Symptoms of Symptomatic Vertebral Artery Occlusion
Symptomatic vertebral artery occlusion presents with posterior circulation ischemia manifesting as dizziness, vertigo, diplopia, perioral numbness, blurred vision, tinnitus, ataxia, bilateral sensory deficits, and syncope. 1, 2
Core Neurological Manifestations
The symptom complex reflects compromised vertebrobasilar perfusion and/or atheroembolic events causing brainstem or cerebellar infarction: 1
Vestibular and Visual Symptoms
- Dizziness and vertigo are among the most common presenting symptoms 1, 2
- Diplopia (double vision) results from brainstem ischemia affecting cranial nerve nuclei 1, 2
- Blurred vision occurs with posterior cerebral circulation compromise 1, 2
Sensory and Motor Deficits
- Bilateral sensory deficits distinguish posterior from anterior circulation ischemia 1, 2
- Perioral numbness is characteristic of vertebrobasilar territory involvement 1, 2
- Ataxia reflects cerebellar ischemia 1, 2
Additional Features
- Tinnitus may accompany vertebrobasilar insufficiency 1, 2
- Syncope can occur with severe posterior circulation compromise 1, 2
Temporal Pattern and Provocation
Recurrent/Progressive Events
- Multiple ischemic episodes are characteristic, with higher risk of early recurrent stroke in patients with vertebrobasilar stenosis 1, 2
- Recurrent or progressive stroke despite aggressive medical therapy indicates dominant vertebral artery occlusion 3
Positional Symptoms
- Symptoms provoked by head turning occur when lesions at the midportion of the vertebral arteries cause mechanical compression by the transverse process of a vertebra 1
- Upper-extremity exertion may aggravate symptoms in subclavian steal syndrome, causing lightheadedness, syncope, vertigo, ataxia, diplopia, or motor deficits 1
Warning Signs
Prodromal Symptoms
- Occipito-cervical headache often precedes cerebellar, vestibular, or medullary infarction 4
Specific Stroke Syndromes
- Wallenberg's syndrome (lateral medullary syndrome) is a frequent clinical presentation 4
- Cerebellar, vestibular, or cerebello-vestibular strokes are the most common clinical disorders 4
- Ipsilateral cerebellar and lateral medullary infarctions occur with vertebral artery occlusion 4
Critical Diagnostic Pitfall
These symptoms are nonspecific and can be caused by other disease entities including cardiac arrhythmias, orthostatic hypotension, and vestibular disorders, requiring careful differentiation. 1 The key distinguishing features are:
- Bilateral sensory deficits (rather than unilateral) 1, 2
- Multiple posterior circulation territory symptoms occurring together 1
- Provocation by head turning or arm exercise 1
- Recurrent stereotyped episodes 1, 2, 3
Mortality Risk
Contrary to common belief, the vital risk in vertebral artery occlusion is not negligible, with mortality rates of 25% reported in case series. 4 Segmental distal occlusion and extensive occlusion carry worse prognosis than benign segmental proximal occlusion. 4