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When the ground sways – finding out where it comes from.
Dizziness is one of the most common complaints of all – and one of the least specific. That is precisely the problem: because so many causes are possible, dizziness is often dismissed too quickly as harmless and the patient is put off. The figures suggest otherwise. In people who come to an emergency department with dizziness, a stroke is behind it in around 5.5 %; for dizziness without any other accompanying signs, European studies report 8.4 %.¹ And a circulatory disorder is only one of the possibilities: a tumour – on the auditory nerve, in the cerebellum, in the brainstem or at the skull base –, a chronic subdural haematoma after a long-forgotten fall, normal pressure hydrocephalus, inflammatory lesions such as in multiple sclerosis, a tear in the vessel wall, a vascular malformation – all conditions that should not be left unattended. With dizziness, therefore, the question is not whether to look – but how closely and how soon.
Important: Sudden, severe chest pain – especially with shortness of breath, cold sweat or pain radiating into the arm, neck or upper abdomen – can be a heart attack. Please call the emergency services on 112 immediately.
Dizziness together with one-sided hearing loss, ringing in the ear or a feeling of pressure in the ear should be assessed. A benign tumour of the auditory nerve – the vestibular schwannoma – grows slowly and causes exactly these symptoms. It can only be reliably detected or ruled out with MRI; on CT it remains invisible.²
Unsteady gait, visual disturbances, abnormal sensations, clumsiness of one hand: such signs shift the question from the inner ear to the brain. A circulatory disorder that goes unrecognised can lead to an infarction – and to further ones. This is exactly why the guideline on secondary prevention after a cerebral circulatory disorder calls for prompt assessment and secondary prevention rather than waiting.³ The brainstem, cerebellum and the vessels supplying the brain can be assessed with MRI, including recent circulatory disorders and inflammatory lesions.⁴
With increasing age, high blood pressure, diabetes, atrial fibrillation or known vascular calcification, the equation changes. Dizziness may then be caused by a small circulatory disorder in the brainstem or cerebellum – too small to cause paralysis, but large enough to be a warning sign. A tear in the vessel wall after a fall or whiplash injury also belongs here. Both can be visualised with diffusion-weighted MRI and MR angiography. And if no cause is found in the head: your case can be discussed directly with our cardiologist – on the same corridor, without a new appointment, without a trip to another part of town and without weeks passing between two questions that belong together.
Dizziness that persists for weeks, recurs or changes – and for which no one has yet found an explanation. “It’s your circulation” is not a diagnosis. Among the causes most frequently overlooked are chronic subdural haematoma after an often long-forgotten fall, normal pressure hydrocephalus with its triad of gait disturbance, urinary urgency and forgetfulness, inflammatory lesions and slowly growing space-occupying lesions – all diagnoses that can be recognised with cross-sectional imaging and not without it. With us you receive a timely appointment, an MRI examination protocol tailored to your symptoms and – if necessary – an angiography to rule out a dangerous vascular pathology. And a consultation about the result.
Which examination makes sense depends on your symptoms. We put the protocol together specifically – not every head MRI is the same.
The brainstem and cerebellum – the control centres of balance – are imaged without radiation. Recent circulatory disorders, inflammatory lesions and space-occupying lesions can be detected here, even when they are small.
A dedicated high-resolution protocol through the inner ear and auditory nerve, with sub-millimetre slices. It is precisely these sequences that decide whether a vestibular schwannoma is found or missed – a standard head MRI is not sufficient for this.²
The vessels from the neck into the brain, usually imaged without contrast agent. Narrowings, tears in the vessel wall and vascular bulges become visible – important for episodic dizziness with neurological signs.
When neck complaints and dizziness occur together, the cervical spine is assessed as well – intervertebral discs, spinal cord and the bony course of the vertebral arteries. This way, the search for the cause does not stop halfway.
Conveniently online or by phone – you will receive a timely appointment through our friendly reception team.
The MRI examination protocol is tailored to your symptoms, supplemented if needed by an angiography of the vessels supplying the brain – in a calm atmosphere, evaluated by experienced specialists.
You receive a detailed report and a personal consultation about the next steps.
Physicist, specialist in radiology and specialist in neuroradiology – a dual qualification that makes the difference for questions concerning the brainstem, inner ear and vessels.
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Dizziness is an umbrella term, not a disease. The following figures answer the question of how often a serious cause lies behind it – and how reliably it can be detected.
| Group studied | Proportion with stroke |
|---|---|
| All patients with dizziness in the emergency department – 29 studies, 161,013 patients¹ | 5,5 % |
| Of these: dizziness without other accompanying signs, worldwide – with considerable variation between regions (3.4 % to 22.9 %)¹ | 13,9 % |
| Of these: European studies¹ | 8,4 % |
| Acute vestibular syndrome in patients with at least one vascular risk factor – proportion with a central cause⁴ | 75 % |
| Early diffusion-weighted MRI that did not show the existing stroke – all within 48 hours⁴ | 12 % |
The first circulatory disorder is often a warning shot. After a cerebral ischaemia, the risk of a further event is highest immediately afterwards – which is why the guideline on secondary prevention calls for prompt assessment and immediate start of secondary prevention, not waiting for weeks.³
There is also a circumstance that is rarely mentioned in consultations: a recent infarction can only be reliably recognised as recent on diffusion-weighted imaging for about one to two weeks. After that the signal normalises, and the question of whether this lesion developed three weeks or three years ago often can no longer be answered with certainty.⁵ Delaying imaging therefore means losing not only treatment time, but also the information itself.
Not every serious cause is an infarction. In dizziness, the following are also relevant: chronic subdural haematoma, normal pressure hydrocephalus, inflammatory lesions – for example in multiple sclerosis – and vascular malformations. And tumours, of which the tumour of the auditory nerve is only the best known: dizziness can equally arise from a space-occupying lesion in the cerebellum or brainstem, from a meningioma of the posterior cranial fossa, from a tumour at the skull base or from a metastasis – regardless of whether it is benign or malignant. Clinically they often cannot be told apart; they become distinguishable on imaging.⁶ ²