Imaging recommendation · Neuro · Head & Neck

Vertigo with neuro signs or persistent / atypical

Q: What's the alternative imaging for vertigo with neuro signs or persistent / atypical when acute vestibular syndrome with central hints findings?

MRI — MRI Brain (urgent posterior fossa focus) (iv contrast).

Q: What's the alternative imaging for vertigo with neuro signs or persistent / atypical when mri unavailable, suspected posterior circulation stroke?

CT — CT Head + CTA Head/Neck (iv contrast).

Recommended: MRI Brain (including IACs) with and without contrast is the preferred imaging study for vertigo with neuro signs or persistent / atypical. Imaging not needed for typical BPPV.

Recommended study

MRI Brain (including IACs) with and without contrast

MRI IV contrast Preferred Neuro · Head & Neck EmergencyAcute inpatientOutpatient Reviewed 2026-05

Imaging not needed for typical BPPV. Use HINTS exam to distinguish peripheral from central. Image for any central features.

If the default doesn't apply

Acute vestibular syndrome with central HINTS findings

MRI MRI Brain (urgent posterior fossa focus) IV contrast

MRI unavailable, suspected posterior circulation stroke

CT CT Head + CTA Head/Neck IV contrast

Watch-outs

Cerebellar stroke can mimic peripheral vertigo

HINTS exam (Head Impulse, Nystagmus, Test-of-Skew) is more sensitive than MRI in first 24-48h for posterior circulation stroke.

Headache + vertigo + risk factors

Consider vertebral artery dissection; image with CTA / MRA neck.

Pearls

BPPV: Dix-Hallpike provokes; Epley resolves. No imaging needed.
Routine non-contrast CT misses ~80% of posterior circulation strokes — MRI is the test of choice when stroke is suspected.
Isolated vertigo without other neuro findings is rarely stroke (< 1%) — but HINTS-negative patients warrant imaging.