Value of Magnetic Resonance Imaging and Audiology in the Emergency Department in Differential Diagnosis of Peripheral and Central Vertigo

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1 ORİJİNAL ARAŞTIRMA Value of Magnetic Resonance Imaging and Audiology in the Emergency Department in Differential Diagnosis of Peripheral and Central Vertigo Engin ÖZAKIN, MD, Msc, a Figen COŞKUN, MD, Assoc.Prof., a Sarp SARAÇ, MD, Prof., b Kader KARLI OĞUZ, MD, Assoc.Prof., c Şebnem BOZKURT, MD, Msc a Departments of a Emergency Medicine, b ENT, c Radiology, Hacettepe University Faculty of Medicine, Ankara Ge liş Ta ri hi/re ce i ved: Ka bul Ta ri hi/ac cep ted: Ya zış ma Ad re si/cor res pon den ce: Engin ÖZAKIN, MD, Msc Hacettepe University Faculty of Medicine, Department of Emergency Medicine, Ankara, TÜRKİYE/TURKEY ABS TRACT Ob jec ti ve: Ver ti go is a com mon comp la int in the emer gency ro om. Ver ti go can be central or pe rip he ral in ori gin and it is im por tant for an emer gency physi ci an to ma ke a cor rect dif fe - ren ti al di ag no sis. The pur po se of our study was to emp ha si ze the ro le of cra ni al mag ne tic re so nan ce ima ging (MRI) and au di o lo gi cal tests in dif fe ren ti al di ag no sis of pa ti ents who pre sent with ver ti go to the emer gency ro om. Ma te ri al and Met hods: Fifty pa ti ents (31 fe ma le, 19 ma le, me an age ye ars) with ver ti go who we re ad mit ted to the Ha cet te pe Uni ver sity Fa culty of Me di ci ne Emergency Ro om (ER) bet we en and we re inc lu ded in the study. Physi cal and ne - u ro lo gi cal exa mi na ti ons of all pa ti ents we re per for med by se ni or re si dents and all pa ti ents we re eva lu a ted by Ear No se Thro at spe ci a lists. Au di o lo gic and ves ti bu lar tests and MRI with 3T (Tes la) mag ne tic fi eld po wer we re per for med in all pa ti ents. Re sults: Among 29 pa ti ents with nor mal ne - u ro lo gi cal exa mi na ti on, only 3 (10.3%) had le si ons on MRI. MRI scans re ve a led le si ons sug ges ting cen tral ver ti go eti o logy in six (18.2%) pa ti ents out of 33 with ab nor mal au di o lo gi cal test sug ges ting pe rip he ral ves ti bu lo pathy. Conc lu si on: In conc lu si on, in our pros pec ti ve study, ur gent cra ni al MRI tech ni qu e in pa ti ents pre sen ting to the emer gency ro om with ver ti go may re ve al sig ni fi cant fin dings re gar ding the dif fe ren ti al di ag no sis and con co mi tant pat ho lo gi es. Ho we ver, me ti cu lo us ne u ro lo gi - cal exa mi na ti on can exc lu de cen tral ver ti go in the ma jo rity of the pa ti ents. Key Words: Ver ti go; emer gen ci es; mag ne tic re so nan ce ima ging ÖZET Amaç: Baş dön me si, acil ser vis te sık kar şı la şı lan bir ya kın ma dır. Baş dön me si san tral ve ya pe - ri fe rik kay nak lı ola bi lir. Ça lış ma mı zın ama cı, acil ser vi se baş dön me si şikâye ti ile baş vu ran has ta - lar da kra ni yal man ye tik re zo nans gö rün tü le me (MRG) yön te mi nin ve od yo lo jik test le rin ayı rı cı ta nı da ki öne mi ni or ta ya koy mak tır. Ge reç ve Yön tem ler: Ça lış ma ya, ara - sın da baş dön me si ya kın ma sı ile Ha cet te pe Üni ver si te si Eriş kin Has ta ne si Acil Ser vi