PurposeTo quantify the diagnostic yield of neuroimaging in adult emergency department (ED) patients presenting with vertigo, and to identify clinical predictors of acute central pathology that can inform imaging decisions.MethodsThis retrospective study reviewed all neuroimaging examinations performed for vertigo at 14 EDs within our health network between May 2016 and January 2025. Adult ED patients (n=4,135; mean age 62.5 years; 62% female) who underwent imaging (n=5,445 exams, approximately 89% CT and 11% MR) were included. Imaging exams with potentially clinically relevant findings were flagged for further review (n=291 exams and patients); these patients were separated into four separate groups based on their imaging findings: 1) acute actionable contributory to vertigo, 2) acute actionable non-contributory to vertigo, 3) non-acute actionable, or 4) non-actionable. Vertigo quality (constant, intermittent/resolved spontaneously, no vertigo), acuity, neurological examination (including cerebellar signs and the Head-Impulse, Nystagmus, and Test-of-Skew [HINTS] exam), and intervention rates were analyzed within these subgroups using Fisher’s exact and chi-square tests.ResultsOf 5,445 exams, 291 (5.3%) were flagged with potentially relevant imaging findings. Of these exams, only 115 (2.1%) yielded actionable findings, and just 65 (1.2%) revealed acute central causes contributing to vertigo. In patients with positive imaging findings, constant vertigo was strongly associated with acute contributory pathology (98.5% in this group vs. 6.0% in other groups, p<0.0001). Acute onset was more frequent in acute contributory cases (63.1% vs. 40.8%, p=0.0006), as were abnormal HINTS or cerebellar signs (44.6% vs. 6.0%, p<0.0001). Most patients with acute contributory findings received specialty consultations resulting in intervention (95.4%). Intermittent or resolved vertigo was commonly seen in patients with benign peripheral diagnoses.ConclusionNeuroimaging frequently yields normal results in ED vertigo cases; acute actionable central findings deemed contributory to vertigo are rare. Only approximately 2% of patients had acute actionable imaging findings and only 1.3% had a stroke. In patients with acute actionable imaging findings, clinical features—especially constant vertigo, acute onset, and abnormal neurological exam—are strongly associated with central causes and should guide selective imaging in the ED.Graphical Abstract