Posterior Circulation Stroke Misdiagnosed as Benign Paroxysmal Positional Vertigo: A Case Report

Area of Science:

• Neurology
• Emergency Medicine
• Neuroscience

Background:

• Posterior circulation strokes are frequently underrecognized in emergency departments, particularly when dizziness is the primary complaint without obvious motor deficits.
• Diagnostic delays are common due to providers anchoring on benign causes like benign paroxysmal positional vertigo.
• Acute infarcts in the posterior fossa may be missed by early computed tomography and magnetic resonance imaging.

Purpose of the Study:

• To highlight the challenges in diagnosing posterior circulation strokes presenting with dizziness.
• To emphasize the utility of bedside neurological examinations in acute vestibular syndrome.
• To advocate for improved diagnostic strategies and clinician training to prevent misdiagnosis.

Main Methods:

• Case report of a 76-year-old male with vascular risk factors presenting with sudden-onset dizziness.
• Review of diagnostic challenges in emergency departments for posterior circulation strokes.
• Comparison of imaging findings with bedside neurological examination results (Head-Impulse, Nystagmus, and Test of Skew plus Hearing examination).

Main Results:

• The patient was initially misdiagnosed with benign paroxysmal positional vertigo, leading to delayed stroke diagnosis.
• Bedside Head-Impulse, Nystagmus, and Test of Skew plus Hearing examination findings suggested central pathology, contrasting with initial assessment.
• Magnetic resonance imaging confirmed a right posterior thalamic infarct, diagnosed outside the therapeutic window.

Conclusions:

• Posterior circulation stroke symptoms can mimic peripheral vestibular disorders, making symptom descriptors alone unreliable for diagnosis.
• Emergency clinicians must recognize red flags such as hemiparesis, lateropulsion, hearing loss, and skew deviation.
• Training in bedside tools, vigilance for red flags, and interdisciplinary collaboration are essential to prevent misdiagnosis of posterior circulation strokes.