The prognosis of unidentified vertigo patients in emergency department and the diagnostic value of MR imaging

Introduction and Purpose: Vertigo is a subjective complaint and is one of the frequent complaints among the ED patient presentations. In the EDs, physicians are excessively using head CT and MRI to diagnose vertigos originating from central pathology. In this study; experimental imaging's (head CT and MRI in different sequences) were conducted to the patients who have physical examination symptoms other than central neural system originated vertigo and other than BPPV. Prognoses of patients were recorded by directing them to the neurology and ENT outpatient clinics after their examinations and treatments were completed in the ED. Thus, prognoses of 100 patients with vertigo and the diagnostic value of experimental imaging's of these patients were evaluated. Methods: This research was carried out in Akdeniz University Faculty of Medicine ED as a prospective analytical and cross-sectional study on patients presented between 04/04/2016 and 06/09/2016. Experimental radiologic examinations in this research were decided to be Computed Head Tomography, Conventional Cranial and Gradient sequence Echo MRI and Diffusional MR. A study form (Appendix 1) was filled out for each patient presented to the ED with "dizzyness" as a chief complain. Patients were then examined by EM physicians and their complaints were decided whether they are primarily "vertigo" or not. Patients with matching our criteria were included to research and accepted as "unidentified vertigo" and then, experimental imaging's were obtained. After physical examinations and treatments, patients were either discharged or hospitalized at the discretion of the physicians following the cases. Discharged patients were provided with close follow-up by Neurology and ENT polyclinics. Patients were monitored for their first, third and sixth month diagnoses; their repeat presentations; treatment response and other diagnostic data via telephone or outpatient clinic records. Results: In our research, most of the patients (60%) applied to the ED with "dizzyness" were females. This ratio was 59% and 61% in patients experimental imaging obtained and in patients with no imagining obtained, respectively. Mean age of all patients was 47 while, it was 54 and 44 for experimental imaging obtained and non-obtained patients, respectively. Only one of the 100 patients (1%) who were scanned by experimental imaging is found to have significant pathology on head CT. This pathological finding was interpreted as "Acute Hydrocephalia and Cerebellar Mass". Conventional Cranial MRI, -applied for experimental purposes- results showed no significant pathology that would lead to any change of the ED management or treatment of any patients subjected in the research (other than the hydrocephalus case). Vertigo-related pathologies, which did not require hospitalization of patients in Neurology Service and can be followed ambulatory, were detected only on 4 patients by Gradient Sequence Echo MRI and their Conventional Cranial MRI results were found to be normal. As for the Diffusion MRI results; no findings were reported in favor of ischemia on any of the patients. 51% of the experimentally scanned patients were discharged with diagnosis of BPPV and/or provided with outpatient clinic follow-up. 2 of the 7 patients monitored with central pathology were hospitalized due to pre-diagnosis of TIA, after neurology consultation in the ED. Remaining 5 patients were discharged for ambulatory follow up for further work up of their clinical conditions. The final diagnoses of these 7 patients were determined as 3 temporary ischemic attack, 1 epileptic seizure and 3 vestibular migraine. Conclusion: Head CT imaging in Unidentified Vertigo patients in the ED is singly sufficient for detection of central pathologies. MRI in the patients having central examination symptoms mostly does not have instructive properties in providing additional information. Hospitalization should be suggested for the patients with neurological deficit, without requirement of Cranial or Diffusion MRI. In a similar manner, ED physicians should not decide to discharge a patient who does not have pathologic neurological symptoms, and yet suffering from vertigo, solely based on the result of Diffusion MRI obtained in the ED. More than half of the Unidentified Vertigo cases are originated from BPPV. Patients who don't have pathological neurological symptoms, can be evaluated in terms of central pathology in neurology outpatient clinic, in early period, after head CT in the ED shows no pathologies. Further imaging techniques can be obtained in outpatient clinics. What really matters is the positive neurological examination findings, rather than MRI results.