Does a 60-year-old female with hypertension (HTN), intermittent vertigo, positional dizziness, and neck irritation radiating to the ear, who recently started lisinopril (angiotensin-converting enzyme inhibitor) and spironolactone (aldosterone antagonist), meet the criteria for a computed tomography (CT) head scan?

Coverage Decision: CT Head Should Be DENIED as Not Meeting MCG Criteria

This CT head request does not meet MCG criteria and should be denied; the patient presents with isolated positional vertigo without focal neurological deficits, which represents a peripheral vestibular disorder (likely benign paroxysmal positional vertigo) that does not warrant brain imaging. 1, 2

Clinical Presentation Analysis

This 60-year-old woman presents with:

• Intermittent positional dizziness for one year, progressively worsening 1
• Left neck "irritation" radiating to ear 3
• Normal neurological examination 1
• No focal neurological deficits 2, 4
• No acute vestibular syndrome features 4

Why This Does NOT Meet MCG Criteria

The MCG A-0016 Brain CT Scan criteria require specific high-risk features under "Neurologic disease signs or symptoms," including:

• Ataxia or gait disturbance
• Cranial nerve palsy
• Focal sensory or motor deficits
• Visual disturbances (diplopia, visual field defects, nystagmus)
• Papilledema

This patient has NONE of these findings on examination. 1, 2

Evidence-Based Rationale Against Imaging

Peripheral vs Central Vertigo Distinction

The American College of Radiology guidelines clearly state that positional vertigo triggered by head movements represents benign paroxysmal positional vertigo (BPPV), a peripheral vestibular disorder that does not require imaging. 1 The diagnostic yield of CT head in patients with isolated vertigo is extremely low at approximately 2%, with most positive findings occurring only when neurological deficits are present. 1

Duration and Pattern Favor Peripheral Cause

Chronic recurrent vertigo lasting one year with positional triggers is characteristic of peripheral vestibular disorders, not central pathology. 1, 5 Central causes (vertebrobasilar insufficiency) typically produce vertigo lasting minutes with associated brainstem symptoms, while peripheral causes produce episodes lasting hours with positional triggers. 5

Neck Pain Does Not Justify Brain Imaging

While this patient reports neck irritation radiating to the ear, neck pain is commonly associated with chronic BPPV (reported in 87% of chronic BPPV patients) and does not indicate central pathology requiring imaging. 3 The association between chronic BPPV and neck pain is well-documented and does not change the peripheral nature of the disorder. 3

Medication-Related Dizziness Consideration

The recent initiation of lisinopril can cause dizziness as a known adverse effect (reported in clinical trials), which may be contributing to symptom worsening. 6 This medication-related etiology further argues against the need for imaging. 6

When Brain Imaging WOULD Be Indicated

The American College of Radiology specifies that brain imaging is appropriate when patients present with: 1, 2, 4

• Acute vestibular syndrome with focal neurological deficits (diplopia, dysarthria, dysphagia, limb weakness) 4
• Abnormal HINTS examination (normal head impulse test, direction-changing nystagmus, skew deviation) 4
• Severe imbalance disproportionate to vertigo 4
• New severe headache or neck pain (not chronic irritation) 4
• Age >50 with vascular risk factors AND acute presentation 4

This patient meets NONE of these high-risk criteria. 2, 4

Appropriate Management Without Imaging

The American College of Radiology and American Academy of Otolaryngology recommend: 1

• Clinical diagnosis through Dix-Hallpike maneuver to confirm BPPV 1, 7
• Canalith repositioning procedures (Epley maneuver) for treatment 7
• Review of lisinopril dosing given temporal relationship to symptom worsening 6
• Reassurance that imaging is not indicated for isolated positional vertigo with normal examination 1

Radiation Risk Without Benefit

CT head carries a relative radiation level of 3 (1-10 mSv) and is considered "usually not appropriate" for isolated vertigo without neurological findings. 1 The American Academy of Otolaryngology gives routine head CT in this scenario a rating of 3, meaning "the study or procedure is unlikely to be indicated" and "the risk-benefit ratio for patients is likely to be unfavorable." 1

Common Pitfall to Avoid

Do not order brain imaging simply because a patient has hypertension and vertigo. 8 Studies demonstrate that vertigo in hypertensive patients is typically unrelated to elevated blood pressure and is instead due to peripheral vestibular disorders or medication-related hypotension. 8 The presence of hypertension alone does not justify imaging in the absence of focal neurological deficits. 8

Coverage Decision Summary

DENY: This request does not meet MCG criteria for Brain CT Scan. The patient presents with chronic positional vertigo consistent with peripheral vestibular disorder (likely BPPV), has a completely normal neurological examination, and lacks any focal deficits or high-risk features that would warrant imaging. 1, 2 The appropriate next step is bedside vestibular testing (Dix-Hallpike maneuver) and treatment with canalith repositioning, not CT imaging. 1, 7