CEREBROVASCULAR DISEASE

CEREBROVASCULAR (VERTEBROBASILAR ) INSUFFICIENCY: CAUSES,

SYMPTOMS, DIAGNOSTIC EVALUATION AND SURGICAL TREATMENT

Prof., Dr. Scs. Povilas Pauliukas

Blood supply to the brain

The brain is the most complex and sophisticated organ in the human body. It enables us to think, to contemplate to

remember. The brain regulates the movements of the body, the speech, the swallowing, feels the sensations. It

regulates the function of all other organs (heart function, breathing, stomach and intestinal function, sweating of the

body, tone of the arteries and veins, arterial pressure etc.) as well. The functioning of other organs and systems of the

body is regulated by the autonomous (vegetative) nerve system, which centers are in the subcortical diencephal,

mesencephal and brain stem areas of the brain, getting blood supply through the vertebral arteries. That’s, why

various vertebral arteries diseases or pathologies diminish blood supply to these most important brain regions and

evoke derangement of functioning of these brain regions. The derangement can be slight and felt by the patient as

visual disturbances (blurring of the vision, diplopia, skotomas, hemianopsia, partial or total blindness), hearing

disturbances (tinnitus, noise in the ears, deafness), speech disorders (dysartria, tongue paresis or paralysis)

swallowing disorders, equilibrium derangement, dizziness, vertigo episodes, sensation disorders and motor disorders

(paresis or paralysis of the body muscles). Due to the fact, that the vital centers (heart regulation center, breathing

regulation center) are in the brain stem, derangement of the blood supply to this brain region through the vertebral

arteries can cause the death of the patient.

There are two kinds of strokes: hemorrhagic (blood effusion into the brain) and ischemic (due to shortage of

blood supply to the brain). I shall not analyze the hemorrhagic strokes in this paper. They constitute about 10 percent

of all strokes. Remaining 90 percent of strokes are ischemic strokes.

Blood is supplied to the brain through the four arteries: two carotid arteries and two vertebral arteries. Carotid

arteries supply the blood to the large hemispheres of the brain. Vertebral arteries supply the blood to the brain stem,

cerebellum, diencephal region of the brain and to the posterior (occipital) portions of the brain hemispheres. These

occipital portions of the brain hemispheres contain the visual cortical brain centers, which perceive the vision.

Therefore, shortage of blood supply to these visual brain centers causes cortical disturbances of vision: from mild

mist in the eyes up to the total cortical blindness in severe cases, despite of the absolutely healthy eyes.

Both vertebral arteries enter the skull and conjugate into one common basilar artery at the base of the skull,

below the brain bridge (pons cerebri). The basilar artery through its symmetrical branches supplies the blood to the

brain stem, cerebellum, diencephalic region of the brain and to the posterior portions of the large hemispheres of the

brain. All this brain territory, supplied by the blood through the vertebral arteries and basilar artery is called

vertebrobasilar region of the brain. Due to the fact, that all this region is supplied by blood through the both vertebral

arteries together, narrowing or occlusion of one vertebral artery causes symptoms from all vertebrobasilar region. In

some instances there can be symptoms corresponding to the particular diseased vertebral artery: noise or tinnitus in

the ear, deafness of the ear.

Insufficient blood supply to the vertebrobasilar region of the brain is called vertebrobasilar insufficiency and

symptoms arising due to insufficient blood flow to this region are called symptoms of vertebrobasilar

insufficiency.

Vertebrobasilar region of the brain is by far more important in comparison with anterior portions of large

hemispheres of the brain, supplied by the blood through the carotid arteries. Therefore, the patient can feel nothing in

case of critical narrowing or even occlusion of one carotid artery (providing he has normal circle of Willis) and can

be absolutely asymptomatic, meanwhile even small reduction of blood supply to the vertebrobasilar region causes

pronounced feelings of discomfort (dizziness, vertigo, nausea, vomiting, headache, noise in the ears, visual

disturbances, equilibrium disturbances, sweating, cardiac rhythm disorders, tachycardia, extrasystolia, obstipations or

conversely – looseness of the bowels etc.) to the patient.

Symptoms of cerebrovascular insufficiency

Interruption of blood supply to the area of the brain causes perish of the neurons in this area and the brain death. Such

situation is easily recognized clinically in accordance with existing symptoms. The extent and area of the brain

damage can be easily identified by contemporary evaluation techniques like computed tomography (CT scan) of the

brain or MRI (magnetic resonance imaging) of the brain.

In the event of ischemic stroke, the neurons die and these lesions are irreversible. Patient after the stroke is

disabled or even dies depending on the area and extent of the brain damage. 30 percent of patients die and 50 percent

of patients are disabled after the first stroke. After the second stroke die 50 percent of patients. Therefore, it is a very

important goal to prevent the stroke. It is possible nowadays due to the ultrasound duplex and color doppler

evaluation techniques of carotid and vertebral arteries. Atherosclerotic narrowing of arteries and other their

pathologies can be easily diagnosed by ultrasound techniques, confirmed angiographically and repaired surgically

before the stroke strikes.

Hypoesthesia or anesthesia of the same side of the face and arm or one side of the body, transient weakness or

paralysis of the ipsilateral extremities, transient paresis or paralysis of the face and the ipsilateral arm are the

symptoms of the imminent ischemic stroke in the large hemisphere of the brain, supplied by the blood through the

carotid artery. The precursor symptom of the stroke in the carotid territory can be transient blindness of the ipsilateral

eye (embolization of the debris from the carotid atherosclerotic plaque into the retinal arteries causes this

phenomenon). These features typically are the signs of critical narrowing of the carotid artery. Timely diagnosis and

surgical cleaning (endarterectomy) of the carotid artery clears the danger of stroke and after the surgery patient is

secure from stroke. Very high likelihood and danger of stroke is in cases when these symptoms are recurring. Such

clinical situation means that the major stroke is imminent and the patient can be paralyzed, disabled or even die

because of stroke. The majority of ischemic strokes in the carotid territory strike without any precursor symptoms.

Patient can feel nothing wrong with himself despite the critical narrowing of his carotid artery. Therefore, all people

over 50 years old should be evaluated by duplex scanner for carotid artery pathology. Especially high probability of

critical stenoses of carotid arteries is in patients having atherosclerotic lesions of other body arteries: leg arteries,

coronary arteries, who have had coronary artery surgery or angioplasty, suffered myocardial infarction, having

diabetes.

By far more complicated establishment of diagnosis is in cases when the blood supply to the brain is merely

diminished, not ceased, and the brain is not lost, dead, but suffers insufficient nutrition (blood supply). The

recognition of such clinical situation in the patient requires large extensive experience of the physician, good

knowledge of the brain functions and symptoms arising due to the deterioration of these functions because of

diminution of blood supply to these brain regions. Most of symptoms arising due to insufficient blood flow to the

vertebrobasilar region are subjective (felt by the patient, but not seen and recognizable by the physician). Most of the

physicians ignore the symptoms of chronic vertebrobasilar insufficiency or even do not recognize them. Therefore,

these patients are doomed to circulate from one doctor to another seeking the diagnosis and help from physicians and

not finding the help. These patients, despite the fact that they are real patients and they do not excogitate the

symptoms, usually are treated by physicians as lightweight neurotic patients and diagnoses of neurosis, psychogenic

dizziness, dystonia of vegetative nervous system, migraine, depression, positional benign vertigo or dizziness are

established for them. These diagnoses, established for the patients, suffering from the insufficient blood flow in the

vertebrobasilar region of the brain, are based only on symptoms and are purely defining only symptoms, not the cause

of the disease in these patients.

Diminution of blood flow through vertebral arteries causes dizziness, sometimes even vertigo episodes,

disequilibrium, nausea, even vomiting in severe cases, headache, noise in the ears or in the head, tinnitus, loss of the

hearing or even deafness, visual disturbances: blurring, diplopia, mist in the eyes, scotomas or even blindness.

Vertigo episodes (spinning of the surroundings in the horizontal or vertical plane around the patient) with nausea are

very characteristic for the kinking and loops of vertebral arteries. These patients sometimes for several days

consistently experience vertigo, nausea, vomiting. Such patients usually are treated with diagnoses: Meniere’s disease

or syndrome, benign positional vertigo, vestibular migraine, vestibular neuritis, labirinthitis, otoliths of the inner ear

etc. Usually physicians prescribe for them high doses of betahistine. However, medication usually only alleviate the

dizziness and vertigo in these patients or even does not help at all. The overwhelming majority of these patients have

abnormal vertebral arteries (congenital anomalies of vertebral arteries or diseased or otherwise narrowed vertebral

arteries) and the diminished blood flow through them to the brain stem is the real cause of vertigo. Fixing the

problems of vertebral arteries and restoring the blood flow through them to normal values clears the vertigo and other

symptoms arising from insufficient blood supply to the vestibular nuclei of the brain stem. This was observed in all

operated by me patients with the pathology of vertebral arteries. In all patients, who have addressed me for the

vertigo episodes, I have found the abnormal vertebral arteries, mainly the congenital anomalies or kinking of

vertebral arteries and surgery cured all of them.

Some patients with insufficient vertebrobasilar blood flow have disorientation episodes, some of them

experience memory loss for hours or even days (transient global amnesia): they do not remember entire period for

hours or even days. Some of them have sudden falling episodes (drop attacks) or lose consciousness. Patients with

congenital anomalies of vertebral arteries and diminished blood flow to the brain stem are prone to fainting. They

cannot tolerate the stuffy airless room, the high temperatures; they feel miserable in such conditions or even faint.

These patients have bad memory, rapid mental tiredness. They feel miserable and fatigue is a common feeling for

these patients. They cannot concentrate the attention and consideration for the long period and therefore efficiency of

their mental work is insufficient. They cannot stand the swinging, even riding the car. Due to insufficient blood flow

to the brain stem, where are located the centers of alertness and wakefulness, the main centers of vegetative nervous

system these patients are sensitive and nervous. They have sleep disturbances, insomnia, inadequate vegetative

responses to environment changes. Patients with congenital anomalies of vertebral arteries in the childhood have

nausea during the ride by car or by boat. This feature is very characteristic for insufficient blood supply to the brain

stem, especially in the childhood, because the vestibular nuclei are the most sensible structures to the insufficient

blood flow in the brain. They are the first, which feel the shortage of blood supply to the brain stem. Pathology

(abnormalities) of vertebral arteries can be encountered from the childhood to the senility, in all patient ages; because

they are very prone to different congenital anomalies and aging process (atherosclerosis and spine osteochondrosis)

affect them as well. Contrary, anomalies of carotid arteries are the curiosity and are encountered very seldom. The

main pathology of carotid arteries is plaque and narrowing of their lumen by atherosclerosis. Loops and kinks of

carotid arteries seldom require the surgical correction (only if they are symptomatic) by resection of carotid artery.

Congenital anomalies of vertebral arteries are the main cause of insufficient blood flow in the vertebrobasilar region

of the brain in the children. Most of them can be easily repaired by the surgery and some of them cannot (for example

in case of aplasia of vertebral artery, when the vertebral artery is absent from the birth or is undeveloped and very

tiny, hypoplastic). Children with diminished blood supply to the vertebrobasilar region have various symptoms of

vertebrobasilar insufficiency: dizziness, sometimes even fainting episodes, headaches, mental retardation, equilibrium

disorders, nausea. They cannot tolerate riding by a car (have motion sickness) because of nausea while riding, cannot

swing and ride the carousel. These children are very sensitive and nervous, they are hyperactive. It is difficult to learn

the lessons for such children. They have poor memory. Some of them are unable even to obtain the education and

profession and are doomed to be inadequate for the social life in adulthood. Such children should be evaluated by

duplex scanner for congenital anomalies of vertebral arteries, because most of them can be easily repaired by surgery.

Fixing the vertebral arteries problems, cures these children and they become absolutely healthy, can enjoy the life,

can obtain the education and profession.

There are many different congenital anomalies of vertebral arteries: aplasia or hypoplasia of one or even both

vertebral arteries, they can originate from the aortic arch, not from the subclavian artery as usually, they can enter the

bony canal in the spinal column abnormally, higher than normally (in such cases they are compressed by deep neck

muscles against the spine), they can be compressed or even strangulated by the sympathetic ganglia or nerves in the

neck etc. Ten percent of population have the undeveloped, hypoplastic one vertebral artery (most commonly the right

vertebral artery). If the opposite vertebral artery has a different pathology (for example is narrowed by

atherosclerosis), such patients can have pronounced symptoms of vertebrobasilar insufficiency, or even can suffer a

vertebrobasilar stroke, if the fully developed vertebral artery occludes and blood flow through it ceases.

The most common symptoms of vertebrobasilar insufficiency are the headache and dizziness. Therefore, I shall

discuss them more widely.

Headache

Headache for many patients with vertebrobasilar insufficiency is one of the most prominent symptoms. Besides the

headache, these patients can have the blurring of vision, nausea, noise or tinnitus in the ears, dizziness. Typically,

neurologists establish for such patients diagnosis of migraine. Additional symptoms like visual disturbances, noise in

the ears, dizziness they attribute to the aura of migraine. Migraine is a fictitious diagnosis for the purpose to say for

the patient the diagnosis when the physician does not know the real diagnosis of the patient and the real cause of

headache. Unfortunately, I cannot evaluate all the patients with migraine, but in patients with migraine, who have

addressed me for the diagnosis and evaluation, I have found in all of them various pathology of vertebral arteries,

most often – various congenital anomalies of vertebral arteries and all of them, who have expressed the wish for

surgery and were operated by me, are healthy and have forgotten the headache. As a rule, the causes of headache in

otherwise healthy patients, are various congenital anomalies of vertebral arteries, especially – compression of

vertebral arteries by deep neck muscles in case of high entering of vertebral artery into the spinal column, or in cases

of anomalous anterior scalene muscle (thoracic or cervical outlet syndromes). Vertebral arteries are arteries of

muscular type. They have smooth muscles in their walls and can fall into the spasm. The spasm occurs when the

vertebral artery is compressed by the muscle, sympathetic nerve or other structures in the neck. Continuous

compression and irritation of vertebral artery makes it very sensitive and spasmophylic (prone for spasm). It is very

clear from the observations during the operations in such patients. Vertebral arteries in these patients are very

spasmophylic and fall into the spasm when they are touched during the operation. Sometimes the spasm is so deep,

that vertebral artery becomes almost with occluded lumen. This spasm event of vertebral arteries causes clinical

symptoms of vertebrobasilar insufficiency, including the headache. Simultaneous spasm of both vertebral arteries can

be even the cause of vertebrobasilar stroke (if the spasm is pronounced and long lasting). Headache typically is felt in

the occipital region of the head or in the side of the head with diminished blood flow through the vertebral artery. In

some patients headache is extending over all head. The headache can be just like a heavy head, compression or

squeezing of the head up to very intensive intolerable headache (such patients as a rule have established diagnosis of

migraine and are treated with medications for migraine). For some of them antimigraineous medications alleviate the

headache (such treatment is just for treating only symptom, not the cause of the headache), for some of them do not

alleviate the headache at all. Headache increases during the mental stress or during the intensive mental work or

during any situation, requiring the enhanced blood flow to the brain. The brain is a very complex, sophisticated and

perfect organ, which regulates the blood flow to itself by the autoregulation mechanism. In case of normal carotid and

vertebral arteries the brain can regulate the blood flow for itself in a wide range and such healthy people feel

themselves comfortably even in the extreme situations. Healthy people have a large reserve for brain blood flow

autoregulation. In such healthy people the brain always tunes the blood flow to itself in an optimal amount for the

particular situation and such people always feel good. In case of narrowing or occlusion of one or more main arteries,

supplying the blood to the brain, the reserve for brain autoregulation decreases and even in maximally open brain

arteries the blood flow to the brain can be insufficient, especially in the extreme situations, requiring the high blood

flow values. In such situations, symptoms of vertebrobasilar insufficiency emerge. Patients with diminished

vertebrobasilar blood flow due to the various pathology of vertebral arteries can be absolutely asymptomatic in

situations when the requirement for blood flow to the brain is minimal and the symptoms appear in situations

requiring the enhanced brain blood flow. This explains why these patients feel almost or completely healthy in

conditions not requiring high blood flow values to the brain and feel miserable or even become symptomatic, having

symptoms of vertebrobasilar insufficiency, in conditions requiring the enhanced blood flow to the brain. The blood

flow to the brain in such patients with diminished blood flow through the vertebral arteries is always the same

(amount, which can pass the vertebral arteries) because the autoregulation mechanism in the brain is always

maximally open. Therefore, the matching of the brain blood flow to the requirements for the blood flow to the brain

depends only on the requirements for the blood flow to the brain because the blood flow to the brain is stable and

does not change (autoregulation mechanism is always constantly open and does not change). This explains the

phenomenon why all conditions requiring the enhanced blood flow trigger and produce headache in these patients.

This autoregulation mechanism of brain blood flow and the diminution of brain blood autoregulation reserve in

patients with abnormal vertebral arteries should be kept in mind if one wants to understand why sometimes these

patients feel good or almost healthy and sometimes – very miserable or even have pronounced symptoms of

vertebrobasilar insufficiency. Such patients have rapid tiredness, especially for the mental work. Intensive mental

work requires increased brain blood flow and produces headache. They have poor memory and poor efficiency of

mental work. Typically, neurologists establish the diagnosis of tension headache for such patients, but they cannot

explain the cause of this headache and cannot effectively treat it. As a rule, medical treatment of headaches due to the

insufficient blood flow to the brain is ineffective, because the drugs cannot enhance the blood flow through the

vertebral arteries noticeably in case of serious obstacle for the blood flow in the vertebral arteries. If there is a

possibility to repair the problem of vertebral arteries surgically, surgery should be performed. Most of the

pathological conditions of vertebral arteries: atherosclerotic narrowing or occlusions, loops, kinks, congenital

anomalies can be repaired surgically very effectively. It is impossible to fix the problem only in case when the patient

was born without the vertebral artery (aplasia of vertebral artery), or if it is very tiny, narrow, hypoplastic.

