gms | German Medical Science

Objective: The Rotational Vertebral Artery Syndrome (RVAS) is a rare cause of vertebrobasilar Insufficiency. Different structural lesions (osteophytes, etc.) can lead to a functional stenosis of the V2-segment of the vertebral artery (VA) between C7 and C2, depending on head positioning and thereby to a compromise of the posterior perfusion. Still, there is controversy regarding the proper surgical treatment. Few authors recommend a microsurgical decompression of the VA in combination with fusion. We report about two patients, treated with microsurgical decompression of the VA without additional fusion.

Method: The first patient presented with transitory ischemic attacks in the brain stem and cerebellum when rotating the head. She suffered from compression of the VA on the C3 level on the left side when rotating the head. We surgically expanded the narrowed transversal foramen through a ventral approach and conducted a medial transposition of the vessel. The second patient presented with multiple ischemic infarctions in the occipital and cerebellar region and multiple transitory ischemic attacks in the vertebrobasilar flow path. He suffered from a stenosis of the VA on the C5 level on the left side due to hypertrophic spondylarthropathy. We conducted a microsurgical decompression of the vessel by partly resecting the constricting bony structures through an anterolateral approach.

Results: In both cases we did not conduct a fusion, which did not lead to postoperative instability. Outcome in both patients was excellent (GOS Score 5). The VA of the first patient was open after surgery and there were no further complications. In the second patient, intraoperative ICG-videoangiography confirmed the VA as open, but an angiography after surgery showed a stenosis of the left sided VA (V1, V2). Nonetheless there was a retrograde opacification of the intracranial segments (V3, V4) via the right VA. A six months follow-up ist still pending.

Conclusions: So far, there are predominantly case reports and smaller case series of this rare condition. Nevertheless, ischemic episodes in the posterior circulation should let one think of this syndrome and anatomical varieties or degeneration of the cervical spine should be considered as possible cause of a compression of the VA. Many case reports prefer a microsurgical decompression of the VA with fusion. We believe, that with the use of appropriate surgical technique, microsurgical decompression of the VA without additional fusion is sufficient.