Vertigo/dizziness, as a common clinical condition, has a broad etiologic differential diagnosis involving many medical specialties, including neuroscience (e.g., vestibular migraine, cerebrovascular disease, epilepsy), otorhinolaryngology (e.g., BPPV, Ménière’s disease, sudden deafness with vertigo, and vestibular paroxysm), internal medicine (e.g., hypoglycemia, cardiac arrhythmia), and psychiatry (e.g., panic attacks). Among these diseases, vertigo/dizziness caused by cerebrovascular disease (including transient ischemic attack, ischemic or hemorrhagic stroke), although uncommon, and epidemiological studies have shown that vertigo/dizziness caused by cerebrovascular disease only accounts for 3% to 7% of patients with vertigo/dizziness, is of widespread concern to clinicians because of the serious consequences and the characteristics of high disabling, lethal, and recurrent effects. Especially in the emergency room, how to quickly and correctly recognize acute or episodic vertigo/dizziness caused by cerebrovascular disease, and detect patients with high risk of stroke in a timely manner poses a great challenge to clinicians. Acute and episodic vestibular syndromes of the International Classification of Vestibular Diseases (ICVD) are common vestibular syndromes with vertigo as the main manifestation in the ED. Rapid access to the differential diagnostic process for acute or episodic vestibular syndromes through focused questioning and optimized examination is more appropriate for patients with vertigo/dizziness in the ED. Quick Start with Focused Clinical Symptoms and History Most patients with vertigo/dizziness in the emergency room are in the acute exacerbation phase, with obvious clinical symptoms and poor compliance with the physician’s history and examination. The physician can quickly and effectively obtain clinical information through focused questioning. Three aspects should be selected: 1) whether the vertigo is acute and persistent or recurrent; 2) the duration of vertigo; and 3) the form of induced vertigo (whether it is related to changes in head position or body position, and it is important to differentiate between vertigo/dizziness exacerbated by head movement and vertigo/dizziness induced by head movement). These 3 questions bring the patient first into the diagnostic framework of acute vestibular syndrome or episodic vestibular syndrome; then attention is paid to other concomitant symptoms, in particular, complaints such as limb motor or sensory abnormalities, abnormalities in speech expression, complaints of unsteadiness in standing or gait, ambiguous or double vision, and hearing loss, in order to further differentiate impairments that may be localized to the central level. Acute vestibular syndromes are distinguished primarily by posterior circulation lesions and vestibular neuritis, and in rare cases, metabolic and toxic factors should be excluded. In the elderly, past history should focus on cardiovascular risk factors, including hypertension, diabetes mellitus, hyperlipidemia, gout, smoking, obesity, coronary/carotid atherosclerosis, or stenting; in the young, it should focus on trauma, strenuous physical activity, migraine, and history of previous vertigo. Optimize the order of physical examination and focus on key signs Since patients with acute vertigo, nausea and vomiting symptoms are severe, sometimes it is difficult to cooperate with the comprehensive physical examination, so the order of bedside examination should be optimized, and mastering the key signs can help to quickly identify acute or episodic vestibular syndrome caused by central diseases. The purpose of the physical examination is to quickly localize the diagnosis. When treating a patient with vertigo/dizziness in the ED, a quick focused history should be accompanied by a prioritized examination of the following signs (with extra attention to even minor complaints of discomfort), which in addition to vital signs should include signs of cranial nerve damage (diplopia or blurred vision, dysarthria, nystagmus and abnormal eye movements, perioral facial numbness, central facial and tongue palsies, and decreased hearing), limb or trunk ataxia (sometimes ataxia of the limbs or trunk (sometimes with only slight clumsiness of movement or postural instability), or weakness of the limbs. In this case, bedside eye movement examination is particularly important. Bedside eye movements can be categorized into static and dynamic examinations. The static examination includes the evaluation of reverse ocular deviation, abnormal eye movements (smooth tracking abnormalities, sweeping abnormalities), and nystagmus (with particular attention to gaze-direction-altering nystagmus). Dynamic examination includes examination of the vestibulo-ocular reflexes by the head toss test and the head shake test.The HINTS (Head Impulse, Nystagmus Type, test of Skew) three-step bedside examination includes a normal horizontally oriented head impulse test, direction-varying nystagmus, and ocular deviation response. However, some patients in the acute phase are unable to cooperate with the head-shaking or head-bobbing test due to severe vertigo, and observation of eye movements (smooth tracking and sweeping movements) and nystagmus is particularly important at this time. Horizontal gaze nystagmus, vertical gaze nystagmus, and torsional nystagmus (especially torsional nystagmus when gazing in different directions) are often indicative of brainstem (pontine or medulla oblongata) or cerebellar lesions. It is important to note that the same nystagmus has different meanings in acute vestibular syndrome and episodic vestibular syndrome. In patients with episodic vestibular syndrome, the Dix-Hallpike test-induced upbeat torsional nystagmus is suggestive of BPPV, whereas in patients with acute vestibular syndrome, the same upbeat torsional nystagmus may be suggestive of a central sign, usually a brainstem stroke. Therefore, it is crucial to differentiate between clinical signs while correctly interpreting the findings. Gross audiometry is easy to perform, and the physician can perform a simple hearing test by rubbing the fingers of both hands against the lateral aspect of the patient’s ears or perform a tuning fork test (Rinne test and Weber test), which can help to detect sudden hearing loss. In addition, attention should be paid to postural balance deficits; postural gait instability is more severe in patients with acute brainstem or cerebellar