Imaging for dizziness and vertigo

Routine imaging for episodic positional dizziness consistent with BPPV is not recommended. Imaging becomes appropriate when:

• Symptoms include focal neurologic findings (weakness, double vision, dysarthria, ataxia)
• Dizziness is sudden, severe, and persistent (concern for stroke)
• New hearing loss accompanies vertigo (asymmetric sensorineural hearing loss)
• A patient has vascular risk factors and new vertigo lasting more than a few hours
• Headache or head trauma is associated

Sudden severe vertigo with focal neurologic signs is a medical emergency — go to an emergency department.

Brain MRI is the standard outpatient study. With dedicated thin slices through the internal auditory canals it evaluates the inner ear nerves and the brainstem.

Head CT is used in the acute setting when hemorrhage or fracture is the concern. CT is less sensitive than MRI for posterior fossa pathology, which is the area most relevant to vertigo.

Note: vascular imaging (MR angiography, CT angiography) is sometimes part of a workup for vertigo with concern for vertebrobasilar disease. Precise focuses on the standard MRI and CT studies; vascular angiographic studies may need to be arranged separately.

A brain MRI for vertigo evaluates:

• The brainstem and cerebellum for acute stroke, demyelination, or tumor
• The internal auditory canals for vestibular schwannoma (acoustic neuroma)
• The temporal bones and middle ear (limited; dedicated temporal bone CT may follow if needed)
• The ventricles for hydrocephalus

Benign paroxysmal positional vertigo (BPPV) — brief positional vertigo from displaced inner ear crystals. Diagnosed clinically and treated with positioning maneuvers.

Vestibular neuritis / labyrinthitis — typically post-viral, with continuous vertigo lasting days. Imaging usually normal.

Vestibular schwannoma (acoustic neuroma) — slow-growing benign tumor of the vestibular nerve; classic presentation is asymmetric hearing loss with or without vertigo. MRI with thin slices through the internal auditory canal is the test of choice.

Cerebellar or brainstem stroke — vertigo with focal neurologic deficit. Emergency.

Migraine-associated vertigo — common, often diagnosed clinically.

Most outpatient MRIs for dizziness are normal, which is reassuring and helps direct further care toward vestibular rehabilitation, ENT evaluation, or medical management. A vestibular schwannoma generally warrants neurosurgical or ENT consultation; small ones are often observed with serial MRIs.

Bring your physician's order; many studies for suspected acoustic neuroma require IV contrast, so plan for a slightly longer appointment. See our brain MRI page for locations, and call 800-558-2223 for a transparent self-pay quote.