Vertebral Artery Origin Interarterial Kinking: A Distinct Anatomical–Pathophysiological Mechanism Mimicking High- Grade Stenosis

Vertebral Artery Origin Interarterial Kinking: A Distinct Anatomical–Pathophysiological Mechanism Mimicking High- Grade Stenosis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Vertebral Artery Origin Interarterial Kinking: A Distinct Anatomical–Pathophysiological Mechanism Mimicking High- Grade Stenosis Kadir Yildirim, Aymer Coşar, Mehmet Erkan Üstün This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8633418/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Multiple pathological mechanisms may lead to vertebral artery (VA) stenosis at its origin. Vertebrobasilar insufficiency, a major cause of neurogenic vertigo, may also present with ataxia and other posterior circulation symptoms. Classical vertebral artery kinking is defined as angulation within a single arterial segment; however, alternative mechanisms may exist that are not adequately captured by this definition. Methods Between 2016 and 2024, 115 patients with vertebrobasilar insufficiency due to V1 segment pathology underwent surgical treatment. Sixty-five patients exhibited kinking in the mid-V1 segment, while 50 demonstrated high-grade stenosis of the V1 segment. Among these, 32 patients showed ≥ 70% stenosis at the vertebral artery origin on preoperative cervical MR or CT angiography and underwent surgical exploration. Results Intraoperatively, 3 patients had external compression by fibrotic bands, and 2 had atherosclerotic plaques extending from the subclavian artery. In the remaining 27 patients (84%), the apparent stenosis was caused by an upward or lateral angulation between the subclavian artery and the vertebral artery at its origin, producing a functional high-grade stenosis without intrinsic luminal disease. Conclusion Vertebral artery origin interarterial kinking represents a distinct anatomical–pathophysiological configuration that may mimic true stenosis on angiographic imaging. Recognition of this mechanism is essential to avoid inappropriate endovascular interventions and to guide appropriate surgical management. vertebral artery dolicoarteriopathies kinking stenosis vertebrobasilar insufficiency Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Dolicoarteriopathies of the vertebral and carotid arteries—including elongation, coiling, and kinking—are well-recognized contributors to cerebrovascular insufficiency and ischemic events [ 1 – 3 ]. Kinking is traditionally defined as an abnormal angulation occurring along the course of a single artery and is commonly classified according to the degree of angular deviation [ 4 ]. In moderate and severe forms, such angulations may significantly impair blood flow and increase the risk of ischemia [ 5 , 6 ]. The vertebral artery, particularly its V1 segment, is uniquely vulnerable due to its anatomical relationship with the subclavian artery, surrounding fibrous bands, and osseous structures of the thoracic outlet [ 7 – 9 ]. Vertebrobasilar insufficiency arising from V1 pathology represents a major cause of neurogenic vertigo and may also manifest with gait instability, ataxia, and other posterior circulation symptoms [ 10 – 12 ]. Although endovascular and surgical techniques for VA-origin stenosis have evolved substantially, diagnostic challenges remain. Angiographic imaging primarily evaluates luminal caliber and often assumes that high-grade narrowing reflects intrinsic stenotic disease [ 13 – 15 ]. However, this assumption may overlook complex three-dimensional arterial relationships that produce functional rather than fixed stenosis [ 16 , 17 ]. In our surgical experience, we repeatedly observed a configuration in which the vertebral artery exhibited an abnormal angulation relative to the subclavian artery at its origin. This angulation, occurring between two distinct arterial structures rather than within a single vessel, consistently appeared as high-grade stenosis on preoperative MR or CT angiography. These findings suggest the presence of a distinct anatomical–pathophysiological mechanism not encompassed by classical definitions of vertebral artery kinking. METHODS Between 2016 and 2024, 115 patients with vertebrobasilar insufficiency attributable to V1 segment pathology underwent surgical treatment. Sixty-five patients had kinking in the mid-V1 segment, while 50 demonstrated high-grade stenosis of the V1 segment [ 18 – 20 ]. Among the stenotic group, 32 patients exhibited ≥ 70% stenosis at the vertebral artery origin on preoperative cervical MR or CT angiography and were selected for surgical exploration based on symptom severity and imaging findings. The study was conducted in accordance with the Declaration of Helsinki and approved by the institutional ethics committee 10/02/2025 (80576354-050-99/664). Written informed consent was obtained from all patients or their legal representatives. Intraoperative findings revealed three distinct mechanisms underlying VA-origin stenosis. External compression by fibrotic bands was identified in 3 patients, consistent with previously described extrinsic compression mechanisms [ 21 ]. Atherosclerotic plaque extension from the subclavian artery accounted for stenosis in 2 patients, in line with classical atheromatous disease patterns [ 22 ]. In the remaining 27 patients (84%), no intrinsic stenosis or external compression was present. Instead, the vertebral artery demonstrated a pronounced upward or lateral deviation at its origin, resulting in an angular relationship with the subclavian artery. This configuration produced a functional narrowing that appeared angiographically indistinguishable from true stenosis. Importantly, this did not represent a kink within the vertebral artery itself but rather an angulation between two