lesions than in vestibular peripheral lesions. Most patients with acute brainstem or cerebellar lesions exhibit postural instability; therefore, patients with vertigo with severe postural instability in the emergency room should be given particular attention. The main disorders to identify in patients with episodic vestibular syndrome include BPPV, vestibular migraine, posterior circulation TIA, Meniere’s disease, and sudden deafness with vertigo. These patients may be in remission at the time of presentation, and if the examination does not reveal any of the above positive abnormal signs, a positional test is required to exclude primary or secondary BPPV, which induces vertigo with characteristic positional nystagmus to help make the diagnosis. Initial etiologic determination in conjunction with history Identification of the etiology of vertigo/dizziness in the emergency room is the next step in etiologic management following symptomatic treatment. The duration and progression of acute vertigo symptoms in acute or episodic vestibular syndromes is important for etiologic differentiation. Patients with peripheral vestibular lesions (e.g., vestibular neuritis) usually have a long progression time, measured in hours or days, before symptoms reach maximum intensity, whereas patients with posterior circulation strokes are often characterized by a rapid acute onset (e.g., peaking within seconds to minutes), followed by a succession of concomitant symptoms. Posterior circulation stroke is highly likely if the patient is of advanced age, has multiple prior cardiovascular risk factors, and one or more abnormal bedside eye examinations. If the patient combines multiple cardiovascular and cerebrovascular disease risk factors and has sudden hearing loss, especially with bilateral tinnitus, an MRI-DWI sequence of the brain and an intracranial MRA or CTA should be performed in order to detect stenotic lesions in the inferior segment of the basilar artery emanating from the AICA or tandem lesions combining with stenosis of the vertebral arteries of the intracranial segment. If necessary, supra-aortic arch CTA and MRA are performed to screen for stenotic lesions in extracranial segments of the vertebral arteries. Atherosclerosis is often the primary cause of stroke, and vertebral or basilar artery entrapment and rare causes (e.g., vertebral basilar artery dilatation and prolongation, vertebral basilar artery spindle aneurysm, cerebral stem cerebellar cavernous hemangioma, etc.) or cardiac embolism also need to be considered. Patients with episodic vestibular syndromes such as Meniere’s disease also have typical progressive attacks of vertigo, but often have cochlear symptoms, such as attacks accompanied by tinnitus, a feeling of ear stuffiness, and hearing loss. Selection of ancillary tests The clinical symptoms of patients with vertigo/dizziness presenting to the emergency department are relatively severe, and rapid control of symptoms of vertigo and vomiting within a short period of time while avoiding misdiagnosis or underdiagnosis of acute central diseases (mainly posterior circulation stroke) is the key to diagnosis and treatment. Reasonable selection of auxiliary tests can help to shorten the time for differential diagnosis. Routine blood tests, blood biochemistry tests, and coagulation indexes are necessary tests for patients with first-ever vertigo in the emergency department. If nystagmus persists when the body position is kept unchanged or other neurological signs are found during the examination, vertigo should be considered as cerebrovascular in origin. Therefore, patients with vertigo/dizziness who combine multiple risk factors for cardiovascular and cerebrovascular disease should have a preferred CT scan of the head, and CTA should be completed when vascular pathology is highly suspected. In patients with onset of 4.5 h, intravenous thrombolysis with recombinant tissue plasminogen activator (rT-PA) may be considered after emergency head CT to rule out posterior cranial fossa hemorrhage or other contraindications to thrombolysis. If emergency head MRI is available, head magnetic resonance DWI and ADC sequences as well as MRA examination can be improved, and DSA examination can be performed to detect posterior circulation artery occlusion, aneurysm, vasospasm, or arterial entrapment if necessary. In addition, noninvasive carotid and vertebral artery ultrasound or transcranial Doppler ultrasound can provide useful information for the rapid assessment of acute stroke at an available medical facility. Cardiac ultrasound and electrocardiographic Holter can help to clarify the presence or absence of vertigo/dizziness due to cardiac structural and rhythmic abnormalities. Somatosensory evoked potentials and brainstem auditory evoked potentials can help provide further information on etiology. However, some of these tests cannot be routinely performed in the emergency room, and patients need to be referred to an outpatient clinic for further testing after their symptoms have resolved. It is important to note that head CT has limited sensitivity for detecting posterior circulation infarcts within 72 h of symptom onset, and MRI-DWI sequences of the head may also show false-negative results. Elective review of brain MRI-DWI and ADC sequences is recommended if clinical signs and symptoms point to a lesion in the posterior circulation supply area, which is most often seen in the medulla oblongata or in small lesions near the midline of the cerebellum. In conclusion, the management of patients with vertigo/dizziness in the ED is more challenging for the clinician, and requires the physician to accurately and efficiently utilize clinical symptoms and history features in conjunction with a focused physical examination and ancillary tests to make a rapid and correct diagnosis for patients with acute dizziness or vertigo. The signs and symptoms of cerebrovascular disease-related dizziness and vertigo can be diverse, depending on the site of the lesion and the area of blood supply from the affected vessel. The process of quickly recognizing the cerebrovascular etiology of vertigo in the emergency room is complex and requires a multidisciplinary approach. Only by better understanding the relationship between vertigo/dizziness and cerebrovascular disease, as well as understanding the limitations of imaging in the diagnosis of the disease, can clinicians target the management of vertigo/dizziness in the ED.