Vertigo (Recent Onset)

Population Covered By The Guidance

This pathway provides guidance on the imaging of adult patients with recent onset of vertigo.

Lead Researcher: Ci Yue Chia

Experts & Contributors: Daren Gibson, Jafri Kuthubutheen

Date reviewed: October 2022

Date Published: September 2025

Cavernous Haemangioma

Vertigo is a symptom of illusory movement arising from damage or dysfunction of the vestibular system.
A history and detailed neurological examination are important to determine whether the symptoms and signs are suggestive of a peripheral or central cause of vertigo. A focus towards identifying timing and triggers instead of dizziness type, has proven value in guiding imaging decisions; this is known as the timing, duration, triggers, and targeted examination (TiTrATE) diagnostic approach.
Head impulse, nystagmus, and test of skew (HINTS) testing for patients with acute onset spontaneous vertigo and nystagmus has high sensitivity and specificity for central cause.
Following specialist review and documentation of neurological findings, magnetic resonance imaging +/- magnetic resonance angiography (MRI +/- MRA) is generally indicated if a central cause of vertigo is suspected.
If MRI is unavailable or significantly delayed, a computed tomography +/- angiography (CT +/- CTA) scan with fine images of the temporal bone/ posterior fossa is a reasonable substitute.
Vestibular migraine as per the Barany society definition needs to be considered in all cases of vertigo

Date of literature search: April 2022

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

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SYMBOL	RRL	EFFECTIVE DOSE RANGE
	None	0
	Minimal	< 1 millisieverts
	Low	1-5 mSv
	Medium	5-10 mSv
	High	>10 mSv

Disclaimer

Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.

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Panning

A focus towards identifying timing (including speed of symptom onset), duration, description of the vertigo and triggers instead of dizziness type, has proven value in guiding imaging decisions. HINTs+ (head impulse, nystagmus, test of skew + hearing loss) is a relatively simple bedside test that can be used to rule out a central cause. HINTs+ assesses head impulse, nystagmus and test of skew with assessment of cranial nerves & includes hearing loss.

History and detailed neurological examination are important in distinguishing between central and peripheral aetiology and will inform subsequent diagnostic evaluation and treatment. Diagnostic index tests and risk stratification tools like TiTrATE (symptom timing, triggers, and targeted bedside eye examinations), HINTS+ (Head Impulse, Nystagmus, Test of Skew + hearing loss), ABCD2 (age, blood pressure, clinical features, duration of symptoms, and diabetes) are useful in estimating the risk of central pathology and assessing stroke risk .
A large body of recent literature suggests a change of paradigm in how to assess patients with vertigo or dizziness, by identifying timing and triggers (TiTrATE diagnostic approach ) instead of type of dizziness to optimise usage of targeted bedside examinations of proven value .

Patients have difficulty describing quality of their symptoms – with 50% changing their dizziness type – but more consistently identify timing and triggers .

HINTS has demonstrated superiority over vascular risk factor stratification (ABCD2 score) and continued superiority over diffusion weighted magnetic resonance imaging (DW-MRI) , particularly in patients with smaller strokes . Similar findings have been confirmed by other groups and two systematic reviews .

This requires correct identification of acute vestibular syndrome (AVS) patients
Acute vestibular syndrome (AVS) is characterized by the rapid onset (over seconds to hours) of vertigo, nausea/vomiting, and gait unsteadiness in association with head-motion intolerance and nystagmus lasting days to weeks .
The head impulse test (HIT) should be reassessed by a neuro-otological expert or quantitative video-oculography HIT to improve accuracy. Currently, accuracy of bedside HIT tests when performed by non-experts is only 58%, with a high sensitivity of 88% but low specificity of 64% for peripheral vertigo .

HINTS+ risk stratification tool includes additional consideration of hearing loss in risk stratification. Clinically, hearing loss is a useful finding in guiding further imaging in the Emergency Department.
- An audiology review prior to semi-urgent MRI may be considered to confirm hearing loss, especially if aetiology is uncertain.
- Tinnitus, unilateral or asymmetrical hearing loss may also prompt further investigation with semi-urgent MRI.

To exclude tumours of the cerebellopontine angle cistern and internal auditory meatus. This should be routinely requested if an MRI scan of the brain is to be performed for the assessment of vertigo to exclude cochlear and retro cochlear pathology.

Investigation of choice after clinical examination if:

A central cause for vertigo is suspected (e.g., vertebro-basilar infarction, intracranial haemorrhage, brainstem neoplasm, multiple sclerosis, or infection) .
A central/peripheral distinction cannot be made, and patient has moderate to high stroke risk or an atypical presentation (e.g., unsteadiness, unilateral hearing loss, noise induced dizziness, spontaneous acute vestibular syndrome (AVS), suspected subarachnoid haemorrhage or brainstem encephalitis) .

MRI has a higher diagnostic yield than CT in detecting central structural causes of vertigo
MRA has been shown to have a sensitivity of 97% and specificity of 98.9% for the diagnosis of large vessel occlusions and stenoses of the posterior circulation when compared to the reference standard of intra-arterial angiography .

A systematic review with meta-analysis demonstrated that diffusion weighted imaging (DWI) has a high sensitivity & specificity for acute posterior circulation infarction when compared with traditional CT, CT angiography (CTA), MRI and MR angiography (MRA) .
Caution is advised in patients with acute vestibular syndrome and suspected ischemic stroke. Be cautious of an early, negative DW-MRI within the first 48 hours as DW-MRI misses 10-20% of larger strokes and up to 50% of small (<1cm) brainstem and cerebellar strokes with a <1 cm diameter .

Repeat delayed DW-MRI (3–7 days after onset of symptoms) may be required to confirm a new infarct .
MRI (+/- non-echo-planar DWI if suspected cholesteatoma) can be used to evaluate the extent of peripheral labyrinthine or intracranial involvement .
A prospective study showed that perfusion-weighted imaging (PWI) may contribute to identification of ischemic strokes especially in those with initially negative DWI .

Vertigo (Recent Onset)