What are the symptoms of vertebral artery occlusion?

Symptoms of Vertebral Artery Occlusion

The primary symptoms of vertebral artery occlusion include dizziness, vertigo, diplopia (double vision), perioral numbness, blurred vision, tinnitus, ataxia, bilateral sensory deficits, and syncope, which can significantly impact mortality and morbidity if not properly identified and treated. 1, 2

Common Clinical Presentations

Vertebral artery occlusion typically manifests with:

• Vestibular symptoms:

  • Vertigo or dizziness (most common)
  • Nausea
  • Balance disturbances

• Visual disturbances:

  • Diplopia (double vision)
  • Blurred vision
  • Nystagmus

• Sensory symptoms:

  • Perioral numbness
  • Bilateral sensory deficits
  • Tinnitus (ringing in ears)

• Motor symptoms:

  • Ataxia (lack of coordination)
  • Abnormal gait
  • Limb weakness

• Other symptoms:

  • Syncope (fainting)
  • Occipito-cervical headache (often precedes other symptoms) 3

Specific Syndromes Based on Location

The clinical presentation varies depending on the location of the occlusion:

1. Proximal vertebral artery occlusion (V1 segment):

   • Often better compensated
   • May be asymptomatic if collateral circulation is adequate 3

2. Distal vertebral artery occlusion (V3-V4 segments):

   • More likely to cause significant symptoms
   • Higher mortality risk 3

3. Bilateral vertebral artery occlusion:

   • More severe presentation
   • Poorer prognosis 4

4. Occlusion with extension to basilar artery:

   • Can present with specific syndromes:
     • Top of basilar syndrome: somnolence, peduncular hallucinosis, vertical gaze paralysis
     • Mid-basilar occlusions: cranial nerve deficits
     • Proximal basilar occlusions: hemiparesis, quadriparesis 2

Pattern of Onset

The onset of symptoms can follow different patterns:

• Sudden onset: Most common with middle and distal basilar artery occlusions 5
• Progressive onset: More common with bilateral vertebral artery occlusions 5
• Transient ischemic attacks (TIAs): Occur in approximately 80% of patients, often with multiple episodes before a definitive stroke 4

Important Clinical Considerations

1. Differential diagnosis: These symptoms can mimic other conditions, including:

   • Cardiac arrhythmias
   • Orthostatic hypotension
   • Vestibular disorders 1

2. Provocative factors: In some cases, symptoms may be provoked by:

   • Head turning (especially with vertebral artery compression by osteophytes) 1, 6
   • Coughing
   • Sudden neck movements 1

3. Risk factors: Common risk factors include:

   • Hypertension (71%)
   • Diabetes mellitus (34%)
   • Hyperlipidemia (31%)
   • Smoking (29%)
   • Coronary artery disease (23%) 4

Prognosis

Without proper treatment, posterior circulation strokes have a mortality range from 45% to 86% 2. However, with appropriate management, approximately 66.7% of patients may have no symptoms or only slight symptoms that cause no disability at 6 months follow-up 4.

Predictors of poor outcome include:

• Older age
• Higher NIHSS score
• Lack of recanalization
• Atrial fibrillation
• Intracranial hemorrhage
• Posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) ≤8 2

Clinical Pitfalls to Avoid

1. Underestimating vertebral symptoms: The NIHSS has limitations in detecting posterior circulation strokes as it focuses more on limb and speech impairments than on cranial nerve lesions 2.

2. Missing the diagnosis: Patients with posterior circulation large vessel occlusion can have an NIHSS score of 0, presenting only with headache, vertigo, and nausea 2.

3. Inadequate imaging: Ultrasound alone is insufficient for diagnosis (sensitivity only 70% compared to 94% for CTA/MRA) 2.

4. Overlooking head position effects: In rare cases, head rotation may cause cryptic recanalization of chronic vertebral artery occlusion, leading to embolic events 6.