se baş vu ran 31 ka dın, 19 er kek (yaş or ta la ma la rı 50,84 yıl) top lam 50 has ta alın mış tır. Tüm has ta la rın fi zik ve nö - ro lo jik mu a ye ne si acil ser vis kı dem li he ki mi ta ra fın dan ya pı lıp, ku lak bu run bo ğaz (KBB) uz man - la rın ca de ğer len di ril miş tir. Tüm has ta la ra od yo ves ti bü ler tet kik le ri ya pıl mış ve 3 tes la man ye tik alan gü cü ne sa hip ci haz la MRG çe kil miş tir. Bul gu lar: Nor mal nö ro lo jik mu a ye ne ye sa hip 33 has - ta nın sa de ce 3 ün de (%10,3) MRG de lez yon mev cut tu. Pe ri fe rik ves ti bu lo pa ti dü şü nü len 33 has - ta nın 6 sın da san tral ver ti go ile iliş ki li lez yon sap tan dı. So nuç: So nuç ola rak, ile ri ye dö nük bu ça lış ma da, baş dön me si ile baş vu ran has ta lar da acil kra ni yal MRG yön te mi nin, ayı rı cı ta nı ve ek pa - to lo ji le re yö ne lik ola rak önem li bul gu lar sun du ğu gös te ril miş tir. An cak dik kat li bir nö ro lo jik mu - a ye ne ile has ta lı ğın san tral ver ti go ola sı lı ğı dış la na bi lir. Anah tar Ke li me ler: Ver ti go; acil ler; man ye tik re zo nans gö rün tü le me Turkiye Klinikleri J Med Sci 2012;32(1):1-6 doi: /medsci Cop yright 2012 by Tür ki ye Kli nik le ri ertigo is one of the most common complaints among patients referring to the emergency room (ER), and it is not always easy to define the underlying disorder because of the complexity of structure Turkiye Klinikleri J Med Sci 2012;32(1) 1

2 Özakın ve ark. and func ti o ning of the systems res pon sib le for the ba lan ce of the or ga nism. 1-3 Pa ti ents fre qu ently re - fer to the term ver ti go to de fi ne the ir va ri o us comp la ints, sin ce the ex tent of this term is not cle - arly de fi ned; the re fo re, ver ti go is a very com mon comp la int. The tru e equ i va lent for ver ti go in terms of ge ne ral pub lic is fe e ling un sa fe. 1,4 Alt ho ugh not a re al mo ti on, ver ti go is the exag ge ra ted or fic ti ti - o us sen sa ti on of mo ti on of the pa ti ent. 5,6 Pa ti ents can des cri be them sel ves as swa ying or mo ving or the sur ro un ding en vi ron ment as mo ving or ro om spin ning. Ver ti go can be con fu sed with diz zi ness, synco pe, ne ar-synco pe, ti red ness or so me psychi - at ric con di ti ons. 7,8 Kulak-Burun-Boğaz Hastalıkları Alt ho ugh the ob jec ti ve was to iden tify the underl ying eti o logy in pa ti ents pre sen ting with ver ti - go, this aim was not ac hi e ved di rectly. In the se si tu a ti ons, pa ti ent sho uld be eva lu a ted from ba sic to comp lex, pro ce e ding from un dif fe ren ti a ted systems to spe ci a li zed systems. The cli ni ci an sho uld try to dif fe ren ti a te the eti o logy of ver ti go, and to de fi ne whet her the pat ho logy ori gi na ted from ves - ti bu lar or ex tra-ves ti bu lar systems, de pen ding on the pa ti ent s his tory and back gro und. 9 La ter, he/she sho uld in ves ti ga te whet her the pe rip he ral or the cen tral ves ti bu lar system is in vol ved. Pa ti ents who se ne u ro lo gi cal exa mi na ti on suggests an in trac ra ni al event are as ses sed with cra ni - al com pu te ri zed to mog raphy (CCT). Ho we ver, CCT is not al ways help ful in the dis cri mi na