Radiological and intraoperative findings of a rare case of vestibular paroxysmia.

Vestibular paroxysmia (VP) is a rare condition. The pathogenesis is linked to a neurovascular conflict (NVC) between an abnormal arterial loop and the VII/VIII cranial nerve complex in the cerebello-pontine angle. Due to its rarity, intraoperative findings are only anecdotally reported. Here we reported on a case of VP, showing the radiological images and the intraoperative surgical video of microvascular decompression (MVD). Further we discussed our findings considering the pertinent literature. We think that in case of VP the concordance between the side of tinnitus/hypoacusia and the side of NVC on magnetic resonance imaging should be always looked for before considering MVD as a therapeutic option.

The patient with acute vertigo - the role of clinical examination and imaging.

Vertigo/dizziness or balance disorders are among the most common patients complaints in emergency clinics. Up to 25% of them are potentially life-threatening, especially cardiovascular or cerebrovascular events. The combination of a careful history taking (triggers, duration of difficulties, associated symptoms) and the performance of a basic vestibular examination (nystagmus, oculomotor, head impulse test, positional maneuvers, standing and walking examination) leads to a reliable differentiation of central and peripheral vestibular etiology. Standardized diagnostic algorithms (HINTS, HINTS+, STANDING) are used to identify high-risk patients requiring urgent care. Imaging methods must be interpreted with caution to their low sensitivity in acute phase (sensitivity of non-contrast brain CT for ischemia in the posterior cranial fossa is only 16%, MRI of the brain is false negative in up to 20% of cases in stroke patients in the first 48 hours).

Diagnostic Contribution of Magnetic Resonance Imaging and Computerized Tomography in Patients with Unidentified Vertigo and Normal Neurologic Examination in Emergency Medicine.

Background: Vertigo and dizziness are common symptoms in patients presenting to emergency medicine (ED) clinics. Vertigo may be caused by peripheral or central origin. Routine imaging is not indicated; however, neuroimaging is increasing, and published studies have revealed a small number of positive findings on imaging modalities. Aims: The aim of this study was to investigate whether neurological imaging was necessary in patients classified as "unidentified vertigo," who were admitted to the emergency department with vertiginous complaints and not revealing typical peripheral vertigo findings and any neurological deficits. Materials and Methods: All patients with "dizzy symptoms" were included in the study. For patients who met the definition of "unidentified vertigo," experimental neurological imaging studies were done. Head computerized tomography (CT), magnetic resonance imaging (MRI) with gradient-echo sequences (GRE), and diffusion weighted images (DWI) were used for imaging. Patients who underwent neuroimaging in the ED were followed up for 6 months in Neurology and ENT clinics. Results: A total of 351 patients were included in the study. Experimental imaging was performed on 100 patients. CT detected a significant pathology associated with the vertigo complaint in only one patient. MRI results were similar to the CT results. MRI-GRE sequences showed some additional pathologies in 14 patients and 4 of them were thought to be related to vertiginous symptoms. None of the patients classified as "non-central causes of vertigo" in the neuroimaging group developed TIA or CVD during 6 months of follow-up. Conclusion: Head CT can be adequate to exclude life-threatening central pathology in "undifferentiated vertigo patients" and the addition of MRI did not add any diagnostic accuracy in ED management. Using the physical examination findings effectively to make a specific diagnosis may reduce misdiagnosis and improve resource utilization.

Changes in Cortical Activation During Dual-Task Walking in Individuals With and Without Visual Vertigo.

BACKGROUND AND PURPOSE: Persons with vestibular disorders are known to have slower gait speed with greater imbalance and veering during dual-task walking than healthy individuals, but the cerebral mechanisms are unknown. The purpose of this study was to determine whether individuals with visual vertigo (VV) have different cerebral activation during dual-task walking compared with control subjects. METHODS: Fourteen individuals with VV and 14 healthy controls (CON) were included (mean 39 years old, 85% women). A cross-sectional experimental study consisting of 4 combinations of 2 surfaces (even and uneven) and 2 task conditions (single- and dual-task) was performed. Participants walked over an even (level flooring) or uneven (wood prisms underneath carpeting) surface, either quietly or while reciting every other letter of the alphabet. Changes in cerebral activation over the bilateral prefrontal cortices were recorded using functional near-infrared spectroscopy during 4 task conditions relative to quiet standing. Gait speed and cognitive performance were recorded. RESULTS: There were no between-group differences in cognitive performance. Both groups slowed when walking on an uneven surface or performing a dual-task; participants in the VV group walked more slowly than those in the CON group in all conditions. Participants with VV had decreased cerebral activation in the bilateral prefrontal regions in comparison to CON participants in all conditions. DISCUSSION AND CONCLUSIONS: Participants with VV had lower prefrontal cortex activation than CON participants during dual-task walking. Lower cortical activity in those with VV may be due to shifted attention away from the cognitive task to prioritize maintenance of dynamic balance.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A303).

