Differential diagnosis of acute vascular vertigo

Purpose of review The current review covers recent advances in vascular vertigo in terms of diagnostic strategies, clinical/laboratory features, pathophysiology, and differential diagnosis. Recent findings Acute strokes presenting with isolated dizziness/vertigo without other obvious symptoms or signs of central nervous system involvements may be easily mistaken as peripheral vestibulopathy. For correct diagnosis of vascular vertigo, the importance of clinical history (timing and triggers) and targeted bedside examination cannot be overemphasized. In addition to Head Impulse-Nystagmus-Test of Skew, several differential strategies have been advanced by adopting a combination of clinical history, bedside or laboratory examination, and imaging for diagnosis of vascular vertigo. Circumscribed cerebellar and brainstem lesions may cause isolated central vestibular syndromes with characteristic vestibular and ocular motor manifestations. Recognition of these findings would aid in localizing the lesions and understanding the function of each central vestibular structure. Central positional nystagmus (CPN) may mimic benign paroxysmal positional vertigo (BPPV), but additional oculomotor or neurological findings mostly permit differentiation of CPN from BPPV. In acute vestibular syndrome, discriminating vascular causes is still challenging especially when other central symptoms and signs are not evident. An integrated approach based on understanding of clinical features, laboratory findings, speculated mechanisms, and limitations of current diagnostic tests will lead to better clinical practice.