Patient Experiences of Posterior Circulation Stroke at Symptom Onset A Qualitative Study
Article Sidebar
Main Article Content
Abstract
Introduction: Posterior Circulation Stroke (PCS) accounts for around 20% of ischaemic strokes but is missed more frequently than Anterior Circulation Stroke (ACS), mainly due to its subtle symptoms and non-specific presentation. Currently there are no studies evaluating PCS patients’ experiences of their symptoms at stroke onset, and so this study aimed to evaluate this to aid in paramedic understanding and detection of PCS.
Methods: A qualitative descriptive approach was adopted. Clinical Nurse Specialists and Advanced Nurse Practitioners in Stroke purposefully sampled PCS patients confirmed by MRI and admitted to the stroke wards of University Hospital Galway and Mayo University Hospital in the West of Ireland. Once consented, semi-structured interviews were carried out, transcribed verbatim, and thematic analysis completed. Inclusion criteria were any stroke in the posterior portion of the brain confirmed by MRI, patient ≥18 and less than four weeks since stroke onset.
Results: Ten patients were interviewed. 90% did not believe they were having a stroke. Only 50% sought help immediately. 70% were taken to hospital by ambulance and 30% were taken by car. 20 different symptoms were reported by participants. Loss of balance was the most prevalent symptom, followed by being unable to walk unaided, dizziness, vision disturbance and headache. 60% had prodromal symptoms prior the onset of their stroke. Qualitative analysis created three main themes: 1) Physical Disturbance, 2) Visual and Spatial Disturbance and 3) Dismissal.
Conclusion: PCS is a difficult condition for patients to recognize, which affects their help seeking behaviour, delays treatment and negatively affects outcomes. These patients described a wide variety of symptoms and their reasons for dismissing them. These results may help inform future paramedic educational programs for PCS awareness and recognition in the prehospital environment.
Article Details
This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.
Publishing in IJOP allows authors to keep their copyright while giving IJOP unrestricted copyright permissions. Articles published in IJOP use Creative Common Attribution 4.0 International (CC BY-ND 4.0) licensing. This license requires that re-users give credit to the creator. It allows re-users to copy and distribute the material in any medium or format in unadapted form only, even for commercial purposes. Additional terms apply and can be accessed here.
Publishing in IJOP also allows authors to have contracts for non-exclusive distribution of the Journal's published version of the article, such as posting to an institutional repository or publication in a book, on the condition that the original publication in the original layout format in IJOP is retained and acknowledged.
We permit and encourage authors to post the articles they published in IJOP on their affiliated websites. This helps share the information, encourages citation in other works, and promotes scholarly discourse in the spirit of open access.
References
Andersson, J., Rejnö, Å., Jakobsson, S., Hansson, P. O., Nielsen, S. J., & Björck, L. (2024). Symptoms at stroke onset as described by patients: a qualitative study. BMC Neurology, 24(1). https://doi.org/10.1186/s12883-024-03658-4
Arch, A. E., Weisman, D. C., Coca, S., Nystrom, K. V., Wira, C. R., & Schindler, J. L. (2016). Missed Ischemic Stroke Diagnosis in the Emergency Department by Emergency Medicine and Neurology Services. Stroke, 47(3), 668–673. https://doi.org/10.1161/STROKEAHA.115.010613
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706QP063OA
Campbell, B. C. V., & Khatri, P. (2020). Stroke. The Lancet, 396(10244), 129–142. https://doi.org/10.1016/S0140-6736(20)31179-X
Carr, P. (2015). Stroke and stroke rehabilitation 2: brain anatomy. British Journal of Healthcare Assistants, 9(12), 604–608. https://doi.org/10.12968/bjha.2015.9.12.604
Comolli, L., Korda, A., Zamaro, E., Wagner, F., Sauter, T. C., Caversaccio, M. D., Nikles, F., Jung, S., & Mantokoudis, G. (2023). Vestibular syndromes, diagnosis and diagnostic errors in patients with dizziness presenting to the emergency department: a cross-sectional study. BMJ Open, 13(3), e064057. https://doi.org/10.1136/bmjopen-2022-064057
