Differential Diagnosis for Sudden Onset Vertigo

Primary Diagnostic Considerations

The American College of Cardiology recommends considering posterior circulation stroke as a major differential diagnosis in patients with prolonged vertigo, given that approximately 25% of patients presenting with acute vestibular syndrome have cerebrovascular disease, rising to 75% in high vascular risk cohorts 1
The European Society of Cardiology suggests that severe postural instability with inability to walk safely is a cardinal red flag for central causes, particularly vertebrobasilar insufficiency and cerebellar lesions 1
The American Heart Association notes that approximately 75-80% of patients with acute vestibular syndrome from posterior circulation infarct have no focal neurologic deficits on standard examination 2
The European Heart Journal recommends considering underlying cardiovascular disease and increased stroke risk in patients with ECG findings such as sinus bradycardia and complete RBBB 3

The American College of Emergency Physicians recommends immediate neuroimaging, preferably MRI brain without contrast, in patients with severe postural instability, prolonged continuous vertigo, and high vascular risk 1, 2
The American Stroke Association suggests that age 85 is a significant vascular risk factor, and normal neurologic exam does not exclude stroke 1, 2

The American Academy of Otolaryngology-Head and Neck Surgery recommends excluding BPPV in patients with negative Dix-Hallpike maneuver and prolonged duration of vertigo 4, 1

The American College of Radiology recommends MRI brain without contrast as the imaging modality of choice for posterior circulation infarcts, given its higher sensitivity compared to CT 2
The American Heart Association suggests performing HINTS examination by a trained examiner, which has 100% sensitivity for posterior circulation stroke versus 46% for early MRI 2
The European Society of Cardiology recommends continuous cardiac monitoring to document any arrhythmias correlating with symptoms, and cardiology consultation for evaluation of bradycardia and complete RBBB in the context of acute neurologic symptoms 3