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Because symptoms and signs overlap, misdiagnosis is frequent and overuse of neuroimaging is common. We assessed the accuracy of bedside findings to differentiate peripheral vestibular from central neurologic causes.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>We performed a systematic search (MEDLINE and Embase) to identify studies reporting on diagnostic accuracy of physical examination in adults with acute, prolonged dizziness\/vertigo (\u201cacute vestibular syndrome\u201d [AVS]). Diagnostic test properties were calculated for findings. Results were stratified by examiner type and stroke location.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>We identified 6,089 citations and included 14 articles representing 10 study cohorts (n\u2009=\u2009800). The Head Impulse, Nystagmus, Test of Skew (HINTS) eye movement battery had high sensitivity 95.3% (95% confidence interval [CI]\u2009=\u200992.5\u201398.1) and specificity 92.6% (95% CI\u2009=\u200988.6\u201396.5). Sensitivity was similar by examiner type (subspecialists 94.3% [95% CI\u2009=\u200988.2\u2013100.0] vs non\u2010subspecialists 95.0% [95% CI\u2009=\u200991.2\u201398.9],<jats:italic>p<\/jats:italic>\u2009=\u20090.55), but specificity was higher among subspecialists (97.6% [95% CI\u2009=\u200994.9\u2013100.0] vs 89.1% [95% CI\u2009=\u200983.0\u201395.2],<jats:italic>p<\/jats:italic>\u2009=\u20090.007). HINTS sensitivity was lower in anterior cerebellar artery (AICA) than posterior inferior cerebellar artery (PICA) strokes (84.0% [95% CI\u2009=\u200965.3\u201393.6] vs 97.7% [95% CI\u2009=\u200993.3\u201399.2],<jats:italic>p<\/jats:italic>\u2009=\u20090.014) but was \u201crescued\u201d by the addition of bedside hearing tests (HINTS+). Severe (grade 3) gait\/truncal instability had high specificity 99.2% (95% CI\u2009=\u200997.8\u2013100.0) but low sensitivity 35.8% (95% CI\u2009=\u20095.2\u201366.5). Early magnetic resonance imaging (MRI)\u2010diffusion\u2010weighted imaging (DWI; within 24\u201348\u2009hours) was falsely negative in 15% of strokes (sensitivity 85.1% [95% CI\u2009=\u200979.2\u201391.0]).<\/jats:p><\/jats:sec><jats:sec><jats:title>Interpretation<\/jats:title><jats:p>In AVS, HINTS examination by appropriately trained clinicians can differentiate peripheral from central causes and has higher diagnostic accuracy for stroke than MRI\u2010DWI in the first 24\u201348\u2009hours. These techniques should be disseminated to all clinicians evaluating dizziness\/vertigo. 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