Dizziness or vertigo is a feeling that many people have experienced. In medical terms, the two are different. Usually, vertigo, also known as true vertigo or vestibular vertigo, is a vestibular dysfunction that causes patients to experience impaired orientation and balance perception of spatial relationships, causing a sensation of spinning. In contrast, dizziness, also known as pseudovertigo or non-vestibular vertigo, patients often do not have a sensation of rotation, but rather a feeling of dizziness, light-headedness, and swaying instability. Vertigo or dizziness is only a symptomatological description and has many different causes, while some of these disorders can seriously affect the patient’s work and life, or even be potentially fatal. Therefore, both doctors and patients need to carefully screen the causes of dizziness or vertigo and treat the symptoms in order to receive good results. The following types of diseases can be well treated by neurosurgical intervention or open surgery. 1. Insufficient blood supply from the vertebral basilar artery: The vestibular system is mainly supplied by the vertebral basilar artery. Bilateral vertebral arteries pass through the bony tunnel formed by the transverse foramen of the 6th to 1st cervical vertebrae, then enter the skull through the foramen magnum and merge into a basilar artery, which then sends out branches to supply mainly the brainstem and cerebellum. Bilateral vertebral artery canal diameters are unequal in 2/3 of cases, and even unilateral vertebral artery is small or absent. Therefore, in patients with a small, occluded or absent vertebral artery on one side, if there is a narrowing of the main blood supplying vertebral artery on the opposite side or the basilar artery distal to it, there will be a shortage of blood supply, leading to vertigo. The most common cause is atherosclerotic plaque that causes the lumen to become thin and narrow. In this case, the stenosis can be opened by balloon dilation and stent placement, or the diseased vessel can be surgically cut open to remove the plaque and improve the blood supply. Another condition is cervical spine osteophytes, bone superfluous formation, and fibrous cords that compress the vertebral artery from outside the blood vessels, resulting in inadequate blood supply. For these reasons, the compression-causing material can be surgically removed to improve blood flow. If the vertebral artery is already occluded and cannot be revascularized by stenting or surgery, bypass surgery can be considered. Generally, we take the saphenous vein from the lower leg and make a bypass between the external carotid artery and the distal end of the occluded vertebral artery to bring blood flow from outside the skull into the skull and improve blood supply. 2. Internal carotid artery system ischemia: Patients with internal carotid artery system ischemia sometimes also have dizziness and drowsiness, but usually do not have the typical vertigo manifestation. Again, these patients can obtain blood flow improvement or reconstruction through internal carotid artery stenting, carotid endarterectomy, and middle cerebral artery-superficial temporal artery bypass surgery. Many of these patients complain of “clearer brain”, “lighter”, “less confused”, etc. after treatment, because the ischemic symptoms have improved. 3, subclavian artery blood theft: usually the vertebral artery originates from the subclavian artery. When the starting segment of the subclavian artery is narrowed or occluded, the blood not only cannot flow into the vertebral artery of the patient to supply blood to the brain, but also may cause the blood of the vertebral artery on the healthy side to flow into the subclavian artery on the affected side, at this time, the subclavian artery steals the blood flow that should supply the brain, resulting in insufficient blood supply to the vertebrobasilar artery, especially when the blood demand of the upper limb activity on the affected side increases, the cerebral ischemia is more obvious. The cerebral ischemia is especially pronounced when the blood demand of the affected upper limb increases. In this case, a stent can be placed in the stenosis of the subclavian artery to improve the stenosis, correct the blood theft and restore the normal blood flow. 4.Intracranial tumor vertigo: Some intracranial tumors can also cause vertigo, which is related to direct tumor invasion, compression or cranial hypertension causing involvement of vestibular system. The common ones are auditory neuroma, brainstem tumor, cerebellar tumor and so on. For these lesions, after the lesions are removed by craniotomy, the associated vertigo or dizziness will often disappear accordingly. Therefore, for patients with dizziness or vertigo, they also need to visit neurosurgery to rule out the above causes. Of course, not all cerebral ischemia requires surgery, but a prudent evaluation is necessary. The doctor needs to make a preliminary judgment based on the patient’s history, symptoms, signs and examination, and often carotid ultrasound, transcranial Doppler, head and neck CTA or MRA, and CT or MRI cerebral perfusion to find the responsible vessel and assess its severity to decide whether interventional or surgical treatment is needed.