Dizziness and Ataxia

Variant: 1 Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRA head and neck with IV contrast	Usually Not Appropriate	O
MRA head and neck without and with IV contrast	Usually Not Appropriate	O
MRA head and neck without IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine with IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine without and with IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine without IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal with IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal without and with IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal without IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
MRI head without and with IV contrast	Usually Not Appropriate	O
MRI head without IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone with IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone without and with IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone without IV contrast	Usually Not Appropriate	☢☢☢
CTA head and neck with IV contrast	Usually Not Appropriate	☢☢☢

Variant: 2 Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI head without IV contrast	May Be Appropriate	O
MRA head and neck with IV contrast	Usually Not Appropriate	O
MRA head and neck without and with IV contrast	Usually Not Appropriate	O
MRA head and neck without IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine with IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine without and with IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine without IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal with IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal without and with IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal without IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
MRI head without and with IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone with IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone without and with IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone without IV contrast	Usually Not Appropriate	☢☢☢
CTA head and neck with IV contrast	Usually Not Appropriate	☢☢☢

Variant: 3 Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI head without IV contrast	Usually Appropriate	O
MRA head and neck with IV contrast	May Be Appropriate (Disagreement)	O
MRA head and neck without and with IV contrast	May Be Appropriate (Disagreement)	O
MRA head and neck without IV contrast	May Be Appropriate (Disagreement)	O
MRI head without and with IV contrast	May Be Appropriate (Disagreement)	O
CT head without IV contrast	May Be Appropriate	☢☢☢
CTA head and neck with IV contrast	May Be Appropriate (Disagreement)	☢☢☢
MRI cervical and thoracic spine with IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine without and with IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine without IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal with IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal without and with IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal without IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone with IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone without and with IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone without IV contrast	Usually Not Appropriate	☢☢☢

Variant: 4 Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI head and internal auditory canal without and with IV contrast	Usually Appropriate	O
CT temporal bone without IV contrast	Usually Appropriate	☢☢☢
MRI head and internal auditory canal without IV contrast	May Be Appropriate	O
MRA head and neck with IV contrast	Usually Not Appropriate	O
MRA head and neck without and with IV contrast	Usually Not Appropriate	O
MRA head and neck without IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine with IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine without and with IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine without IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal with IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
MRI head without and with IV contrast	Usually Not Appropriate	O
MRI head without IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone with IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone without and with IV contrast	Usually Not Appropriate	☢☢☢
CTA head and neck with IV contrast	Usually Not Appropriate	☢☢☢

Variant: 5 Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRA head and neck with IV contrast	Usually Appropriate	O
MRA head and neck without and with IV contrast	Usually Appropriate	O
MRA head and neck without IV contrast	Usually Appropriate	O
MRI head without IV contrast	Usually Appropriate	O
CTA head and neck with IV contrast	Usually Appropriate	☢☢☢
MRI head without and with IV contrast	May Be Appropriate (Disagreement)	O
CT head without IV contrast	May Be Appropriate	☢☢☢
MRI cervical and thoracic spine with IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine without and with IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine without IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal with IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal without and with IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal without IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone with IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone without and with IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone without IV contrast	Usually Not Appropriate	☢☢☢

Variant: 6 Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI head without and with IV contrast	Usually Appropriate	O
MRI head without IV contrast	Usually Appropriate	O
MRI cervical and thoracic spine without IV contrast	May Be Appropriate	O
MRA head and neck with IV contrast	Usually Not Appropriate	O
MRA head and neck without and with IV contrast	Usually Not Appropriate	O
MRA head and neck without IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine with IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine without and with IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal with IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal without and with IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal without IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone with IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone without and with IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone without IV contrast	Usually Not Appropriate	☢☢☢
CTA head and neck with IV contrast	Usually Not Appropriate	☢☢☢

Variant: 7 Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI cervical and thoracic spine without and with IV contrast	Usually Appropriate	O
MRI cervical and thoracic spine without IV contrast	Usually Appropriate	O
MRA head and neck with IV contrast	Usually Not Appropriate	O
MRA head and neck without and with IV contrast	Usually Not Appropriate	O
MRA head and neck without IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine with IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal with IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal without and with IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal without IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
MRI head without and with IV contrast	Usually Not Appropriate	O
MRI head without IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone with IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone without and with IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone without IV contrast	Usually Not Appropriate	☢☢☢
CTA head and neck with IV contrast	Usually Not Appropriate	☢☢☢

Variant: 8 Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.