ti on of pe rip he ral and cen tral ca u ses of ver ti go. CCT is not as sen si ti ve as mag ne tic re so nan ce ima ging (MRI) in iden ti fi ying in trac ra ni al con di ti ons that co uld cli ni cally pre sent with ver ti go such as ce re bel lar isc he mic le si ons, dem ye li ni zing di se a ses, in trac ra ni - al mass le si ons, pon to ce re bel lar le si ons, and mass le si ons of the 7 th and 8 th cra ni al ner ves. Be si des, in ca ses with a sus pi ci on of pe rip he ral ver ti go, MRI is elec ti vely plan ned af ter con sul ting the ear-no sethro at (ENT) de part ment. Ho we ver, elec ti ve MRI can ca u se a de lay in the di ag no sis in the se pa ti ents whe re early di ag no sis and tre at ment is es sen ti al for a low mor ta lity and mor bi dity. The re fo re, we ai med to iden tify the cri te ri a for ur gent as sess ment of au di o lo gi cal tests and MRI accor ding to da ta ob ta i ned with his tory and physi cal exa mi na ti on in pa ti ents re sen ting to the ER with ver ti go. We ho pe that the cri te ri a set in this study will fa ci li ta te the di ag no sis and tre at ment of con diti ons with high mor ta lity and mor bi dity wit ho ut de lay, sin ce au di o lo gi cal tests and MRI can not be run in every pa ti ent re fer ring to the ER du e to costef fec ti ve ness and ti me res tric ti ons. MA TE RI AL AND MET HODS Fifty con se cu ti ve pa ti ents re fer ring to the Ha cet te - pe Uni ver sity Hos pi tal Adult Emer gency Ro om bet we en and with ver ti go we re as ses sed pros pec ti vely. This study was ap pro - ved by the Lo cal Et hics Com mi te e of the Ha cet te - pe Uni ver sity. In for med con sents we re ob ta i ned from each pa ti ent. All pa ti ents pre sen ting with perip he ral and cen tral ver ti go we re inc lu ded in the study. Pa ti ents yo un ger than 16 ye ars, tho se with ver ti go du e to me ta bo lic and he ma to lo gi cal con di - ti ons, preg nant ca ses, pa ti ents with ver ti go with known eti o logy, uns tab le pa ti ents du e to ot her ca - u ses, and pa ti ents who we re not su i tab le for MRI we re exc lu ded from the study. Age, gen der, comp la int, on set of symptoms, his tory of pre vi o us at tack, me di ca ti ons, con co mi - tant ill nes ses, pre vi o us sur gery, and ha bits of the pa ti ents we re no ted. Inc lu ded pa ti ents we re as ses - sed and exa mi ned by emer gency ro om se ni or re si - dent and ob ta i ned da ta we re re cor ded in the pre vi o usly pre pa red forms. The pa ti ents we re consul ted with physi ci ans from the Ear-No se-thro at (ENT) de part ment and au di o ves ti bu lar tests we re per for med in the au di o logy unit pri or to ini ti a ti on of tre at ment. Au di o lo gi cal tests me a su red pu re spe ech au di o metry, acus tic ref lex, spe ech dis cri - man ti on sco res (SDS), and coch le ar sen si ti vity (dis tur ban ce from so und in ten sity of 90 de ci bel or less in he a ring test). Loss of he a ring in lo wer fre qu - en ci es and pre sen ce of coch le ar sen si ti vity in he a - ring tests we re con si de red in fa vor of pe rip he ral ves ti bu lo pathy. In ves ti bu lar tests, Rom berg test, ce re bel lar tests, wal king on a stra ight li ne, and Dix- Hall pi ke ma ne u ver we re per for med for po si ti o nal nystag mus. The se tests we re eva lu a ted by an ENT spe ci a list. Af ter ENT con sul ta ti on, the pa ti ents un- 2 Turkiye Klinikleri J Med Sci 2012;32(1)

