Neuroimaging not necessary for all patients who present to ED with vertigo
Neuroimaging may not be necessary for all patients who present to emergency departments with vertigo, according to new research.
Although new onset vertigo can prompt concerns for serious central nervous system pathologies, such as stroke, hemorrhage and malignancy, the condition is most often of benign origin. This makes the decision whether to utilize neuroimaging challenging for providers.
Now, a new paper is providing updated guidance for determining whether a patient requires imaging to rule out more sinister causes of vertigo. Published in Emergency Radiology, the paper details the association of specific clinical features with positive neuroimaging findings.
“Despite limited yield, imaging is performed in up to 35% of vertigo-related ED presentations,” Warren Chang, MD, from the Allegheny Health Network in Pittsburgh, and colleagues noted. “The combination of high imaging utilization and low diagnostic yield results in substantial healthcare costs and exposes patients to risks of radiation, incidental findings, and unnecessary intervention.”
For their work, experts retrospectively reviewed all cases of vertigo at their ED between 2016 and 2025, resulting in over 5,400 instances. The team focused on patients who had imaging during their visit, highlighting all exams that had relevant findings flagged for further review. Findings were divided into four categories: 1) acute actionable contributory to vertigo, 2) acute actionable non-contributory to vertigo, 3) non-acute actionable, or 4) non-actionable.
Additionally, the group included patients’ clinical data—the type and severity of vertigo, neurological symptoms and medical history—in their assessment to determine if specific factors were more likely to be associated with positive imaging exams.
Of all the cases studied, just 5.3% had imaging findings flagged for additional review. Of those, 115 (2.1%) contained actionable findings, while just 65 (1.2%) revealed acute central causes contributing to vertigo. The group observed strong correlations between constant vertigo and acute contributory pathology; acute onset, abnormal Head-Impulse, Nystagmus, and Test-of-Skew (HINTS) results and cerebellar signs also were associated with acute pathology linked to vertigo. Over 95% of patients with these findings underwent some sort of intervention.
“While acute central causes of vertigo remain rare in ED patients undergoing neuroimaging, careful integration of symptom quality, symptom acuity, and bedside neurological examination can significantly improve the identification of high-risk patients,” the authors suggested. “Specifically, those presenting with constant vertigo of < 24 hour duration and abnormal HINTS or cerebellar signs may represent a subgroup warranting high suspicion for central pathology and urgent neuroimaging.”
The group added that the clinical information highlighted in their study can better stratify patients based on risk, reducing the over-utilization of imaging in emergency settings.
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In addition to her background in journalism, Hannah also has patient-facing experience in clinical settings, having spent more than 12 years working as a registered rad tech. She began covering the medical imaging industry for Innovate Healthcare in 2021.