Rotational vertebrobasilar ischemia: hemodynamic assessment and surgical treatment

Rotational vertebrobasilar insufficiency is a severe and incapacitating condition. Proper investigation and management are essential to reestablish normal posterior circulation hemodynamics, improve symptoms, and prevent stroke. We present a series of 10 patients with rotational vertebrobasilar ischemia who were treated surgically and emphasize the importance of transcranial Doppler in the diagnosis and management of this condition.

All patients presented with symptoms of vertebrobasilar insufficiency induced by head turning. Transcranial Doppler documented a significant decrease in the posterior cerebral artery velocities during head turning that correlated with the symptoms in all patients. A dynamic cerebral angiogram was performed to demonstrate the site and extent of vertebral artery compression.

The surgical technique performed was tailored to each individual patient on the basis of the anatomic location, pathogenesis, and mechanism of the vertebral artery compression. Five patients underwent removal of osteophytes at the level of the subaxial cervical spine, one patient had a discectomy, two patients had a decompression only at the level of C1-C2, and two patients had a decompression and fusion at the C1-C2 level.

The transcranial Doppler is extremely useful to document the altered hemodynamics preoperatively and verify the return of normal posterior circulation velocities after the surgical decompression in patients with rotational vertebrobasilar ischemia. Surgical treatment is very effective, and excellent long-term results can be expected in the vast majority of patients after decompression of the vertebral artery.