By Mary Henderson
Up to 4% of emergency department (ED) visits are due to vertigo, and many of these patients undergo brain imaging. Yet, the diagnostic yield of neuroimaging in the ED performed to evaluate vertigo is consistently low, revealing acute actionable central causes in less than 2% of patients.
In a Tuesday session, Raven Spencer, MD, a third-year radiology resident at the Allegheny Health Network in Pittsburgh, presented the results of a 10-year retrospective analysis of actionable imaging findings of patients presenting to the ED with vertigo.
“Vertigo is a big complaint in EDs, and we know from previous studies that benign etiologies are very common in these patients,” Dr. Spencer said. “The risk of stroke in this population is less than 5%.”
According to Dr. Spencer, despite various efforts to mitigate unnecessary imaging, including the use of the ACR appropriateness criteria, clinical risk algorithms, and the HINTS exam, about 35% of patients presenting with vertigo undergo CT, CT angiogram (CTA), or MRI due to concerns related to stroke.
“This leads to substantial health care costs, increased radiation exposure, and incidental findings that may lead to unnecessary follow-up or interventions,” he said.
While these risks are significant, Dr. Spencer emphasized that most patients presenting with vertigo have benign positional paroxysmal peripheral vertigo (BPPV), or another peripheral cause. However, when vertigo is due to a central pathology, the consequences can be much more serious.
“So that's the clinical conundrum,” he said. “Early differentiation is important to prevent morbidity.”“Our study showed, very importantly, that vertigo symptom quality, acuity and physical exam findings offer meaningful predictive value to ED physicians deciding which patients need urgent imaging.”
Raven Spencer, MD
The study included 5,445 neuroimaging studies in 4,135 patients who presented to the network’s EDs with vertigo between 2016 and 2025. Imaging exams performed on the patients included 2,630 head CTs, 457 brain MRIs, 2,143 CTA, and 140 MR angiograms. Of all imaging exams performed, the researchers identified only 291 (5.3%) with potentially relevant findings. A board-certified neuroradiologist and a neurologist independently reviewed each potentially relevant study and the associated electronic medical record.
Of the 291 reviewed cases, only 65 (1.2%) patients had acute actionable imaging findings deemed contributory to vertigo (leading to a hospital admission or a change in management). Of note, 27 (0.5%) of patients had acute actionable findings unrelated to vertigo, including supratentorial infarcts/hemorrhage and other findings, and 23 (0.4%) had non-acute actionable findings. The remainder of patients had clinically insignificant or non-actionable findings.
Significantly, the study found that acute, constant vertigo was highly associated (70%) with stroke.
“Patients who reported constant vertiginous symptoms, such as waking up at 5 am with a constant ‘room spinning’ sensation, had a much higher likelihood of having acute central pathology,
including strokes, brain bleeds and tumors,” he said. “Presenting with intermittent vertigo was strongly predictive of peripheral vertigo.”
Patients with non-actionable findings were most often diagnosed with peripheral vertigo or another diagnosis. Of the non-actionable cases, 73 were discharged from the ED without
consultation. Of the 176 cases evaluated, 100 (57%) were diagnosed with BPPV.
“Our study showed, very importantly, that vertigo symptom quality, acuity and physical exam findings offer meaningful predictive value to ED physicians deciding which patients need urgent imaging,” Dr. Spencer said.
“Hopefully, with careful triage and attention to vertigo symptom quality and timing, and better training, routine imaging may be avoided in patients with low-risk clinical features, potentially reducing costs and preventing overdiagnosis while still ensuring detection of critical but incidental cerebrovascular disease,” he concluded.
Access the presentation, “Low Prevalence of Actionable Imaging Findings in Emergency Department Patients Presenting With Vertigo: 10 Year Retrospective Analysis in a Large Health System,” (T3-SSNR07-6) on demand at RSNA.org/MeetingCentral
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The RSNA 2025 Daily Bulletin is the official publication of the 110th Scientific Assembly and Annual Meeting of the Radiological Society of North America. Published online Sunday, November 30 — Thursday, December 4.
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