Limited usefulness of routine head and neck CT angiogram in the imaging assessment of dizziness in the emergency department

Abstract

Objective To assess the usefulness of head and neck computed tomography angiogram for the investigation of isolated dizziness in the emergency department in detecting significant acute findings leading to a change in management in comparison to non-contrast computed tomography scan of the head. Methods Patients presenting with isolated dizziness in the emergency department investigated with non-contrast computed tomography and computed tomography angiogram over the span of 36 months were included. Findings on non-contrast computed tomography were classified as related to the emergency department presentation versus unrelated/no significant abnormality. Similarly, computed tomography angiogram scans were classified as positive or negative posterior circulation findings. Results One hundred and fifty-three patients were imaged as a result of emergency department presentation with isolated dizziness. Fourteen cases were diagnosed clinically as of central aetiology. Non-contrast computed tomography was positive in three patients, all with central causes with sensitivity 21.4%, specificity 100%, positive predictive value 100%, negative predictive value 92.6% and accuracy 92.8%. Computed tomography angiogram was positive for angiographic posterior circulation abnormalities in five cases, and only two of them had a central cause of dizziness, with sensitivity 14.3%, specificity 97.7%, positive predictive value 40%, negative predictive value 91.46% and accuracy 92.1%. Conclusion Both non-contrast computed tomography and computed tomography angiogram of the head and neck have low diagnostic yield for the detection of central causes of dizziness, However, non-contrast computed tomography has higher sensitivity and positive predictive value than computed tomography angiogram, implying a lack of diagnostic advantage from the routine use of computed tomography angiogram in the emergency department for the investigation of isolated dizziness. Further studies are required to determine the role of computed tomography angiogram in the work-up of isolated dizziness in the emergency department.

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

“…Our systematic review identified a single retrospective study of 153 patients with undifferentiated dizziness, in whom the attending physician decided (for unspecified reasons) to perform a head and neck CTA. The CTA showed findings in five patients but only two of them (2/153, 1.3%) had findings that were causing their dizziness 44 . Indirect evidence of CTA is consistent with this finding.…”

Diagnostic accuracy of neuroimaging in emergency department patients with acute vertigo or dizziness: A systematic review and meta‐analysis for the guidelines for reasonable and appropriate care in the emergency department

“…5,20,23 three studies evaluated the outcome of all central causes, with sensitivity ranging from 21.4% to 43.4% and specificity ranging from 90% to 100%. 19,21,22 Meta-analysis revealed a pooled sensitivity of 28.5% (95% CI 14.4%-48.5%), specificity of 98.9% (95% CI 93.4%-99.8%), positive likelihood ratio (LR) of 26.2 (95% CI 5.6-123.4), and negative LR of 0.72 (95% CI 0.58-0.91). When a subgroup of the four studies with a high risk of bias was analyzed, sensitivity estimates increased slightly to 38.8% (95% CI 25.6%-53.8%) without a significant change in specificity (Table 3).…”

Enfoque del mareo y vértigo en el servicio de urgencias

“…Según Guarnizo et al (18), tanto la TAC sin contraste como la angiografía por tomografía computarizada (ATC) de la cabeza y el cuello tienen un bajo rendimiento diagnóstico para la detección de causas centrales de mareos. La TAC de cráneo simple presentó una sensibilidad del 21,4 % y una especificidad del 100 %; mientras que la ATC presentó una sensibilidad del 14,3 % y una especificidad del 97,7 % en la identificación de causas centrales de vértigo/mareo.…”