To compare the clinical profiles of patients with symptomatic vertebral artery compression of the medulla (Vertebral Artery Compression Syndrome-sVACS) and those with asymptomatic vascular brainstem compression (aVBC), and to highlight the importance of VACS as a potential cause of spontaneous episodic vertigo.

Spontaneous episodic vertigo can result from transient ischemic attacks within the vertebrobasilar circulation. In rare cases, vertebral arteries in the subarachnoid space may compress the medulla oblongata, producing recurrent vertigo, sensory disturbances, weakness, and other brainstem symptoms. Limited data exist on the clinical spectrum of this entity, known as Vertebral Artery Compression Syndrome (VACS).

This observational study was conducted between March 2025 and October 2025 at a Neuro-Vestibular clinic. All patients underwent detailed neurotological evaluation, including history, examination, and video-oculography. Magnetic resonance imaging (MRI) of the brain was performed when indicated. Patients with MRI evidence of vertebral artery compression of the medulla were categorized as symptomatic (VACS) or asymptomatic (aVBC).

Over a 8-month period, eight patients were identified in each group. The mean age of VACS patients was 46 years (range 27–63), while that of aVBC patients was 36.3 years (range 24–48). MRI revealed ventrolateral medullary compression by angulated or dilated vertebral arteries in all cases. Recurrent transient ischemic attacks occurred in all VACS patients, with one developing a lateral medullary infarction. Seven of eight symptomatic patients received antiplatelet therapy, resulting in resolution of symptoms except in the single infarction case. None of the aVBC patients required treatment.

This represents one of the largest series of VACS cases reported from the Middle East. VACS should be considered in patients presenting with spontaneous episodic vertigo. Further multicentric studies are warranted to define its prevalence, clinical course, and optimal management strategies.