3 Ear-Nose-Throat Diseases der went cra ni al MRI scre e ning with 3 tes la magne tic fi eld po wer mac hi ne (Al leg ra, Si e mens, Er lan gen, Ger many). First, T2-we igh ted Tur bo Spin-Ec ho ima ging met hod with 20 sli ces of 1 mm in ter vals and 5 mm thick ness on trans ver se pla in was ob ta i ned in or der to ru le out in trac ra ni al pat - ho lo gi es such as tu mor, dem ye li na ting di se a ses, hydro cep haly and cor ti cal in farc ti on (T2WTSE) (Ti me to re pe at (TR)/ec ho ti me (TE): 4000/100 msec, mat rix: 128x256). La ter, dif fu si on-we igh ted ima ging (DWI) ef fec ti ve in iden ti fi ca ti on of acu te isc he mic le si ons (TR/TE; 2800/78, b: 0,500/1000 mm 2 /sec) and thre e di men si o nal cons truc ti ve inter fe ren ce in ste ady sta te (CISS) for ima ging of ce - re bel lo pon ti ne ang le cysterns, in ter nal acus tic ca nals, mass le si ons of the 7 th and 8 th ner ve comp - le xes (TR/TE; 7.6/3.8. Flip ang le: 48 ) we re per for - med. Ima ges we re re vi e wed by a ne u ro ra di o lo gist. In ca se of pre sen ce of ot her in trac ra ni al pat ho lo gi - es, scan was re pe a ted ac cor ding to the le si ons detec ted. In pa ti ents di ag no sed with pe rip he ral ver ti go with a ne ga ti ve MRI re sult, ap prop ri a te tre - at ment was star ted with fol low-up by ENT con sul - ta ti on. Pa ti ents di ag no sed with cen tral ver ti go we re con sul ted to the re le vant de part ment and furt her tre at ment was pro vi ded. Me an stan dard was cal cu la ted to as sess the de mog rap hic fe a tu res of pa ti ents; Mar gi nal Homo ge ne ity Test and McNe mar Test we re used to com pa re the da ta. For all tests p< 0.05 was con si - de red sta tis ti cally sig ni fi cant. Sta tis ti cal da ta we - re used to find out which pa ti ents sho uld be eva lu a ted with au di o lo gi cal tests and MRI. SPSS for Win dows 15.0 sta tis ti cal soft wa re was used for analy sis of da ta. RE SULTS Fifty pa ti ents pre sen ting to the ER con se cu ti vely bet we en and we re inc lu ded in the study. Ni ne te en pa ti ents (38%) we re ma les, and 31 (62%) we re fe ma les. Me an age of the pa ti - ents was ye ars (mi ni mum 17 ye ars, ma xi mum 87 ye ars, me di an 50 ye ars). Thirty-thre e pa ti ents pre sen ted with ver ti go, na u se a and vo mit ting, 1 pa ti ent had tin ni tus, 5 pati ents had ear pres su re, 4 pa ti ents had tin ni tus and Özakın et al. ear pres su re, and 7 pa ti ents had tin ni tus and he a - ring loss. On set of symptoms was wit hin mi nu tes in 2 pa ti ents, wit hin ho urs in 40 pa ti ents, and wit hin days in 8 pa ti ents, and his tory of pre vi o us at tack was pre sent in 24 pa ti ents. His tory of me di ca ti on was ab sent in 31 pa ti ents, whe re as 9 pa ti ents we re on me di ca ti on for car di o vas cu lar system di se a ses, 2 pa ti ents for ne u ro lo gi cal system di se a ses, 4 pa ti - ents used non-ste ro i dal an ti-inf lam ma tory drugs, and 4 pa