Predictors of false negative diffusion-weighted MRI in clinically suspected central cause of vertigo

Vertigo is classified as peripheral and central. Differentiation of stroke mimics is the most important diagnostic challenge. There is no clinical guidance for the indications of neuroimaging in isolated vertigo patients. The primary aim of this study is to test the diagnostic value of a DWI-MRI protocol to rule-out a central cause in patients with acute isolated vertigo in the ED.

We prospectively enrolled 144 patients who were presented with isolated vertigo to the ED. A detailed neurological examination and maneuvers were performed for differential diagnosis. All patients underwent CT and/or DW-MRI either during ED visit or at the follow-up, if necessary. Out-patient follow-up exams and evaluations were repeated until all patients had a definitive diagnosis.

In the study, 137 of the 144 patients completed the follow-up period, and 34 of 137 patients were diagnosed with central vertigo. Six of 34 central vertigo patients had normal DW-MRI findings. One was diagnosed with migraine headache and five with vertebra-basilar insufficiency during the out-patient follow-up. One of the 28 patients with a pathological MRI was diagnosed with mass and the rest was stroke. The utility of DW-MRI in vertigo patients was moderately high (sensitivity: 82%, specificity: 100%). We found that age, history of HT, history of CAD and vertigo unresponsive to ED treatment were significantly associated with a central cause of vertigo.

We suggest that unresponsiveness to ED treatment, especially in patients with a history of HT and CAD, should alert physicians for central causes and warrant DW-MRI imaging.