Avoiding Misdiagnosis in Patients With Posterior Circulation Ischemia: A Narrative Review

Posterior circulation strokes represent 20% of all acute ischemic strokes. Posterior circulation stroke patients are misdiagnosed twice as often compared to those with anterior events. Misdiagnosed patients likely have worse outcomes than correctly diagnosed patients because they are at risk for complications of the initial stroke as well as recurrent events due to lack of secondary stroke prevention and failure to treat the underlying vascular pathology. Understanding important anatomic variants, the clinical presentations, relevant physical examination findings, and the limitations of acute brain imaging may help reduce misdiagnosis. We present a symptom-based review of posterior circulation ischemia focusing on the subtler presentations with a brief discussion of basilar stroke, both of which can be missed by the emergency physician. Strategies to avoid misdiagnosis include establishing an abrupt onset of symptoms, awareness of the nonspecific presentations, consideration of basilar stroke in altered patients and using a modern approach to diagnosis of the acutely dizzy patient.