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Clinical Review Volume 18 Issue 2
When vertigo is a stroke: Recognising posterior circulation Ischaemia in the acutely dizzy patient
Anirudda Deshpande
Received: June 18, 2026 | Published: July 17, 2026
Citation: Khardenavis S, Godse G, Khardenavis V, et al. When vertigo is a stroke: Recognising posterior circulation Ischaemia in the acutely dizzy patient.J Otolaryngol ENT. 2026;18(2):57‒59. DOI: 10.15406/joentr.2026.18.00588
Abstract
Background: Acute vertigo and dizziness are among the most common reasons for emergency presentation, and the overwhelming majority have a benign peripheral cause. A small but dangerous minority, however, are the first manifestation of posterior circulation ischaemia. These strokes are missed at first contact far more often than anterior circulation events, because isolated vertigo can be the sole symptom, the neurological examination may appear normal, and clinicians instinctively reach for imaging that performs poorly in exactly this setting. Objective: To synthesise the contemporary evidence on how posterior circulation stroke masquerades as a peripheral vestibular disorder, and to set out a structured, examination-led approach that outperforms early neuroimaging at the bedside. Discussion: A focused oculomotor assessment — the Head Impulse, Nystagmus, Test of Skew (HINTS) battery, extended to HINTS-plus by the addition of new unilateral hearing loss — discriminates central from peripheral acute vestibular syndrome with greater sensitivity than diffusion-weighted MRI obtained within the first 24 to 48 hours. The single most counterintuitive lesson is that a normal horizontal head impulse response in a patient with continuous spontaneous vertigo points towards, not away from, a stroke. The principal barriers to applying this knowledge are not gaps in the evidence but gaps in delivery: examiner training, consistent technique, and equitable access to confirmatory tools across district general and regional hospitals. Conclusion: The acutely dizzy patient is a problem of clinical reasoning before it is a problem of technology. Disciplined bedside assessment, an honest understanding of the limits of early MRI, and investment in training and quantitative video-oculography together offer the most realistic route to closing a persistent and harmful diagnostic gap.
Keywords: acute vestibular syndrome, posterior circulation stroke, HINTS, vertigo, diffusion-weighted imaging, video-oculography, diagnostic error
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