Posterior circulation ischaemic stroke

A 63 year old man with a history of migraine with visual aura, hypertension, and anxiety presented to the local emergency department with a five day history of headache (see “A patient’s perspective”). This headache started similarly to previous migrainous episodes, but became more severe than usual and was accompanied by intermittent double vision and disturbed balance, speech, and swallowing. The patient was treated in the emergency department with intravenous fluids and analgesia and discharged with a diagnosis of migraine. The following day, his symptoms worsened; clinical examination revealed vertical diplopia, gaze-evoked jerk nystagmus, right sided past-pointing, and an ataxic gait. Computed tomography (CT) of the head and CT angiography demonstrated an acute right superior cerebellar artery territory infarct and thrombus in the V3 and V4 (distal) segments of the right vertebral artery; subsequent brain magnetic resonance imaging (MRI) revealed other posterior circulation infarcts (fig 1).