ti ents used car di o vas cu lar and ne u ro lo gi cal me di ca ti ons. No co-mor bid di se a ses we re fo und in 29 pa ti ents. Eight pa ti ents had a his tory of con ges - ti ve he art fa i lu re and hyper ten si on, 1 tran si ent isc he mic at tack, 2 hyper ten si on and ce reb ro vas cu lar ac ci dent, and 10 pa ti ents had di se a ses con cer ning ot her systems. Ot her di se a ses inc lu ded chro nic illnes ses such as os te o art hri tis and os te o po ro sis. No pat holo gi cal fin dings we re ob ta i ned in the ne u ro lo gi cal exa mi na ti on of 29 pa ti ents. In 21 pati ents pat ho lo gi cal fin dings we re de tec ted; 5 pati ents had nystag mus, 4 ata xi a, 4 ata xi a and nystag mus, 4 dysmet ri a and dysdi a doc ho ki ne si a, and 3 ata xi a, dysmet ri a, and dysdi a doc ho ki ne si a. Among 21 pa ti ents who se ne u ro lo gi cal exa mi na ti - on yi el ded pat ho lo gi cal fin dings, 8 had le si ons asso ci a ted with ver ti go on MRI (Tab le 1). MRI sho wed pat ho lo gi cal fin dings as so ci a ted with ver ti go and ab nor mal ne u ro lo gi cal exa mi na - ti ons in 8 pa ti ents. In one pa ti ent with nystag mus, MRI sho wed fe tal pos te ri or ce reb ral ar tery (PCA) and ba si lar ar tery with nar row ca lib ra ti on. Ce re - bel lar in farc ti on was pre sent in 2 pa ti ents with ata xi a. Sub du ral he ma to ma and su ba rach no id hemor ra ge (SAH) was de tec ted in one pa ti ent with dysmet ri a. Two pa ti ents had nystag mus and ata xi a. MRI sho wed pi locy tic as trocy to ma in one of the se and aber rant ar tery pres su re on the 7 th and 8 th crani al ner ves in the ot her pa ti ent. Ata xi a, dysmet ri a and dysdi a doc ho ki ne si a was ob ser ved in two pa ti - ents; one of them had pon ti ne de mi ye li ni za ti on in his MRI, and the ot her had ce re bel lar in farc ti on. On ENT exa mi na ti on of pa ti ents, 4 pa ti ents had im pac ted ce ru men, 3 had per fo ra ted tympa nic mem bra ne, and 1 had pse u do mem bra ne on tympa - Turkiye Klinikleri J Med Sci 2012;32(1) 3

4 Özakın ve ark. Kulak-Burun-Boğaz Hastalıkları TABLE 1: Comparison of neurological examination findings and MRI results. (HS test= , p= 0.78)*. MRI Neurological examination Normal+ lesion not associated with vertigo Lesion associated with vertigo Total Normal Nystagmus Ataxia Dysmetria and dysdiadochokinesia Nystagmus and ataxia Ataxia, dysmetria and dysdiadochokinesia Total * Marginal Homogeneity Test was used. MRI: Magnetic resonance imaging. nic mem bra ne. No pat ho lo gi es we re fo und in 42 pa ti ents. In au di o lo gi cal tests, 21 pa ti ents had coch - le ar sen si ti vity. In he a ring tests, he a ring loss at low fre qu en ci es was de tec ted in 22 pa ti ents. Au di o lo - gi cal tests of pa ti ents with he a ring loss at low frequ en ci es and coch le ar sen si ti vity we re con si de red ab nor mal. Thirty-thre e pa ti ents with coch le ar sensi ti vity and/or he a ring loss at low fre qu en ci es accor ding to au di o lo gi cal tests we re di ag no sed with pe rip he ral ves ti bu lo pathy (Tab le 2). When MRI results of pa ti ents with pe rip he ral ves ti bu lo pathy we - re as ses sed, MRI of 6 out of 33 pa ti ents re