Do I need imaging for acute dizziness or vertigo?

Acute dizziness and vertigo are a common presentation in out A&E departments. The job of the medical professionals assessing these symptoms is to identify what is causing these symptoms and treat appropriately. Of the presentations of acute dizziness and vertigo in an A&E, 70% of these are down to benign causes, such as BPPV and vestibular neuritis (Royl et al, 2011). 30% of these are non-benign, for example stroke.

Nearly 10% of strokes are misdiagnosed at first medical contact (Tarnutzer et al, 2017). Misdiagnosis is most common in younger patients (age<50), women and minority groups. The symptoms of dizziness and vertigo are most tightly linked to this misdiagnosis. Delays in diagnosis for stroke lead to increased mortality and morbidity. In addition to this many acutely dizzy patients with benign vestibular causes for their symptoms are over tested, misdiagnosed and under-treated (Kerber et al, 2015). This is something that I certainly see on a regular basis.

In an emergency department, imaging such as CT and MRI are at a doctors disposal. However, they are time consuming, and they are expensive. So, are they useful? CT scans have a low sensitivity in identifying acute ischaemic strokes with one study showing that they will only identify between 7-16% of strokes (Newman- Toker et al, 2016). So, they are of little use. An MRI scan fares better but still misses 15-20% of acute strokes within the 1st 48 hours of the onset of symptoms strokes (Newman- Toker et al, 2016) 

The good news is that there is very strong evidence that a thorough history and bedside examination is very effective in ruling out stroke and is a lot more accurate than an early MRI (Saber Tehrani et al, 2014). The clinician taking the history should be able to identify the timing and trigger of the symptoms. Based on this, they can hone in on specific tests looking at eye movements to differentiate between a vestibular issue and a stroke. The addition of a simple bedside hearing test can further reduce the risk missed acute strokes.

The most important and effective aspect of identifying the cause of acute dizziness and vertigo is this bedside assessment. Generally, if imaging is needed in a patient with acute dizziness and vertigo, it should be an MRI and depending on the timing of the MRI, a repeat MRI may be necessary.

At PMC Physiotherapy, our experienced team is here to provide support and guidance through personalised vestibular rehabilitation programs designed to restore balance and enhance quality of life. Book a visit with us today, and together, we can help you regain stability, confidence, and freedom of movement.

References:
Royl G, Ploner CJ, Leithner C. Dizziness in the emergency room: Diagnoses and misdiagnoses. Eur Neurol. 2011; 66:256–263
Tarnutzer AA, Lee SH, Robinson KA, Wang Z, Edlow JA, Newman-Toker DE. Ed misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis. Neurology. 2017; 88:1468–1477
Kerber KA, Newman-Toker DE. Misdiagnosing dizzy patients: Common pitfalls in clinical practice. Neurol Clin. 2015; 33:565–575
Newman-Toker DE, Della Santina CC, Blitz AM. Vertigo and hearing loss. Handb Clin Neurol. 2016
Saber Tehrani AS, Kattah JC, Mantokoudis G, Pula JH, Nair D, Blitz A, et al. Small strokes causing severe vertigo: Frequency of false-negative mris and nonlacunar mechanisms. Neurology. 2014