Recognising Posterior Stroke – Dr Alan Sim

This article, adapted from the NB Medical version, is to help differentiate when acute vertigo symptoms might be due to an acute posterior circulation stroke as opposed to a peripheral cause such as vestibular neuritis.

Symptoms of an acute posterior stroke may include:   visual changes, vertigo, dysarthria, dysphagia, nausea, drowsiness.

Diagnosis: The 3 steps HINTS examination is now recommended and is more accurate than early MRI scanning in these patients.

The tests below are all best explained via You Tube.

  1. Head impulse test (HIT)
  2. Nystagmus
  3. Test of Skew (cover testing)


Diagnosis Head Impulse Nystagmus Test of Skew
Posterior stroke

(central vertigo)

At least one of:

Normal. No lag either way Direction changing – horizontal then vertical in eccentric vision Skew deviation
ENT (peripheral vertigo)

Needs ALL of:

Abnormal – WITH lag. Nystagmus does not change direction NO skew deviation.



  1. If posterior stroke suspected then 300mg aspirin stat.
  2. Refer for immediate imaging.

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