Procedure	Appropriateness Category	Relative Radiation Level
MRI head without IV contrast	May Be Appropriate	O
MRA head and neck with IV contrast	Usually Not Appropriate	O
MRA head and neck without and with IV contrast	Usually Not Appropriate	O
MRA head and neck without IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine with IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine without and with IV contrast	Usually Not Appropriate	O
MRI cervical and thoracic spine without IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal with IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal without and with IV contrast	Usually Not Appropriate	O
MRI head and internal auditory canal without IV contrast	Usually Not Appropriate	O
MRI head with IV contrast	Usually Not Appropriate	O
MRI head without and with IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone with IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone without and with IV contrast	Usually Not Appropriate	☢☢☢
CT temporal bone without IV contrast	Usually Not Appropriate	☢☢☢
CTA head and neck with IV contrast	Usually Not Appropriate	☢☢☢

Panel Members

Lily L. Wang, MBBS, MPH^a; Trevor A. Thompson, MD^b; Robert Y. Shih, MD^c; Amna A. Ajam, MD, MBBS^d; Ketan Bulsara, MD^e; Judah Burns, MD^f; Melissa A. Davis, MD, MBA^g; Jana Ivanidze, MD, PhD^h; Aleks Kalnins, MD, MBAⁱ; Phillip H. Kuo, MD, PhD^j; Luke N. Ledbetter, MD^k; Jeffrey S. Pannell, MD^l; Jeffrey M. Pollock, MD^m; Vikram G. Shakkottai, MD, PhDⁿ; Richard D. Shih, MD^o; Bruno P. Soares, MD^p; Karl A. Soderlund, MD^q; Pallavi S. Utukuri, MD^r; Sarah Woolsey, MD, MPH^s; Bruno Policeni, MD, MBA^t.

Summary of Literature Review

Introduction/Background

Special Imaging Considerations

Initial Imaging Definition

Initial imaging is defined as imaging at the beginning of the care episode for the medical condition defined by the variant. More than one procedure can be considered usually appropriate in the initial imaging evaluation when:

There are procedures that are equivalent alternatives (i.e., only one procedure will be ordered to provide the clinical information to effectively manage the patient’s care)

There are complementary procedures (i.e., more than one procedure is ordered as a set or simultaneously wherein each procedure provides unique clinical information to effectively manage the patient’s care).

Discussion of Procedures by Variant

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
A. CT head with IV contrast

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
B. CT head without and with IV contrast

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
C. CT head without IV contrast

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
D. CT temporal bone with IV contrast

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
E. CT temporal bone without and with IV contrast

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
F. CT temporal bone without IV contrast

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
G. CTA head and neck with IV contrast

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
H. MRA head and neck with IV contrast

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
I. MRA head and neck without and with IV contrast

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
J. MRA head and neck without IV contrast

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
K. MRI cervical and thoracic spine with IV contrast

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
L. MRI cervical and thoracic spine without and with IV contrast

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
M. MRI cervical and thoracic spine without IV contrast

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
N. MRI head and internal auditory canal with IV contrast

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
O. MRI head and internal auditory canal without and with IV contrast

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
P. MRI head and internal auditory canal without IV contrast

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
Q. MRI head with IV contrast

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
R. MRI head without and with IV contrast

Variant 1: Adult. Brief episodic vertigo. Triggered by specific head movements (eg, Dix-Hallpike maneuver). Initial imaging.
S. MRI head without IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
A. CT head with IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
B. CT head without and with IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
C. CT head without IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
D. CT temporal bone with IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
E. CT temporal bone without and with IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
F. CT temporal bone without IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
G. CTA head and neck with IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
H. MRA head and neck with IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
I. MRA head and neck without and with IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
J. MRA head and neck without IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
K. MRI cervical and thoracic spine with IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
L. MRI cervical and thoracic spine without and with IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
M. MRI cervical and thoracic spine without IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
N. MRI head and internal auditory canal with IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
O. MRI head and internal auditory canal without and with IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
P. MRI head and internal auditory canal without IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
Q. MRI head with IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
R. MRI head without and with IV contrast

Variant 2: Adult. Acute persistent vertigo. Normal neurologic examination and HINTS examination examination consistent with peripheral vertigo. Initial imaging.
S. MRI head without IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
A. CT head with IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
B. CT head without and with IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
C. CT head without IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
D. CT temporal bone with IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
E. CT temporal bone without and with IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
F. CT temporal bone without IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
G. CTA head and neck with IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
H. MRA head and neck with IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
I. MRA head and neck without and with IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
J. MRA head and neck without IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
K. MRI cervical and thoracic spine with IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
L. MRI cervical and thoracic spine without and with IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
M. MRI cervical and thoracic spine without IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
N. MRI head and internal auditory canal with IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
O. MRI head and internal auditory canal without and with IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
P. MRI head and internal auditory canal without IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
Q. MRI head with IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
R. MRI head without and with IV contrast

