Discriminating strokes in patients with acute dizziness/vertigo is challenging especially when other symptoms and signs of central nervous involvements are not evident. Despite the developments in imaging technology over the decades, a significant proportion of acute strokes may escape detection on imaging especially during the acute phase or when the lesions are small. Thus, small strokes causing isolated dizziness/vertigo would have a higher chance of misdiagnosis in the emergency department. Even though several diagnostic algorithms have been advanced for acute vascular vertigo, we still await more comprehensive and sophisticated ones that can also be applied to transient vestibular symptoms due to vascular compromise. In this respect, vascular and perfusion imaging would be informative. Application of artificial intelligence and tele-consultation may be future perspectives for real-time decision in acute dizziness and vertigo. Several new constellations of ocular motor and vestibular findings have been added to the strokes involving the brainstem and cerebellum. Defining these characteristics would help understanding the function of central vestibular structures and allow more accurate localization of the strokes involving these structures.