PMC9062892_01
Magnetic resonance imaging on admission. (a) Diffusion-weighted image showing high-intensity area in the right cerebellum. (b and c) Faint opacification of the right VA (arrow). (d) BPAS demonstrating the diameter of the right VA is smaller than that of the left (arrow). (e) Stenosis of spinal canals at C4/5 (arrow) in addition to C5/6.
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F1
Angiography showed it transiently compressed the right VA when the head was rotated to the right, but with relief of VA compression, when the head was rotated to the left [Figures 1-3].
Preoperative CE-CT images. (a) Stenosis of the right VA due to compression by the bony spur at C5/6 (arrow). (b) An axial image at the level of C5/6. The right VA is not demonstrated due to transient occlusion.
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F2
Angiography showed it transiently compressed the right VA when the head was rotated to the right, but with relief of VA compression, when the head was rotated to the left [Figures 1-3].
Preoperative angiography of the right VA with neck rotation. The right VA is stenotic under the neutral neck position (mid panel). It is occluded with head rotation to the right and the stenosis is improved with rotation to the left.
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F3
Angiography showed it transiently compressed the right VA when the head was rotated to the right, but with relief of VA compression, when the head was rotated to the left [Figures 1-3].
Intraoperative images. (a) The right side of joint of Luschka is exposed (arrow). (b) After resection of the osteophyte, the right VA is exposed and decompressed (arrow). (c) The right VA is visualized by indocyanine green video angiography.
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F4
To prevent recurrent thromboembolic events, the right VA was decompressed by performing a routine C5-C6 ACDF with excision of the right-sided C5-C6 osteophyte; this successfully decompressed the right VA [Figures 4a and b]. Patency and sufficient blood flow through the right VA were confirmed intraoperatively utilizing indocyanine green video angiography [Figure 4c].
Postoperative images. (a) X-ray images showing ACDF are successfully performed. (b) MIP image of CE-CT showing resection of the osteophyte and no stenosis in the right VA (arrowhead). (c) MRA showing improvement of the blood flow of the right VA.
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F5
Following these decompressions, threaded titanium cages filled with bone graft substitutes were inserted into the C4/5 and C5/6 intervertebral spaces [Figure 5a]. Sufficient right-sided C5-C6 osteophyte resection and right VA decompression were confirmed on the postoperative CECT and 3D-CTA [Figure 5b]. The postoperative MRA documented right VA patency along with no further evidence of cerebellar infarctions awhile [Figure 5c].
Follow-up angiography of the right VA with neck rotation. Angiography of the right VA after ACDF showing sufficient blood flow regardless of neck position.
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F6
Angiography 3 months later again demonstrated no residual right-sided C5-C6 VA stenosis in any position and the MRI showed no additional/recurrent posterior circulation strokes [Figure 6].