ve a led le si ons as so ci a ted with ver ti go. One pa ti ent had fe - tal pos te ri or ce reb ral ar tery (PCA) and nar row ba - si lar ar tery, 2 had ver teb ral ar tery hypop la si a, 1 had ce re bel lar in farc ti on, 1 had an ab be rant ar tery pressu ring on the 7 th and 8 th cra ni al ner ves, and 1 had sub du ral and su ba rach no id ble e ding. Of 5 pa ti ents with nor mal au di o lo gi cal tests, 3 had ce re bel lar infarc ti on, 1 had mass le si on in ce re bel lar he misp he - re con sis tent with pi locy tic as trocy to ma, and 1 had dem ye li na ting fin dings on the pons (con sis tent with mul tip le scle ro sis). No pat ho logy was de tedc ted in the MRI of 23 pa ti ents. Of the re ma i ning 16 pa ti ents, 9 had nonspe ci fic le si ons, 4 had chro nic isc he mic gli o tic le si - ons, 1 had pa ri e tal re sor bed he ma to ma, 1 had la cu ner in farc ti on, and an in ci den tal me nen gi o ma was fo und in 1 pa ti ent. DIS CUS SI ON Va ri o us cli ni cal con di ti ons sho uld be con si de red for the dif fe ren ti al di ag no sis of ver ti go. 3 Thus, for ac cu ra te dif fe ren ti al di ag no sis, it is im por tant to eva lu a te and ma na ge a pa ti ent with ver ti go ac cor - ding to an al gorythm. Prompt and exact iden ti fi ca - ti on of pos sib le pat ho lo gi cal con di ti ons that wo uld re qu i re emer gent in ter ven ti on in a pa ti ent with seve re symptoms re fer ring to the ER is cru ci al. In ad di ti on, iden ti fi ca ti on and tre at ment of the underl ying pat ho logy in the fas test and che a pest way is im por tant for cost-ef fec ti ve ness. Stu di es show that the pa ti ent s his tory is very use ful in dif fe ren - ti a ti on of cen tral and pe rip he ral ca u ses of ver ti go. 10 In pa ti ents with chro nic re cur rent ver ti go at tacks, physi cal exa mi na ti on and ves ti bu lar func ti ons are TABLE 2: Comparison of audiological test results and MRI (x 2 = , p= 0.000)*. MRI Audiology Normal+ lesion not associated with vertigo Lesion associated with vertigo Total Audiology normal 12 (70.6%) 5 (29.4%) 17 (100%) Audiology abnormal 27 (81.8%) 6 (18.2%) 33 (100%) Total 39 (78%) 11 (22%) 50 (100%) * Mc Nemar Test was used. MRI: Magnetic resonance imaging. 4 Turkiye Klinikleri J Med Sci 2012;32(1)

5 Ear-Nose-Throat Diseases usu ally nor mal. 10 In our study, of the 24 pa ti ents with a his tory of re cur rent ver tigo at tacks, ne u ro - lo gi cal exa mi na ti on was nor mal in only 13 and ves ti bu lar tests we re con sis tent with pe rip he ral ves ti bu lo pathy in 16 pa ti ents. We eva lu a ted he a ring in low fre qu en ci es and coch le ar sen si ti vity with au di o ves ti bu lar tests in or - der to iden tify the ca u ses that co uld le ad to ver ti go. Coch le ar sen si ti vity is de fi ned as dis tur ban ce at a so - und in ten sity be low 90 de ci bels. The pre sen ce of he - a ring loss at low fre qu en ci es and coch le ar sen si ti vity fa vors the di ag no sis of pe rip he ral ves ti bu lo pathy. In this con di ti on, no MRI is re qu i red ex cept for so me se lec ted ca ses. Ho we ver, Mark AS et al. re por ted in the ir study that pat ho lo gi es with cen tral ori gin we - re fo und