What is the appropriate workup for a patient presenting with dizziness?

Workup for Dizziness in the Emergency Department

Use a timing-and-triggers approach to categorize dizzy patients into three key syndromes—acute vestibular syndrome (AVS), spontaneous episodic vestibular syndrome, or triggered episodic vestibular syndrome—then apply syndrome-specific bedside examinations and selective neuroimaging rather than relying on symptom quality (vertigo vs. presyncope) or routine CT scanning. 1, 2

Overarching Principle: Abandon the Traditional Approach

The outdated paradigm of classifying dizziness by symptom quality (vertigo, presyncope, disequilibrium) does not distinguish benign from dangerous causes and should be discarded. 1, 2 Instead, focus on timing and triggers to guide your differential diagnosis and physical examination. 2

Step 1: Categorize by Timing and Triggers

Acute Vestibular Syndrome (AVS)

• Continuous vertigo lasting days with nausea/vomiting, gait instability, nystagmus, and head-motion intolerance 3
• Key distinction: presence or absence of neurologic symptoms increases stroke risk 3

For AVS patients WITH nystagmus:

• Perform HINTS examination (Head Impulse, Nystagmus, Test of Skew) if you are trained in its use 1
• Add finger rub test to further exclude stroke 1
• Critical caveat: HINTS is inaccurate when applied by emergency clinicians without specialized training, and most emergency physicians have not received this training 1. It is not standard of care as of 2023 when used by untrained providers 1

For AVS patients WITHOUT nystagmus:

• Use severity of gait unsteadiness to assess stroke risk 1

Spontaneous Episodic Vestibular Syndrome

• Recurrent episodes of vertigo lasting minutes to hours without a positional trigger 2
• Search for symptoms or signs of cerebral ischemia to differentiate transient ischemic attack from vestibular migraine 1
• If concern for TIA exists, obtain CT angiography or MR angiography 1

Special consideration for chronic recurrent vertigo:

• With hearing loss or tinnitus: suspect Menière disease 3
• With brainstem neurologic deficits: suspect chronic vertebrobasilar insufficiency 3

Triggered (Positional) Episodic Vestibular Syndrome

• Vertigo triggered by head position changes 2
• Perform Dix-Hallpike test to diagnose posterior canal benign paroxysmal positional vertigo (BPPV) 1
• If pc-BPPV confirmed, treat with Epley maneuver 1

Step 2: Neuroimaging Strategy

What NOT to Order

Brain CT has no role in routine dizziness evaluation:

• Sensitivity for stroke is only 28.5% (95% CI 14.4%-48.5%) 4
• Do not use CT in AVS patients 1
• Do not use CT in spontaneous episodic vestibular syndrome 1
• Do not use CT in triggered episodic vestibular syndrome 1
• Despite low yield, CT positivity rate in all ED dizziness patients is approximately 2%, with most findings being ischemic stroke, neoplasm, or hemorrhage 3

CTA has even lower sensitivity:

• Only 14.3% sensitivity for central etiology (95% CI 1.8%-42.8%) 4

When to Order MRI

MRI is the preferred neuroimaging modality but has important limitations:

• Sensitivity 79.8% (95% CI 71.4%-86.2%) and specificity 98.8% (95% CI 96.2%-100%) 4
• MRI will miss approximately one in five strokes if obtained early after symptom onset 4
• Do not use routine MRI as first-line test if a clinician trained in HINTS is available 1
• Use MRI as confirmatory test in patients with central or equivocal HINTS examinations 1

Specialized MRI protocols are most cost-effective:

• Specialized brain MRI (including multiplanar high-resolution DWI) is the most cost-effective strategy with US$13,477 greater cost and 0.48 greater quality-adjusted life years compared with noncontrast CT 5
• Conventional MRI is the next-best option 5

Advanced Vascular Imaging

Conventional diagnostic angiography may be used for:

• Episodic vertigo with clinical concern for positional insufficiency of posterior circulation 3
• Suspected vertebrobasilar insufficiency or vertebral artery dissection 3
• Real-time dynamic evaluation of vessel patency in various neck positions 3

Transcranial Doppler ultrasound shows promise:

• Demonstrates differences in vascular flow parameters between VBI-related vertigo and other causes 3
• Sensitivity ranges 30%-53.6%, specificity 94.9%-100% 4

Step 3: Syndrome-Specific Management

For Vestibular Neuritis

• Consider short-term steroids as a treatment option 1

For Posterior Canal BPPV

• Treat with Epley maneuver 1

Common Pitfalls to Avoid

1. Do not rely on neuroimaging alone to rule out stroke—it will miss cases, particularly early presentations 4
2. Do not perform HINTS if untrained—misapplication leads to misdiagnosis 1
3. Do not order routine CT—it has unacceptably low sensitivity and does not change management in most cases 1, 4
4. Do not use symptom quality (spinning vs. lightheadedness) to guide workup—this approach is not evidence-based 2

Training Requirements

Emergency clinicians should receive formal training in:

• Bedside physical examination techniques for AVS (HINTS) 1
• Diagnostic and therapeutic maneuvers for BPPV (Dix-Hallpike test and Epley maneuver) 1