Creswell, J. W., & Miller, D. L. (2000). Determining Validity in Qualitative Inquiry. Theory Into Practice, 39(3), 124–130. https://doi.org/10.1207/S15430421TIP3903_2
Devlin, S., & Bury, G. (2023). Paramedic recognition of posterior circulation stroke: a vignette and focus group study. British Paramedic Journal, 8(2), 1–9. https://doi.org/10.29045/14784726.2023.9.8.2.1
Doijiri, R., Uno, H., Miyashita, K., Ihara, M., & Nagatsuka, K. (2016). How Commonly Is Stroke Found in Patients with Isolated Vertigo or Dizziness Attack? Journal of Stroke and Cerebrovascular Diseases, 25(10), 2549–2552. https://doi.org/10.1016/j.jstrokecerebrovasdis.2016.06.038
Feeney, A., Barry, T., Hayden, D., Higgins, L., Kavanagh, E., MacMahon, P., O’Reilly, M., Teeling, S. P., Kelly, P. J., & Murphy, S. (2016). Pre-Hospital Fast Positive Cases Identified by DFB Ambulance Paramedics: Final Clinical Diagnosis. Irish Medical Journal, 109(4), 397. https://pubmed.ncbi.nlm.nih.gov/27685491
Floßmann, E., & Rothwell, P. M. (2003). Prognosis of vertebrobasilar transient ischaemic attack and minor stroke. Brain, 126(Pt 9), 1940–1954. https://doi.org/10.1093/brain/awg197
Gulli, G., & Markus, H. S. (2012). The use of FAST and ABCD2 scores in posterior circulation, compared with anterior circulation, stroke and transient ischemic attack. Journal of Neurology, Neurosurgery & Psychiatry, 83(2), 228–229. https://doi.org/10.1136/JNNP.2010.222091
Harbison, J., Hossain, O., Jenkinson, D., Davis, J., Louw, S. J., & Ford, G. A. (2003). Diagnostic accuracy of stroke referrals from primary care, emergency room physicians, and ambulance staff using the face arm speech test. Stroke, 34(1), 71–76. https://doi.org/10.1161/01.STR.0000044170.46643.5E
Hejazian, S. S., Shahjouei, S., Sadr, A. V., Vemuri, A., Bahrami, S., Abedi, V., & Zand, R. (2025). Risk of Ischemic Stroke After Transient Ischemic Attack in Patients Receiving Comprehensive Versus Noncomprehensive Diagnostic Workup: A Systematic Review and Meta-Analysis. Journal of the American Heart Association , 14(21), 42175. https://doi.org/10.1161/JAHA.125.042175
Hoyer, C., & Szabo, K. (2021). Pitfalls in the Diagnosis of Posterior Circulation Stroke in the Emergency Setting. Frontiers in Neurology, 12. https://doi.org/10.3389/fneur.2021.682827
Hu, X., Liu, S., Wu, X., Yan, S., Shen, J., Zhu, L., Liu, X., Wang, Z., Chen, C., Yang, T., Fang, C., & Li, Q. (2025). Prevalence of Stroke and Diagnostic Performance of Emergency MRI in Acute Isolated Dizziness. Annals of Clinical and Translational Neurology, 12(12), 2514–2522. https://doi.org/10.1002/acn3.70195
Hunt, B., Zhao, H., Cassidy, A., Peart, S., & Olaussen, A. (2024). Diagnostic Accuracy of Posterior Circulation Stroke by Paramedics: A Systematic Review. Prehospital Emergency Care, 28(6), 823–831. https://doi.org/10.1080/10903127.2023.2270041
IPSOS. (2023). Ipsos/Irish Heart Foundation Stroke Awareness Research Results. https://www.ipsos.com/en-ie/ipsosirish-heart-foundation-stroke-awareness-research-results
Irish Heart Foundation. (2020). Irish Heart Act F.A.S.T. https://irishheart.ie/campaigns/fast
Jones, S. P., Bray, J. E., Gibson, J. M. E., McClelland, G., Miller, C., Price, C. I., & Watkins, C. L. (2021). Characteristics of patients who had a stroke not initially identified during emergency prehospital assessment: a systematic review. Emergency Medicine Journal, 38(5), 387–393. https://doi.org/10.1136/emermed-2020-209607
Kaski, D., Tarnutzer, A. A., Agrawal, Y., Carey, J., Cha, Y. H., Eggers, S. D., Furman, J., Kim, H. A., Kim, J. S., Lempert, T., López-Escámez, J. A., Magnusson, M., Newman-Toker, D. E., Seemungal, B. M., Staab, J. P., Strupp, M., van de Berg, R., von Brevern, M., Ward, B. K., & Bisdorff, A. (2025). The International Classification of Vestibular Disorders: Achievements, challenges, and future directions. Journal of Vestibular Research, 35(3), 105. https://doi.org/10.1177/09574271251313803
Kerber, K. A., & Newman-Toker, D. E. (2015). Misdiagnosing the Dizzy Patient: Common Pitfalls in Clinical Practice. Neurologic Clinics, 33(3), 565. https://doi.org/10.1016/j.ncl.2015.04.009
