Vertebral artery-thyrocervical trunk transposition for complex extracranial vertebral artery occlusion with vascular dissection: illustrative case.

BACKGROUND: Symptomatic extracranial vertebral artery stenosis or occlusion is a common etiology of posterior circulation ischemia and ischemic stroke. Although endovascular therapy represents the first‑line treatment for most patients, surgical revascularization remains an indispensable strategy in complex cases in which endovascular approaches are not feasible. OBSERVATIONS: A 57-year-old female presented with dizziness and acute pontine infarction. Preoperative CT revealed left extracranial vertebral artery occlusion, focal dissection at the origin of the left subclavian artery, and a stenotic and hypoplastic contralateral vertebral artery. Left vertebral artery-thyrocervical trunk transposition was performed to restore posterior circulation perfusion. Postoperative and 6-month follow-up evaluations showed a patent anastomosis, restored perfusion, significant symptomatic improvement, and no stroke recurrence. LESSONS: Vertebral artery-thyrocervical trunk transposition is safe and effective in appropriately selected patients with complex extracranial vertebral artery occlusion. This procedure serves as a valuable alternative when endovascular treatment or conventional transposition is not feasible or is suboptimal. https://thejns.org/doi/10.3171/CASE26466.