Isolated enhancement of the superior semi-circular canal on inner ear MRI: acute vestibular syndrome or superior semi-circular canal dehiscence?

PURPOSE: Recently, it has been reported that patients with acute vestibular syndrome (AVS) could present a marked enhancement of the semi-circular canals, involving mostly the superior semi-circular canals on delayed inner ear MRI. METHODS: We reported one patient having AVS and another one having superior semi-circular canal dehiscence syndrome (SCDS) who underwent delayed inner ear MRI performed 4 h after contrast media administration. RESULTS: On delayed inner ear MRI, a marked enhancement of the superior semi-circular canal was observed in both patients. Although the clinical presentation is clearly not the same, the co-existence between these two disorders is possible. For this reason, in patients with AVS, the presence of a marked enhancement of the superior semi-circular canal should rule out the presence of a co-existing SCDS on temporal bone CT, particularly if the patient reported cochlear symptoms such as pulsatile tinnitus and/or autophony. CONCLUSION: To our knowledge, this is the first report showing this finding on delayed inner ear MRI in a patient with SCDS. In AVS patients, this radiological anomaly could be particularly disturbing and should rule out the presence of a co-existing SCDS.

The Spectrum of Vestibular Migraine: Clinical Features, Triggers, and Examination Findings.

OBJECTIVE: To assess the ictal symptoms, interictal symptoms, psychiatric comorbidities, and interictal neuro-otologic examination findings in vestibular migraine (VM). METHODS: Retrospective chart review of 491 patients seen from August 2014 until March 2018 at a tertiary neurology referral center for vestibular disorders to identify patients fulfilling the 2012 VM criteria. RESULTS: One hundred and thirty-one patients (105 women) were identified. Mean age of VM onset was 44.3 (±13.7) years. Preceding the onset of vestibular symptoms, most had migraine (57.3%) and motion sickness (61.1%). It was common to have a family history of migraine (50.8%) and episodic vestibular symptoms (28.1%). Common ictal symptoms were triggered (visually induced and head-motion) and spontaneous vertigo, accompanied by photophobia and phonophobia (118/131 [90.1%] patients), nausea (105/131 [80.2%] patients), aural symptoms (79/131 [60.3%] patients), and headache (65/131 [49.6%] patients). Interictally, many experienced visually induced (116/131 [88.6%] patients), head-motion (86/131 [65.6%] patients), and persistent (67/131 [51.1%] patients) dizziness. Psychiatric comorbidities include anxiety (92/131 [70.2%] patients), depression (53/131 [40.5%] patients), insomnia (38/131 [29.0%] patients), phobic disorders (15/131 [11.5%] patients), and psychogenic disorders (11/131 [8.4%] patients). Common triggers were stress (52/131 [39.7%] patients), bright lights (35/131 [26.7%] patients), weather changes (34/131 [26.0%] patients), and sleep deprivation (34/131 [26.0%] patients). Interictal neuro-otologic examination was abnormal in 56/131 (42.7%), usually hyperventilation-induced, head-shaking-induced, vibration-induced, and positional nystagmus. The most common balance-test finding was impaired sharpened Romberg's test (22/130 [16.9%] patients). CONCLUSIONS: In this single center study, we found that VM typically affects women in their 40s, with a personal and family history of migraine. Typical ictal symptoms were triggered and spontaneous vertigo, associated with photophobia and phonophobia, nausea, aural symptoms, and headache. Interictal vestibular symptoms, comorbid psychiatric disorders, and non-specific interictal neuro-otologic findings were common.

The correlation between SNPs within the gene of adrenergic receptor and neuropeptide Y and risk of cervical vertigo.

