study won’t change my practice. But I would love to see this replicated in a large-scale, prospective, US-based study to see how it performs in populations more applicable to my practice. I would welcome any and all effective clinical screening tools toward this difficult to manage situation where an MRI is only about 80% sensitive and where we struggle to perform the HINTS exam accurately. Another concern with this tool is that it requires patients being able to differentiate between vertigo and dizziness.

Editor’s note: I included this study because it is interesting. However, it is not ready for clinical use. To Jason’s point, GRACE-3 noted, “Evidence shows that patients’ dizziness descriptors (e.g., “vertigo” vs. “lightheadedness” or “imbalance,” “unsteadiness,” and others) often change when reassessed even minutes later and that many patients simultaneously endorse multiple descriptors, undercutting the logic of a symptom quality–based paradigm.” I’m not optimistic I will be able to use the TriAGe+ score in practice. ~Clay Smith

The TriAGe + score for vertigo or dizziness: A validation study in a university hospital emergency department in Hong Kong. Am J Emerg Med. 2024 Mar;77:39-45. doi: 10.1016/j.ajem.2023.10.055. Epub 2023 Nov 10. PMID: 38096638.