Can left vertebral artery occlusion cause left eye ptosis?

Left Vertebral Artery Occlusion and Left Eye Ptosis

Left vertebral artery occlusion typically does not cause isolated left eye ptosis, as ptosis is more commonly associated with carotid artery pathology, particularly in the setting of Horner syndrome, or with direct cranial nerve compression.

Vertebral Artery Occlusion: Clinical Presentation

Vertebral artery occlusion primarily affects the posterior circulation of the brain and typically presents with a different constellation of symptoms than isolated ptosis:

• Common symptoms of vertebral artery occlusion include 1:
  • Headache and neck pain
  • Vertigo, nausea
  • Visual disturbances (not typically ptosis)
  • Syncope
  • Ataxia
  • Bilateral sensory deficits

The American College of Cardiology Foundation/American Heart Association guidelines specifically note that symptoms associated with vertebral artery occlusive disease include "dizziness, vertigo, diplopia, perioral numbness, blurred vision, tinnitus, ataxia, bilateral sensory deficits, and syncope" 1. Notably absent from this list is ptosis.

Ptosis in Vascular Disease

Ptosis (drooping of the eyelid) in the context of vascular disease typically occurs through different mechanisms:

1. Horner syndrome: Results from interruption of sympathetic innervation and presents with the triad of ptosis, miosis, and anhidrosis. This is commonly associated with carotid artery dissection rather than vertebral artery pathology 1.

2. Cerebral ptosis: Research shows that ptosis can occur in hemispheric strokes, particularly with right hemispheric lesions, but this is associated with middle cerebral artery territory infarcts rather than vertebral artery occlusion 2.

3. Ophthalmic artery occlusion: Can cause ptosis along with complete ophthalmoplegia, but the ophthalmic artery is a branch of the internal carotid artery, not the vertebral artery 3, 1.

Differential Diagnosis for Ptosis with Vascular Etiology

When evaluating a patient with ptosis that may have a vascular cause, consider:

• Carotid artery dissection with Horner syndrome 1
• Hemispheric stroke affecting cortical eyelid control centers 2
• Ophthalmic artery occlusion 1
• Cavernous sinus thrombosis or other compressive lesions affecting cranial nerve III

Clinical Pearls and Caveats

• Ptosis in the setting of acute neurological symptoms should prompt immediate evaluation for stroke, regardless of the presumed vascular territory 1.

• The presence of ptosis with other neurological deficits in a patient with large hemispheric infarction may be a warning sign of impending herniation 2.

• While vertebral artery occlusion can cause various neurological symptoms, isolated ptosis would be an unusual and atypical presentation, suggesting alternative diagnoses should be considered.

• Dynamic vertebral artery occlusion (such as in Bow Hunter syndrome) can cause positional symptoms with head rotation but typically presents with vertebrobasilar insufficiency symptoms rather than isolated ptosis 4, 5.

In conclusion, while there is an anatomical and pathophysiological disconnect between left vertebral artery occlusion and isolated left eye ptosis, any patient presenting with acute ptosis should undergo comprehensive neurovascular evaluation to rule out potentially serious underlying vascular pathologies.