Navigating the Diagnostic Challenges of Posterior Circulation Ischaemic Strokes: A Case Report of Delayed Diagnosis

Posterior circulation infarcts (POCI) can present with non-specific symptoms, making diagnosis challenging and often delayed. We present a 58-year-old lady with a history of migraine who attended the emergency department of a district general hospital with sudden onset of vertigo, nausea, and vomiting but without focal neurological deficits. At the initial assessment, she experienced marked dizziness, which was worse on opening her eyes. Unenhanced brain computed tomography (CT) scan as well as CT angiography were normal. A provisional diagnosis of atypical presentation of migraine or benign paroxysmal positional vertigo was made. A stroke physician's opinion was sought, and in view of her persistent symptoms, magnetic resonance imaging (MRI) brain was carried out. This demonstrated three small acute infarcts: one in the posterior left temporal lobe, one in the inferior left occipital lobe, and one in the left cerebellar vermis. Further comprehensive stroke investigations were unremarkable. She was treated with dual antiplatelet therapy and statin. This case highlights the diagnostic challenges of posterior circulation ischaemic stroke and the importance of considering it in patients with unexplained vertigo, particularly those with stroke risk factors (migraine with aura, elevated cholesterol, and family history of stroke in this patient), to prevent misdiagnosis and serious complications.