What are the symptoms of vertebral artery occlusive disease?

Vertebral Artery Occlusive Disease Symptoms

Symptoms associated with vertebral artery occlusive disease include dizziness, vertigo, diplopia, perioral numbness, blurred vision, tinnitus, ataxia, bilateral sensory deficits, and syncope, all of which can be caused by other disease entities including cardiac arrhythmias, orthostatic hypotension, and vestibular disorders. 1, 2

Clinical Presentation

• Vertebral artery atherosclerosis may be the causative basis for approximately 20% of posterior circulation strokes 1
• Symptoms may be provoked by head turning, especially when lesions occur at the midportion of the vertebral arteries, where the transverse process of a vertebra may impinge on the artery 1
• Vertebrobasilar arterial stenosis is associated with multiple ischemic episodes and a higher risk of early recurrent stroke 1, 3
• Compromised vertebrobasilar perfusion is not the only mechanism of symptoms, as atheroembolism may also cause brainstem or cerebellar infarction 1

Common Symptoms in Detail

• Dizziness/Vertigo: Often the most common presenting symptom, occurring in up to 73% of patients with vertebral artery disease 4
• Visual Disturbances:
  • Diplopia (double vision) 1, 2
  • Blurred vision 1
• Sensory Symptoms:
  • Perioral numbness (numbness around the mouth) 1
  • Bilateral sensory deficits 1, 2
• Balance Issues:
  • Ataxia (lack of muscle coordination) 1
• Other Symptoms:
  • Tinnitus (ringing in the ears) 1, 2
  • Syncope (fainting) occurring in approximately 20% of patients 1, 4

Anatomical Considerations

• The vertebral arteries have 4 segments (V1-V4), with the first 3 being extracranial 1, 2
• Approximately 5% of individuals have the left vertebral artery arising from the aortic arch rather than the subclavian artery 1, 2
• Atherosclerotic stenosis most commonly affects the first portion (V1) of the vertebral arteries or extends from plaques that compromise the origin of the vertebral arteries 1, 5

Clinical Significance and Diagnostic Challenges

• Symptoms of vertebrobasilar insufficiency may precede neurological sequelae in up to 50% of patients 6
• Many symptoms of vertebral artery disease overlap with other common conditions, making diagnosis challenging 1
• Intermittent symptoms may represent transient ischemic attacks (TIAs), which carry a high risk of stroke - up to 13% in the first 90 days 3
• V4 segment stenosis affects the intracranial portion of the vertebral artery, which has fewer collaterals and poses a higher risk for posterior circulation stroke 3

Diagnostic Approach

• Evaluation should begin with a thorough clinical history and examination followed by non-invasive imaging 1
• MRA or CTA are recommended as first-line imaging modalities with higher sensitivity (94%) and specificity (95%) than ultrasonography (sensitivity 70%) 1, 2
• Catheter-based angiography is typically required before revascularization for patients with symptomatic posterior cerebral ischemia 1

Clinical Pitfalls

• Delaying evaluation of intermittent dizziness in the setting of known high-grade vascular stenosis can lead to preventable strokes 3
• Failing to recognize that dizziness may be the only presenting symptom of posterior circulation ischemia can have devastating consequences 3
• The symptoms of vertebral artery disease can be easily mistaken for more benign conditions such as vestibular disorders 1