Most neuroimaging studies in our cohort revealed normal or clinically non-significant findings (94.7%), with only 1.2% of exams having acute central pathology contributing to vertigo. This low incidence—particularly of acute posterior fossa infarcts—aligns with prior literature describing similarly low rates of acute central pathology in ED patients presenting with vertigo [4, 6,7,8, 22,23,24]. These findings reaffirm the limited diagnostic yield of neuroimaging in patients presenting with vertigo, supporting the case for more selective imaging based on risk stratification [9, 10].

Our data highlights the diagnostic value of vertigo symptom quality and acuity. Within the subgroup of patients flagged with potentially clinically relevant imaging findings, those with constant vertigo and symptom onset within 24 hours were more likely to harbor acute contributory imaging pathology, whereas patients with chronic, intermittent, or spontaneously resolved symptoms were more likely to have peripheral etiologies such as BPPV. These clinical distinctions echo prior work on the diagnostic importance of timing and triggers in differentiating acute vestibular syndrome from episodic or positional vertigo [5, 23].

Among existing studies, our cohort size surpasses previous reports evaluating neuroimaging yield in emergency department patients presenting with vertigo. For example, Happonen et al. analyzed 1,169 emergency brain MRIs to assess imaging outcomes in dizziness and vertigo, representing the next largest cohort identified in the literature [8]. Other multicenter or risk score validation studies, such as Yu et al. (TriAGe+ Score; N=498) and Ohle et al. (Sudbury Vertigo Risk Score; N=2078), have contributed important insights into risk stratification but included fewer patients and often focused exclusively on imaging outcomes or diagnostic accuracy of specific modalities [18, 19]. In contrast, our study not only provides the most extensive system-level analysis to date but also incorporates detailed clinical characterization by systematically examining presenting symptoms, examination findings, and demographic variables in relation to acute neuroimaging diagnoses. This comprehensive approach offers greater granularity and generalizability, enabling more nuanced triage recommendations and optimizing imaging stewardship for vertigo-related ED presentations.

Neurological examination findings further stratified risk in the patients with potentially relevant imaging findings. Abnormal HINTS exam and/or focal cerebellar signs were much more common in patients with acute contributory findings compared to the other groups, including patients with acute non-contributory findings. Conversely, patients with negative or unremarkable examinations were far less likely to harbor actionable causes of vertigo. These results reinforce the established high sensitivity of the HINTS exam for posterior circulation stroke [15,16,17]. Consultation and intervention patterns paralleled these findings. Nearly all patients with acute contributory imaging pathology underwent specialty consultation and acute changes in management (95.4%), compared with only 34.2% of all others and just 10.2% of those with non-actionable findings. Importantly, rates of acute change in management were comparably high among the acute non-contributory group, which is an expected observation given that acute central imaging findings—even if not explanatory for vertigo—frequently prompt specialty engagement and management.

Re-stratifying patients instead by vertigo quality symptom profile, as demonstrated in Table 4, further underscored the diagnostic importance of clinical presentation. In patients with potentially clinically relevant imaging findings, constant vertigo was highly predictive of acute central pathology, while intermittent or positional vertigo was strongly associated with peripheral etiologies such as BPPV. This bidirectional validation (pathology → symptoms in Table 3; symptoms → pathology in Table 4) strengthens the evidence that symptom quality alone offers meaningful predictive value in triage, a finding that may help clinicians decide which patients warrant urgent advanced neuroimaging.

While age and cardiovascular or stroke risk factors traditionally inform overall stroke risk, these variables fall outside the specific focus of our study, which aims to identify bedside features that stratify patients requiring urgent neuroimaging for vertigo itself. It is important to acknowledge that advanced age and multiple vascular risk factors may nonetheless warrant imaging when clinical concern exists for alternative diagnoses unrelated to vertigo. Our analysis strongly suggests that among patients presenting with true vertiginous symptoms and potentially relevant imaging findings, abrupt and constant vertigo, symptom onset within 24 hours, and the presence of positive HINTS or focal cerebellar signs on neurological examination are strongly associated with acute contributory pathology. Conversely, patients in this cohort that had chronic, intermittent, or positional vertigo, or symptoms that have resolved, are less likely to harbor acute central causes and may not require immediate imaging. This approach aligns with current guidelines emphasizing targeted clinical evaluation and may enhance diagnostic accuracy while optimizing resource utilization in the emergency department.

