STANDING-M Study: Diagnostic Accuracy of the STANDING Algorithm for Vertigo

STANDING-M Study: Diagnostic Accuracy of the STANDING Algorithm for Vertigo

Ronchetti et al., Emergency Medicine Journal, August 2025
 PMID: 40730460 • DOI: 10.1136/emermed-2025-214902

📌 Conclusions

  • The STANDING algorithm is:

    • Highly accurate for ruling out central causes of vertigo

    • Especially useful as a screening tool given its very high NPV

  • Associated with:

    • Lower neuroimaging use

    • Shorter ED length of stay

  • Provides a safe and efficient alternative to imaging-heavy evaluation

👨⚕️ Clinical Implications for Emergency Physicians

  • Consider implementing STANDING in your ED after appropriate training

  • Use it as a rule-out tool for central vertigo in low-risk, isolated vertigo presentations

  • Reduces reliance on CT, which has limited utility in detecting posterior circulation stroke

  • Training matters: ensure clinicians are skilled in the maneuver for best results

🧪 Study Design

  • Prospective, multicentre cohort study

  • Conducted in 4 EDs across Tuscany (1 hub, 3 spokes)

  • Adult patients presenting with isolated vertigo

  • Diagnostic pathways:

    • STANDING group: examined by trained EP using the algorithm

    • Usual care group: examined by non-trained EPs

  • Final diagnosis adjudicated by expert panel with 30-day follow-up

📊 Results

  • Total patients: 456

    • STANDING group: 242 (53%)

    • Usual care: 214 (47%)

  • Prevalence of central vertigo: 8.6%

    • Ischemic stroke: 4.2%

🔍 Diagnostic Accuracy of STANDING

  • Sensitivity: 88.2%

  • Specificity: 91.6%

  • Positive Predictive Value (PPV): 44.1%

  • Negative Predictive Value (NPV): 99.0%

  • Compared to usual care:

    • Lower specificity (36.5%)

    • Lower PPV (14.7%)

🧠 Resource Utilization

  • CT head usage:

    • STANDING: 48.3%

    • Usual care: 66.8% (p < 0.05)

  • Median ED Length of Stay:

    • STANDING: 271 min

    • Usual care: 339 min (p < 0.05)

Ronchetti, M., Bartalucci, P., Pepe, G., Canaroli, G., Magazzini, S., De Curtis, E., Di Sacco, F., Bartolucci, M., Pecci, R., Casula, C. and Pelagatti, L., 2025. Diagnostic accuracy of the STANDING algorithm in patients with isolated vertigo: a multicentre prospective study (STANDING-M). Emergency Medicine Journal.

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