in so me ca ses in which MRI was not re qu - i red. 11 In our study, MRI of 6 out of 33 pa ti ents with pe rip he ral ves ti bu lo pathy re ve a led a cen tral le si on as so ci a ted with ver ti go. Alt ho ugh the dif fe ren ce bet we en pat ho lo gi es iden ti fi ed with MRI and ab nor - mal au di o ves ti bu lar tests was not sig ni fi cant, the re was cli ni cal sig ni fi can ce. In a pa ti ent with ver ti go, af ter de ta i led physi - cal and ne u ro lo gi cal exa mi na ti on, ne u ro ra di o lo gi - cal ima ging tech ni qu es that may be se lec ted are CCT, MRI and mag ne tic re so nan ce an gi og raphy (MRA). The ro le of ima ging tech ni qu es in pa ti ents with pe rip he ral ver ti go is a de ba te. 12 CCT and MRI are tech ni qu es that are usu ally used for de fi ni ti ve di ag no sis. CCT and MRI sho uld be con si de red in sus pec ted ca ses af ter a de ta i led cli ni cal exa mi na ti - on. 12 Among the se two tech ni qu es, MRI is shown to be the first cho i ce in cen tral ver ti go In our study, among 50 pa ti ents, 23 had no pat ho logy, 16 pa ti ents (32%) had le si ons not as so - ci a ted with ver ti go, and 11 pa ti ents (22%) had lesi ons as so ci a ted with ver ti go (Tab le 3). Our re sults sug gest the im por tan ce of as ses sing a ver ti go pa ti - ent with MRI. MRI de tec ted le si ons as so ci a ted with ver ti go in 11 out of 42 pa ti ents with nor mal ENT exa mi na ti on and 3 out of 29 pa ti ents with nor mal ne u ro lo gi cal exa mi na ti on. Alt ho ugh our results did not yi eld sta tis ti cal sig ni fi can ce, this ne - eds to be re e va lu a ted in stu di es with lar ger se ri es be ca u se le si ons de tec ted with MRI ha ve cli ni cal sig ni fi can ce. In a pros pec ti ve study per for med by Norr ving B et al, si mi lar to the re sults in our study, one out of every 4 pa ti ents with iso la ted acu te verti go, cli ni cal mis di ag no sis led to over di ag no sis of ca u dal ce re bel lar in farc ti on. 16 Our re sults sug gest that, ne u ro lo gi cal exa mi na - ti on and au di o ves ti bu lar fin dings may not al ways be suf fi ci ent to dif fe ren ti a te the un derl ying pat ho logy and MRI tech ni qu e can pro vi de im por tant fin dings for the di ag no sis. 17 Lar ger stu di es are ne e ded to se e if MRI al so has a po ten ti al to pre sent sta tis ti cally signi fi cant dif fe ren ces in the de tec ti on of cli ni cally impor tant pat ho lo gi es mo re ac cu ra tely and ear li er. As we fo und in our study, 10% of pa ti ents with nor mal ne u ro lo gi cal exa mi na ti on had le si ons on MRI. The re fo re, me ti cu lo us ne u ro lo gi cal exa - min ta i on can exc lu de the ma jo rity of cen tral ver ti - go pa ti ents. LI MI TA TI ONS Özakın et al. TABLE 3: MRI findings of patients associated with vertigo. Gender Age MRI Findings M 18 Pilocytic astrocytoma M 35 Cerebellar infarction M 37 Fetal PCA, narrow basilar artery F 17 Demyelinization in brain stem F 50 Vertebral artery hypoplasia F 52 Cerebellar infarction F 55 Vertebral artery hypoplasia F 50 Cerebellar infarction M 85 Cerebellar infarction M 84 Aberrant artery pressing on the 7 th and 8 th nerve M 60 Subdural hematoma + SAH on