Acute vestibular disorder is a frequent cause of urgent hospitalization in elderly patients. A CNS vascular disorder is often thought to be a cause of vertigo and a patient is diagnosed with stroke or transitory ischemic attack (TIA) or vertebral-basilar insufficiency. Despite the higher risk of cerebrovascular disease in the elderly, stroke and TIA are not the only cause of acute vestibular disorder. Hyperdiagnosis of cerebrovascular diseases in patients with acute vertigo often leads to underdiagnosis of peripheral vestibular disorders that could be successfully treated if timely diagnosed. The differential diagnosis of the lesions of central and peripheral vestibular systems is based on clinical examination of patients with acute vertigo including an analysis of cerebrovascular risk factors, characteristics of vertigo, nystagmus and careful identification of focal neurological symptoms.