The Use of Neuroimaging Studies and Neurological Consultation to Evaluate Dizzy Patients in the Emergency Department

Abstract

Background and Purpose: Dizziness is a frequent reason for neuroimaging and neurological consultation, but little is known about the utility of either practice. We sought to characterize the patterns and yield of neuroimaging and neurological consultation for dizziness in the emergency department (ED). Methods: We retrospectively identified consecutive adults presenting to an academic ED from 2007 to 2009, with a primary complaint of dizziness, vertigo, or imbalance. Neurologists reviewed medical records to determine clinical characteristics, whether a neuroimaging study (head computed tomography [CT] or brain magnetic resonance imaging [MRI]) or neurology consultation was obtained in the ED, and to identify relevant findings on neuroimaging studies. Two neurologists assigned a final diagnosis for the cause of dizziness. Logistic regression was used to evaluate bivariate and multivariate predictors of neuroimaging and consultation. Results: Of 907 dizzy patients (mean age 59 years; 58% women), 321 (35%) had a neuroimaging study (28% CT, 11% MRI, and 4% both) and 180 (20%) had neurological consultation. Serious neurological disease was ultimately diagnosed in 13% of patients with neuroimaging and 21% of patients with neurological consultation, compared to 5% of the overall cohort. Headache and focal neurological deficits were associated with both neuroimaging and neurological consultation, while age ≥ 60 years and prior stroke predicted neuroimaging but not consultation, and positional symptoms predicted consultation but not neuroimaging. Conclusion: In a tertiary care ED, neuroimaging and neurological consultation were frequently utilized to evaluate dizzy patients, and their diagnostic yield was substantial.

Value of Head CT Scan in the Emergency Department in Patients with Vertigo without Focal Neurological Abnormalities

“…Analysing the incidence of clinically significant findings in this study, screening methods should be taken into account, considering that all of the patients were examined by residents of neurology or neurology specialist unlike in other studies where CT scan was required by emergency physicians, general practitioner, internal medicine specialists and other. Navi et al, [ 21 ] reported 7% of relevant abnormal head CT scans in the ER what is consistent with our results. Grossman et al, [ 22 ] reported 5% of abnormal head CT findings after excluding patients with trauma, altered mental status, seizure and hypoglycaemia what is also similar to our results.…”

“…Mitsunaga et al, [ 16 ] reported 18.6% admission to the hospital for the patients with vertigo. We also report an admission rate of 27.8% for patients with vertigo, which is similar to the 22% of patients admitted to the hospital from the ED in the study Navi et al, [ 21 ]. In our study patients with vertigo with positive clinically significant CT findings had higher admission rate which is consistent with study Mitsunaga et al, [ 18 ].…”

Risk of acute brain lesions in dizzy patients presenting to the emergency room: who needs imaging and who does not?

“…Dizziness is one of the most common presenting complaints in emergency departments (EDs) [17,30]. Diagnosing patients with dizziness is challenging and ED physicians often request neurological consultation and brain imaging studies to differentiate non-vestibular medical causes (e.g., orthostatic dizziness) from peripheral (e.g., benign paroxysmal positional vertigo) or central vestibular disorders (e.g., brainstem/cerebellar stroke) [11,27]. The likelihood of detecting an acute brain lesion (ABL), for instance a stroke, inflammatory lesion or tumor, varies greatly depending on the clinical preselection process of patients and the modality and timing of brain imaging studies.…”

Diagnostic yield and impact of MRI for acute ischaemic stroke in patients presenting with dizziness and vertigo

“…Most comparable series have utilized CT as the neuroimaging tool of choice 12,21 and not unexpectedly, reported low diagnostic yields, although a few studies have recently included MRI. 20,34 A study comparable to the present study 34 reported a diagnostic yield of MRI of 9.2%, although MRI was performed within 2 weeks of the patient being seen in the emergency department so a false-negative rate (due to reversal of DWI changes without T2/fast low-angle shot [FLAIR] changes on follow-up) 35 for stroke may have lowered the overall yield.…”