Podcast #499: Posterior Circulation Ischemia - The Emergency Medical Minute

Podcast # 499: Posterior Circulation Strokes

Contributor: Neal O’Connor, MD

Educational Pearls:

  • Dizziness is a very common complaint in the emergency department, but how can we find patients with a dangerous cause of their symptoms, namely a posterior circulation stroke?
  • Consider a posterior circulation stroke in those with an abrupt onset of headache with neck pain, balance problem, blurred vision, or dysphagia
  • Thorough cranial nerve exam can be important to screen for posterior circulation stroke, as much of the brainstem is supplied by the posterior circulation.
  • The most common posterior circulation stroke is a lateral medullary infarct (Wallenberg Syndrome), which produces dysphagia due to cranial nerve IX and XII involvement
  • Other physical exam findings include truncal ataxia, extremity ataxia, visual field cuts, and Horner syndrome (Ptosis, Miosis, Anhidrosis)
  • The HINTS exam (Head Impulse – Nystagmus – Test of Skew)can be used to differentiate between peripheral and central causes of dizziness
  • Concerning exam findings for central cause may include vertical nystagmus, gaze skew, or inability to track with head impulse


Áine Merwick, David Werring. Posterior circulation ischaemic stroke. BMJ 2014;348:g3175 doi: 10.1136/bmj.g3175

Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504–3510. doi:10.1161/STROKEAHA.109.551234

Nouh A, Remke J, Ruland S. Ischemic posterior circulation stroke: a review of anatomy, clinical presentations, diagnosis, and current management. Front Neurol. 2014;5:30. Published 2014 Apr 7. doi:10.3389/fneur.2014.00030

From CarePoint PA Academy, 2019

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