Migraine

I am absolutely convinced, that migraine, which is a fictitious diagnosis, exists in patients due to abnormalities of

vertebral arteries, mainly due to congenital anomalies and most commonly due to compression of vertebral arteries by

the deep neck muscles in case of abnormal entering of vertebral arteries into the spinal column, or in cases of

abnormal their branching from the subclavian artery, or from the aortic arch, or in case of abnormal scalenus muscles.

Compression of vertebral artery provokes its spasm and diminution of blood flow to the vertebrobasilar region of the

brain, which produces the headache and the migraineous episode lasts as long as lasts the spasm of vertebral artery, or

both vertebral arteries. In all the patients (over 1000 patients) who have came to me because of migraineous

headaches I have found the abnormalities, mainly the congenital anomalies of vertebral arteries and all of them are

healthy without any headache after the surgery. For most of them congenital anomalies of vertebral arteries were

repaired surgically. The fact, that migraine have disappeared after the fixing vertebral arteries anomalies, restoring

the blood flow to the normal value proves the statement that migraineous headaches are due to the insufficient blood

flow to the vertebrobasilar region of the brain. Actually, the congenital anomalies of vertebral arteries are inherited in

autosomal way and there is a great probability to have the same vertebral arteries anomalies in children of patients

with anomalies of vertebral arteries. I have operated many patients from the same families: parents and children,

siblings. As you know, the migraine is also inheritable disease and the tendency of inheritance is the same like for the

anomalies of vertebral arteries. Moreover, the typical symptoms, attributed to the aura of migraine: visual

disturbances, dizziness, nausea, noise in the ears, disequilibrium etc are the very genuine symptoms of vertebrobasilar

insufficiency.

Nowadays, the modern evaluation techniques of cerebral blood flow show that during the migraineous episode

there is a pronounced diminution of blood flow in the vertebrobasilar region of the brain. Especially dramatic fall in

blood flow in this region is in case of basilar artery migraine episode when clear symptoms of insufficient blood flow

in the territory of basilar artery manifest. There is a huge evidence in medical literature, that patients having migraine,

have several times greater risk for ischemic stroke in vertebrobasilar region in comparison with population without

the migraine. All these data prove that the cause of migraine is an insufficient blood flow to the vertebrobasilar region

of the brain due to congenital anomalies of vertebral arteries.

Dizziness

Second most common symptom of vertebrobasilar insufficiency is dizziness. Many people suffer from dizziness and

most of them cannot get even the correct diagnosis from the physicians. Without the correct diagnosis, there is an

impossible effective treatment of dizziness.

There a two types of dizziness: vertigo and lightheadedness.

Lightheadedness is a feeling that you are about to faint or “pass out”. Although you may feel dizzy, you do not

feel as though you or your surroundings are moving. Lightheadedness often goes away or improves when you lie

down. If lightheadedness gets worse, it can lead to a feeling of almost fainting or a fainting episode (syncope).

Fainting is a result of a deep diminution of blood flow to the brain stem. Slowing of blood flow in the brain stem

below critical level causes loss of consciousness (fainting) and in severe cases can be associated with loss of control

of sphincters: patient can involuntary urinate and evacuate the bowels. In very severe cases, even seizures can occur

due to very low blood supply level to the brain stem.

Lightheadedness is a result of insufficient, lowered blood flow to the brain stem and is felt almost constantly by

patients. The causes of lightheadedness can be: anemia, low arterial pressure due to various reasons, inefficient heart

work (various heart diseases) etc. However, the most common cause of lightheadedness is insufficient blood flow to

the brain stem because of narrowing of vertebral arteries or due to other their diseases, including congenital their

anomalies. Combination of two diseases or pathologies leading to the lightheadedness, aggravate the latter. Surgical

repair of vertebral artery pathology eliminates the lightheadedness.

Vertigo is a feeling that you or your surroundings are moving when there is no actual movement. You may feel

as though you are spinning, whirling, falling or tilting. When you have severe vertigo, typically you have nausea or

vomit. You may have trouble walking or standing and you may lose balance and fall. As a rule, vertigo is associated

with spontaneous nystagmus (involuntary rhythmic eye movements in horizontal, vertical or rotational directions).

These patients usually have motion sickness.

Causes of vertigo are the diseases of the inner ear (labirinthitis, Meniere’s disease, otoliths in the vestibular

apparatus), the diseases of the brain (brain tumors, multiple sclerosis, inflammative brain diseases, congenital brain

diseases). However, the most common cause of vertigo is an insufficient blood flow to the vestibular nuclei in the

brain stem and vertigo is encountered in almost all vertebrobasilar stroke cases and chronic vertebrobasilar

insufficiency cases. Vertigo and nystagmus are very typical and characteristic symptoms for chronic and acute

vertebrobasilar insufficiency. Unfortunately, most physicians, having little or no knowledge about vertebral arteries

pathology, attribute the vertigo to the inner ear problems and are trying to treat these patients with high doses of

betahistine. As a rule, this treatment is ineffective or has little effect on dizziness, because the cause is established

incorrectly: in overwhelming majority of cases, the cause of vertigo is shortage of blood flow in the brain stem

(hypoperfusion of the vestibular nuclei). Nowadays modern evaluation techniques in medicine enable physicians to

determine the correct cause of vertigo or dizziness. The patients should be evaluated by ultrasound duplex scanner,

magnetic resonance angiography, conventional angiography, magnetic resonance imaging of the brain and by other

techniques and investigations to establish the correct diagnosis and treatment. Very important tool in evaluation of

these patients is a duplex scanning of vertebral and carotid arteries, because duplex scanning enables not only to

visualize the arteries and their lumen, but to measure the blood flow through the vertebral and carotid arteries as well.

Angiography does not give any information about the blood flow velocity in the blood vessels, just the anatomical

appearance of the arteries.

Problem with diagnostic evaluation of patients, having vertebrobasilar insufficiency, is that most duplex

scanning evaluations are performed by technicians or by physicians unfamiliar with the pathological varieties of

vertebral arteries. Therefore, they do not know what pathology they are searching for and are unable to establish the

correct diagnosis. The optimal situation is when the surgeon, operating these pathological varieties of vertebral

arteries, is evaluating the patient with the duplex scanner himself. He knows what pathological conditions and

varieties are encountered in vertebral arteries and knows what pathology of vertebral arteries to look for in the

patient. Surgeon, having extensive experience in the operations on vertebral arteries, knows what symptoms are

related to the found pathology of vertebral arteries and which not, because on his own experience he knows what

symptoms disappear after the surgical repair of vertebral artery and which not. This fact enables the experienced

surgeon to decide when to suggest an operation for the patient and when not. Therefore, only surgeon, having large

experience in the field of surgical treatment of vertebral arteries pathology can correctly appreciate the clinical

situation in the patient and properly decide to operate the patient or not.

As my experience shows, most of my operated patients before addressing me have addressed many physicians,

including neurologists and cardiologists, because these patients as a rule have cardiac rhythm disorders

(extrasystolias, tachycardias etc), heartaches due to vegetative nervous system disorders, so characteristic for these

patients. Cardiologists do not find anything wrong with the heart in these patients. Fixing the pathology of vertebral

arteries restores the heart work to normal and clears the heartaches and cardiac rhythm disorders. For some patients

the pain in the upper chest is because of the compression and irritation of the brachial nerve plexus in thoracic and

cervical outlet syndromes. Heartaches and cardiac rhythm disorders are very characteristic symptoms for

compression or strangulation of vertebral artery with the sympathetic trunk or ganglion. Sympathetic nerve or

ganglion compresses and narrows the vertebral artery diminishing the blood flow through it and, conversely, the

pulsating vertebral artery irritates the sympathetic ganglion or trunk and, consequently, the sympathetic cardiac

nerves arising from this sympathetic trunk and going to the heart. These sympathetic cardiac nerves stimulate the

heart. Irritation of these sympathetic cardiac nerves causes heartaches, extrasystolias, tachycardias in otherwise

healthy heart. Surgical correction of vertebral artery problem ceases the cardiac disorders in these patients.

Tinnitus (noise in the ears)

Tinnitus (Latin word tinnitus meaning ringing) is the perception of sound within the human ear in the absence of

corresponding external sound. Tinnitus is not a disease, but a symptom, that can result from a wide range of

underlying causes: abnormally loud sounds in the ear canal for even the briefest period (but usually with some

duration), ear infections, foreign objects in the ear, nasal allergies that prevent (or induce) fluid drain, or wax build-

up. Withdrawal from a benzodiazepine addiction may cause tinnitus as well. In-ear headphones, whose sound enters

directly into the ear canal without any opportunity to be deflected or absorbed elsewhere, are a common cause of

tinnitus when volume is set beyond modest or moderate levels. Tinnitus can also be caused by natural hearing

impairment (as in aging), as a side effect of some medications, and as a side effect of genetic (congenital) hearing

loss. As tinnitus is usually a subjective phenomenon, it is difficult to measure using objective tests, such as by

comparison with noise of known frequency and intensity, as in an audiometric test. The condition is often rated

clinically on a simple scale from "slight" to "catastrophic" according to the practical difficulties it imposes, such as

interference with sleep, quiet activities, and normal daily activities. Tinnitus is common; about one in five people

between 55 and 65 years old report symptoms on a general health questionnaire, and 11.8% on more detailed tinnitus-

specific questionnaires. Over 50 million Americans experience tinnitus to some degree and 12 million have severe

enough tinnitus to seek medical attention. About two million people are so seriously disturbed by tinnitus that they

cannot function on a day-to-day basis (American Tinnitus Association, 2010). In overwhelming majority of these

patients, the cause of tinnitus is the insufficient blood flow to the cochlear (acoustic) nuclei in the brain stem.

Tinnitus can be perceived in one or both ears or in the head. It is usually described as a ringing noise, but in

some patients, it takes the form of a high-pitched whining, electric buzzing, hissing, humming, tinging or whistling

sound, or as ticking, clicking, roaring, "crickets" or "tree frogs" or "locusts (cicadas)", tunes, songs, beeping, or even

a pure steady tone like that heard during a hearing test. It has also been described as a "wooshing" sound, as of wind

or waves. Tinnitus can be intermittent, or it can be continuous, in which case it can be the cause of great distress. In

some individuals, the intensity can be changed by shoulder, head, tongue, jaw, or eye movements.

Most people with tinnitus have some degree of hearing loss in that they are often unable to hear clearly external

sounds that occur within the same range of frequencies as their "phantom sounds".

The sound perceived may range from a quiet background noise to one that can be heard even over loud external

sounds.

The overwhelming majority of patients with vertebrobasilar insufficiency have tinnitus in the ears. This symptom

means that the blood flow to the cochlear (acoustic) nuclei in the brain stem is insufficient and neurons are suffering

from the insufficient nutrition. Tinnitus is the signal from acoustic neurons that they are in danger for death due to the

shortage of blood supply to them. Restoration of blood supply to these nuclei through the vertebral arteries to normal

value ceases the tinnitus and restores the impaired hearing (if present). If the blood supply is not restored to the

normal level to these acoustic nuclei, tinnitus becomes worse and worse and hearing loss is progressing. Restoration

of blood supply to normal level in vertebrobasilar territory in patients with impaired hearing improves the hearing to

some extent but usually there is no total restoration of hearing loss, because some part of neurons are already dead.

Therefore, it is important to fix the vertebral arteries pathology and restore the blood flow to normal in these patients

before the pronounced hearing loss appear, because timely restoration of blood flow to acoustic nuclei in these

patients eliminates the tinnitus and prevents the hearing loss. As a rule, tinnitus is in the ear corresponding to the

diseased vertebral artery: for example, it is very typical situation when the tinnitus is in the ear on the same side as is

hypoplastic, undeveloped vertebral artery, supplying insufficient blood flow to the acoustic nucleus on the same side.

My large experience in this field shows, that usually in these patients and opposite (contralateral) vertebral artery is

compromised (has pathology) as well, because if even only one vertebral artery is absolutely normal, these patients

are asymptomatic, healthy. Repairing the opposite vertebral artery to the hypoplastic artery, causing tinnitus, ceases

the tinnitus on the hypoplastic vertebral artery side. Therefore, in patients with one hypoplastic vertebral artery,

having the tinnitus on the ipsilateral side of the head, one must evaluate the opposite vertebral artery very carefully,

because usually this contralateral (opposite) vertebral artery has a pathology, diminishing blood flow in the territory

of both vertebral arteries, but most prominently in the territory of the hypoplastic, small vertebral artery. One must

remember that both vertebral arteries conjugate in the skull into the one common basilar artery and their blood supply

territory is a common one just the acoustic nuclei are nourished preferably by the ipsilateral vertebral artery. The

phenomenon, that after the restoration of blood flow to normal level in the opposite vertebral artery ceased the

tinnitus and restored the hearing in the ear corresponding to the hypoplastic vertebral artery, was observed by me in

hundreds of cases. Therefore, I can state, that tinnitus is a very characteristic symptom of chronic vertebrobasilar

insufficiency and is a result of chronic hypoperfusion of the acoustic nuclei.

Some patients are unable to appreciate where the noise exists: in the ears or in the head. It does not matter

where the subjective noise is felt, the cause is always insufficient blood flow to the acoustic nuclei in the brain stem.

Arterial hypertension of cerebroischemic origin

High grade narrowing or obstacles for flow in both vertebral arteries or even in three or four main arteries, supplying

the blood to the brain, causes permanent total opening of autoregulation mechanism in the brain blood flow. The

brain is unable to maintain the adequate blood supply to itself by autoregulation mechanism: it is inadequate, because

the obstacles are in the main arteries in the neck, supplying the blood to the brain. The only measure empowering the

brain to maintain the adequate brain blood supply is to elevate the blood pressure and in this way to increase the

blood flow through the narrowed vertebral arteries. Diminution of blood supply in the large hemispheres of the brain,

supplied with blood by carotid arteries is not so important, because all vital centers are in the brain stem, supplied

with blood by vertebral arteries. Therefore, the brain protects very carefully the vital centers in the brain stem from

the shortage of blood supply, because the pronounced fall in blood flow to these vital centers means the death of the

brain and the human. That’s, why shortage of blood supply in the brain stem is compensated by increased arterial

pressure. These my statements are based on my large clinical experience of operated by me more than 6 000 patients

with vertebrobasilar insufficiency due to various pathology of vertebral arteries. Overwhelming majority of patients,

having marked chronic vertebrobasilar insufficiency, has arterial hypertension, which is compensatory (due to the

brain reaction to the shortage of blood flow to the brain stem). The deeper is a fall of blood flow to the brain stem, the

higher is the level of arterial hypertension in these patients. Restoration of blood flow to normal levels in vertebral

arteries in these patients returns arterial blood pressure to normal level if the numbers of arterial hypertension are not

very high and the hypertension is not very overdue. The long lasting expressed arterial hypertension causes

irreversible changes in the kidneys, arteries, even in the arteries of the large hemispheres of the brain, because the

blood supply usually is normal through the carotid arteries to the large hemispheres in these patients and therefore,

the arteries of the large hemispheres of the brain contract in order to control the pressure and blood supply to the

hemispheres. This leads to the thickening of the arterial wall in the arteries of large brain hemispheres and

consequently leads to the constant narrowing of their lumen and total occlusion. This process is known and is called

in medical literature as hypertonic encephalopathy. Therefore, the restoration of blood flow to normal level in

vertebral arteries revert the arterial pressure to normal in patients with moderate numbers of arterial pressure if the

hypertension is not long lasting. In long lasting arterial hypertension with high numbers of arterial pressure, repair of

vertebral artery and restoration of blood flow to normal level in vertebrobasilar region lowers the arterial pressure,

but it does not return to normal, because the secondary mechanisms of arterial hypertension already exist. However,

the hypertension crises (episodic elevations of arterial pressure) usually disappear, because the blood flow to the brain

stem after surgery on vertebral arteries is stable, without fluctuations. These crises are very characteristic for the

loops and kinks of vertebral arteries. When the vertebral artery kinks at the loop and the blood flow to the brain stem

impairs, the arterial pressure elevates for compensation of diminished blood flow to the brain stem.

My vast experience with surgical treatment of vertebral arteries pathology in hypertensive patients shows, that if

there are no other causes for the arterial hypertension, the cause of arterial hypertension is the shortage of blood flow

to the brain stem and the repair of vertebral artery cures the hypertension. I am highly convinced, that overwhelming

majority of hypertensive patients not having other specific causes of hypertension (renal diseases, renovascular

disease, endocrine diseases etc) are the patients with chronic vertebrobasilar insufficiency, compensated by elevated

arterial blood pressure. Some of these patients feel pretty well due to the good compensation of blood flow shortage

to the brain stem by the elevated arterial pressure, others have and feel the symptoms of vertebrobasilar insufficiency.

Depression

The vast majority of patients having chronic vertebrobasilar insufficiency have depression. Depression in these

patients is a reaction of the brain to the insufficient blood flow to the brain, most importantly – to the brain stem.

