<p>Posterior circulation (PC) ischemic stroke accounts for approximately a fourth of all acute ischemic strokes and is associated with high disability and mortality. Rapid diagnosis and management can be challenging as it often presents with non-specific signs and symptoms. We performed a systematic review and meta-analysis to describe the prevalence of signs and symptoms in PC ischemic stroke. Two databases (PubMed and EMBASE) were searched for English-written observational studies reporting data on signs and symptoms in patients with a diagnosis of PC ischemic stroke. Data were extracted by two independent researchers. We assessed the risk of bias (RoB) and calculated the pooled prevalence and 95% confidence intervals (CI) using random effect models. We performed subgroup analyses according to type of diagnosis (clinical vs imaging) and location of lesion (cerebellar vs other) in each study. Twenty-eight studies involving three thousand four hundred sixty-two patients were included in the study. RoB was mainly medium/low; in 18/28 studies, diagnosis was performed on imaging. The most common signs were limb weakness (48%; 95% CI 39–58%) and dysarthria (48%; 95% CI 37–59%), while the least frequent was hemianopia (15%; 95% CI 7–25%). The most common symptoms were vertigo/dizziness (41%; 95% CI 30–52%) and nausea/vomiting (41%; 95% CI 32–50%), while the least frequent was diplopia (9%; 95% CI 6–13%). In patients with cerebellar stroke, the most frequent sign was gait ataxia (70%; 95% CI 56–82%), and the most common symptom was vertigo (50%; 95% CI 32–68%). In acute patients with PC ischemic stroke, gait ataxia, vertigo/dizziness, limb weakness, and dysarthria were the most frequent presentations. Our results may inform clinicians and help to refine stroke scales, improving early recognition of PC ischemic stroke in the acute setting.</p>