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

Posterior circulation strokes are frequently underrecognized in emergency departments, especially when dizziness is the presenting complaint without overt motor deficits. Diagnostic delays often occur when providers anchor on benign causes such as benign paroxysmal positional vertigo. Early computed tomography and magnetic resonance imaging may miss acute infarcts in the posterior fossa, whereas the bedside head-impulse, nystagmus, and test of skew plus hearing examination has demonstrated greater sensitivity for detecting stroke in acute vestibular syndrome. A 76-year-old male with vascular risk factors presented to a satellite emergency department with sudden-onset dizziness described as "the room is spinning." Without imaging or a structured bedside assessment, he was diagnosed as having benign paroxysmal positional vertigo and transferred for admission. On subsequent evaluation, he exhibited severe lateropulsion, left hemiparesis, impaired gaze holding, new unilateral right-sided hearing loss, and subtle skew deviation. Head-impulse, nystagmus, and test of skew plus hearing examination findings suggested central pathology. Magnetic resonance imaging confirmed a right posterior thalamic infarct, diagnosed beyond the reperfusion window. Posterior circulation stroke frequently mimics peripheral vestibular disorders, and symptom descriptors alone are unreliable for diagnosis. Anchoring on "room spinning" led to a missed opportunity for timely stroke activation. Emergency clinicians including physicians, advanced practice registered nurses, registered nurses, and physical therapists must recognize red flags such as hemiparesis, lateropulsion, hearing loss, and skew deviation. Advanced providers and physicians are often the first to triage and assess dizziness. Training in bedside tools such as the head-impulse, nystagmus, and test of skew plus hearing examination; vigilance in identifying red flags; and interdisciplinary advocacy are essential to prevent misdiagnosis.