Our study describes the early symptoms and signs of 85 patients with either basilar artery occlusion or bilateral distal vertebral artery occlusion documented by selective angiography. The most common prodromal symptoms were vertigo, nausea, and headache, which occurred during the 2 weeks before the stroke. Angiographic findings of 49 patients were classified into proximal, middle, and distal basilar artery occlusions. Twenty-two of these patients had additional vertebral artery lesions. A fourth group was composed of 36 patients with bilateral distal vertebral artery occlusion without opacification of the basilar artery through a vertebral artery injection. Onset was sudden in 20 patients; sudden, but preceded by prodromal symptoms in 11 patients; and progressive in 54 patients. Patients with progressive strokes often had bilateral vertebral artery occlusions. Most patients with acute onset had occlusion of the middle and distal basilar artery. An embolic origin of basilar artery occlusion from an arteriosclerotic vertebral artery lesion was assumed to be an important mechanism. An embolus reaching the basilar artery may not necessarily reach the top of the artery, but may also become lodged more proximally. (Stroke 1990;21:1135-1142) B asilar artery occlusions have been well recognized since Kubik and Adams 1 first suggested that this condition could be diagnosed during life. The disease had been known for many decades; however, it had only been recognized postmortem. The introduction of angiography for patients with posterior circulatory disease 2 was an important landmark in diagnosis. Nevertheless, because there was no effective treatment and prognosis was very poor, the effort toward accurate diagnosis was limited until recently.Since the advent of local intra-arterial fibrinolytic therapy by Zeumer et al, 3 -5 basilar artery thrombosis has become a potentially treatable disease, which, in turn, has provided a stimulus to improve noninvasive diagnostic methods such as Doppler ultrasound 6 and evoked potentials. -8 There have been many descriptions of clinical symptoms resulting from basilar artery occlusions, especially concerning the locked-in syndrome, which is an indicator of an advanced stage of the disease. However, there is still a lack of data concerning the premonitory spells and early clinical signs, which are still the first and most important diagnostic clues. Therefore, in this paper we focus on these early symptoms and signs and their correlation with angiographic findings, irrespective of the further Received September 22, 1989; accepted April 19, 1990. clinical course and the influence of therapy; the latter has been described previously. 9-10

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Local intra-arterial administration of fibrinolytic agents has been successfully used to achieve recanalization in acute thrombotic stroke patients (Zeumer, H., J Neurol 231:287-294, 1985).65 consecutive patients with clinical signs of severe brainstem ischemia and angiographically demonstrated vertebrobasilar (VB) thrombotic occlusion were treated with antithrombotic therapy.22 patients (Group A) received antiplatelet/anticoagulant treatment. 43 patients (Group B) received local intra-arterial infusion of streptokinase or urokinase proximal to the thrombotic occlusion. In 19 patients of Group B (Group B1) arterial recanalization was achieved as demonstrated angiographically; in 24 patients (Group B2) the arterial occlusion could not be resolved. None of the patients in Group B2 survived.When clinically favorable (minimal/moderate deficit) and unfavorable (severe deficit/demise) outcomes are compared, the results are highly significant (B1 vs A; p <0.007; B1 vs B2; p <0.0003 .It was possible to describe the vascular conditions associated with angiographically unsuccessful fibrinolytic therapy (Group B2) and to identify the clinical conditions associated with an unfavorable clinical outcome in patients with successful lysis (Group B1). These data indicate that successful fibrinolytic therapy is associated with a beneficial clinical effect in VB thrombotic stroke.