These patients feel miserable and their working and living abilities are compromised. They cannot feel happy because

of their illness and this is not because of psychological or psychiatric origin. This is because of insufficient blood

flow to the brain stem, because the centers, responsible for the mood and for the psychological brain reactions are in

the brain region, supplied by blood through the vertebral arteries. Insufficient nutrition of these brain centers causes

depression. Antidepressant drugs temporarily change the mood, but they do not cure the disease, they alleviate only

symptoms and must be taken continuously. Depression recurs after disruption of medical treatment. Surgical repair of

vertebral arteries with restitution of blood flow to normal levels in the brain stem cures the depression. It has been

seen by me and documented in thousands of patients.

Some anatomical hints on vertebral arteries

Vertebral arteries are the first branches of subclavian arteries. They pass freely the vertebral triangle (free space left

for vertebral artery to pass the neck before it enters the spinal column) and then they travel up the neck inside the

bony canal in the spinal column. Then they enter the skull, where they conjugate into one common basilar artery.

Symmetrical branches of basilar artery distribute the blood to the brain stem, cerebellum and posterior occipital

regions of the large brain hemispheres. One must have minimal anatomical knowledge about the normal vertebral

arteries in order to understand the anomalies of vertebral arteries and how they influence the blood flow through

them. Figure 1 illustrates the normal anatomy of vertebral artery.

Figure 1

Figure 2 illustrates the view of the brain from bottom and the arterial circle of Willis.

Figure 1: Anatomy of vertebral artery

1 – subclavian artery (supplies the blood to the arm);

2 – common carotid artery;

3 – vertebral artery;

4 – external carotid artery (supplies the blood to the face

and external tissues of the head);

5 – internal carotid artery (supplies the blood to the

large hemisphere of the brain);

6 – basilar artery (supplies the blood to the brain stem,

cerebellum, subcortical regions of the brain and the

posterior occipital regions of the large hemispheres of the

brain);

7 – transverse process of the 6-th cervical vertebra;

8 – arterial trunk, supplying the blood to the thyroid

gland and to the neck muscles (truncus thyreocervicalis).

Figure 2

Arterial circle of Willis is comprised of all six main cerebral arteries and of one anterior and two posterior

communicating arteries, connecting all these six main cerebral arteries into the one common basin of blood flow and

supply. Such normal arterial circle of Willis can redistribute the blood flow to all territories of the brain despite the

occlusion of one, two or even three main cerebral arteries in the neck. Unfortunately, such normal circle of Willis

exists only in one third of population. Another two thirds of population have abnormal circle of Willis and cannot

redistribute and compensate the blood flow in case of occlusion of one or two main cerebral arteries. The most

commonly encountered anomaly of the circle of Willis is absence of one or both posterior communicating arteries.

People with absent both posterior communicating arteries of the circle of Willis have totally isolated vertebrobasilar

region of blood supply from carotid arteries region. These patients cannot compensate the shortage of blood flow in

the vertebrobasilar region from carotid arteries and are very vulnerable in case of narrowing or occlusion of vertebral

arteries. Conversely, the patients having both posterior communicating arteries can survive even occlusion of both

vertebral arteries. The integrity of the circle of Willis in that particular patient should be always kept in mind when

considering the clinical picture and the symptoms, arising due to narrowing or occlusion of vertebral arteries.

Physicians not taking into account the role of the circle of Willis in redistribution of blood supply to the brain are

making crucial mistakes in making decisions as to the role of vertebral arteries in blood supply to the brain and while

concerning the expedience of surgical repair of vertebral arteries. Due to the fact, that both vertebral arteries

conjugate into one common basilar artery and their basin is common, occlusion of one vertebral artery can be

tolerated by the patient without any serious sequelae, except the diminution or even disappearance of brain blood

flow autoregulation reserve in the vertebrobasilar region. All situations requiring the elevated blood flow to the brain

in such patient will evoke symptoms of vertebrobasilar insufficiency, because the brain will not have the reserve due

to occlusion of one vertebral artery for blood flow enhancement.

The circle of Willis determines the capability of the brain to compensate the shortage of blood flow in

the vertebrobasilar region and the severity of symptoms and the clinical picture in various pathological conditions of

vertebral arteries in that particular patient, having normal or abnormal circle of Willis.

Causes of vertebrobasilar insufficiency (pathology of vertebral arteries) and their surgical

treatment

Most common causes of vertebrobasilar insufficiency are atherosclerotic stenoses or occlusions of vertebral arteries,

loops and kinks of vertebral arteries, various congenital anomalies of vertebral arteries. Atherosclerotic lesions of

vertebral arteries are the most understandable and easy to appreciate by angiography. They are not disputed as to the

Figure 2: Arterial circle of Willis

ACoA – anterior communicating artery

ACA – anterior cerebral artery

MCA – middle cerebral artery

PCoA – posterior communicating artery

PCA – posterior cerebral artery

B A – basilar artery

LVA – left vertebral artery

RVA – right vertebral artery

FL – frontal lobe of brain

TL – temporal lobe of brain (left temporal lobe is

partially removed)

OL - occipital lobe

P – pons cerebri (bridge of the brain)

M – Medulla oblongata

C – cerebellum (left hemisphere of the cerebellum is

removed for better visualization of the occipital lobe).

importance of blood flow blockage by them in the vertebral arteries, but they are still disputed by neurologists as to

the expedience of their surgical treatment.

Figure 3 illustrates the angiographic appearance of the normal right vertebral artery (A), atherosclerotic critical

narrowing of the orifice of the left vertebral artery (B), and the loop of the left vertebral artery (C).

Figure 3

A B C

Figure 3: 1 – subclavian artery; 2 – vertebral artery; 3 – critical atherosclerotic stenosis (narrowing) of the left

vertebral artery orifice; 4 – loop of the left vertebral artery with kinking and narrowing of the lumen of vertebral

artery.

Figure 3(A) is an angiographic appearance of normal right vertebral artery. You can see the wide smooth patent

lumen of vertebral artery without any narrowing or obstructions. Figure 3(B) is an angiographic appearance of

atherosclerotic lesion of the orifice (critical stenosis) of the left vertebral artery. Residual lumen at the narrowed

orifice of vertebral artery is so tiny, less than 1 mm in diameter (3). Atherosclerosis typically affects the orifice of

vertebral arteries. Upper (distal) part of vertebral artery usually is not affected by atherosclerosis and thanks to that it

is possible an easy surgical repair of the orifice of vertebral artery. In case of total occlusion of the orifice of vertebral

artery it thromboses up to the base of the skull and the surgical restitution of blood flow through it is more

complicated: one needs to create the so called distal shunt to the vertebral artery (autologous venous shunt from the

side of common carotid artery to the side or end of vertebral artery at the base of the skull). Figure 3(C) is an

angiographic appearance of the loop of the left vertebral artery in its proximal part, close to the orifice. Loop or kink

of vertebral artery narrows the lumen of vertebral artery due to protrusion of the arterial wall into the lumen of the

artery at the site of the kink. This narrowing of the lumen usually is not stable and changes from almost normal lumen

up to the almost total occlusion of vertebral artery. Therefore, it is so characteristic for these patients to have

repetitive episodes of acute vertebrobasilar insufficiency, mainly with vertigo episodes. Surgical repair of the loop or

kink of vertebral artery cures these patients from vertigo episodes and other symptoms of vertebrobasilar

insufficiency.

Atherosclerotic lesions of vertebral arteries are easy to diagnose by ultrasound techniques and especially by

angiography. The expediency of their surgical repair evokes little dispute between the vascular surgeons and

therefore I shall not discuss them in more detail.

Loops and kinks of vertebral arteries

Some loops of vertebral arteries are congenital, others are acquired. With aging due to wearing out of intervertebral

cartilagineous disks, neck becomes shorter. Neck arteries with aging tend to elongate, especially in hypertensive

patients. This creates a problem with the length of vertebral and carotid arteries. They become relatively too - long for

the length of the neck and this creates the kinking or even loops of vertebral or carotid arteries. As I have written

earlier, the diminishing of blood flow through the carotid arteries is not so important and usually is not felt by the

patient. Conversely, diminution of blood flow through the vertebral arteries is very important and is felt by the patient

clearly as symptoms of vertebrobasilar insufficiency. If one does not believe in the importance of kinking and looping

of vertebral arteries in diminishing the blood flow through the vertebral arteries, he can perform an experiment with

the hose while irrigating the flowers or something else. Kinking of the hose or producing the loop like in the vertebral

artery will diminish the water flow from the hose distinctly. In the vertebral artery this diminution of blood flow

through the kinked or looped vertebral artery is very clearly and precisely appreciated and estimated by the

ultrasound studies, mainly duplex scanner or color doppler. Figure 4 illustrates various kinks and loops of vertebral

arteries.

Figure 4

A B C D E

F G H

There is a clearly seen narrowing of the lumen of vertebral artery at the site of the kink on the angiograms (Fig. 4 A,

B, C). Loop of vertebral artery produces the kink of the artery and twisting of the artery at the site of the loop (Fig. 4

D – H).

Surgical technique for repair of kinks, loops and even the atherosclerotic lesions (stenosis) of the orifice of

vertebral artery is the same. Abnormal vertebral artery is cut away from the subclavian artery, shortened as needed (in

case of atherosclerotic narrowing with plaque the narrowed proximal part of vertebral artery is excised) and

reimplanted back into the widened hole in the subclavian artery. In case there is no enough length to reimplant the

shortened atherosclerotic vertebral artery back into the subclavian artery, it can be implanted into the side of common

carotid artery or its proximal segment can be replaced by autologous vein, harvested from the leg.

Figure 5 represents the schematic drawing of the standard operation performed for kinks, loops and for

atherosclerotic lesions of the orifice of vertebral artery.

Figure 4: Various types of kinks and loops in

vertebral arteries

A, B, C – Different types of kinks in vertebral

arteries.

D, E, F, G – Various types of loops in the

proximal part of vertebral artery.

H – Loop of vertebral artery in the middle of

the neck (high entrance of the vertebral artery

into the spinal column, at the 4-th cervical

vertebra).

Figure 5

Figure 6 is the operative photograph of the kinked left vertebral artery before the reconstruction and figure 7 is an

operative photograph of the same vertebral artery as in figure 6 after its reconstruction by the technique described in

figure 5.

Figure 6

Figure 7

Figure 5: Schematic drawing of operation with

shortening and reimplantation of vertebral artery

back into the subclavian artery

1 – Vertebral artery; 2 – Subclavian artery.

A – Vertebral artery is cut away from the

subclavian artery.

B – The hole in the subclavian artery is enlarged

as needed, vertebral artery is shortened as needed

and incised logitudinally along the posterior its

wall in order to make its orifice wider.

C – The vascular suture is begun from the upper-

posterior corner of the vertebral and subclavian

arteries (they are approximated at this point).

D, E – Suture is continued along the both sides of

anastomosis towards the anterior corner of it.

F – Both ends of the suture are tied together.

Figure 6: Kink of the vertebral artery (operative

photograph))

VA – Vertebral artery

SN – Sympathetic nerve

SA – Subclavian artery;

PhN – Phrenic nerve

Blue arrows point to the kink of vertebral artery. At that site,

the lumen of vertebral artery is significantly narrowed due to

the protrusion into the lumen of the duplicature of the arterial

wall (kink).

The lateral branch of the sympathetic trunk (sympathetic nerve)

abnormally crosses the vertebral artery in front of it. During

the reconstruction it is placed behind the vertebral artery as it

normally should pass.

Figure 7: Operative photograph of the same vertebral artery

as in figure 6 after its shortening and reimplantation back

into the subclavian artery by the technique depicted in figure

5

VA – Vertebral artery

SN – Sympathetic nerve

SA – Subclavian artery;

PhN – Phrenic nerve

The vertebral artery is shortened, straightened and reimplanted

back into the subclavian artery with creation of wide vertebral

artery orifice. Note the conus shaped orifice and the proximal

part of the vertebral artery.

Blue arrow points to the anastomosis (vascular suture).

Congenital anomalies of vertebral arteries

Embryological development of vertebral arteries is a very complex process, because they develop from the vertical

anastomotic branches of segmental arteries of the embryo. Therefore, various congenital anomalies of vertebral

arteries are very common in humans. There are the cases with total absence of both vertebral arteries, when vertical

anastomoses of segmental arteries do not conjugate and vertebral arteries do not develop. Usually in such cases, the

embryo dies because the brain stem cannot develop and miscarriage follows. In case the embryo is viable, he has the

compensating anomalies of blood supply to the brain, supplying the blood to the brain through the anomalous other

arteries in the neck and the brain instead of missing normal vertebral arteries. Typically, these newborns and children

have the symptoms of vertebrobasilar insufficiency up to the paralyses (cerebral palsy). I am deeply convinced that

most of the children, born with the cerebral palsy, especially having symptoms mostly form vertebrobasilar region of

the brain, have congenital anomalies of vertebral arteries restricting blood supply to the brain stem. These children

should be evaluated for the pathology (anomalies) of vertebral arteries by the ultrasound studies and by angiographic

techniques.

Below is presented the case of the patient born with absent both vertebral arteries (aplasia of both vertebral

arteries). He addressed me because of repetitive vertigo episodes, which appeared especially in the neck position with

his head tilted back. The man was 35 years old and was a truck driver. He had problems with vertigo episodes,

dizziness, headaches and imbalance. The last episode was very severe, when he lost the consciousness and had

vertigo for several days when gazed at the plane high in the sky. Otherwise, he was a healthy man. Ultrasound studies

and conventional angiography showed absent both vertebral arteries and hypertrophied left occipital artery, serving as

a compensatory blood flow pathway to the brain stem. No surgical treatment was possible and the patient was advised

not to tilt the neck and head backwards, because in that position the hypertrophied compensating left occipital artery

was compressed between the skull and the first vertebra at the base of the skull and the blood flow to the brain stem

was ceased in that position. That situation is clearly seen on the angiogram (Figure 8 D). The left occipital artery

which normally is a branch of external carotid artery and has a small junction with the vertebral artery at the base of

the skull due to increased blood flow through it because of not developing vertebral arteries became very large,

hypertrophied, the same diameter as a basilar artery and secured the blood flow to the brain stem. Derangement of

development of vertebral arteries causes the shortage of blood supply in the vertebrobasilar region of the brain and

this in turn produces the development of alternative blood flow pathways to the brain. In case the alternative

pathways of blood flow to the brain stem are inadequate, the death of embryo and miscarriage follows. In milder

cases, the congenital baby cerebral palsy results from the insufficient blood flow to the brain.

Figures 8 A, B, C, D are the angiograms of the above described patient.

Figures 8 A, B

A B

Figures 8 A, B: Absence of both vertebral arteries from

the birth (aplasia of both vertebral arteries): Angiographic

appearance

A – Contrast dye is injected into the right subclavian

artery. No right vertebral artery is seen on the angiogram.

Hypertrophied, enlarged right cervical ascending artery,

compensating the absent blood flow through the right

vertebral artery, is seen.

B - Contrast dye is injected into the left subclavian artery.

No left vertebral artery is seen on the angiogram. The left

cervical ascending artery is less hypertrophied in

comparison with the right one due to the compensation of

blood flow to the brain stem through the hypertrophied left

occipital artery instead of the missing left vertebral artery.

CAA – Cervical ascending artery; IThA – Inferior thyroid

artery; SA – Subclavian artery.

Figures 8 C, D

C D

From the figure 8 D it is obvious why the patient was unable to tilt the head backwards without having dizziness,

vertigo or even fainting episodes. Tilting the head backwards compressed the left hypertrophied occipital artery,

serving as an only pathway to nourish all the vertebrobasilar region of the brain, between the skull and the atlas (first

vertebra) and ceased the blood flow to the brain stem. Patient experienced dizziness, vertigo or even fainted in such

situations. Note on figures 8 C, D that the patient had totally disconnected posteriorly the circle of Willis and he

could not compensate the shortage of blood flow in the vertebrobasilar region from the internal carotid arteries

through the posterior communicating arteries (both posterior communicating arteries of the circle of Willis are absent

in this patient). Therefore, he was very dependent on the flow through the only pathway to the vertebrobasilar region

– the hypertrophied left occipital artery. If one is in doubt that both vertebral arteries were absent in that patient, I can

assure, that all other anomalies of vertebral arteries were ruled out, including the origination of vertebral arteries from

the aortic arch. Therefore, it was absolutely proved that both vertebral arteries were absent from the birth in that

patient with compensation of this aplasia of both vertebral arteries by the hypertrophied left occipital artery.

I have published this case in the journal Khirurgia (Хирургия), Moscow, in 1990, in Russian (П.А. Паулюкас,

А.И.Драненка, И.И.Бичкувене. Аплазия обеuх позвоночных артерий. Хирургия. 1990, No 5, стр.53-56) and

in English in the article: Pauliukas P.A, Barkauskas E.M, Ziburkus J.J, Gaigalaite V.B. Surgical Correction of

Vertebral Artery Anomalies causing Vertebrobasilar Insufficiency. In the book: Cerebral Revascularisation,

published by Med-Orion, London, 1993: pages 359 – 378.

In case of absence (aplasia) of one vertebral artery, its blood flow usually is compensated through the primitive

trigeminal artery (arteria trigemina primitiva), connecting the internal carotid artery directly with the basilar artery in

the skull (Figure 9 C). These primitive arteries in embryo normally shrink and disappear when the vertebral arteries

are developing normally and supplying enough blood to the brain. In case there are the problems with the

development of vertebral arteries, these primitive trigeminal arteries do not shrink and do not disappear and even

enlarge to supply enough blood to the vertebrobasilar region of the brain.