BACKGROUND: The current investigation was aimed to explore the potential associations of SNPs within ADRB2, ADRB1, NPY, and ADRA1A with risk and prognosis of cervical vertigo. METHODS: Altogether 216 patients with cervical vertigo and 204 healthy controls were gathered, and their DNAs were extracted utilizing the whole-blood DNA extraction kit. Besides, the PCR reactions were conducted using the TaqManR single nucleotide polymorphism (SNP) genotyping assays, and the SNPs were detected on the 7900HT real-time fluorogenic quantitative polymerase chain reaction (PCR) instrument. Finally, the severity of cervical vertigo was classified according to the JOA scoring, and the recovery rate (RR) of cervical vertigo was calculated in light of the formula as: [Formula: see text] RESULTS: The SNPs within ADRA1A [rs1048101 (T>C) and rs3802241 (C>T)], NPY [rs16476 (A>C), rs16148 (T>C), and rs5574 (C>T)], ADRB1 [rs28365031 (A>G)] and ADRB2 [rs2053044 (A>G)] were all significantly associated with regulated risk of cervical vertigo (all P < .05). Haplotypes of ADRA1A [CT and TC] and NPY [CCT and ATT] were also suggested as the susceptible factors of cervical vertigo in comparison with other haplotypes. Furthermore, the SNPs within ADRA1A [rs1048101 (T>C)], NPY [rs16476 (A>C), rs16148 (T>C)], as well as ADRB1 [rs28365031 (A>G)] all appeared to predict the prognosis of cervical vertigo in a relatively accurate way (all P < .05). Ultimately, the haplotypes of ADRA1A (CC) and NPY (CCT) tended to decrease the RR. CONCLUSIONS: The SNPs within ADRB2, ADRB1, NPY, and ADRA1A might act as the diagnostic biomarkers and treatment targets for cervical vertigo.

Pathogenetic Role of Endothelial Dysfunction in Idiopathic Vestibulopathy.

Comparative analysis of the groups of patients with idiopathic bilateral vestibular hypofunction and a group of vestibulopathy patients with vertebrobasilar insufficiency demonstrated identity of the basic and additional diagnostic parameters in these syndromes as well as similarity in clinical diagnostic and anamnesis data. In all cases, functional assessment of endothelium-dependent vasodilation and selected biochemical marker sICAM-1 revealed endothelial dysfunction. Drug correction of endothelial dysfunction positively affected the manifestations of major and minor features of the syndrome, which confirmed the contribution of endothelial functional disturbances to the pathogenesis of bilateral vestibular hypofunction.

Neurosonology Accuracy for Isolated Acute Vestibular Syndromes.

OBJECTIVES: The clinical approach to acute vestibular syndromes is often complex for the physician. Neurosonology offers a noninvasive method to study the cervicocephalic circulation when a vascular etiology is suspected. We aim to evaluate the diagnostic accuracy of a vascular neurosonological exam in isolated acute vestibular syndrome. METHODS: All patients submitted to cerebrovascular ultrasound and magnetic resonance imaging during the period between 2011 and 2015 with acute isolated vestibular syndrome. Those with any clinical sign of brainstem lesion on presentation were excluded. All patients performed the neuroimaging study (brain computed tomography and magnetic resonance imaging) and neurologic surveillance. Neurosonological exam included all intra- and extracranial segments of the vertebrobasilar circulation. Positive ultrasound exam was defined as the presence of stenotic or occlusive disease in any of these segments related to the infarcted area. RESULTS: A total of 108 patients were included: 60 (53.6%) were males (mean age: 60.75 years (standard deviation, 14.17)). In 27 patients (25.0%) a cerebral ischemic lesion was found to be the cause of the vertigo. Neurosonological assessment showed a sensitivity of 40.7% (95% confidence interval (CI): 22.4; 61.2), specificity of 100% (95% CI: 95.5; 100.0), positive predictive value (PPV) of 100% (95% CI: 71.5; 100.0), and negative predictive value (NPV) of 83.5% (95% CI: 74.6; 90.3). CONCLUSIONS: Our study suggests that cerebrovascular ultrasound is a highly specific method for the diagnosis of cerebrovascular vertigo. However, its low sensitivity makes it a poor candidate for screening.

Vertebral Artery Hypoplasia and Posterior Circulation Infarction in Patients with Isolated Vertigo with Stroke Risk Factors.

