The Incidence of Central Neurological Disorders Among Patients With Isolated Dizziness and the Diagnostic Yield of Neuroimaging Studies

Abstract

Objectives: Dizziness is a common symptom among emergency department (ED) patients and is often associated with benign processes. The aim of this study was to investigate the incidence of severe central neurological pathologies in isolated dizziness cases and the diagnostic efficiency of neuroimaging studies. Methods: All applications for isolated dizziness to an academic ED between January 1, 2011, and December 31, 2017 were retrospectively reviewed. The frequency of these admissions, the demographic data of the patients, the results of cranial computed tomography (CT) and diffusion-weighted magnetic resonance imaging (DW-MRI) studies, and the central neurological causes of isolated dizziness were recorded. Results: The percentage of patients with isolated dizziness among all ED admissions was 2.5% (29,510/1,190,857). The median age of these patients was 52 years (interquartile range: 38 to 66) and 58% were female. During the study period, the rate of neuroimaging studies for isolated dizziness increased year by year, and a total of 6406 (21.7%) cranial CTs and 2896 (9.8%) DW-MRIs were performed. The diagnostic yield of neuroimaging studies was 0.6% for cranial CT and 3.9% for DW-MRI. Central neurological disorders were detected in 143 (0.48%) patients with isolated dizziness. The most common causes were posterior circulation ischemic strokes (47.5%), other ischemic strokes (18.9%), vertebrobasilar insufficiency (10.5%), and transient ischemic attack (8.4%). Conclusions: Isolated dizziness is rarely associated with central neurological pathologies. Neuroimaging studies, especially cranial CT, have low diagnostic yield in isolated dizziness and should therefore not be routine in the evaluation process.

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

“…[33][34][35][36][37][38][39][40] Approximately 10%-25% of cases of AVS are due to stroke, the vast majority of which are ischemic. 8,39 In a study of over 5500 ED patients with dizziness, 27% had a CT scan done and 3% had magnetic resonance imaging (MRI), presumably in an attempt to avoid missing a stroke. 41 Importantly, the sensitivity of CT for early-presenting acute ischemic stroke has been shown to be as low as 10%.…”

“…42 This low prevalence of stroke among all-comers with acute dizziness, coupled with the very low sensitivity of CT for ischemic stroke, underscores the limited diagnostic utility of CT for patients presenting with dizziness. 7,8,[43][44][45][46][47][48][49] Although CT is far more sensitive for intracerebral hemorrhage (ICH), ICH is an uncommon cause of patients presenting with isolated dizziness. 50 In this study of 595 ICH cases, only 13 (2.2%) presented with dizziness and a NIHSS of <2.…”

“…Acute dizziness or vertigo is a common emergency department (ED) presentation, accounting for 2.1%-3.6% of visits per year, [6][7][8][9][10] with an estimated annual cost approximating $10 billion in the United States, a large proportion of which is related to imaging. 11 Resource use and ED length of stay for these patients are higher than in patients with other chief complaints.…”

“…Among the subset of dizzy patients with AVS, the most common causes are vestibular neuritis (also referred to as acute unilateral peripheral vestibulopathy) and posterior circulation ischemic stroke; labyrinthitis is an uncommon peripheral cause 33–40 . Approximately 10%–25% of cases of AVS are due to stroke, the vast majority of which are ischemic 8,39 . In a study of over 5500 ED patients with dizziness, 27% had a CT scan done and 3% had magnetic resonance imaging (MRI), presumably in an attempt to avoid missing a stroke 41 .…”

Use of Neuroimaging for Patients With Dizziness Who Present to Outpatient Clinics vs Emergency Departments in the US

“…These studies and our study documented reliance on the insensitive head CT scan in the urgent time frame, which is concerning because 35% of strokes among patients presenting to the ED with dizziness are missed . Among ED presentations for dizziness, only 0.6% to 3.6% of CT scans and 3.9% to 12.2% of MRI scans revealed clinically significant findings . Morbidity from missed pathology, particularly stroke, may justify imaging regardless of yield, but higher use of neuroimaging was not associated with higher yields …”