Beyond the associations identified in our cohort, our findings also illustrate persistent diagnostic challenges in the evaluation of vertigo in the emergency department. First, patient-reported symptomatology is often imprecise. Prior studies have shown that many patients struggle to distinguish true vertigo from nonspecific dizziness, lightheadedness, or orthostatic complaints, leading to frequent mislabeling and potential over-utilization of imaging [5, 25]. In our cohort of patients with potentially relevant imaging findings, more than one fourth of patients denied vertiginous symptoms on subsequent reassessment despite “vertigo” being the original documented imaging indication. This underscores the need for more structured, targeted questioning emphasizing timing and triggers to improve diagnostic accuracy and avoid unnecessary neuroimaging.

Second, although abnormal neurologic findings were more prevalent among patients with acute contributory pathology, fewer than half of these patients had documented neurologic exam abnormalities. Only 44.6% of the acute contributory subgroup had documentation of abnormal HINTS and/or focal cerebellar signs, despite prior evidence that such findings strongly predict posterior circulation stroke [15,16,17]. This mirrors other series reporting that 40–60% of patients with posterior fossa pathology have abnormal bedside exam findings [17, 26]. Moreover, HINTS was explicitly documented in only 25.4% of cases flagged for review — paralleling prior demonstrations of underuse and inconsistent application of this exam in real-world ED practice [27,28,29,30,31]. These observations highlight the dual challenges of exam sensitivity and provider variability in documentation, reinforcing the need for more consistent implementation of validated bedside tools for acute vestibular syndrome.

The retrospective design of this study introduces several inherent limitations. As our patient selection relies on existing clinical and imaging records, it is susceptible to practice heterogeneity and incomplete or inconsistent documentation. Dependence on recorded clinical examination findings led to underestimation of bedside physical exam utilization, as previously discussed. Additionally, some patients received consultations, admissions, or therapies for reasons unrelated to acute imaging findings, potentially confounding downstream management analyses. For example, patients admitted with alternative diagnoses such as hypertensive urgency or trauma may have received specialty consultations and/or medication adjustments that were not directly attributable to imaging results. Furthermore, patients transferred to other institutions for intervention had incomplete follow-up, leading to underestimation.

Another limitation of our study is that detailed chart review of presenting symptoms and neurological examinations was conducted only for patients flagged with new or concerning imaging findings. The decision to conduct an extensive chart review only on these patients was intended to focus on potentially actionable imaging findings, rather than clinical outcomes for all patients presenting to the ED with vertigo. As a result, our analysis does not include symptom data for the larger cohort of patients with negative imaging, which limits the generalizability of symptom-imaging associations observed. Consequently, while our results suggest that constant, acute vertigo and abnormal neurological exam increase the likelihood of identifying acute central pathology, this relationship cannot be conclusively extended to all ED patients presenting with vertigo in our study. That being said, numerous clinical studies in the ER literature [15, 17,18,19,20,21] have identified acute vestibular syndrome as being highly associated with acute central pathology. Future prospective studies encompassing both positive and negative imaging groups could further confirm high-risk clinical features and more accurately inform neuroimaging triage strategies.

In conclusion, while acute central causes of vertigo remain rare in ED patients undergoing neuroimaging, careful integration of symptom quality, symptom acuity, and bedside neurological examination can significantly improve the identification of high-risk patients. Specifically, those presenting with constant vertigo of < 24 h duration and abnormal HINTS or cerebellar signs may represent a subgroup warranting high suspicion for central pathology and urgent neuroimaging. Adoption of such a selective approach may improve diagnostic accuracy and reduce inappropriate imaging overutilization.