Figure 9 A, B, C, D illustrates the patient with the primitive trigeminal artery, supplying the blood to the upper part of

basilar artery. The lower part of basilar artery in this patient was supplied by the anomalous right vertebral artery,

entering the spinal column high in the neck into the transverse process of the 5-th cervical vertebra and compressed

by the deep muscles of the neck. The left vertebral artery was very hypoplastic, less than 1 mm in diameter, ended in

the muscles of the neck and did not participate in the nourishment of the brain. The patient had frequent intensive

Figures 8 C, D: Normal right occipital artery and hypertrophied enlarged left occipital artery, proceeding into

the skull as the basilar artery and nourishing all the vertebrobasilar territory of the brain

C – The dye is injected into the right common carotid artery. Note the normal, not hypertrophied right occipital

artery, nourishing the superficial external tissues of the occiput.

D – The dye is injected into the left common carotid artery. Note the large, hypertrophied left occipital artery,

nourishing all the vertebrobasilar region of the brain. The basilar artery is a continuation of the hypertrophied

left occipital artery.

ICA –Internal carotid artery; ECA – External carotid artery; OA – Occipital artery; ACA – Anterior cerebral

artery; MCA – Middle cerebral artery; PCA – Posterior cerebral artery; BA – Basilar artery.

vertigo episodes, tinnitus in both ears and other symptoms of vertebrobasilar insufficiency. Due to the fact, that all

lower part of basilar artery, where the vestibular nuclei are located, was nourished by the only right anomalous

vertebral artery (the upper part of basilar artery was isolated from the lower part of basilar artery and nourished

separately by the primitive trigeminal artery), the episodic compressions of the right vertebral artery by the scalenus

anterior and longus colli muscles evoked the spasm of the only right vertebral artery and the fall in blood supply to

the brain stem. This in turn produced the vertigo episodes. The surgical treatment was proposed for the patient and he

was operated. The right scalenectomy (removal of the right scalenus anterior muscle) with freeing of the right

vertebral artery up to its entrance into the spinal column with resection of redundant length of the vertebral artery and

reimplantation of the vertebral artery back into the subclavian artery was performed. The outright disappearance of

vertebrobasilar symptoms was observed in that patient after the surgery. Patient was followed for 25 years. No

vertigo episodes and no other vertebrobasilar symptoms he has experienced after the surgery and he is healthy.

Figure 9 represents the angiographic study of this patient. Figure 9 A Figure 9 B

Figure 9 C Figure 9 D

Figure 9 A, B: Extreme hypoplasia (functionally aplasia) of

the left vertebral artery and high entrance into the spinal

column with compression of the right vertebral artery

CAA – Cervical ascending artery; VA – Vertebral artery;

SA – Subclavian artery; CCA – Common carotid artery.

Figure 9 A – Extreme hypoplasia (functionally aplasia,

because the left vertebral artery does not participate in the

brain nourishment and terminates in the neck muscles) of the

left vertebral artery with slight hypertrophy of the left cervical

ascending artery.

Figure 9 B – High entrance of the right vertebral artery into

the spinal column with compression of the vertebral artery

between the crossing tendons of scalenus anterior and longus

colli muscles. Red arrow points to the site of compression.

Figure 9 C: Primitive trigeminal artery (red arrow) connecting the left internal carotid artery with the upper

part of basilar artery and nourishing only the basin of the left posterior cerebral artery.

Figure 9 D: The right posterior cerebral artery is originating from the right internal carotid artery (posterior

trifurcation of the right internal carotid artery). The basin of the right posterior cerebral artery is nourished from

the right internal carotid artery. The right anomalous vertebral artery, compressed by the deep neck muscles,

solely nourishes the remaining lower part of basilar artery and its entire basin. Left vertebral artery does not

participate in the brain blood nourishment because of extreme hypoplasia (it terminates in the neck muscles).

LPCA – Left posterior cerebral artery; BA – Basilar artery; ICA – Internal carotid artery; ECA – External carotid

artery; ACA – Anterior cerebral artery; MCA Middle cerebral artery; RPCA – Right posterior cerebral artery.

The patient have not had the symptoms from the posterior occipital lobes of the large hemispheres of the brain

because the blood flow in both posterior cerebral arteries was steady and adequate: to the right posterior cerebral

artery - from the right carotid artery and to the left posterior cerebral artery - through the primitive trigeminal artery

from the left carotid artery. Actually, entire both large hemispheres of the brain, including the territories of both

posterior cerebral arteries were nourished through the both carotid arteries. The lower (main) part of basilar artery

was nourished solely by the right anomalous vertebral artery. Fluctuations of blood flow in the right vertebral artery

due to its compression by the deep neck muscles and evoked spasm of the right vertebral artery caused the

hypoperfusion (insufficient blood flow) of the brain stem, mainly of the vestibular and acoustic nuclei. Therefore, the

most prominent symptoms in that patient were vertigo, dizziness and tinnitus in the ears. Surgical decompression

(freeing from compression), shortening and straightening of the right vertebral artery totally cured the patient and the

patient is symptom free for 25 years follow up.

Another primitive trigeminal artery in the patient with pronounced hypoplasia of both vertebral arteries is

presented in Figure 10.

Figure 10

Why one or both vertebral arteries do not develop or develop incompletely and are hypoplastic or even terminate in

the neck muscles? The answer is that normal blood flow through the vertebral arteries is required for the normal

development of vertebral arteries. In case the vertebral artery does not conjugate with basilar artery and terminates in

the neck muscles, the blood flow through it is low, like in all muscular arteries (muscles have much higher resistance

to the blood flow than brain) and it is the cause why in all these cases such vertebral arteries, terminating in the neck

are very small, tiny, less than 1 mm in diameter. The same cause is in all cases of hypoplasia of vertebral arteries. The

low blood flow state in the vertebral artery in embryo does not stimulate its development and the vertebral artery

remains undeveloped, hypoplastic. Analogical phenomenon is seen in arteries in the adult man. Arteries with

enhanced high flow state expand and become large in diameter (like arteries supplying arterio-venous fistulae or

enlarged arterial collaterals with high flow rates). Arteries with low flow rates with the time shrink and become small

in diameter. This mechanism determining the diameter of arteries is acting in embryo as well. Therefore, in case of

hypoplasia of vertebral artery one must establish the cause of its hypoplasia.

The degree of hypoplasia of vertebral artery can vary from very slight (3,5 mm in diameter) to expressed

hypoplasia (less than 1 mm in diameter) or even total aplasia of vertebral artery. Normal diameter of vertebral artery

is 4 millimeters. When one vertebral artery is hypoplastic or otherwise compromised, the normal vertebral artery can

be larger than normally: 5 or even 6 mm in diameter (it develops to a larger diameter due to enhanced blood flow

through it compensating the diminished or absent blood flow through the contralateral hypoplastic vertebral artery).

Figure 11 illustrates the aortic arch angiogram. Hypoplasia of the right vertebral artery (diameter – 2, 0 mm) is

seen on the angiogram. The left vertebral artery is normal 5,1 mm in diameter.

Figure 10: Primitive trigeminal artery (red arrow) connecting directly

the internal carotid artery with the basilar artery in the patient with

pronounced hypoplasia of both vertebral arteries

ACA – Anterior cerebral artery; MCA – Middle cerebral artery;

PCA – Posterior cerebral artery; BA – Basilar artery;

ICA – Internal carotid artery.

Figure 11

Figure 12 illustrates hypoplasia of vertebral arteries.

Figure 12

A B C D

Figure 13 illustrates the highly hypoplastic left vertebral artery, 1 mm in diameter terminating in the neck muscles.

This degree of hypoplasia is equal to aplasia functionally, because the vertebral artery nourishes only the neck

muscles and does not participate in the blood supply to the brain.

Figure 13

A B

Figure 11: Aortic arch angiogram with hypoplastic

right vertebral artery

CCA – Common carotid artery;

RVA – Right vertebral artery (small, hypoplastic,

undeveloped, diameter – 2, 0 mm);

LVA – Left vertebral artery (diameter – 5, 1 mm)

SA – Subclavian artery;

AoA – Aortic arch;

AAo – Ascending aorta (Angiography catheter is seen in

the ascending aorta. The contrast dye is injected through

it into the ascending aorta and the dye together with

blood flow fills all the branches of the aortic arch;

DAo – Descending aorta.

Figure 12:

A – Normal 4 mm diameter right vertebral

artery;

B - hypoplastic, 1, 5 mm diameter right

vertebral artery;

C – hypoplastic left vertebral artery

terminating in the posterior inferior

cerebellar artery (PICA);

D - hypoplastic left vertebral artery

terminating in the posterior inferior

cerebellar artery (PICA) and originating

from the aortic arch, from the chest, not

from the subclavian artery.

VA – Vertebral artery: SA – Subclavian

artery; PICA – Posterior inferior

cerebellar artery.

Figure 13: Highly hypoplastic left vertebral

artery terminating in the neck muscles

A – Antero-posterior (frontal) view

B – Lateral view of the same artery

VA – Vertebral artery

SA – Subclavian artery

It is clearly seen from the lateral view with

enlargement (B) that vertebral artery terminates

branching into muscle branches in the neck

muscles and does not participate in the brain

blood supply.

Figure 14 illustrates the peculiarity of blood supply to the brain stem in case of highly hypoplastic right vertebral

artery. Contrast dye is injected into the left subclavian artery. The contrast with blood flow enters and fills the arteries

of vertebrobasilar region in the same succession as the blood nourishes the brain. With the aid of filming with camera

one can see the direction of blood flow and the sequence of filling of arteries in the brain. In this case, the intracranial

part of the right vertebral artery is nourished by the blood in retrograde (reversed) direction, because the left normal

vertebral artery supplies normal high arterial pressure to the basilar artery and the blood flows from the basilar artery

into the right vertebral artery where the arterial pressure is lower than in the left normal vertebral artery and basilar

artery.

Figure 14

In case of aplasia or high-grade hypoplasia of vertebral artery nothing can be done surgically, because when the

vertebral artery is very small in diameter, the blood flow will be minimal because of small diameter of the artery

itself. However, if the patient has symptoms of vertebrobasilar insufficiency with one hypoplastic vertebral artery

usually it means that the another, normal in diameter vertebral artery has problems: atherosclerotic stenosis, kink or

some other type of congenital anomaly, because even only but normal vertebral artery should supply enough blood

flow to the vertebrobasilar region. Therefore, this normal in diameter vertebral artery should be evaluated carefully

for its pathology, especially for other types of congenital pathologies of vertebral arteries, because typically it has the

pathology, removal of which as a rule cures the patient. Unfortunately, most physicians consider the hypoplastic

vertebral artery as a single cause of vertebrobasilar insufficiency and do not evaluate the contralateral vertebral artery

carefully for pathology.

Aplasia of vertebral artery is a rare pathological variation. Hypoplasia is a common pathology. Hypoplasia of

the right vertebral artery is encountered in 10 percent of population. The left vertebral artery is affected by hypoplasia

less frequently than the right vertebral artery.

Branching anomalies of vertebral arteries

Normally, vertebral arteries are the first branches of subclavian arteries. However, the vertebral arteries can originate

from the aortic arch or from common carotid artery. Anomalous branching itself does not determine the diminution of

blood flow through the vertebral artery and does not mean the pathology of vertebral artery. However, the anomalous

branching of vertebral artery is frequently accompanied by other anomalies of vertebral arteries, especially – by

compression of vertebral arteries with sympathetic trunk, nerves or deep neck muscles, because the vertebral artery

travels abnormal route in the neck, sometimes very long (in case of branching from aortic arch) and frequently enters

spinal column abnormally, at higher level than normally.

Angiography reveals the anomalous branching of vertebral artery and most of its pathological conditions,

however it does not provide any information about the blood flow velocity in the vertebral artery. All hemodynamic

data of blood flow in the vertebral arteries can be assessed easily and reliably by duplex scanning study of vertebral

arteries.

Figure 15 illustrates the anomalous branching of the right vertebral artery from the common carotid artery in a

16 year old girl. The girl had dizziness, fainting episodes, vertigo episodes, headaches. She had difficulties with

learning at school due to the bad memory and rapid mental tiredness. Ultrasound studies of her vertebral arteries

revealed anomalous branching of the right vertebral artery from the right common carotid artery, high its entrance

into the spinal column at the 5-th cervical vertebra and compression with deep neck muscles. The left vertebral artery

Figure 14: The reversed (retrograde) direction of blood flow in the

intracranial part of hypoplastic right vertebral artery

RPCA – Right posterior cerebral artery

LPCA – Left posterior cerebral artery

BA – Basilar artery

RVA – Right vertebral artery

LVA – Left vertebral artery

Small arrows show the direction of blood flow. The left normal

vertebral artery supplies the blood to all arteries of vertebrobasilar

region: basilar artery and all its branches and in retrograde

(reversed) direction supplies the blood to the intracranial part of the

right vertebral artery.

had the same anomaly of high entrance into the 5-th cervical vertebra with its compression by the deep neck muscles.

The left vertebral artery originated normally from the left subclavian artery. Both vertebral arteries were highly

spasmophylic and very easy and frequently have been falling into the spasm (for example while examining the

vertebral arteries by duplex scanner or during the light massage of neck muscles).

Figure 15

A B

The surgical correction of the right vertebral artery was performed for that girl. The right vertebral artery was freed

from the compression with the deep neck muscles by removing the anterior scalenus muscle and partially excising the

lateral border of longus colli muscle up to the entrance of the vertebral artery into the spinal column. The right

vertebral artery was detached from the common carotid artery and implanted into its normal position onto the right

subclavian artery creating a wide orifice for the vertebral artery. Intraoperative studies of blood flow through the right

vertebral artery after its reconstruction showed normal blood flow velocity in the right vertebral artery. After the

surgery, all vertebrobasilar symptoms cleared in that girl and she has never had any vertebrobasilar symptoms later.

The left vertebral artery was left with anomaly of high entrance into the spinal column without surgical repair,

because the girl was healthy, asymptomatic after the surgical repair of the right vertebral artery. Therefore, there was

no need to repair the left vertebral artery because the right vertebral artery was able to supply enough blood to the

vertebrobasilar region. Figure 16 represents the operative photograph of the right vertebral artery of this girl after its

reconstruction.

Figure 16

Figure 15: Angiographic appearance of the right vertebral artery

branching (originating) from the right common carotid artery

A – Oblique view

B – Lateral view

CCA – Common carotid artery

VA – Vertebral artery

It is clearly seen on the angiogram that the vertebral artery

originates from the common carotid artery. However, it is

impossible to ascertain from the angiogram where the vertebral

artery enters the spinal column. The place of entrance of the

vertebral artery into the spinal column is easily ascertained by the

duplex scanner or color doppler. Blood flow velocity through the

vertebral artery is easily determined, blood flow disturbances are

easily appreciated and their causes established by duplex scanner.

Figure 16: Operative photograph of the

right vertebral artery after its

transplantation from the right common

carotid artery onto the right subclavian

artery

VA – Vertebral artery

SA – Subclavian artery

PhN – Phrenic nerve

Arterial suture – Arrow points to the

arterial anastomosis (suture).

Blue arrow points to the place where the

vertebral artery has been compressed by

the tendons of the deep neck muscles. You

can see the still existing spasm of the

vertebral artery despite the freeing of it

from compression and despite the surgical

desympatization of the vertebral artery.

Left vertebral artery originates from the aortic arch in 3 percent of population. The right vertebral artery originates

from the aortic arch rarely. This difference in the frequency between the right and left vertebral arteries is due to

different embryological development of the right and left vertebral arteries in the embryo. Both vertebral arteries

originate from the aortic arch very rarely and I have encountered in my long lasting practice only two such cases.

Originating from the aortic arch itself does not create the hemodynamic problems. However, the route of

vertebral artery is very long in such cases and very frequently the vertebral artery is crossed and compressed by the

sympathetic trunk or its branches in the thorax or neck, or by the deep neck muscles, because very frequently such

vertebral artery enters the spinal column abnormally, at the higher level than normally.

Figure 17 represents the angiographic appearance of the left vertebral artery originating from the aortic arch. Figure 17

Vertebral artery, branching from the aortic arch, can be diseased by the same diseases as vertebral arteries branching

normally from the subclavian artery and can have atherosclerotic lesions, kinks, loops, compressions with

sympathetic nerves or deep neck muscles etc. Below, in Figure 18 there are presented several examples of various

pathological conditions of vertebral artery, which originates from the aortic arch.

Figure 18

A B C

Figure 18: Branching of left vertebral artery

from the aortic arch

A – Left vertebral artery originates from the

aortic arch and enters the spinal column at the

3-rd cervical vertebra (white arrow). Black

arrow points to the place, where the orifice of

vertebral artery should be normally.

B - Left vertebral artery originates from the

aortic arch and enters the spinal column at the

5-th cervical vertebra. The longus colli muscle

tendon at the transverse process of the 6-th

cervical vertebra compresses it (arrow) .

C – Left vertebral artery originates from the

aortic arch and has a loop.

BA – Basilar artery; PCA – Posterior cerebral

artery; LVA – Left vertebral artery.

Figure 17: Aortic arch angiogram with left vertebral artery originating from

the aortic arch

RVA – Right vertebral artery; LVA – Left vertebral artery;

RSA – Right subclavian artery; LSA – Left subclavian artery.

Left vertebral artery originates from the aortic arch, not from the left

subclavian artery. Its orifice is seen on the aortic arch between the orifices of

the left common carotid artery and left subclavian artery.

Right vertebral artery originates normally, from the right subclavian artery.

