Posterior Circulation Infarct Does NOT Present with Only a Positive Romberg Sign
No, posterior circulation infarcts (POCI) do not present with only a positive Romberg sign—they typically manifest with multiple neurological deficits, and relying on isolated clinical findings alone leads to frequent misdiagnosis.
Clinical Presentation Reality
The most common symptoms in POCI are homolateral hemiplegia (53.6%), central facial/lingual palsy (40.7%), and hemisensory deficits (36.4%)—not isolated balance abnormalities. 1
- A positive Romberg sign indicates proprioceptive or vestibular dysfunction, but this finding alone is neither sensitive nor specific for POCI 1
- The so-called "typical" posterior circulation signs (crossed motor/sensory deficits, Horner's syndrome, oculomotor palsies) occur far less frequently than expected, with sensitivities ranging only 1.3% to 4.0% 1
- Inaccurate localization occurs commonly when clinicians rely on neurological deficits alone to differentiate posterior from anterior circulation strokes 1
Why Clinical Examination Alone Fails
- Multiple acute infarcts in the posterior circulation usually involve the cerebellum, and when distal territory is affected (most common pattern), patients present with consciousness disturbances, gait ataxia, ocular motor disturbances, and visual field deficits—not isolated findings 2, 3
- Mesencephalic involvement presents with third-nerve palsy and contralateral motor deficits, while middle territory infarcts show consciousness disturbances with dysarthria and horizontal ocular motor disorders 2
- The substantial overlap in symptoms between anterior and posterior circulation strokes makes clinical differentiation unreliable 4
Diagnostic Imperative
Neuroimaging is vital to ensure accurate localization of cerebral infarction—clinical examination cannot be trusted alone. 1
- MRI brain without contrast with diffusion-weighted imaging (DWI) is the imaging modality of choice, detecting ischemic changes within minutes of onset 5
- CT head has extremely low sensitivity (~10%) for detecting POCI and should not be relied upon to exclude stroke 5
- MRA of head and neck should be performed in patients with suspected POCI, particularly those eligible for mechanical thrombectomy 5
Critical Pitfall to Avoid
Do not assume that a normal or minimally abnormal neurological examination excludes POCI—posterior circulation strokes can present with NIHSS of 0 yet still represent large vessel occlusion. 5
- Approximately 20-25% of all ischemic strokes involve the posterior circulation, and diagnosis is frequently delayed due to non-focal presenting symptoms 4, 6
- The diagnostic yield of MRI in isolated dizziness is approximately 4%, with ischemic stroke being the most common abnormality (70% of positive findings) 7
- A positive Romberg sign in isolation should prompt comprehensive neuroimaging, not reassurance that the patient has a benign peripheral vestibular disorder 5, 7