BACKGROUND: We aimed in this study to investigate the prevalence of vertebral artery hypoplasia (VAH) in a population with isolated vertigo in association with stroke risk factors, to determine whether VAH is an independent risk factor for posterior circulation infarction (PCI). METHODS: We sequentially enrolled 245 patients with isolated vertigo with at least 1 vascular risk factor, who were divided into PCI and non-PCI groups, according to present signs of acute infarction on diffusion-weighted magnetic resonance imaging. All patients underwent magnetic resonance angiography and cervical contrast-enhanced magnetic resonance angiography to screen for VAH. Univariate and multivariate logistic regression analyses were performed to identify the significant risk factors for PCI. RESULTS: VAH was found in 64 of 245 patients (26%). VAH (odds ratio [OR] = 2.70, 95%confidence interval [CI] 1.17-6.23, P = .020), median stenosis of the posterior circulation (OR = 7.09, 95%CI = 2.54-19.79, P < .001), and diabetes mellitus (OR = 3.13, 95%CI 1.38-7.12, P = .006) were independent risk factors for PCI. The predominant Trial of Org 10172 in Acute Stroke Treatment subtype in our patients with isolated vertigo with PCI complicated by VAH was mainly small-artery occlusion. CONCLUSIONS: Our findings suggest that VAH is an independent risk factor for PCI in patients with isolated vertigo with confirmed risk from stroke.

Evalution of the effectiveness of multimodal approach to the management of cervical vertigo.

INTRODUCTION: Vertigo is one of the most common complaints among patients consulting neurologists and general practitioners - family medicine. A special form of dizziness is cervical vertigo. However, the presence of chronic vertigo and imbalance in this group of patients makes it possible to include the treatment of vestibular rehabilitation in the program. AIM: Evalution of the effectiveness of multimodal approach to the management of cervical vertigo. MATERIAL AND METHODS: 109 patients aged from 18 to 45 with vertigo together with myofascial pain syndrome of neck and shoulder area were examined. The survey included a sample of Dix-Hallpike, neurological and otoneurological examinations, Doppler ultrasound of the main arteries of the head and neck, brain MRI, functional spondylography of the cervical spine. For quantitive evaluation of the impact of vertigo on daily life the questionnaire DHI (Dizziness Handicap Inventory) was used. Testing was performed in two stages - before treatment and in 2 weeks' time. Patients were randomly divided into 3 groups which differ in their therapeutic tactics. RESULTS: In all three groups the normalization of the biomechanical pattern and elimination of musculo-tonic disorders accompanied by a decrease of a pain syndrome and a decrease in the severity or complete regression of dizziness and postural instability. At the same time, in groups 2 and 3, in which in addition to manual therapy, patients received acupuncture, there was a distinct positive dynamics of a pain syndrome according to VAS, Neck Disability Index and the Dizziness Handicap Inventory. A marked regression of vertigo and postural instability can be observed in patients in which the treatment along with manual therapy and acupuncture, a complex of vestibular rehabilitation was used. CONCLUSIONS: The multimodal approach using manual therapy in combination with acupuncture and vestibular rehabilitation showed the maximum therapeutic effect on elimination of musculo-tonic disorders, reduction of a pain syndrome with a complete regression of vertigo and postural instability.

Progressive multifocal leukoencephalopathy in a patient without apparent immunosuppression.

Progressive multifocal leukoencephalopathy (PML) is a viral demyelinating disease due to the reactivation of the JC virus (JCV), which usually occurs in the context of immunosuppression in HIV infection, malignancy, or in patients on disease modifying therapy for autoimmune diseases, such as multiple sclerosis (MS) and Crohn's disease. Notably, there is growing recognition that PML can occur in patients with transient immune dysfunction. Here, we present a case of a 55-year-old man without history of immunosuppression or evidence of ICL who was diagnosed with PML on brain biopsy. We will discuss the potential etiologies of mild and transient immunosuppression that can lead to PML with non-apparent immunosuppression.

Recent Advances in Cerebellar Ischemic Stroke Syndromes Causing Vertigo and Hearing Loss.

Cerebellar ischemic stroke is one of the common causes of vascular vertigo. It usually accompanies other neurological symptoms or signs, but a small infarct in the cerebellum can present with vertigo without other localizing symptoms. Approximately 11 % of the patients with isolated cerebellar infarction simulated acute peripheral vestibulopathy, and most patients had an infarct in the territory of the medial branch of the posterior inferior cerebellar artery (PICA). A head impulse test can differentiate acute isolated vertigo associated with PICA territory cerebellar infarction from more benign disorders involving the inner ear. Acute hearing loss (AHL) of a vascular cause is mostly associated with cerebellar infarction in the territory of the anterior inferior cerebellar artery (AICA), but PICA territory cerebellar infarction rarely causes AHL. To date, at least eight subgroups of AICA territory infarction have been identified according to the pattern of neurotological presentations, among which the most common pattern of audiovestibular dysfunction is the combined loss of auditory and vestibular functions. Sometimes acute isolated audiovestibular loss can be the initial symptom of impending posterior circulation ischemic stroke (particularly within the territory of the AICA). Audiovestibular loss from cerebellar infarction has a good long-term outcome than previously thought. Approximately half of patients with superior cerebellar artery territory (SCA) cerebellar infarction experienced true vertigo, suggesting that the vertigo and nystagmus in the SCA territory cerebellar infarctions are more common than previously thought. In this article, recent findings on clinical features of vertigo and hearing loss from cerebellar ischemic stroke syndrome are summarized.