Figure 18 C will be explained in more detail, because I hope that physicians will read this paper as well. The lumen

of the vertebral artery is kinked and twisted at the loop. This creates a narrowing (stenosis) of the lumen of vertebral

artery. One can convince himself to this fact simply by producing the same shape of loop in the water-hose when

irrigating the flowers. Such shape of the loop in the hose will diminish the water flow significantly. It is difficult to

ascertain the degree of stenosis (obstacle) in the vertebral artery just from the angiographic appearance of the

vertebral artery. However, the experienced physician will see on the angiogram so called secondary signs of retarded,

diminished blood flow in the vertebral artery. The blood flow through the left vertebral artery is so low, that basilar

artery is mainly nourished by the right vertebral artery with the pure blood without the contrast (because the contrast

is injected directly into the orifice of the left vertebral artery). Therefore, the basilar artery and all its branches are

faintly seen on the angiogram. The contrast, entering the basilar artery from the left vertebral artery is diluted and

washed out by the more strong pure blood stream from the right vertebral artery.

Appreciation of the hemodynamic significance of the pathology of vertebral arteries from the angiogram is

possible only if the angiography is performed carefully, the angiographer understands the laws of hemodynamics and

hydraulics and if the angiographic process is filmed by high-speed camera. In such case, it is possible from the

angiogram to appreciate the blood flow velocity in the diseased vertebral artery. Furthermore, there are secondary

angiographic signs of the diminished blood flow seen on the angiogram. One of them I just have mentioned above in

this article.

Definitely, the angiography can not match the accuracy of duplex study in assessing the blood flow velocity and

other hemodynamic data of the diseased vertebral artery.

Figure 19 represents the angiographic appearance of both vertebral arteries, originating from the aortic arch.

These both vertebral arteries have had other problems additionally to the originating from the aortic arch: the left

vertebral artery was compressed by the sympathetic trunk and by the deep neck muscles and the right vertebral artery

had the kink. The left vertebral artery entered the spinal column higher than normally – into the 5-th cervical vertebra.

Patient from the childhood had frequent intensive vertigo episodes, dizziness, headaches, blurring in the eyes, tinnitus

and other symptoms of vertebrobasilar insufficiency. She had motion sickness, could not tolerate riding with a car or

even train, she had fainting episodes. Diagnosis of migraine was established for her and she was treated with

antimigraineous drugs without any success. Duplex study revealed both vertebral arteries originating from the aortic

arch, left vertebral artery entering the spinal column abnormally, into the 5-th cervical vertebra and the left vertebral

artery compressed and stenosed by the sympathetic trunk and higher - compressed by the deep neck muscles. The

right vertebral artery had extra length and was kinked with stenosis at the kink site. The angiographic study was

performed for the patient, which confirmed the duplex data. The patient was operated. The left vertebral artery was

found originating from the aortic arch, entering the spinal column into the transverse process of the 5-th cervical

vertebra and at two sites vertebral artery was compressed: at the level of the 7-th cervical vertebra it was compressed

by the sympathetic ganglion (ganglion stellatum) and at the 6-th cervical vertebra it was compressed by the tendons

of deep neck muscles: scalenus anterior and longus colli muscles. The vertebral artery was freed from the

compression with the deep neck muscles (scalenus anterior was totally removed and the longus colli muscle was

partially excised), was ligated in the neck, cut, withdrawn from the stellate ganglion and implanted into the left

subclavian artery, into its normal place. After the surgery, all vertebrobasilar symptoms cleared outright in this patient

and she had never had any dizziness, vertigo episodes, fainting or headache after the surgery and is healthy for more

than 20 years. The right vertebral artery was left unrepaired, because the patient was asymptomatic and healthy after

the repair of only one left vertebral artery.

Figure 19

A B

Figure 19: Both vertebral arteries originate from the aortic arch

(contrast dye is injected through the catheter inserted directly into the

both vertebral arteries)

A – The right vertebral artery originates from the aortic arch, enters the

spinal column normally into the 6-th cervical vertebra, has extra length

and episodically kinks (white arrow points to the kink).

B – The left vertebral artery originates from the aortic arch and enters

the spinal column abnormally high into the 5-th cervical vertebra. It has

compression at two sites: white arrow points to the site of compression

with the sympathetic trunk and the blue arrow points to the compression

by the deep neck muscles (longus colli and scalenus anterior muscles).

Figure 20 presents the angiograms of the patient with the left vertebral artery originating from the aortic arch

and strangulated (compressed) by the sympathetic trunk.

Figure 20

A B C D E

VA – Vertebral artery.

Figure 20 A is an angiogram of the left vertebral artery. The catheter is inserted into the vertebral artery and the

contrast dye is injected directly into the left vertebral artery. The site of strangulation (compression) of the left

vertebral artery by the sympathetic trunk (blue arrows) is faintly seen on the angiogram and can be easily missed by

inexperienced examiner physician. Fig. B is an angiogram of the same artery as in Fig. A with the balloon catheter

introduced into the left vertebral artery and inflated with the contrast dye. The compression of the balloon at the site

of compression of the vertebral artery is clearly seen (blue arrow). Fig. C: The balloon is forcefully inflated and the

sympathetic trunk surrounding and compressing the vertebral artery is stretched so, that vertebral artery is no longer

compressed by the sympathetic trunk. You can see the smooth dilated balloon in the lumen of vertebral artery. Blue

arrow points to the site of previous compression of the vertebral artery. Fig. D is an angiogram of the same vertebral

artery as in figures A,B,C after its dilatation and stretching with the balloon. The vertebral artery is dilated to normal

its diameter. The lumen is smooth without any narrowing at the previous site of compression (blue arrow). Fig. E is

an angiogram of the same vertebral artery 6 months after its dilatation with balloon. Blue arrow points to the

narrowing of the vertebral artery at the previous site of compression with the sympathetic trunk. The sympathetic

trunk compressed the vertebral artery repeatedly due to scarring after the dilatation of vertebral artery and

stretching the sympathetic trunk. The spasm of the proximal part of vertebral artery, compressed by the sympathetic

trunk, is clearly seen on the angiogram (extracanal proximal part of vertebral artery is narrowed in comparison with

the normal lumen of the vertebral artery inside the bony canal in the spinal column).

The patient, which angiograms are presented in figure 20 had the headaches, dizziness and vertigo episodes from the

childhood. During the vertigo episodes, she was unable to walk, even stand due to expressed spinning of the

surroundings around her and have had nausea, even vomiting. For a long time her illness was treated as a migraine

without any success. Later Meniere’s disease diagnosis was established for her and high doses of betahistine were

prescribed for her without any improvement of the disease. Then she addressed me and ultrasound study (duplex

scanning) revealed the hypoplastic right vertebral artery (1,8 mm in diameter) and left vertebral artery originating

from the aortic arch and strangulated (compressed) at the level of 7-th cervical vertebra with the sympathetic trunk.

Angiographic study (Fig. 20A) confirmed the ultrasound data. The angiographer physician decided to dilate the

strangulated left vertebral artery with the balloon through the transfemoral intraarterial route. The inflation of the

balloon clearly demonstrated the site and the degree of compression of the vertebral artery (Fig. 20 B). Dilatation of

the balloon dilated the vertebral artery to normal its diameter and stretched the sympathetic nerve sufficiently to allow

free passage of the vertebral artery between the sympathetic nerve and the spinal column (Figure 20 D). After the

dilatation of the left vertebral artery with balloon patient felt herself very well, all vertebrobasilar symptoms

disappeared. However, this lasted not for a long period, because scarring of the stretched sympathetic nerve and

surrounding tissue caused repeated compression and narrowing of the left vertebral artery. Even more important in

such cases is a spasm of vertebral artery, because compressed vertebral artery reacts to the compression by its spasm,

which can cause very severe narrowing of the lumen and diminution of blood flow through the vertebral artery. This

spasm is clearly seen in Figure 20 E (the part of vertebral artery, involved in spasm, is narrowed with irregular

lumen). The symptoms of vertebrobasilar insufficiency returned to the patient, including vertigo episodes. Namely,

the spasm of vertebral artery evoked the vertigo episodes in the patient, not the compression itself, because the

compression is the same all the time and namely the spasm of vertebral artery worsens the blood flow through the

vertebral artery and causes the vertigo episodes. The patient was operated. The left vertebral artery was ligated low in

the neck, extracted from the constringement with sympathetic nerves and implanted into the left subclavian artery,

into normal position of the left vertebral artery. After this operation patient was free of symptoms outright and was

healthy and asymptomatic for more than 20 years of follow up. She has forgotten the headaches and vertigo episodes.

Postoperative duplex study revealed normal blood flow in the left vertebral artery. Its lumen was wide, smooth and

otherwise normal.

The conclusion from this case is that dilatation of extravasally compressed vertebral artery is inadequate for the

releasing of this artery from the compression, because the extravasal compression typically causes the spasm of

vertebral artery and scarring of the stretched tissue causes repeated compression of vertebral artery. Therefore, the

dilatation of vertebral artery in cases of its compression with deep neck muscles or sympathetic trunk is meaningless.

Surgical repair of this problem, as a rule, cures the patient.

Posterior branching of vertebral arteries

Posterior branching (originating) of vertebral artery is called situation when the vertebral artery originates from the

posterior surface of the subclavian artery. Normally, vertebral artery originates from the superior (upper) surface of

the subclavian artery. When the vertebral artery originates from the posterior surface of the subclavian artery, it flexes

just at the orifice at 90-degree angle and partially closes the orifice. If the vertebral artery has extra length, then it

changes a direction of its route by a 90-degree angle with the aid of kink and the vertebral artery kinks and narrows

its lumen the same way as it does in simple kink due to its extra length. Both these situations significantly diminish

the blood flow through the vertebral artery and symptoms of vertebrobasilar insufficiency appear. The posterior

branching of vertebral artery is more common for the right vertebral artery than for the left. In young people this

pathology is congenital and very often in these cases the vertebral artery is hypoplastic, small in diameter, because it

has not been developed to the normal diameter due to diminished small amount of blood flowing through it because

of partially closed, narrowed orifice of vertebral artery. In older people, this pathology can be congenital and can be

acquired as well, because with the age, especially in hypertensive patients subclavian arteries elongate and can rotate

around their long axis pushing the orifice of the vertebral artery to its posterior surface. This pathology of vertebral

artery is easily missed by angiographers and surgeons reviewing the angiograms, because typically the orifice of

vertebral artery is hidden, obscured by the subclavian artery in the standard anterior-posterior (sagital) view

angiogram. This is a main reason why this pathology is misdiagnosed in patients having expressed symptoms of

vertebrobasilar insufficiency or even in patients who have had the ischemic strokes in vertebrobasilar territory of the

brain. These patients are told that their vertebral arteries are normal and that they cannot be the cause of symptoms of

vertebrobasilar insufficiency or even stroke and are left without any help, though they could be healthy if the

pathology would be diagnosed and surgically repaired. Good visualization of the orifice and proximal part of

vertebral artery in these cases is achieved by taking angiograms in the oblique direction (view). Even better

visualization is obtained by the duplex scanner, because duplex scanner enables to visualize the vertebral artery and

its orifice in all directions and to obtain hemodynamic data of blood flow through the vertebral artery. This makes the

duplex scanning the most accurate diagnostic tool in diagnosing the posterior branching of vertebral arteries and

determining the hemodynamic significance of this pathology.

Figure 21 illustrates the hemodynamic significance of posterior branching of vertebral artery, which can be

assessed by the standard angiography if examiner understands the secondary signs of diminished blood flow in

vertebral artery. Figures 21 A, B are the standard angiograms of the right vertebral artery made in the patient with

expressed symptoms of vertebrobasilar insufficiency who have had ischemic vertebrobasilar stroke in history. The

left vertebral artery of this patient had a loop with kink. The angiographer physician told the patient that her right

vertebral artery is normal and printed and delivered the angiogram of the right vertebral artery, which is seen in figure

21 A to the physician who referred her for the angiography. The wrong conclusion was drawn that patient does not

need the surgery. This patient addressed me for the suffered vertebrobasilar stroke and for the expressed

vertebrobasilar insufficiency symptoms. I looked at the angiogram (Fig. 21 A) and noted the hypertrophied cervical

ascending artery, which means the compromised blood flow through the right vertebral artery and decided to review

all the angiographic data. The angiography was performed and filmed with movie camera, so the appreciation of the

blood flow velocity in the vertebral artery was possible. Figure 21 B is one of the first pictures taken by the movie

camera when the contrast dye was started to inject into the right subclavian artery. Figure 21 A is a picture taken at

the end of dye injection when the vertebral artery was completely filled with dye. Figures 21 C and D are the same

pictures as in figures 21 A, B just with the explanations.

Figure 21 Posterior branching of the right vertebral artery

A B C D

A – Picture taken with completely filled vertebral artery at the end of injection of the contrast dye into the right

subclavian artery; B –The same injection of the contrast dye into the right subclavian artery as in picture A, just in

the earlier phase of injection;; C – The same picture as in figure A, just with explanations ; D – The same picture as

in figure B, just with explanations.

CAA - Cervical ascending artery; SA - Subclavian artery; VA - Vertebral artery.

The orifice of the right vertebral artery is on the posterior surface of the subclavian artery and is not seen, hidden,

obscured by the subclavian artery as well as the kinked proximal part of vertebral artery. The place of the orifice of

vertebral artery is depicted by the broken lines and red arrows. The cervical ascending artery like the other muscular

branches of the subclavian artery is a muscular artery and the blood flow velocity in it is by far lower in normal

conditions than in the vertebral artery, which is a brain supplying artery, but not in this case. In this patient, the

blood flow in the cervical ascending artery is more rapid than in the right vertebral artery, because the right

vertebral artery is kinked at the orifice due to its posterior branching. You can see on the figure 21 B that cervical

ascending artery is already filled with contrast and supplies the blood to the upper part of the right vertebral artery,

meanwhile the vertebral artery has very slow blood flow and just begins to fill with the contrast dye. Cervical

ascending artery hypertrophies and becomes large in cases when the blood flow through the proximal part of

vertebral artery is compromised and cervical ascending artery serves as a collateral pathway for blood flow to the

brain (to the upper part of vertebral artery). It has connections with vertebral artery in the upper part of the neck.

The patient would have been discharged from the hospital without any surgery if I would not accidentally have seen

the angiogram depicted on figure 21 A. I have noticed the large hypertrophied right cervical ascending artery, which

typically is a mark of low blood flow velocity in the vertebral artery due to obstacle in the proximal part of it.

Furthermore, the patient has had expressed vertebrobasilar insufficiency symptoms and has had vertebrobasilar

ischemic stroke in history. Patient could not have the vertebrobasilar stroke and expressed vertebrobasilar

insufficiency with one normal vertebral artery. Therefore, I decided to go and review the angiograms in the

angiography department. The review of angiograms gave me additional data, supporting my suspicion of the

pathology of the right vertebral artery. At the beginning of the contrast dye injection into the subclavian artery it is

clearly seen, that vertebral artery fills with the dye very slowly, much slower than the dye fills the cervical ascending

artery and other muscular branches of the subclavian artery. Normally, the dye must fill very rapidly the vertebral

artery and only later, slowly it should fill the cervical ascending artery and other muscular branches of the subclavian

artery. The cervical ascending artery in this patient serves as a collateral pathway, supplying the blood to the upper

part of the vertebral artery and brain. Due to the fact, that cervical ascending artery branches from the subclavian

artery and has connections with the upper part of the vertebral artery and in this case was shunting the proximal part

of the vertebral artery, the obstacle for the blood flow had to be in the orifice or the proximal, hidden behind the

subclavian artery part of vertebral artery. The orifice of the vertebral artery was not seen on the angiogram due to

very slow blood flow in the vertebral artery: subclavian artery was already filled with contrast dye while the vertebral

artery just began to fill and the orifice and proximal part of vertebral artery was hidden by the completely opacified

subclavian artery. If the angiographer would appreciated the pathological situation in the right vertebral artery as I

have done, he would performed the angiography in the oblique plane (view) and the orifice and proximal part of

vertebral artery would be clearly seen on an angiogram. The visualization of posterior branching of vertebral artery

requires the angiography performed in oblique plane.

This my comment in detail of the above illustrated in figure 21 angiograms is with purpose to explain for You

how it is important to perform the angiography skillfully and creatively with the appreciation of the secondary signs

of the impaired blood flow in the vertebral artery, in this case – hypertrophied cervical ascending artery and slow

filling of the vertebral artery with the contrast dye.

Duplex scanning revealed posterior branching of the right vertebral artery with sharp kink and very slow blood

flow velocity in the right vertebral artery because of kink. The left vertebral artery had a loop; however, its blood

flow was better than in the right vertebral artery.

The patient was operated. At the operation, the right vertebral artery was found originating from the posterior

surface of the subclavian artery and sharply kinked at the orifice with very slow blood flow. The vertebral artery was

ligated at the orifice, cut away and implanted into normal position onto the superior surface of the subclavian artery.

Intraoperative blood flow measurement showed normal blood flow through the right vertebral artery after its

reconstruction. The vertebrobasilar symptoms cleared outright after the surgery and the patient is healthy without any

vertebrobasilar symptoms for 25 years follow up period.

Angiographic appearance of the posterior branching of vertebral artery is presented in figures 22, 23 and 24.

Figure 22 is an oblique view of the right vertebral artery, originating from the posterior surface of the subclavian

artery. Figures 23 and 24 are the sagital (anterior-posterior) views of the right vertebral artery, originating from the

posterior surface of the subclavian artery. These two pictures are those rare cases, when the orifice and proximal part

of vertebral artery can be seen through the shadow of subclavian artery.