Khan, F., Yogendrakumar, V., Lun, R., Ganesh, A., Barber, P. A., Lioutas, V. A., Vinding, N. E., Algra, A., Weimar, C., Ögren, J., Edwards, J. D., Swartz, R. H., Ois, A., Giralt-Steinhauer, E., Khanevski, A. N., Leng, X., Tian, X., Leung, T. W., Park, H. K., … Hill, M. D. (2025). Long-Term Risk of Stroke After Transient Ischemic Attack or Minor Stroke: A Systematic Review and Meta-Analysis. JAMA, 333(17), 1508–1519. https://doi.org/10.1001/jama.2025.2033
Kim, J. sung, Bae, H. J., Kim, M., Ahn, S., Sohn, C. H., Seo, D. W., & Kim, W. Y. (2021). Stroke prediction in patients presenting with isolated dizziness in the emergency department. Scientific Reports 2021 11:1, 11(1), 6114-. https://doi.org/10.1038/s41598-021-85725-1
McCormack, J., Brych, O., Cassidy, T., Glynn, M., Coleman, S., & Prendergast, C. (2024). Irish National Audit of Stroke 2024 and Organisational Audit Report 2025, National Office of Clinical Audit. https://www.noca.ie/publications
Mellon, L., Hickey, A., Doyle, F., Dolan, E., & Williams, D. (2014). Can a media campaign change health service use in a population with stroke symptoms? Examination of the first Irish stroke awareness campaign. Emergency Medicine Journal, 31(7), 536–540. https://doi.org/10.1136/emermed-2012-202280
Merwick, Á., & Werring, D. (2014). Posterior circulation ischaemic stroke. BMJ (Clinical Research Ed.), 348. https://doi.org/10.1136/bmj.g3175
Prehospital Emergency Care Council. (2014). PHECC Education and Training Standards. https://www.phecit.ie/PHECC/Education_and_careers/Education_and_Training_Standards/Education_and_Training_Standards.aspx?hkey=1733bd9d-1ea7-41e7-af20-8ab0f40ab846
Prehospital Emergency Care Council. (2023). PHECC 2021 edition CPGs (updated 2023). https://www.phecit.ie/PHECC/Clinical_Resources/Clinical_Practice_Guidelines__CPGs_/2021_edition_CPGs.aspx
Prehospital Emergency Care Council. (2025). 2026 PHECC Education and Training Standards and Competency Frameworks. https://www.phecit.ie/PHECC/Education_and_careers/Education_and_training_standards/PHECC/Education_and_careers/Education_and_Training_Standards/Education_and_Training_Standards.aspx?hkey=1733bd9d-1ea7-41e7-af20-8ab0f40ab846
Price, C. I., Rae, V., Duckett, J., Wood, R., Gray, J., McMeekin, P., Rodgers, H., Portas, K., & Ford, G. A. (2013). An Observational Study of Patient Characteristics Associated with the Mode of Admission to Acute Stroke Services in North East, England. PLOS ONE, 8(10), e76997. https://doi.org/10.1371/journal.pone.0076997
Price, C., & Paramedic, B. (2017). A survey of UK paramedics’ views about their stroke training, current practice and the identification of stroke mimics. British Paramedic Journal, 2(1), 4–15. https://www.collegeofparamedics.co.uk
Public Health England. (2021). Relaunch of the Act FAST campaign to improve stroke outcomes. https://www.gov.uk/government/news/relaunch-of-the-act-fast-campaign-to-improve-stroke-outcomes
Rowe, F. J., Dent, J., Allen, F., Hepworth, L. R., & Bates, R. (2020). Development of V-FAST: a vision screening tool for ambulance staff. Journal of Paramedic Practice, 12(8), 324–331. https://doi.org/10.12968/JPAR.2020.12.8.324
Searls, D. E., Pazdera, L., Korbel, E., Vysata, O., & Caplan, L. R. (2012). Symptoms and Signs of Posterior Circulation Ischemia in the New England Medical Center Posterior Circulation Registry. Archives of Neurology, 69(3), 346–351. https://doi.org/10.1001/archneurol.2011.2083
Shannon, J. (2023). Irish Heart Public awareness of stroke signs shows worrying decline. https://irishheart.ie/news/public-awareness-of-stroke-signs-shows-worrying-decline
Sommer, P., Posekany, A., Serles, W., Marko, M., Scharer, S., Fertl, E., Ferrari, J., Lang, W., Vosko, M., Szabo, S., Kiechl, S., Knoflach, M., & Greisenegger, S. (2018). Is Functional Outcome Different in Posterior and Anterior Circulation Stroke? Stroke, 49(11), 2728–2732. https://doi.org/10.1161/STROKEAHA.118.021785
Tao, W. D., Liu, M., Fisher, M., Wang, D. R., Li, J., Furie, K. L., Hao, Z. L., Lin, S., Zhang, C. F., Zeng, Q. T., & Wu, B. (2012). Posterior versus anterior circulation infarction: how different are the neurological deficits? Stroke, 43(8), 2060–2065. https://doi.org/10.1161/STROKEAHA.112.652420
Tarnutzer, A. A., Lee, S. H., Robinson, K. A., Wang, Z., Edlow, J. A., & Newman-Toker, D. E. (2017). ED misdiagnosis of cerebrovascular events in the era of modern neuroimaging: A meta-analysis. Neurology, 88(15), 1468–1477. https://doi.org/10.1212/WNL.0000000000003814