Posterior semicircular canal dehiscence secondary to jugular enlargement.

Semicircular canal dehiscence is an important entity often presenting with symptoms of noise or pressure induced vertigo, autophony, aural fullness and conductive hearing loss. Due to its varied presentation and mimic of other otologic conditions its consideration is of increased importance. Within we report a case of right sided posterior semicircular canal dehiscence secondary to an enlarged and high jugular bulb. The results of this observation indicate a need for patients with auditory symptoms and high riding jugular bulbs to be evaluated for possible posterior semicircular canal dehiscence.

Missed strokes using computed tomography imaging in patients with vertigo: population-based cohort study.

BACKGROUND AND PURPOSE: The purpose of this study was to determine the proportion of emergency department (ED) patients with a diagnosis of peripheral vertigo who received computed tomography (CT) head imaging in the ED and to examine whether strokes were missed using CT imaging. METHODS: This population-based retrospective cohort study assessed patients who were discharged from an ED in Ontario, Canada, with a diagnosis of peripheral vertigo, April 2006 to March 2011. Patients who received CT imaging (exposed) were matched by propensity score methods to patients who did not (unexposed). If performed, CT imaging was presumed to be negative for stroke because brain stem/cerebellar stroke would result in hospitalization. We compared the incidence of stroke within 30, 90, and 365 days subsequent to ED discharge between groups, to determine whether the exposed group had a higher frequency of early strokes than the matched unexposed group. RESULTS: Among 41 794 qualifying patients, 8596 (20.6%) received ED head CT imaging, and 99.8% of these patients were able to be matched to a control. Among exposed patients, 25 (0.29%) were hospitalized for stroke within 30 days when compared with 11 (0.13%) among matched nonexposed patients. The relative risk of a 30- and 90-day stroke among exposed versus unexposed patients was 2.27 (95% confidence interval, 1.12-4.62) and 1.94 (95% confidence interval, 1.10-3.43), respectively. There was no difference between groups at 1 year. Strokes occurred at a median of 32.0 days (interquartile range, 4.0-33.0 days) in exposed patients, compared with 105 days (interquartile range, 11.5-204.5) in unexposed patients. CONCLUSIONS: One fifth of patients diagnosed with peripheral vertigo in Ontario received imaging that is not recommended in guidelines, and that imaging was associated with missed strokes.

Diagnostic yield and impact of MRI for acute ischaemic stroke in patients presenting with dizziness and vertigo.

AIM: To identify predictors of acute ischaemic stroke (AIS) and evaluate the diagnostic yield and impact of magnetic resonance imaging (MRI) in patients imaged for dizziness and vertigo. MATERIALS AND METHODS: Patients imaged using MRI, including diffusion-weighted imaging (DWI) with or without computed tomography (CT), for dizziness and vertigo over a 2-year period were identified retrospectively. MRI findings were categorised as "acute ischaemic stroke", "significant", or "non-significant". We reviewed the medical records to identify presenting symptoms and signs, vascular risk factors, duration of symptoms, and pre- and post-MRI clinical management in patients with proven stroke. RESULTS: One hundred and eighty-eight patients were included: 39 with vertebrobasilar AIS (20.7%), 32 (17%) with a significant but non-ischaemic abnormality, and 117 (62.2%) with a normal or non-related abnormality. The sensitivity of CT in diagnosing AIS was 9.52% (95% CI: 1.67-31.8%). Posterior inferior cerebellar artery (PICA) territory infarcts were the most common (38.5%). Patients with AIS were significantly more likely to be older than 50 years (p = 0.04), have a greater number of cardiovascular risk factors (p < 0.01), shorter duration of symptoms (p = 0.03), and at least one neurological sign (p = 0.02). DWI MRI had a diagnostic impact on 21.6% patients with stroke. CONCLUSION: MRI plays an important role in differentiating peripheral and central aetiology when this proves challenging clinically. Predictors of AIS were identified that aid patient selection for MRI, to increase the yield and impact of neuroimaging.