Figure 22 Figure 23 Figure 24

Figure 22: Oblique view of the posterior branching of vertebral artery.

Figures 23, 24: Sagital (anterior-posterior) view of the posterior branching of vertebral artery.

CCA – Common carotid artery; VA – Vertebral artery; SA – Subclavian artery.

Red arrow points to the orifice of vertebral artery. Blue arrow points to the site of vertebral artery kinking, which is

seen on the oblique view angiogram (fig. 22) and is totally obscured by the subclavian artery shadow in the sagital

(anterior-posterior) view (figures 23, 24).

Figure 25 is an ultrasound view taken by color doppler of posterior branching of vertebral artery. Figure 25

Figure 25: Color doppler view of posterior branching of

vertebral artery.

SA – Subclavian artery

VA – Vertebral artery

Subclavian artery is seen in the transverse section and the

vertebral artery is seen in long axis section. It is clearly seen, that

proximal part of vertebral artery is narrowed due to the kink of

vertebral artery at its orifice.

Color doppler and duplex scanning enables examiner to see the orifice and proximal part of vertebral artery and

enables to assess easily the blood flow velocities at the site of the kink and more distally, including the upper normal

vertebral artery inside the spinal column, where it is with normal lumen. Blood flow in the upper vertebral artery

inside the spinal column, where it is normal, reflects the real blood flow (blood supply) to the brain. Therefore, the

importance and value of the ultrasound studies in diagnosing the posterior branching of vertebral artery as well as

other anomalies of vertebral arteries cannot be overestimated.

Lateral branching of vertebral arteries

Lateral branching (originating) of vertebral arteries is called the situation when vertebral artery branches from the

subclavian artery more lateral than normally. Normally, the vertebral artery is a first branch of the subclavian artery

and is close to the neck midline, medial to the scalenus anterior muscle. In lateral branching, the orifice of vertebral

artery is located at the same sagital plane as thyreocervical trunk or even more lateral than it. In such situation the

orifice and proximal part of vertebral artery is under the scalenus anterior muscle and is compressed by this muscle

against the transverse process of the seventh cervical vertebra. Usually, the compression of vertebral artery and

subclavian artery by scalenus anterior muscle rotates both these arteries towards the spinal column and partial closure

of vertebral artery orifice or kink of the vertebral artery result from such compression and rotation. This diminishes

the blood flow through the vertebral artery to the brain significantly. Vertebral artery reacts to compression by spasm.

This results in even more deep diminution of blood flow through the vertebral artery. All these hemodynamic features

in vertebral artery are easily recognized and assessed by means of ultrasound studies: color doppler or duplex

scanning. Figure 26 is a color doppler view of lateral branching of vertebral artery.

Figure 26

Figure 27

Figure 26: Color doppler view of lateral branching of

vertebral artery

CAA – Cervical ascending artery

VA – Vertebral artery

SA – Subclavian artery

Vertebral artery branches from the subclavian artery in

the same sagital plane as thyreocervical trunk and its

main branch – cervical ascending artery.

The cervical ascending artery is very large,

hypertrophied, the same diameter as vertebral artery,

because it serves as a collateral for the compromised

vertebral artery. There is a turbulence, seen as yellow

whirls during the systole in the subclavian and

vertebral arteries due to compression of them by

scalenus anterior muscle.

Figure 27: Color doppler view of lateral branching of

vertebral artery with high-grade compression of the

proximal part of vertebral artery

CAA – Cervical ascending artery

VA – Vertebral artery

SA – Subclavian artery

Thyreoc. trunk – Thyreocervical trunk

Proximal part of vertebral artery is compressed by the

scalenus anterior muscle and is hidden in this muscle.

Yellow whirls are seen in the vertebral artery as the

spurt of blood is injected into the vertebral artery

through the compressed, narrowed its part during the

cardiac contraction (systole).

Cervical ascending artery is hypertrophied, the same

diameter as vertebral artery, because it serves as a

collateral pathway.

Figure 28

Figures 26, 27, 28 are the color doppler views of lateral branching of vertebral artery. Vertebral artery branches from

the subclavian artery in the same sagital plane as branches from it the thyreocervical trunk and its main branch –

cervical ascending artery. In this situation, the proximal part of vertebral artery and its orifice is compressed by

scalenus anterior muscle. The blood flow in the vertebral artery is diminished and the cervical ascending artery

enlarges because it serves as a shunting collateral for the vertebral artery. The blood flow in the cervical ascending

artery becomes significant, with high linear velocity very similar to the vertebral artery. Compression of the vertebral

artery and subclavian artery as well, creates the turbulence of blood flow during the systole (cardiac contraction). It is

heard by stethoscope as a systolic murmur over the clavicle and is heard with ultrasound evaluation techniques as

well. Color doppler study, as a rule, shows yellow, or even yellow-blue whirls inside the vertebral and subclavian

arteries, appearing during the spurt of blood injected at the cardiac systole. Blue color means the reversed direction of

blood flow in the whirls inside the blood spurt.

Figure 29 illustrates the yellow-blue color whirls in the vertebral artery because of its compression due to lateral

branching of vertebral artery.

Figure 29

Figure 30 illustrates the color doppler view of lateral branching of vertebral artery with the kink of vertebral

artery at the orifice due to compression and rotation of subclavian and vertebral arteries by scalenus anterior muscle.

Figure 28: Cervical ascending artery serving as

collateral in lateral branching of vertebral artery with

compression of its proximal part

VA – Vertebral artery

SA – Subclavian artery

CAA – Cervical ascending artery

Blood flow velocity in the hypertrophied large cervical

ascending artery is as high as in the vertebral artery,

because it serves as collateral pathway for

compromised, compressed vertebral artery. Doppler

flow probe is placed in the cervical ascending artery

(arrow). Blood flow curve in the cervical ascending

artery is very similar to the curve of vertebral artery,

because it serves as an artery supplying the blood to the

brain. Curve is characteristic for high-grade turbulence

(yellow whirls) in the artery.

Figure 29: Lateral branching of vertebral

artery: Injection of blood spurt during cardiac

contraction (systole) with yellow-blue color

whirls inside the blood stream

High-grade blood flow turbulence in the

vertebral artery, subclavian artery and

thyreocervical trunk, seen as yellow-blue whirls

in the blood spurt is created due to compression

of the orifice and proximal part of vertebral

artery and subclavian artery as well by the

scalenus anterior muscle.

Doppler flow curve is characteristic for

compression of vertebral artery (high systolic

velocity and turbulence).

Figure 30

Figure 31 is the same vertebral artery as in figure 30, just without a color doppler (black-white duplex scanning

mode).

Figure 31

As you can see from the above illustrations the color doppler and duplex scanning are very informative and accurate

diagnostic tools in lateral branching of vertebral artery as well as in other anomalies and pathologies of vertebral

arteries. They permit not only the visualization of the vertebral artery and its lumen and surrounding vertebral artery

tissues, but enable to assess the hemodynamic significance of the pathology as well, because ultrasound techniques

allow to determine and to record the blood flow velocities inside the artery. Determination of blood flow in vertebral

artery inside the spinal column, above the obstacle, where its lumen is already normal, allows to assess the real blood

flow through that artery to the brain and to estimate the hemodynamic significance of the obstacle at the proximal

part of vertebral artery.

Figures 32 A, B, C are the angiographic appearance of lateral branching of vertebral artery.

Figure 30: Kink of the vertebral artery due to its

lateral branching, its compression and rotation of

subclavian artery by scalenus anterior muscle

Vertebral artery is kinked close to its orifice because

of its compression by scalenus anterior muscle and

rotation of subclavian artery. Yellow-blue color

whirls are seen inside the subclavian artery and

thyreocervical trunk during the cardiac systole and

blood spurt injection.

Doppler flow curve is characteristic for high grade

narrowing of vertebral artery (high systolic velocity

and very high turbulence during all the cardiac

cycle).

Figure 31: Black-white duplex scanning mode of

lateral branching of vertebral artery with compression

and kink of the proximal part of vertebral artery (the

same artery as in figure 30)

Proximal part of vertebral artery is compressed by

scalenus anterior muscle and kinked. The lumen of

vertebral artery is narrowed, orifice of vertebral artery –

partially closed. Subclavian artery is compressed and

rotated by the scalenus anterior muscle as well.

Blood flow velocity curve confirms high grade

narrowing of vertebral artery (high systolic flow velocity

134 cm/sec and very pronounced turbulence during all

the cardiac cycle). Curve descends below zero line, what

means reversed blood flow direction in the whirls).

Figure 32

A B C

Figure 32 A is a typical angiographic appearance of lateral branching of vertebral artery. Both orifices of vertebral

artery and thyreocervical trunk are very close one to another and are located in the same sagital plane. In such cases,

the orifice of vertebral artery is kinked and partially closed. Figures 32 B and C are the angiographic appearance of

lateral branching of vertebral artery with the compression of subclavian artery and proximal part of vertebral artery

by scalenus anterior muscle (Fig.32 B is an anterior-posterior or sagital view and Fig. 32 C is an oblique view of the

same vertebral artery). This patient has had the thoracic outlet syndrome symptoms (neurogenic and vertebrobasilar

insufficiency symptoms). Scalenus anterior muscle was pressing onto the brachial plexus nerve roots, subclavian

artery and proximal part of vertebral artery. Subclavian artery is seen on Figures 32 B and C compressed by scalenus

anterior muscle, its arch is elevated high into the neck, orifice of vertebral artery is rotated backwards and partially

closed. Scalenectomy (removal of scalenus anterior muscle) completely cured the patient from symptoms of

vertebrobasilar insufficiency and from symptoms of neurogenic thoracic outlet syndrome.

Combination of thoracic outlet syndrome with lateral branching of vertebral artery is a common clinical situation and

physicians should be aware of these both pathologies in such patients.

Angiography visualizes the vertebral artery, but it does not give any information about the velocity and quantity

of blood flow in the vertebral artery. That’s, why duplex scanning or color doppler are superior to the angiography in

evaluating the pathology of vertebral arteries.

There is long known and is described in medical literature scalenus anterior muscle syndrome (upper thoracic

outlet or cervical outlet syndrome), when the scalenus anterior muscle compresses the brachial plexus nerve roots. It

is cured usually surgically by scalenectomy (removal of scalenus anterior muscle). It is well known, that very often in

these patients the scalenus anterior muscle compresses and vertebral artery and that very often the vertebral artery

originates in these patients laterally under the scalenus anterior muscle. Therefore, patients having symptoms of

vertebrobasilar insufficiency and of neurogenic thoracic outlet syndrome should be evaluated before the operation by

duplex scanning or color doppler by experienced and qualified examiner for determination of vertebral arteries

pathology, because if left unrepaired while removing the scalenus anterior muscle, the vertebral artery is very

difficult to repair in second time operation for the vertebral artery pathology. It is by far better to repair it at the same

time as removing the scalenus anterior muscle.

Figures 33 and 34 are the illustrations of lateral branching of both vertebral arteries. The left vertebral artery

due to its compression with the scalenus anterior muscle has had very low blood flow from the birth and has not

developed to the normal diameter, stayed hypoplastic, narrow. Both vertebral arteries are compressed by scalenus

anterior muscle. Both subclavian arteries are compressed by scalenus anterior muscle as well. This situation is

attributed to the cervical outlet syndrome, because the scalenus anterior muscle compresses the brachial nerve plexus

as well as subclavian and vertebral arteries. These patients typically have symptoms of vertebrobasilar insufficiency

and symptoms of neurogenic thoracic (cervical) outlet syndrome as well. Usually these patients suffer by far more

from vertebrobasilar insufficiency symptoms than from the neurogenic thoracic outlet syndrome symptoms and are

seeking doctors help because of vertebrobasilar symptoms. Establishing the correct diagnosis enables to cure

completely these patients surgically. Scalenectomy (removal of scalenus anterior muscle) completely cures these

patients from the vertebrobasilar insufficiency and from the compression of brachial nerve plexus.

Figure 33 is a magnetis resonance angiography and figure 34 is a CT angiography of the same patient, having

lateral branching of vertebral arteries and compression of both vertebral and subclavian arteries with scalenus anterior

muscle.

Figure 32: Angiographic appearance of

lateral branching of vertebral artery

CCA – Common carotid artery

SA – Subclavian artery

VA – Vertebral artery

Figure 33

Figure 34

I have to present you some anatomical knowledge on the anatomy of deep neck muscles, because further I shall

write a lot about the problems arising between the deep neck muscles and vertebral arteries. Deep neck muscles are

depicted in Figure 35. On the left side of the neck the scalenus anterior muscle and long muscle of the head (longus

capitis muscle) are removed in order to show the place of insertion of scalenus anterior muscle onto the first rib

(scalene tubercle). Vertebral artery triangle is a free space left for the vertebral artery to pass freely from its origin on

the subclavian artery to its entrance into the transverse process of the 6-th cervical vertebra. Normally, vertebral

artery passess freely in this triangle and is not compressed by the deep neck muscles. The problem arises when the

vertebral artery enters the bony canal higher than normally (into the 5-th, 4-th or even 3-rd cervical vertebra), or when

the deep neck muscles attach to the spinal column abnormally and conjugate lower than normally. In such cases

vertebral artery is compressed by the deep neck muscles (between them and against the transverse processes of the

cervical vertebrae).

Figure 33: Lateral branching of both vertebral arteries:

compression of both subclavian and both vertebral arteries by

scalenus anterior muscle (magnetic resonance angiography)

1- The right vertebral artery

2- The left hypoplastic vertebral artery

3- Sites of compression of the left subclavian and left vertebral

arteries

4- Sites of compression of the right subclavian and vertebral

arteries.

The left vertebral artery from the embryological period is

compressed by scalenus anterior muscle. Therefore, she has low

blood flow from that period and due to this reason it has not

developed to the normal lumen and stayed narrow, hypoplastic.

Figure 34: Computer reconstructed image of CT angiography

(the same patient and the same arteries as in the figure 33)

1- The right vertebral artery

2- The left hypoplastic vertebral artery

3- Site of compression of the left vertebral artery

4- Site of compression of the left subclavian artery

5- Site of compression of the right vertebral artery

6- Site of compression of the right subclavian artery

Both vertebral arteries originate from subclavian arteries more

laterally than normally, together with the thyreocervical trunk

under the scalenus anterior muscle and are compressed by them

(so called lateral branching of vertebral arteries). The orifices

of both vertebral arteries are on the posterior aspect of the

subclavian arteries and during the compression are partially

closed. Both subclavian arteries are compressed and narrowed

by scalenus anterior muscle as well.

Figure 35

Figure 36

Figure 35: Anatomy of vertebral artery triangle (on

the left side the scalenus anterior and longus capitis

muscles are removed for better visualization)

Normally vertebral artery enters the spinal column

through the hole in the transverse process of the 6-th

cervical vertebra and further it travels inside the spinal

column and is secured from the compression by the deep

neck muscles.

Longus colli and scalenus anterior muscles conjugate

both together at the transverse process of the sixth

cervical vertebra and form like a roof for the entrance

of vertebral artery into the spinal column.

In case these muscles conjugate lower, they compress

the vertebral artery between their tendons even in

normal entering of vertebral artery into the spinal

column. In cases when vertebral artery enters the spinal

column higher than normally (into 5-th, 4-th or even 3-

rd cervical vertebrae) it is always compressed between

these deep neck muscles and against the spinal column

by these muscles.

Figure 36: Neck anatomy

6 – Transverse process of the 6-th cervical

vertebra

SAM – Scalenus anterior muscle

LCM – Longus colli muscle

CCA – Common carotid artery

SA – Subclavian artery

SV – Subclavian vein

The clavicle and attached to it muscles are

removed on the right side.

Brachial plexus and subclavian artery pass

through the gap between the scalenus

anterior and medius muscles.

Brachial plexus, subclavian artery and

subclavian vein pass between the clavicle

and first rib from the neck into the armpit.

Normally, vertebral artery originates from

the subclavian artery medial to the scalenus

anterior muscle and thyreocervical trunk,

passes freely in the vertebral triangle

between the scalenus anterior and longus

colli muscles and enters the spinal column

at the transverse process of the 6-th cervical

vertebra.

Extravasal (extrinsic) compressions of vertebral arteries

The most common causes of extrinsic compressions of vertebral arteries are deep neck muscles (in cases of abnormal

originating or abnormal entering the spinal column of vertebral artery), sympathetic structures (stellate ganglion,

sympathetic trunk or their sympathetic branches), various fibrous or ligamentous abnormal structures in the neck. The

aging process of the spinal column produces deformations, osteochondrosis and osteophytes in the spinal column.

These deformities and bony compressions of vertebral artery inside the spinal column narrow the vertebral artery and

diminish blood flow through it significantly, sometimes even thrombosis of the compressed vertebral artery can

occur. These deformities and compressions of vertebral arteries, narrowing their lumen inside the spinal column, are

easily visualized angiographically and their diagnostic evaluation is simplex and not disputable. Therefore, I shall not

discuss them in detail. I just want to say, that the most effective and reliable operation in these cases is the so called

distal shunt to the vertebral artery at the base of the skull. The narrowed or occluded vertebral artery inside the spinal

column or when it is completely occluded in the proximal part is bypassed by means of autologous superficial vein

harvested from the leg and sutured one end to the side of common carotid artery (or to the subclavian artery, there are

also modifications of operation with suturing the external carotid artery “end to end” to the vertebral artery etc) and

another end to the side or end of vertebral artery at the level of the first cervical vertebra.