Variant 3: Adult. Acute persistent vertigo. Abnormal neurologic examination or HINTS examination is consistent with central vertigo. Initial imaging.
S. MRI head without IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
A. CT head with IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
B. CT head without and with IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
C. CT head without IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
D. CT temporal bone with IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
E. CT temporal bone without and with IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
F. CT temporal bone without IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
G. CTA head and neck with IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
H. MRA head and neck with IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
I. MRA head and neck without and with IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
J. MRA head and neck without IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
K. MRI cervical and thoracic spine with IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
L. MRI cervical and thoracic spine without and with IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
M. MRI cervical and thoracic spine without IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
N. MRI head and internal auditory canal with IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
O. MRI head and internal auditory canal without and with IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
P. MRI head and internal auditory canal without IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
Q. MRI head with IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
R. MRI head without and with IV contrast

Variant 4: Adult. Chronic recurrent vertigo. Associated with unilateral hearing loss or tinnitus. Initial imaging.
S. MRI head without IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
A. CT head with IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
B. CT head without and with IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
C. CT head without IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
D. CT temporal bone with IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
E. CT temporal bone without and with IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
F. CT temporal bone without IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
G. CTA head and neck with IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
H. MRA head and neck with IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
I. MRA head and neck without and with IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
J. MRA head and neck without IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
K. MRI cervical and thoracic spine with IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
L. MRI cervical and thoracic spine without and with IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
M. MRI cervical and thoracic spine without IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
N. MRI head and internal auditory canal with IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
O. MRI head and internal auditory canal without and with IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
P. MRI head and internal auditory canal without IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
Q. MRI head with IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
R. MRI head without and with IV contrast

Variant 5: Adult. Chronic recurrent vertigo. Associated with other brainstem neurologic deficits. Initial imaging.
S. MRI head without IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
A. CT head with IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
B. CT head without and with IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
C. CT head without IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
D. CT temporal bone with IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
E. CT temporal bone without and with IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
F. CT temporal bone without IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
G. CTA head and neck with IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
H. MRA head and neck with IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
I. MRA head and neck without and with IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
J. MRA head and neck without IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
K. MRI cervical and thoracic spine with IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
L. MRI cervical and thoracic spine without and with IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
M. MRI cervical and thoracic spine without IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
N. MRI head and internal auditory canal with IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
O. MRI head and internal auditory canal without and with IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
P. MRI head and internal auditory canal without IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
Q. MRI head with IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
R. MRI head without and with IV contrast

Variant 6: Adult. Chronic disequilibrium with signs of cerebellar ataxia. Initial imaging.
S. MRI head without IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
A. CT head with IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
B. CT head without and with IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
C. CT head without IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
D. CT temporal bone with IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
E. CT temporal bone without and with IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
F. CT temporal bone without IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
G. CTA head and neck with IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
H. MRA head and neck with IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
I. MRA head and neck without and with IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
J. MRA head and neck without IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
K. MRI cervical and thoracic spine with IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
L. MRI cervical and thoracic spine without and with IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
M. MRI cervical and thoracic spine without IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
N. MRI head and internal auditory canal with IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
O. MRI head and internal auditory canal without and with IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
P. MRI head and internal auditory canal without IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
Q. MRI head with IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
R. MRI head without and with IV contrast

Variant 7: Adult. Chronic disequilibrium with signs of sensory or proprioceptive ataxia. Initial imaging.
S. MRI head without IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
A. CT head with IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
B. CT head without and with IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
C. CT head without IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
D. CT temporal bone with IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
E. CT temporal bone without and with IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
F. CT temporal bone without IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
G. CTA head and neck with IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
H. MRA head and neck with IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
I. MRA head and neck without and with IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
J. MRA head and neck without IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
K. MRI cervical and thoracic spine with IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
L. MRI cervical and thoracic spine without and with IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
M. MRI cervical and thoracic spine without IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
N. MRI head and internal auditory canal with IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
O. MRI head and internal auditory canal without and with IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
P. MRI head and internal auditory canal without IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
Q. MRI head with IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
R. MRI head without and with IV contrast

Variant 8: Adult. Nonspecific dizziness without vertigo, ataxia, or other neurologic deficits. Initial imaging.
S. MRI head without IV contrast

Summary of Highlights

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

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Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.