The differentiation between peripheral vertigo and central vertigo can be exceedingly difficult as symptoms of both clinical entities largely overlap. This diagnostic dilemma can be particularly painful for Emergency Medicine physicians and their patients as the workup for central vertigo rules out "can't miss" pathology with imaging that typically takes hours to obtain. This post aims to reconcile a trend in Emergency Medicine where a significant proportion of physicians set out to rule out central vertigo however ultimately order the wrong imaging tests or an incomplete version of the "right" imaging tests. Not only is ordering the right imaging tests to evaluate central vertigo best for the patient, but also there is a large number of malpractice cases where the physician considered the right diagnosis but ordered the wrong imaging test.

This post does not aim to identify why wrong or incomplete workups for central vertigo exist, however an unfamiliarity with MRI imaging and/or lack of consderation of the clinical entities that cause central vertigo undoubtedly must play a role. While Chiari malformation, Multiple Sclerosis, and atypical seizures can present as central vertigo, the more common and emergent dianoses to exclude include:

• Vertebrobasilar Arterial Insuffiency (TIA, embolic stroke, dissection, physical occlusion)
• Cerebellar Ischemia or Hemorrhage
• Brainstem Ischemia

To put it simply, you want to look at the arteries of the vertebrobasilar system (which include the arteries of the head and neck) and the brain.

Correct Imaging Tests:

1. MRI Brain With and Without Contrast
2. MRA Head
3. MRA Neck
   

If MRI imaging cannot be obtained, proceed with CT imaging however the diagnostic yield drops off dramatically.