Two case reports of bilateral vertebral artery tortuosity and spiral twisting in vascular vertigo.

BACKGROUND: Tortuous blood vessels are commonly seen in the cerebral arteries. The association between vertebrobasilar artery tortuosity and vascular vertigo remains obscure. CASE PRESENTATION: We describe two patients with vascular vertigo who had bilateral curving and spiral looping in multiple segments of the vertebral arteries and also exhibited basilar artery tortuosity. Both patients had cerebrovascular risk factors and exhibited clinical features of vertigo with high severity, slow recovery, and recurrent tendencies. Contrast enhanced magnetic resonance angiography of the neck showed bilateral tortuosity in the V2 segments and spiral twisting in the V4 segments of the vertebral arteries, and basilar artery curving. No obvious sign of atherosclerotic stenosis was found in the vertebrobasilar arteries and no abnormalities were observed in the internal carotid arteries. Transcranial Doppler ultrasound showed decreased blood flow in tortuous vertebrobasilar arteries. Brainstem auditory evoked potentials showed that the interpeak latencies (IPL) of waves III-IV were prolonged, with a ratio of IPL III-V/IPL I-III > 1. CONCLUSIONS: Vertebrobasilar tortuosity in combination with cerebrovascular risk factors may lead to vascular vertigo in these patients.

New treatment of vertigo caused by jugular bulb abnormalities.

OBJECTIVE: Jugular bulb abnormalities can induce tinnitus, hearing loss, or vertigo. Vertigo can be very disabling and may need surgical treatments with risk of hearing loss, major bleeding or facial palsy. Hence, we have developed a new treatment for vertigo caused by jugular bulb anomalies, using an endovascular technique. PATIENTS: Three patients presented with severe vertigos mostly induced by high venous pressure. One patient showed downbeat vertical nystagmus during the Valsalva maneuver. The temporal-bone computed tomography scan showed a high rising jugular bulb or a jugular bulb diverticulum with dehiscence and compression of the vestibular aqueduct in all cases. INTERVENTION: We plugged the upper part of the bulb with coils, and we used a stent to maintain the coils and preserving the venous permeability. RESULTS: After 12- to 24-month follow-up, those patients experienced no more vertigo, allowing return to work. The 3-month arteriographs showed good permeability of the sigmoid sinus and jugular bulb through the stent, with complete obstruction of the upper part of the bulb in all cases. CONCLUSION: Disabling vertigo induced by jugular bulb abnormalities can be effectively treated by an endovascular technique. This technique is minimally invasive with a probable greater benefit/risk ratio compare with surgery.

Imaging Outcomes of Emergency MR Imaging in Dizziness and Vertigo: A Retrospective Cohort Study.

BACKGROUND AND PURPOSE: Patients exhibiting acute dizziness or vertigo often represent a diagnostic challenge, and many undergo neuroimaging for stroke detection. We aimed to demonstrate the imaging outcomes of first-line emergency MR imaging among patients with acute dizziness or vertigo and to determine the clinical risk factors for stroke and other acute pathology. MATERIALS AND METHODS: This retrospective study included consecutive patients with acute dizziness or vertigo referred for emergency MR imaging in a tertiary hospital during 5 years. We recorded and analyzed patient characteristics, relevant clinical information, and imaging outcomes. Risk score models were derived to predict which patients were more likely to present with positive MR imaging findings. RESULTS: A total of 1169 patients were included. Acute stroke was found in 17%; other clinically significant pathology, in 8% of patients. In 75% of the patients, emergency MR imaging showed no significant abnormalities. Risk factors for acute stroke included older age, male sex, and a prevalence of cardiovascular risk factors and neurologic signs. Isolated dizziness had no discriminative power on imaging outcomes, and 14% of these patients showed acute stroke. Risk scores had only moderate performance in predicting acute ischemic stroke (receiver operating characteristic area under curve = 0.75) or any significant pathology (receiver operating characteristic area under curve = 0.70). CONCLUSIONS: Acute dizziness and vertigo remain challenging even when emergency MR imaging is readily available. One in 4 patients had acute pathology on MR imaging. Predictors for acute pathology (older age, male sex, cardiovascular risk factors, and neurologic signs) may aid in patient selection for MR imaging, optimizing the yield and clinical impact of emergency neuroimaging. Low diagnostic yields of CT and internal acoustic canal MR imaging may offer an opportunity to reduce health care expenditures in the future.