Figure 37 A is a postoperative angiogram of the distal shunt to the end of vertebral artery at the base of the skull

from the side of common carotid artery and Figure 37 B is a photograph taken during the operation after the

completion of creating this shunt.

Figure 37

A B

Distal shunt to the vertebral artery at the base of the skull is the only possible variant of surgical repair in cases of

total (complete) occlusion of the proximal part of vertebral artery. It is an ideal variant of operation for vertebral

artery occlusion or narrowing due to its deformation in the spinal column because of atherosclerosis, osteochondrosis

or spondyloarthrosis. Qualitatively performed distal shunt ensures the life long good blood supply to the

vertebrobasilar region, because the shunt is outside the spinal column and the spinal deformities in the senility does

not affect it and blood flow through it is normal all the time.

Strangulation or compression of vertebral arteries with sympathetic structures

Normally, the sympathetic trunk, its ganglia or branches do not cross the vertebral artery in front of it and do not

compress it. However, there are abnormal anatomical situations when the sympathetic structures cross the vertebral

artery in front of it and compress, strangulate or even constringe it. Two such cases are already described in this paper

and their angiographic appearance are presented in Figures 19 B and Figure 20. Figure 38 illustrates the normal

relationship between the sympathetic structures and the vertebral artery.

Figure 37: Distal shunt to the vertebral

artery at the base of the skull

A – Postoperative angiogram

B – Intraoperative photograph

PCA – Posterior cerebral artery BA – Basilar

artery

VA – Vertebral artery

ICA – Internal carotid artery

ECA – External carotid artery

CCA – Common carotid artery

Red arrows in Fig. 35 A and respectively green

arrows in Fig. 35 B point to the anastomoses

between the autologous vein shunt and the end

of vertebral artery and the side of common

carotid artery.

The blood from the common carotid artery is

supplied to the vertebral artery at the base of

the skull.

Figure 38

The vertebral artery can be strangulated with the sympathetic trunk or its branch, or stellate ganglion, or can be

kinked due to extra length and fixation with the sympathetic structures to the spinal column. Figure 39 presents the

drawing from F. Koskas article “Extrinsic compressions of vertebral arteries “ published in the book “Chirurgie de

l’Artere Vertebrale”, Paris, 2001, which illustrates the kinking of vertebral artery due to its fixation with stellate

ganglion.

Figure 39

Figure 40 is an angiographic appearance of vertebral artery strangulation with the branch of sympathetic trunk.

Figure 38: Normal anatomical relationship between

vertebral artery and sympathetic structures in the neck

1 – Ganglion cervicale superior (Upper sympathetic node)

2 – Ganglion cervicale medium (Middle sympathetic node)

3 – Ganglion cervicale inferior or Stellatum (Lower

sympathetic node)

4 – Ansa subclavia (subclavian loop of sympathetic trunk)

VA – vertebral artery.

Normally, stellate ganglion is located behind the vertebral

artery and lies on the longus colli muscle. Middle cervical

ganglion lies on the longus colli muscle as well just medial

from the vertebral artery below and on the transverse process

of the 6-th cervical vertebra. Medial and lower (stellate)

ganglia are connected by the sympathetic subclavian loop

(ansa subclavia), which encircles the subclavian artery. It goes

in front and medial to the vertebral artery and does not

compress it.

However, the anatomy of sympathetic structures vary

significantly in patients and can cross the vertebral artery in

front of it and compress or strangulate it. Stellate ganglion

itself can encircle and constringe vertebral artery.

Figure 39: Strangulation with kink of vertebral artery due to its

constringement with stellate ganglion.

CCA – Common carotid artery

VA – Vertebral artery

SA – Subclavian artery

MCG – Middle cervical ganglion

C6 – Transverse process of the 6-th cervical vertebra

Vertebral artery is fixed to the spinal column and kinked with the

stellate ganglion. Normally, stellate ganglion lies behind the vertebral

artery and does not encircle or compress it.

Figure 40

A B

Figures 41 and 42 are the angiograms of strangulated and compressed vertebral arteries with sympathetic nerves.

Figure 41

A B C D E

Figure 42 illustrates the less visible on angiograms strangulations of vertebral arteries, which were responsible for

expressed symptoms of vertebrobasilar insufficiency and which can be easily missed by inexperienced and not aware

of them physician.

Figure 40: Angiographic appearance of vertebral artery

strangulated with the lateral branch of sympathetic trunk

A – Sagital (anterior – posterior view)

B – Oblique view

VA – Vertebral artery; SA – Subclavian artery

Red arrows point to the site of strangulation of vertebral artery

with the branch of sympathetic trunk.

It is clearly seen on the angiogram that the lumen of vertebral

artery is sharply narrowed due to strangulation with the

sympathetic nerve. At the operation was found that the branch of

sympathetic trunk was crossing the vertebral artery in front of it

at that site and strangulating it. This sympathetic branch was cut,

vertebral artery was freed from strangulation and the lumen of

vertebral artery became normal and the blood flow through the

vertebral artery became normal. All vertebrobasilar symptoms

disappeared in that patient and she became healthy. The right

vertebral artery was hypoplastic, 1,7 mm in diameter in that

patient and the left vertebral artery was the only and very

important blood flow pathway to the vertebrobasilar region of the

brain.

Figure 41 A, B, C, D, E: Angiographic appearance of compression and strangulation of vertebral artery with

sympathetic nerves

VA – Vertebral artery; SA – Subclavian artery.

Red arrows point to the sites of compression or strangulation of vertebral arteries by sympathetic nerves (lateral

branches of sympathetic trunk).

Figure 42

A B C D E

Strangulations and compressions of vertebral arteries with sympathetic structures are common in patients with

symptoms of vertebrobasilar insufficiency and physicians who perform the angiography must be aware of them. All

these strangulations of vertebral arteries, shown in Figures 40- 45 were the causes of expressed vertebrobasilar

insufficiency and all these patients are healthy, without any vertebrobasilar symptoms after the operation, freeing the

vertebral artery from compression. Of course, these compressions and strangulations are easily diagnosed and

appreciated by the ultrasound techniques: color or duplex scanner. Figure 43 illustrates several more strangulations of

vertebral arteries with sympathetic nerves. Strangulation of vertebral artery in figure 43 C can be easily missed by

physician. In Figure 43 D, this strangulation is better seen due to contrast dye elimination from the subclavian artery

and proximal part of vertebral artery (proximal to strangulation).

Figure 43

A B C D

Figure 42 A, B, C, D, E: Angiographic appearance of compression and strangulation of vertebral artery with

sympathetic nerves

VA – Vertebral artery; SA – Subclavian artery; CCA – Common carotid artery.

Red arrows point to the sites of compression or strangulation of vertebral arteries by sympathetic nerves (lateral

branches of sympathetic trunk).

Figure 43 A, B, C, D: Angiographic appearance of compression and strangulation of vertebral artery with

sympathetic nerves

VA – Vertebral artery; SA – Subclavian artery.

Red arrows point to the sites of strangulation of vertebral arteries by sympathetic nerves (lateral branches of

sympathetic trunk). In Figure D is the same vertebral artery as in Figure C, just in the later phase of contrast dye

elimination from the arteries. The injection of contrast dye is finished and the dye is flowing away from the

subclavian artery. The blood flow is faster in the subclavian artery than in the vertebral artery, because the

vertebral artery is strangulated and sharply narrowed by the sympathetic nerve. Therefore, the blood is almost

standing in the vertebral artery. Normally, the blood flow is by far faster in vertebral artery than in the subclavian

artery.

Below is described the clinical case of a patient, who had very pronounced vertebrobasilar insufficiency symptoms

and physicians were unable to establish the correct diagnosis. From the childhood patient had headaches, dizziness,

vertigo episodes. Later, vertigo episodes became very severe and frequent. The diagnosis of Meniere’s disease was

established for her and she was treated for years with high doses of betahistine without any improvement. After one

of episodes the left sided hemiparesis developed and visual field narrowing appeared. Later, paraparesis of both legs

appeared. Noise in the ears and deafening of hearing was progressing. Multiple sclerosis diagnosis was established

for her and she has got the treatment for multiple sclerosis without any improvement. Then, neurologist referred her

to me for consultation, because a systolic bruit was heard over the both clavicles. Duplex scanning revealed tight

stenosis of the left vertebral artery close to its orifice due to strangulation and hypoplastic (2,0 mm in diameter) right

vertebral artery, which had lateral and posterior branching (for that reason it did not developed up to the normal

diameter). Angiography was performed. The right vertebral artery was hypoplastic, with lateral-posterior branching.

The left vertebral artery looked normal on angiogram. Both posterior communicating arteries of the circle of Willis

were absent. The vertebrobasilar region was supplied solely by the left vertebral artery and little bit by the right

hypoplastic vertebral artery. The patient was discharged from the hospital despite the duplex scanning data showing

tight stenosis of the left vertebral artery. After 4 months patient returned to our department because the episodes of

vertigo, dizziness, ataxia, visual blurring were incapacitating. Duplex scanning showed the same pathology of the

vertebral arteries. Angiography was performed repeatedly with high speed filming camera. Figure 44 A illustrates the

left vertebral artery angiogram obtained from the first time angiography and Figure 44 B – from the second time

angiography.

Figure 44

A B

The operation was very easy. The lateral branch of sympathetic stellate ganglion, compressing and strangulating

the left vertebral artery was cut away and the left vertebral artery obtained normal appearance and lumen. No other

surgical maneuvers were required. The blood flow, measured at the time of operation through the left vertebral artery

became normal. Patient was free of vertebrobasilar symptoms outright after the operation and is free from them and

absolutely healthy for more than 30 years of follow up.

Figure 45 is an angiographic and operative view of strangulation with sympathetic nerves of the same left

vertebral artery.

Figure 44: Angiographic appearance of strangulation with

sympathetic nerve of the left vertebral artery

A – First time angiography

B – Second time angiography

VA – Vertebral artery

SA – Subclavian artery

Red arrows point to the site of left vertebral artery strangulation with

the sympathetic nerve.

Second time angiography with high speed camera showed the tight

narrowing (almost occlusion) of the left vertebral artery. The blood

flow in the left vertebral artery was very low, slower than in the

subclavian artery.

At operation at that site was found the tough lateral branch of stellate

ganglion going to the brachial plexus and compressing and

strangulating the left vertebral artery.

Figure 45

A B

Due to vertebrobasilar symptoms patient was operated, both strangulating nerves were cut away and the patient is

free of vertebrobasilar symptoms postoperatively.

In some cases, it is found at operation that vertebral artery is encircled and constringed with the stellate

ganglion itself. In all cases of compression and strangulation with sympathetic structures vertebral arteries are very

prone to spasm and fall into spasm easily, just from the touching the artery. The spasm of vertebral arteries is very

important factor for genesis of vertebrobasilar insufficiency and symptoms in cases of extrinsic compressions of

vertebral arteries, because it diminishes the blood flow to the vertebrobasilar region of the brain significantly,

sometimes even more than the strangulation or compression itself. Due to permanent compression and irritation -

stimulation the vertebral artery becomes very sensitive and prone to the spasm. It has a smooth muscles inside the

wall and can contract and to diminish its lumen and size. The blood flow drops down dramatically during the spasm

of vertebral artery and symptoms of vertebrobasilar insufficiency appear up to the vertebrobasilar stroke. Another

very important thing is the stimulation and irritation of sympathetic cardiac (heart) nerves while pulsating vertebral

artery is twitching the sympathetic nerves encircling and strangulating it, because the cardiac nerves originates from

all three sympathetic neck ganglia and pass closely to the vertebral artery down to the heart. This evokes the

heartaches and heart rhythm disorders (tachycardias, extrasystolias etc). That is, why these patients before obtaining

the correct diagnosis from the vascular surgeon, as a rule, consult cardiologists and many sophisticated heart

evaluations are performed for them, including angiography of coronary arteries, but nothing wrong with the heart is

not found in them. Surgical repair of strangulation of vertebral artery and freeing the vertebral artery from

compression with sympathetic nerves and freeing the sympathetic nerves from twitching and irritating by vertebral

artery cures the patient from vertebrobasilar symptoms and from symptoms of irritation of cardiac sympathetic

nerves.

The diagnosis of extrinsic compression of vertebral artery is easily established by duplex scanner or color

doppler provided the examiner is qualified and experienced in ultrasound studies of vertebral arteries. At the site of

strangulation or compression of vertebral artery, the lumen is narrowed with very high linear blood flow velocity at

that site. Higher, (distal to the narrowing) in the spinal column, the blood flow is slow, turbulent and poststenotic.

Angiography should be performed in sagital and oblique views in order to visualize the strangulation clearly.

Figure 45: Angiographic (A) and operative (B) views of strangulation with sympathetic nerves of the same left

vertebral artery.

VA – Vertebral artery; SA – Subclavian artery

Red arrows point to the sites of strangulation with the sympathetic nerves of the left vertebral artery. In the figure

45 B (operative photograph) it is seen, that the vertebral artery is strangulated with the branches of the sympathetic

stellate ganglion, passing the vertebral artery in front of it. Part of stellate ganglion lies in front of vertebral and

subclavian arteries. Normally, the stellate ganglion lies behind the subclavian and vertebral arteries and its

branches pass to the brachial plexus behind the vertebral artery and do not compress or strangulate it.

Below, there are several hints on operative technique for strangulation and compression of vertebral arteries

with sympathetic structures. In case the vertebral artery has loop or kink or has extra length, the vertebral artery is cut

away from the subclavian artery, extracted from the sympathetic structures (ganglion, trunk or nerves), preserving the

integrity of sympathetic structures, extra length of vertebral artery is cut away and it is reimplanted back into the

subclavian artery in front of sympathetic structures (Figures 6 and 7). Cutting or damaging the sympathetic trunk or

its ganglia causes Horner’s syndrome (ptosis, myosis, enophthalmus). The ipsilateral eye becomes less, the pupil is

less than on the contralateral side and the upper eyelid descends down. It has no sequelae for the health, although it

has great cosmetic importance, especially for women. Therefore, the sympathetic structures must be preserved with

great care; the vertebral artery should be cut away from the subclavian artery, extracted from the sympathetic

structures and reimplanted back into the subclavian artery in front of sympathetic structures. Only the lateral branches

of the stellate ganglion going towards the brachial plexus can be cut without any sequelae. The Horner’s triad is

encountered in 5 percent of operated patients for vertebral artery pathology. Only 0, 4 percent of them are permanent,

others clear with time.

Compression of vertebral arteries with deep neck muscles. Abnormal entering of vertebral

artery into the spinal column

Vertebral artery can be compressed with deep neck muscles permanently or episodically in cases of abnormal and

even normal entering of it into the spinal column. The anatomy of deep neck muscles and relationship between them

and vertebral artery is shown in Figures 35, 36 and 38. Normally, the longus colli and scalenus anterior muscles

conjugate at the transverse process of the 6-th cervical vertebra and attaches to it. This conjunction forms like a roof

for the entrance of vertebral artery into the spinal column. In case the vertebral artery enters spinal column higher

than normally, into the 5-th, 4-th or even third cervical vertebrae it is inevitably compressed between the deep neck

muscles and between them and spinal column. This diminishes the lumen of vertebral artery and the blood flow

through it. Another, even more important, mechanism of blood flow impairment through the vertebral artery in such

cases is the spasm of vertebral artery, because vertebral arteries due to permanent compression and irritation become

very sensitive to the compression and react to compression by spasm of the walls. This diminishes the lumen of the

artery and the blood flow through it additionally to the primary compression. Such spasm periods of vertebral arteries

can evoke pronounced vertebrobasilar symptoms, even vertebrobasilar stroke.

High entrance of vertebral artery into the spinal column is best diagnosed with the duplex scanner or color

doppler, because these ultrasound techniques enable examiner to see where the vertebral artery enters the spinal

column, to see and to estimate the lumen of vertebral artery, to appreciate its spasm, to measure and to estimate the

blood flow velocities in the vertebral artery: at the site of compression and higher, in the spinal column, where the

vertebral artery is with normal lumen. Typically, the most compressed part of vertebral artery in case of its high

entering into the spinal column is at the transverse process of the 6-th cervical vertebra.

Figure 46 is a black-white duplex scan (echoscopy) view of the compressed at the transverse process of the 6-th

cervical vertebra left vertebral artery, which has an anomaly, high entrance into the spinal column. In Figure 46, you

can see the vertebral artery bypassing the transverse process of the 6-th cervical vertebra, do not entering it and

compressed at the transverse process of the 6-th cervical vertebra. The lumen of vertebral artery at the site of

compression (red arrow) is 2, 0 mm in diameter, when its normal, not compressed lumen is 5, 2 mm in diameter.

Such compression of vertebral artery diminishes the lumen more than the diameter, because the cross sectional area

of the lumen at the site of 2, 0 diameter will be 3, 14 mm2, while at the site of 5, 2 mm diameter the cross sectional

area of the lumen will be 21, 2 mm2. Therefore, the lumen of vertebral artery at the site of compression will be seven

times less than the normal, not compressed, lumen of vertebral artery. Therefore, the lumen of vertebral artery at the

site of compression in this case is diminished 7 times and the blood flow will be diminished through this vertebral

artery very significantly.

Figure 46

Physicians who do not appreciate the hemodynamic importance of high entering of vertebral artery into the spinal

column are doomed to failure in understanding the genesis of vertebrobasilar symptoms in these patients, because

they cannot explain the genesis of vertebrobasilar symptoms or even vertebrobasilar stroke in these patients.

Figure 47 is an echoscopic view of the compressed vertebral artery at the transverse process of the 6-th cervical

vertebra due to high entering of vertebral artery into the 5-th cervical vertebra in another patient.

