Accounting for approximately one out of five acute ischemic strokes, posterior circulation strokes may have significant overlap with benign vestibular syndromes and present a diagnostic challenge to the treating physician. The primary mechanism for cerebral ischemia related to the posterior circulation is large-vessel atherosclerotic disease, which is subdivided into intracranial atherosclerosis (ICAS) and extracranial atherosclerosis (ECAS). Stroke mechanisms in the setting of atherosclerotic disease include artery-to-artery embolism, local branch occlusion, in situ thrombus occlusion, as well as hemodynamic impairment. All patients with suspected acute ischemic stroke should be evaluated urgently for possible reperfusion therapy per guidelines. Intravenous thrombolytic therapy remains a mainstay of stroke treatment and has shown similar efficacy in both anterior and posterior circulation strokes.