Rotational vertebrobasilar ischemia due to vertebral artery dynamic stenoses complicated by an ostial atherosclerotic stenosis

Abstract

Abstract We describe a patient with rotational vertebrobasilar ischemia (RVBI) due to vertebral artery (VA) compressive stenoses during neck rotation, complicated by an ostial atherosclerotic stenosis (OAS). Referred for ‘near-syncopal spells’, inquiry revealed a symptom-complex consistent with vertebrobasilar transient ischemic attacks (TIAs) provoked by head rotation. VA dynamic angiography with imaging via prevertebral subclavian injections in neck-rotated positions while reproducing symptoms, demonstrated two compressive stenoses not present in the neck-neutral position, establishing the diagnosis of RVBI due to CT-demonstrated cervical spondylosis. There was an occluded contralateral VA, isolated posterior circulation, and absent vertebral collateral flow. Disabling symptoms persisted despite using a cervical collar. Surgical decompression of the dynamic stenoses would not address the OAS, was considered high risk, and absence of a suitable donor artery precluded distal VA reconstruction. RVBI resolved with ostial stent placement by improving perfusion pressure across the compressive stenoses. To our knowledge, this is the first report of RVBI in which the affected VA had an obstructive atherosclerotic stenosis in addition to the characteristic rotation-induced dynamic stenoses, and the first report of stent placement in the culprit artery to treat this disorder. Diagnosis depends on recognizing the association of symptoms with positional neck changes and VA dynamic angiography demonstrating the compressive stenosis while reproducing symptoms. This case illustrates the management complexities when there are coexisting abnormalities, emphasizing the need to individualize treatment. RVBI is a potentially correctable cause of TIAs and particularly relevant due to the aging population which has a significant incidence of both degenerative cervical and atherosclerotic cerebrovascular disease.