Figure 47

The angiographic appearance of high entering of vertebral artery into the spinal column is presented in Figures 48, 49

and 50. The compression of vertebral artery (arrow) at the entrance into the spinal column is seen in Figure 48 A.

Figures 48 B and C illustrate the expressed spasm of extracanal (compressed) part of vertebral artery, which impairs

the blood flow through the vertebral arteries even more than compression itself.

All these patients, which angiograms are presented in Figures 48, 49, 50, 51 and 52 were operated and all of

them are healthy after the operation. The high entrance of vertebral artery into the spinal column with its compression

and frequently with vertebral artery spasm is an important clinical situation, which can be effectively cured by

surgery: excision of compressing the vertebral artery muscles.

Figure 46: Echoscopic view of the lumen of

vertebral artery, compressed at the transverse

process of the 6-th cervical vertebra due to its high

entering into the 5-th cervical vertebra

The vertebral artery is compressed (red arrows)

significantly at the transverse process of the 6-th

cervical vertebra despite the relaxed neck muscles

in lying position of the patient. The diameter of the

vertebral artery at the site of compression is 2, 0

mm, while the normal, not compressed its diameter

is 5, 2 mm.

The vertebral artery is not compressed only in the

proximal part, below the transverse process of the

6-th cervical vertebra. Higher, up to its entrance

into the spinal column the vertebral artery is

compressed between the deep neck muscles and its

diameter is equal to 3, 0 millimeters.

Figure 47: Echoscopic view of the lumen of

vertebral artery in case of its high entering

into the spinal column at the 5-th cervical

vertebra

Red arrows point to the compressed part of

vertebral artery. The narrowest part of

vertebral artery, as usually, is at the transverse

process of the 6-th cervical vertebra.

Figure 48

A B C

Figure 49

A B C

Figure 50 is an illustration how the angiography can be misleading if the angiogram is taken in a standard fashion.

Figure 50 A is an angiogram of the right vertebral artery in an anterior-posterior (sagital) view in patient lying with

relaxed neck muscles. The right vertebral artery seems normal, just originates laterally, in the same plane as

thyreocervical trunk. Figure 50 B is the same vertebral artery, just the patient is asked to rotate his head to the

opposite side from the evaluated vertebral artery (to the left side). This maneuver tautened the scalenus anterior

muscle, which completely occluded (compressed) the vertebral artery. No blood flow is present in the vertebral

artery. Red arrow points to the site of compression of vertebral artery. As I have written earlier, the color doppler and

duplex scanner are the most valuable diagnostic techniques in extrinsic compressions of vertebral arteries. These

techniques enable examiner to see where the vertebral artery enters the spinal column, to see its lumen and the site of

narrowing of it and to appreciate and estimate the hemodynamic significance of the compression on the blood flow

through the vertebral artery. The changes in the diameter of the lumen of vertebral artery are easily appreciated and

the blood flow abnormalities inside the lumen are easily identified with these ultrasound techniques. The blood flow

at the site of stenosis (narrowing) of vertebral artery will be with high linear velocity, and distally, above the obstacle,

the blood flow will be slow and turbulent, poststenotic.

Figure 48: Angiographic appearance of high entering of

vertebral artery into the spinal column

A – Vertebral artery enters transverse process of the 5-th

cervical vertebra and is compressed at the transverse process

of the 6-th cervical vertebra with longus colli muscle tendon

(arrow).

B – Vertebral artery enters transverse process of the 5-th

cervical vertebra and is compressed between longus colli and

scalenus anterior muscles (arrow).

C – Vertebral artery enters transverse process of the 5-th

cervical vertebra and is compressed by deep neck muscles and

its extracanal part has fallen into the spasm because of

compression and irritation of the artery (compare the

extracanal and intracanal parts of vertebral artery). Arrow

points to the site of entrance into the spinal canal.

Figure 49: Angiographic appearance of high entering of vertebral

artery into the spinal column Black arrows point to the site of entrance of vertebral artery into the

spinal column.

Fig. A and B – Vertebral arteries have a loop below the entrance

into the spinal column. Fig. B – Extracanal part of vertebral artery

has fallen into the spasm, narrower than intracanal part of vertebral

artery.

Fig. C – Vertebral artery enters transverse process of the 4-th

cervical vertebra, is compressed by deep neck muscles and has fallen

into the spasm. Basilar artery has fallen into the spasm (red arrow)

as well.

As a rule, neurologists establish for such patients diagnosis of

basilar artery migraine. Medical treatment usually is ineffective and

surgery completely cures these patients.

Figure 50

The clinical picture and the symptoms of the patient which angiograms are presented in Figure50 were very typical

for lateral branching of vertebral artery with its compression with scalenus anterior muscle and associated

compression of brachial nerve plexus, irritation of sympathetic fibers in the brachial plexus and in the subclavian

artery wall. This 23-year-old girl came to me because of very sensitive to cold hands, bluish color of hands between

the episodes of spasm of hand arteries. During the cold exposure, the hands became pale, painful, cold. Diagnosis of

Raynaud syndrome was established for her and she was treated with antispasmic and vasodilatating drugs. She had

expressed symptoms of vertebrobasilar insufficiency as well, including dizziness, vertigo episodes, blurring of vision,

noise in the ears, headaches. Clinical picture was characteristic for thoracic (cervical) outlet syndrome. Color doppler

and duplex scanning revealed lateral branching of both vertebral arteries with extrinsic compression of both vertebral

arteries at the transverse process of the 6-th cervical vertebra, with significant stenoses of both vertebral arteries with

high blood flow velocities (over 140 cm/sec) at the sites of compression and very low, turbulent, poststenotic blood

flow in both vertebral arteries above the compression, inside the spinal column. On both sides Adson’s test was

positive: pulse in the arms disappeared in that position. Roos test was positive on both sides as well. Functional

angiography with tautened neck muscles revealed compression of both vertebral arteries at the transverse process of

the 6-th cervical vertebra. The patient was operated. At first operation right scalenectomy (removal of scalenus

anterior muscle) was performed. The right hand became normal, no longer sensitive to the cold exposure and

obtained a normal color. Vertebrobasilar symptoms disappeared as well. After 3 months the left scalenectomy was

performed. Patient is healthy without any vertebrobasilar symptoms and vasospastic phenomenon in the hands for

more than 15 years follow up.

The next clinical case (figure 51) is a patient with compression of the left vertebral artery despite its normal

entering into the spinal column, into the transverse process of the 6-th cervical vertebra. Her left vertebral artery was

compressed between the tendons of scalenus anterior and longus colli muscles, despite the normal entering of it into

the spinal column because the above mentioned muscles conjugated lower than normally and compressed between

their tendons the vertebral artery. The right vertebral artery was hypoplastic, 2, 9 mm in diameter. Duplex scanning

revealed tightly narrowed left vertebral artery just below its entrance into the spinal column with very high linear

blood flow velocity at the narrowed site and very slow, turbulent, poststenotic blood flow above the stenosis, inside

the spinal column. The right vertebral artery was hypoplastic and had lateral branching anomaly.

The patient was 34-year-old woman, which had headaches from the childhood. Diagnosis of migraine was

established for her and she was treated with antimigraineous drugs without any success. In an age of 26 vertigo

episodes appeared and they became very frequent and incapacitating. Some of them lasted for several days. She had a

tinnitus in her left ear. The tinnitus typically worsened before the onset of vertigo episodes. Diagnosis of Meniere’s

syndrome was established for her and she was treated with high doses of betahistine without any success. The patient

herself addressed me because of vertigo episodes. Ultrasound studies revealed extrinsic compression of the left

vertebral artery with the deep neck muscles and hypoplastic, with lateral branching anomaly, right vertebral artery.

Angiography confirmed the duplex study data. High-grade stenosis due to compression of the left vertebral artery at

the entrance into the spinal column was confirmed. The extracanal part of the left vertebral artery has been fallen into

the spasm. The right vertebral artery was hypoplastic, with lateral branching anomaly. The circle of Willis was

anomalous. Both posterior communicating arteries were absent on the angiograms. The patient was unable to

compensate the shortage of blood flow in the vertebrobasilar region from the internal carotid arteries.

Figure 50: Angiography of the right vertebral artery

with relaxed (A) and tautened (B) deep neck muscles

VA – Vertebral artery

CCA – Common carotid artery

SA – Subclavian artery

Tr. Br. – Truncus brachiocephalicus

Red arrow points to the site of compression of the right

vertebral artery at the transverse process of the 6-th

cervical vertebra. Note the completely occluded right

vertebral artery with contrast dye not flowing and filling

the intracanal part of vertebral artery.

Figure 51

The patient has been operated. At operation, the left vertebral artery was found compressed between the longus colli

and scalenus anterior muscles tendons and very spasmophylic: a mere touching of the artery provoked the deep spasm

of the vertebral artery. Otherwise, the vertebral artery was normal, with normal originating from the subclavian artery

and without any other pathology. The scalenus anterior muscle was excised totally up to the transverse process of the

6-th cervical vertebra and the lateral border of the longus colli muscle was excised in order to create enough free

space for the vertebral artery. No other surgical maneuvers were required and performed. After freeing from

compression and moistening with the papaverine solution, the vertebral artery obtained normal appearance, normal

lumen and normal blood flow through it. After the operation, all vertebrobasilar symptoms disappeared, including the

tinnitus in the left ear and vertigo episodes. Patient was followed and is healthy for more than 30 years.

This clinical case, as multiple others described in this article, confirms my statement that most common cause

of vertigo episodes is a pathology of vertebral arteries, especially loops, kinks and congenital anomalies, mainly

extrinsic compressions of vertebral arteries with evoked by compression spasm of vertebral arteries. The endorsement

to this postulate is the fact that vertigo episodes disappear after the surgical repair of the pathology of vertebral

arteries.

Figure 52 is a schematic representation of the typical operation performed for the compression of vertebral

artery with the deep neck muscles. The vertebral artery is compressed by the tendons of scalenus anterior and longus

coli muscles in all cases of its high entrance into the spinal column and even in some cases of normal entering of

vertebral artery into the spinal column (when these muscles conjugate lower than normally) (figures 51, 52).

The scalenus anterior muscle and the lateral border of longus colli muscle at the operation are excised up to the

entrance of the vertebral artery into the spinal column in order to create enough free space for the passage of the

vertebral artery from the origin on the subclavian artery up to the entrance into the spinal column. The extent of

muscles excision depends on the height of entrance of vertebral artery into the spinal column.

Figure 51: Angiographic appearance of the left vertebral artery, compressed

between the scalenus anterior and longus colli muscles tendons in case of normal

entering of the vertebral artery into the spinal column

Red arrows point to the site of compression of the left vertebral artery between longus

colli and scalenus anterior muscles. Just above the compression, vertebral artery

enters the spinal column, where its lumen is normal. Extracanal part of vertebral

artery is fallen into the spasm. Spasm of vertebral artery is very characteristic for the

extrinsic compression of vertebral artery. Namely, the spasm of vertebral artery is

responsible for the vertigo episodes and episodes of worsening of vertebrobasilar

symptoms. While the vertebral artery was not sensitized and not reacted to the

compression by spasm, there were no vertigo episodes. Sensitizing of vertebral artery

to the compression and reacting to the compression with spasm evoked worsening of

vertebrobasilar symptoms and vertigo episodes. When the vertebral artery is already

sensitized to the compression and reacts to it by spasm, only surgery can stop and end

the problem.

Figure 52

In case the vertebral artery enters the spinal column at the 4-th or 3-rd cervical vertebrae, the surgical procedure is

the same; just the excision of muscles in shape of groove is extended up to the site of entrance of vertebral artery into

the spinal column in order to create the free pathway for vertebral artery.

Figure 53 is a photograph, taken during the operation, after the removal of scalenus anterior muscle and lateral parts

of longus colli and longus capitis muscles up to the transverse process of the 4-th cervical vertebra. The vertebral

artery entered transverse process of the 4-th cervical vertebra and has been compressed between the deep neck

muscles.

Figure 53

No other surgical maneuvers were required in this case. The vertebral artery was normal, with normal origination

from the subclavian artery, normal orifice, was straight, without kinking and any other pathology. Doppler study on

Figure 52: Schematic representation of compression of

vertebral artery between the scalenus anterior and longus colli

muscles and typical surgical procedure performed in these

patients

LCM – Longus colli muscle

SAM – Scalenus anterior muscle

SMM – Scalenus medius muscle

VA – Vertebral artery

SA – Subclavian artery

Tr. thyr. – Truncus thyreocervicalis.

A – Normal anatomy: vertebral artery enters transverse process

of the 6-th cervical vertebra, scalenus anterior and longus colli

muscles conjugate and attach to the transverse process of the 6-

th cervical vertebra.

B – Vertebral artery enters transverse process of the 5-th

cervical vertebra. It is compressed between the tendons of

scalenus anterior and longus colli muscles and against the

transverse process of the 6-th cervical vertebra.

C – In case scalenus anterior and longus colli muscles conjugate

lower than normally, they compress the vertebral artery even in

cases of normal entering of it into the spinal column.

D – Standard surgical procedure performed in cases of

compression of vertebral artery with the deep neck muscles:

scalenus anterior muscle and the lateral border of longus colli

muscle are removed up to the entrance of vertebral artery into

the spinal column.

Figure 53: Operative view of the free pathway

for the vertebral artery, made by excising the

scalenus anterior muscle and lateral border of

longus colli and longus capitis muscles

4 – Transverse process of the 4-th cervical

vertebra;

5 – Transverse process of the 5-th cervical

vertebra;

6 – Transverse process of the 6-th cervical

vertebra.

Vertebral artery enters the spinal column at the

transverse process of the 4-th cervical vertebra.

the operative table revealed normal blood flow in the left vertebral artery after its freeing and the operative wound

was closed in layers. After operation, all vertebrobasilar symptoms cleared in this patient and he is healthy for 15

years of follow up.

Conclusions

The role of vertebral artery pathology in producing vertebrobasilar insufficiency symptoms and vertebrobasilar stroke

is still underestimated by most neurologists, vascular surgeons and other physicians. The pathology of vertebral

arteries is very diverse. It is frequently encountered in patients. Therefore, physicians should be aware of it and

should evaluate the patients for the pathology of vertebral arteries. All patients having vertebrobasilar insufficiency

symptoms should be evaluated by duplex scanner and color doppler. Ultrasound techniques are harmless and

inexpensive. Therefore, they should be used more widely. Angiography should be reserved for the patients which

ultrasound studies were positive for vertebral artery pathology. Surgery is very effective and curative in most cases of

vertebral artery pathology. Therefore, surgery should be applied more widely. Neurologists should work together

with vascular surgeons as a team, because establishment of correct diagnosis in vertebrobasilar insufficiency requires

extensive personal experience in diagnostic evaluation and surgical treatment of these patients.

I have performed over 6 000 operations on vertebral arteries. The following statements are based on my

intensive and extensive experience in diagnostic evaluation and surgical treatment of patients with vertebrobasilar

insufficiency.

The cause of vertigo episodes in overwhelming majority of patients is the pathology of vertebral arteries,

mainly loops, kinks and congenital anomalies. Repairing of this pathology cures the patients from

vertigo episodes.

Dizziness is a symptom caused by insufficient blood flow in the brain stem. In most cases, the cause is

the pathology of vertebral arteries. Other causes like anemia or cardiac failure are less frequent.

Headache is a common symptom of vertebrobasilar insufficiency. Migraineous headaches, as a rule, are

due to congenital anomalies of vertebral arteries. Especially they are characteristic for extrinsic

compression and falling into the spasm of vertebral arteries.

Tinnitus, noise in the ears or noise in the head, loss of hearing are the symptoms indicatory for the

chronic vertebrobasilar insufficiency and usually are resistant to the medical treatment. Surgical repair

of vertebral artery and restitution of blood flow to normal cures these symptoms and restitutes the

hearing.

Arterial hypertension, provided all other causes (renovascular hypertension, renal diseases, hormonal

disorders) are ruled out, should be suspected to be a compensatory cerebroischemic hypertension due to

shortage of blood supply to the brain stem. My large experience shows that “primary” or ‘essential”

arterial hypertension is as a rule a consequence of chronic vertebrobasilar insufficiency. Repair of

vertebral artery and restoring the blood flow to normal value cures or improves (in case the treatment

was delayed) the arterial hypertension.

All my experience and my results of surgical treatment suggest that a big part of patients, suffering

from depression, are patients having chronic vertebrobasilar insufficiency and can be successfully cured

from depression by restoring the blood supply to the vertebrobasilar region to normal value by surgical

repair of vertebral arteries pathology. I have hundreds of operated patients who are healthy after the

operation without any antidepressant drugs and who where unsuccessfully treated before operation by

antidepressants. Normalization of blood supply to vertebrobasilar region cures the depression in these

patients.

Cerebral palsy in children and some other congenital deteriorated brain functions in some cases are the

consequence of insufficient blood flow to the brain stem. All affected children should be evaluated for

vertebral artery pathology by ultrasound techniques, magnetic resonance angiography and conventional

angiography (if the pathology of vertebral arteries is established or suspected by ultrasound methods).

Congenital anomalies of vertebral arteries should be anticipated in these children and these patients

should be evaluated very carefully for them. Correction of vertebral artery pathology and normalization

of blood supply to the brain cures or improves the mental and physical status in these children.

For evaluation and consultation call phone +370 69888112.

For vascular surgery call the same phone number +370 69888112.

Inquiries by E-mail: povilas.pauliukas@gmail.com

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More information on the internet at address: vascularsurgery.eu