Intended for healthcare professionals

Practice Easily Missed?

Posterior circulation ischaemic stroke

BMJ 2018; 361 doi: (Published 19 April 2018) Cite this as: BMJ 2018;361:k1185
  1. Gargi Banerjee, clinical research associate1,
  2. Sheldon P Stone, consultant physician for older people and stroke medicine, and senior lecturer in geriatric medicine2,
  3. David J Werring, professor of clinical neurology and honorary consultant neurologist1
  1. 1Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London WC1B 5EH, UK
  2. 2Department of Medicine, Royal Free Campus, University College London Medical School, and University College Hospital, London, UK
  1. Corresponding author: D J Werring d.werring{at}

What you need to know

  • Posterior circulation stroke causes a wide range of non-specific presenting symptoms

  • More than a third of posterior circulation strokes are initially misdiagnosed

  • Explore the possibility of posterior circulation stroke in patients with new vertigo or disequilibrium, and those with new headache or changed migraine

  • A negative HINTS examination in a patient with isolated vertigo can help rule out posterior circulation ischaemia

A 63 year old man with a history of migraine with visual aura, hypertension, and anxiety presented to the local emergency department with a five day history of headache (see “A patient’s perspective”). This headache started similarly to previous migrainous episodes, but became more severe than usual and was accompanied by intermittent double vision and disturbed balance, speech, and swallowing. The patient was treated in the emergency department with intravenous fluids and analgesia and discharged with a diagnosis of migraine. The following day, his symptoms worsened; clinical examination revealed vertical diplopia, gaze-evoked jerk nystagmus, right sided past-pointing, and an ataxic gait. Computed tomography (CT) of the head and CT angiography demonstrated an acute right superior cerebellar artery territory infarct and thrombus in the V3 and V4 (distal) segments of the right vertebral artery; subsequent brain magnetic resonance imaging (MRI) revealed other posterior circulation infarcts (fig 1).

Fig 1

Magnetic resonance imaging (MRI) of brain of the patient described in the case history. Axial T2 sequences (A, B) and axial diffusion weighted sequences (C, D) show acute infarcts (arrows) in the right occipital lobe (A, C) and right cerebellum (B, D). Contrast enhanced magnetic resonance angiography (E) shows an abrupt occlusion of the right vertebral artery (thick arrow). The left vertebral artery (thin arrow) continues via a tortuous route, before terminating in the posterior inferior cerebellar artery (interrupted arrow). The basilar artery (arrowhead) receives no flow from either vertebral artery, and …

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