right cerebral cortex M: ma le, F: fe ma le; MRI: Mag ne tic re so nan ce ima ging; PCA: Pos te ri or ce reb ral ar tery; SAH: subarachnoid hemorrage. Du e to the small samp le si ze in the cur rent study, we can not ma ke a cle ar sta te ment re gar ding the va lu e of MRI and au di o logy in the dif fe ren ti a ti on of pe rip he ral ver sus cen tral ver ti go in the Emergency De part ment. Furt her stu di es inc lu ding lar - ger samp le si zes are ne e ded. Turkiye Klinikleri J Med Sci 2012;32(1) 5

6 Özakın ve ark. Kulak-Burun-Boğaz Hastalıkları 1. Wal ker JS, Bar nes SB. Diz zi ness. Emerg Med Clin North Am 1998;16(4):845-75, vi i. 2. Ka ra taş M. [Ver ti go in the Emer gency De part - ment]. Tur ki ye Kli nik le ri J Surg Med Sci 2007;3(37): Se lek ler K. [Ver ti go and ca u ses]. Tur ki ye Kli - nik le ri J Med Sci 1983;3(2): Drach man DA. Cli ni cal cros sro ads. Con fe ren - ces with pa ti ents and doc tors Beth Is ra el De - a co ness Me di cal Cen ter. J Ame ri can Med As so ci a ti on 1998;24(1): Ned zels ki JM, Bar ber HO, McIl moyl L. Di ag - no ses in a diz zi ness unit. J Oto lary ngol 1986;15(2): Cey lan A, Tu tar H. [Me di cal tre at ment of verti go]. Tur ki ye Kli nik le ri J Surg Med Sci 2006;2 (49): Al maç A, Can bay E. [Benign positional vertigo]. Tur ki ye Kli nik le ri J Med Sci 1987;7(6): REFERENCES 8. Sta ab JP. Chro nic diz zi ness: the in ter fa ce bet we en psychi atry and ne u ro-oto logy. Tur ki ye Kli nik le ri J Ne u rol 2008;3(1): En sa ri N, Gök su N. [Ap pro ach to diz zi ness]. Tur ki ye Kli nik le ri J Surg Med Sci 2006;2(28): Ba loh RW. Dif fe ren ti a ting bet we en pe rip he ral and cen tral ca u ses of ver ti go. Oto lary ngol He - ad Neck Surg 1998;119(1): Mark AS, Selt zer S, Nel son-dra ke J, Chapman JC, Fitz ge rald DC, Gul ya AJ. Lab yrint hi - ne en han ce ment on ga do li ni um-en han ced mag ne tic re so nan ce ima ging in sud den de af - ness and ver ti go: cor re la ti on with au di o lo gic and elec trony stag mog rap hic stu di es. Ann Otol Rhi nol Lary ngol 1992;101(6): Bruz zo ne MG, Gri so li M, De Si mo ne T, Reg - na-gla din C. Ne u ro ra di o lo gi cal fe a tu res of ver ti go. Ne u rol Sci 2004;25(Suppl 1):S Lo ur yan S. [Di ag nos tic ima ging of pe rip he ral ver ti go]. Rev Med Brux 2002;23(4):A Park SU, Kim HJ, Cho YK, Lim MK, Kim WH, Suh CH, et al. The use ful ness of MR ima ging of the tem po ral bo ne in the eva lu a ti on of pa ti - ents with fa ci al and au di o ves ti bu lar dysfunc ti - on. Ko re an J Ra di ol 2002;3(1): Cas sel man JW, Kuh we i de R, De ha e ne I, Am - pe W, Dev li es F. Mag ne tic re so nan ce exa mi - na ti on of the in ner ear and ce re bel lo pon ti ne ang le in pa ti ents with ver ti go and/or ab nor mal fin dings at ves ti bu lar tes ting. Ac ta Oto lary ngol Suppl 1994;513: Norr ving B, Mag nus son M, Holtås S. Iso la ted acu te ver ti go in the el derly; ves ti bu lar or vascu lar di se a se? Ac ta Ne u rol Scand 1995;91(1): Ak pı nar Z. [Ves ti bu lar tests and the ir in ter pre - ta ti on: re vi ew]. Tur ki ye Kli nik le ri J Med Sci 2005;25(5): Turkiye Klinikleri J Med Sci 2012;32(1)

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