Depending on whether the artery spasm occurs due to irritation of the

afferent fibers of the vertebral nerve (plexus) or due to a reflex response

to irritation of the afferent structures, the vertebral artery can manifest
its clinical failure in two forms: a) in the form of compression-irritative
syndrome of the vertebral artery and b ) in the form of reflex angiospastic
syndrome.
Compression-irritative form of the syndrome occurs with direct mechanical
compression of the vertebral artery. There is irritation of its efferent
sympathetic formations with impaired vertebrobasilar blood flow and
ischemia of cerebral structures.

The vertebral artery can be compressed at different levels and by different

mechanisms, which the doctor must determine based on clinical and
radiological data.
1) Before it enters the canal of the transverse processes (Fig. 8).

The most common cause of compression here is the spasmodic scalene

muscle (Fig. 9).
 This is observed with an anomaly of the separation of the vertebral
artery from the subclavian (the first starts from the posterior wall
of the subclavian). This whole complex of anatomical features and
clinical manifestations constitutes the essence of the Paurs
syndrome.
2) In the canal of the transverse processes (Fig. 10). Most often this
occurs with an increase and deformation of the hooked processes directed
laterally and exerting pressure on the medial wall of the artery: with
Kovacs subluxations, when the anterior upper angle of the superior
articular process, sliding forward of the vertebra, exerts pressure on the
posterior wall of the artery; a similar effect on the artery is exerted by
the articular processes in the presence of their anterior growths due to
spondyloarthrosis; in rare cases, the artery is deformed due to a herniated
disc, sometimes "breaking through" through the uncovertebral joint.
3) At the point of exit from the canal of the transverse processes, the
vertebral artery is compressed: in case of anomalies of the upper cervical
vertebrae - above the upper edge of the atlas arch, where the groove for
the artery may be too deep or even turned into a bone canal (Chimerli's
anomaly); it is also possible to press the artery to the CI-CII joint by
the spasmodic inferior oblique muscle of the head. This is the only site in
the "canal" of the vertebral artery, where it is not covered behind by the
articular processes and where the "point of the vertebral artery" is
palpable (Fig. 11).
Reflex angiospastic syndrome owes its origin to the common innervation of
the vertebral artery, intervertebral discs and intervertebral joints. In
dystrophic processes in the disc, violation of the capsular-ligamentous
apparatus, irritation of sympathetic and other receptor formations occurs,
the flow of pathological impulses reaches the sympathetic plexus of the
vertebral artery. In response to irritation of these efferent sympathetic
formations, the vertebral artery reacts with a spasm.

Thus, the mechanism of compression-irritative and reflex syndromes is

similar - a decrease in the lumen of the artery and its branches due to
compression or angiospasm in the vertebrobasilar system with ischemia in
the zone of its vascularization. The clinical manifestations of both
syndromes, of course, are not entirely similar. Accordingly, therapy in
both cases is carried out taking into account the pathogenetic mechanism.

The course and peculiarity of the clinic. With lesions of the vertebral
arteries depends on a number of factors: the functional state of the circle
of Willis, the rate of occlusion of the vertebral artery, the presence of
anastomoses with the subclavian artery. The severity of the clinical
symptom complex is determined not only by the severity of morphological
disorders. Still, persistent ischemia in the vertebrobasilar system
develops preferably in persons with rough phenomena of compression of an
artery, its persistent stenosis and in the presence of inferiority of
collateral circulation in the other vertebral artery. In this case,
ischemia of cerebral formations occurs in the form of transient disorders
of cerebral circulation, chronic vertebrobasilar vascular insufficiency,
and cerebral infarction.
The clinical manifestations of vertebral artery syndrome include:
paroxysmal (rarely persistent) headaches, often of a hemicranic type.
Moreover, the irradiation of the headache is characteristic: starting in
the cervical region, the occipital region, it spreads to the forehead, eye,
ear, temple (test of "taking off the helmet"). Often the scalp is painful
even with a light touch, hair combing. There is a clear connection between
headaches and head movements, prolonged work incline, uncomfortable head
position during sleep.

When turning or tilting the head, pain often appears, a "crunch" in the
neck, a burning sensation, often spreading to the shoulder girdle, cochleo-
vestibular disorders, systemic dizziness with nausea, sometimes vomiting,
noise, ringing in the ears, hearing loss, especially during time of attack
on the side of the headache. The described subjective cochleo-vestibular
disorders are detected during an objective otoneurological examination,
which must be carried out in this category of patients. There are also
visual disturbances, veil, fog before the eyes, "flies", narrowing of the
visual fields.

Signs of dysfunction of the caudal group of cranial nerves, up to bulbar

disorders, often develop. Atactic disorders are possible. They are
associated with circulatory disorders in the cerebellar arteries extending
from the vertebral artery (posterior inferior cerebellar) and other trunks
of the vertebrobasilar system.

The manifestations of compression of the vertebral artery are paroxysmal

conditions clearly associated with head turns. This includes the following
seizures.

Sudden fall syndrome: following the turn of the head, the patient falls,
“as if knocked down” (he does not lose consciousness); soon gets up on its
own.
Syncope syndrome Unterharnscheidt: just after a sudden movement of the
head, the patient suddenly falls. Consciousness is lost. There are no
seizures. After 5 - 20 minutes the patient comes to his senses, gets up,
but for a long time he feels the most severe general weakness. The
development of such paroxysms is based on ischemia of the reticular
formation of the brainstem.

There are cases of paroxysmal and permanent hypersomnia.

There are always vegetative disorders of varying severity: from short-term
sensations of hunger and thirst, a feeling of heat or chills to severe
hypothalamic crises. The latter are more often of a mixed nature, less
often - vagoinsular or sympathoadrenal. Such gross hypothalamic discharges
with insufficiency of the cervical part of the vertebral arteries develop
in persons with premorbid dysfunction of the higher autonomic centers.

As a result of the discoordination of regulatory mechanisms, violations of

vascular tone often occur, extending to the vessels of the fundus, and
possibly affecting intraocular hydrodynamics. The pressure in the central
retinal artery is often increased, narrowing of the arteries is observed in
the fundus, and on rheoencephalograms - signs of ischemia in the vessels of
the vertebrobasilar basin. Often, with pathology of the vertebral arteries,
blood pressure figures are increased. As a rule, there are metabolic
disorders of oxycorticosteroids, ketosteroids, mineralocorticoids with a
change in the quantitative level and a violation of their daily biorhythm.
The vertebral artery syndrome is naturally combined with other vertebral
neurological manifestations (cervical and cervicobrachial).

Although the clinical manifestations of both forms of vertebral artery

syndrome are similar, reflex angiospastic syndrome has its own distinctive
features. It is characterized by: 1) bilateral and diffuse cerebral
vegetative-vascular disorders; 2) the predominance of vegetative
manifestations over focal; 3) relatively less connection between seizures
and head turns; 4) compression-irritative syndrome is more common in
pathology of the lower cervical spine and is combined with brachial and
pectoral syndromes, reflex syndrome - in case of damage to the upper and
middle cervical levels.