BACKGROUND: We assessed whether detection of stroke underlying acute vertigo using HINTS plus (head-impulse test, nystagmus type, test of skew, hearing loss) can be improved by video-oculography for automated head-impulse test (V-HIT) analysis. METHODS: We evaluated patients with acute vestibular syndrome (AVS) presenting to the emergency room using HINTS plus and V-HIT-assisted HINTS plus in a randomized sequence followed by cranial MRI and caloric testing. Image-confirmed posterior circulation stroke or vertebrobasilar TIA were the reference standards to calculate diagnostic accuracy. We repeated statistical analysis for a third protocol that was composed post hoc by replacing the head-impulse test with caloric testing in the HINTS plus protocol. RESULTS: We included 30 AVS patients (ages 55.4 +/- 17.2 years, 14 females). Of these, 11 (36.7%) had posterior circulation stroke (n = 4) or TIA (n = 7). Acute V-HIT-assisted HINTS plus was feasible and displayed tendentially higher accuracy than conventional HINTS plus (sensitivity: 81.8%, 95% CI 48.2-97.7%; specificity 31.6%, 95% CI 12.6-56.6% vs. sensitivity 72.7%, 95% CI 39.0-94.0%; specificity 36.8%, 95% CI 16.3-61.6%). The new caloric-supported algorithm showed high accuracy (sensitivity 100%, 95% CI 66.4-100%; specificity 66.7%, 95% CI 41-86.7%). CONCLUSIONS: Our study provides pilot data on V-HIT-assisted HINTS plus for acute AVS assessment and indicates the diagnostic value of integrated acute caloric testing.