Subaxial Vertebral Artery Rotational Occlusion Syndrome: An Overview of Clinical Aspects, Diagnostic Work-Up, and Surgical Management

Abstract

Extrinsic compression of the subaxial vertebral artery (VA) may cause rotational occlusion syndrome (ROS) and contribute to vertebrobasilar insufficiency potentially leading to symptoms and in severe cases, to posterior circulation strokes. The present literature review aimed to report the main clinical findings, diagnostic work-up, and surgical management of the subaxial VA-ROS, the diagnosis of which can be difficult and is often underestimated. An illustrative case is also presented. A thorough literature search was conducted to retrieve manuscripts that have discussed the etiology, diagnosis, and treatment of ROS. Total 41 articles were selected based on the best match and relevance and mainly involved case reports and small cases series. The male/female ratio and average age were 2.6 and 55.6±11 years, respectively. Dizziness, visual disturbances, and syncope were the most frequent symptoms in order of frequency, while C5 and C6 were the most affected levels. Osteophytes were the cause in >46.2% of cases. Dynamic VA catheter-based angiography was the gold standard for diagnosis along with computed tomography angiography. Except in older patients and those with prohibitive comorbidities, anterior decompressive surgery was always performed, mostly with complete recovery, and zero morbidity and mortality. A careful neurological evaluation and dynamic angiographic studies are crucial for the diagnosis of subaxial VA-ROS. Anterior decompression of the VA is the cure of this syndrome in almost all cases.

Keywords: Cerebral angiography; Posterior circulation; Spondylosis; Stroke; Vertebral artery; Vertebrobasilar insufficiency.

Fig. 1.

Bar graph showing the distribution by age decades.

Fig. 2.

Pie graph reporting the prevalence of the main vascular risk factors for stroke.

Fig. 3.

Bar graph showing the main neurological findings.

Fig. 4.

Bar graph describing the rate of the involvement of the different subaxial cervical levels.

Fig. 5.

Pie graph about the sideness.

Fig. 6.

Bar graph showing the prevalence of the different etiological factors.

Fig. 7.

Bar graph reporting the sensitivity of the vascular neuroimaging techniques. MRA, magnetic resonance angiography; CTA, computed tomography angiography.

Fig. 8.

Pie graph about the type of surgical treatment.

Fig. 9.

Pie graph reporting the overall outcome.

Fig. 10.

Axial (A) and sagittal (B) contrast enhanced CT angiography showing a left C5–C6 margin-somatic osteophyte narrowing the near transverse foramen and causing a severe compression of the vertebral artery (arrowheads).

Fig. 11.

Catheter-based digital subtraction angiography of the left vertebral artery. Static anterior-posterior projection (A) and dynamic right oblique projection (B) acquired during the right axial rotation of the head, and revealing a tethering of the vertebral artery at C6 level.

Fig. 12.

Main surgical steps of the left anterolateral approach to the sub-axial V2 segment of the vertebral artery. (A) Platysma muscle; (B) pre-sternocleidomastoid precarotid corridor with medialization of the omohyoid muscle; (C) identification of the retro-longus colli corridor; (D) picture-in-picture operative image showing the compression of the vertebral artery by osteophyte and the indocyanine green video angiography (IR 800, Zeiss Kinevo 900; Carl Zeiss AG, Oberkochen, Germany); (E) unroofing of the left C6 transverse foramen. (F) Picture-in-picture operative picture and video angiography showing the vertebral artery completely decompressed. Pl, platysma muscle; St, sternothyroid muscle; Om, omohyoid muscle; SCM, sternocleidomastoid muscle; LCo, longus colli muscle; LCa, longus capitis muscle.

Fig. 13.

Postoperative axial (A), sagittal (B) (arrowheads), and dynamic three-dimensional–rendered (C) computed tomography angiography of the vertebral artery revealing its complete release.

Fig. 14.

Precarotid pre-longus colli corridor.

Fig. 15.

Retro-jugular trans-longus colli corridor.

Fig. 16.

Retro-longus colli corridor.

Fig. 17.

Retro-longus colli (green arrow) and pre-scalenic (purple arrow) paramuscular corridor. Lco, longus colli muscle; Lca, longus capitis muscle; AS, anterior scalene muscle; Phr. n., phrenic nerve: NR, nerve root.