We reported a 66-year-old man who complained of headache, vertigo, vomiting and chest oppression sensation. He could not walk veering to right and spontaneous contrarateral horizontal nystagmus was noted. A MRI DWI showed scattered multiple small high signals within the territory of left medial branch of posterior inferior cerebellar artery. Cerebellar infarcts specifically affected the tonsil and nodulus, which has tight connections with vestibular labyrinth and vestibular nuclei. Digital subtraction angiography exhibited tapered occlusion on the V4 segment of the right vertebral artery. Stroke mechanism of artery to artery embolism from occlusive site was presumed. As small multiple infarcts were limited within the cerebellar tonsil and nodulus, repeated CT or MRI T2 weighted image did not showed obvious findings. It is worth noting for differential diagnosis that small cerebellar infarcts only detected by diffusion MRI can produce strong vertigo, nausea and chest oppression.