Should patients with benign positional vertigo be imaged?

Unexpected intra-cranial pathology is unusually encountered in patients with BPV in the presence of a classically positive Hallpike's response and in the absence of any other neurological signs or symptoms. We carried out a retrospective review to assess the incidence of unexpected intra-cranial pathology in patients with a clinical diagnosis of benign positional vertigo (BPV) and to review the role of radiological imaging in these patients. 145 consecutive patients seen by the senior author with a diagnosis of posterior semi-circular canal BPV over a five-year period were reviewed. In the series of 63 patients who underwent MRI, two cases (3.2%) had cerebral aneurysms, one patient had an epidermoid cyst (1.58%) and one patient had a large right parietal arterio-venous malformation. We would conclude that possible warning signs exist that may alert the clinician to the possibility of unexpected intracranial pathology including failed response to the initial Epley manoeuvre or any asymmetry in hearing. Thus, we would advocate imaging be performed on this sub-group of patients with BPV.