Vertigo is a common symptom and can have a variety of etiologies ranging from benign pathologies such as benign positional paroxysmal vertigo (BPPV) and labyrinthitis, to more concerning conditions such as stroke or cerebellopontine angle tumors. Not uncommonly, vertigo may also be a side effect of a medication. Vertigo can be classified as peripheral or central depending on whether the origin of vertigo is the inner ear or central neurologic pathways in the brainstem or cerebellum. Symptoms that favor a peripheral etiology of vertigo include auditory neurologic symptoms such as hearing loss and tinnitus, whereas findings such as non-fatigable nystagmus favor more central etiologies. Regardless of the etiology, MRI is typically the best modality when imaging is indicated.

Red flags that support imaging

1. Presence of nonauditory neurologic deficits
2. Strong risk factors for cerebrovascular disease
3. Hearing loss that is progressive and asymmetric
4. Asymmetric cerebellar findings
5. Suggestion of a central cause for vertigo without clear etiology

Imaging is not needed when there is a typical history for a peripheral cause of vertigo such as:

• BPPV: Episodic vertigo, <1 minute in duration, brought on by head movement, without additional neurologic symptoms
• Vestibular neuritis or labyrinthitis: Post-viral, acute onset, with only peripheral symptoms and gradual improvement after 24-72 hours

What test to order?

Regardless of suspicion for peripheral or central etiology, for episodic or persistent vertigo, if imaging is indicated the best test is MRI Brain and internal auditory canal with and without IV contrast.

MRI is preferred over CT due to its superiority in visualizing the posterior fossa, which is often the location for a central etiology of vertigo. MRI will rule out acute and chronic ischemic disease, cerebellopontine lesions such as vestibular schwannomas and meningiomas, as well as multiple sclerosis.

Alternative tests include:

• MRA or CTA of the head and neck if a vascular etiology such as dissection, vascular insufficiency or high flow vascular malformation is suspected
• CT of the temporal bone without contrast if otic capsule process or other specific bony abnormality is suspected.

This work is intended for use to assist hospital and healthcare audiences; however, Johns Hopkins makes no representations or warranties concerning the content or clinical efficacy of this work, its accuracy or completeness. Johns Hopkins is not responsible for any errors or omissions or for any bias, liability or damage resulting from the use of this work. This work is not intended to be a substitute for professional judgment, advice or individual root cause analysis.