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We enjoyed A practical approach to acute vertigo by Seemungal and Bronstein in the August issue. However, we disagree that the head impulse test “will only be positive in patients with vestibular neuritis”1 and so be useful in differentiating acute unilateral peripheral vestibulopathy, cerebellar stroke and migraine. By chance, we had discussed in a recent journal club two papers on the diagnostic accuracy of this test in consecutive patients presenting with acute vestibular syndrome (rapid onset of sustained vertigo, nausea and vomiting in association with nystagmus, unsteady gait and head motion intolerance) using MR diffusion weighted imaging as the “gold standard” to diagnose stroke.2, 3 We extracted data from both papers (table); the positive predictive value was only 69%, meaning that 31% of patients who present with an acute vestibular syndrome and a positive (abnormal) head impulse test will have had a stroke, not acute vestibular neuritis. Therefore, we suggest that all these patients should be referred acutely for MRI to exclude a cerebellar or brain stem stroke—not just those with a normal head impulse test.