separate arterial axes. TERMINOLOGICAL DEFINITION Based on consistent intraoperative findings, we use the term vertebral artery origin interarterial kinking to describe the pathological angulation occurring between the subclavian artery and the vertebral artery at its origin. Unlike classical vertebral artery kinking—which involves deformation within a single vessel—this entity reflects a geometric mismatch between two distinct arterial structures at their junction. This terminology emphasizes the anatomical and functional distinction of this mechanism from previously described dolicoarteriopathies and facilitates clearer communication in both surgical and radiological contexts [ 23 , 24 ]. RADIOLOGICAL–SURGICAL DISCORDANCE Standard MR and CT angiography reliably detect luminal narrowing but are limited in differentiating intrinsic stenosis from angulation-related functional narrowing [ 13 , 16 ]. In vertebral artery origin interarterial kinking, static imaging fails to capture the three-dimensional geometry and dynamic flow alterations at the arterial junction. This limitation explains the frequent discrepancy between radiological appearance and intraoperative findings observed in our series. Similar radiological–surgical discordance has been described in other vascular territories where geometric deformation rather than luminal disease predominates [ 25 – 27 ]. DISCUSSION The present study describes a distinct anatomical–pathophysiological configuration at the vertebral artery origin that may mimic high-grade stenosis on conventional angiographic imaging. Unlike classical vertebral artery kinking, which involves angulation within a single arterial segment, the mechanism observed in this series arises from an angular relationship between two separate arterial structures—the subclavian artery and the vertebral artery—at their junction. This distinction is not merely semantic but has important diagnostic and therapeutic implications. One potential point of debate is whether this configuration represents a truly new pathological entity or a previously unrecognized variant of known dolicoarteriopathies. While it may be argued that vertebral artery origin interarterial kinking constitutes a subtype of kinking, existing classification systems are based exclusively on intravascular angular deformation within a single vessel. They do not account for interarterial geometry at branching points. The consistent intraoperative identification of this configuration, coupled with its high prevalence (84%) among surgically explored VA-origin stenoses in our series, supports the concept that this mechanism represents a distinct anatomical–functional phenomenon rather than an incidental variation. Another critical issue concerns the apparent discrepancy between radiological and intraoperative findings. Cervical MR angiography and CT angiography are optimized for evaluating luminal caliber and fixed stenotic lesions; however, they are inherently limited in depicting three-dimensional arterial geometry and dynamic flow alterations at vascular junctions. In the cases presented, angulation-related functional narrowing at the vertebral artery origin produced angiographic appearances indistinguishable from true high-grade stenosis. This radiological–surgical discordance highlights an intrinsic limitation of static imaging rather than an interpretive error and underscores the need for heightened clinical suspicion in selected patients. Advanced imaging techniques incorporating dynamic or flow-based assessment may help bridge this gap in the future, although such methods are not yet routinely available. From a clinical perspective, recognition of vertebral artery origin interarterial kinking is particularly important in treatment planning. Lesions interpreted as fixed stenoses on angiography are often considered candidates for endovascular intervention. However, when the underlying mechanism is angular misalignment rather than intrinsic luminal disease, angioplasty or stenting may not only fail to resolve symptoms but may also increase the risk of arterial injury, dissection, or occlusion due to altered vessel geometry. In this context, surgical exploration provides both diagnostic clarification and an opportunity for definitive management tailored to the underlying anatomical configuration. The relatively limited sample size of the present study may raise concerns regarding the generalizability of these findings. It should be emphasized that the aim of this report is not to establish epidemiological prevalence but to describe and define a recurrent intraoperative observation encountered within a well-characterized surgical population. As is often the case in vascular and skull base surgery, recognition of new anatomical or pathophysiological mechanisms frequently originates from surgical experience and is subsequently refined through broader validation. The present study provides a conceptual framework intended to stimulate further investigation rather than to offer definitive conclusions. Taken together, these findings suggest that vertebral artery origin interarterial kinking represents an underrecognized mechanism of vertebrobasilar insufficiency. Its identification challenges the assumption that all angiographic stenoses at the VA origin reflect intrinsic disease and emphasizes the importance of integrating radiological findings with detailed anatomical and surgical assessment. Increased awareness of this entity may help prevent inappropriate treatment selection and contribute to the development of more precise diagnostic and therapeutic strategies. CONCLUSION Intraoperative observations continue to reveal vascular mechanisms not readily apparent on preoperative imaging. Vertebral artery origin interarterial kinking represents a distinct anatomical–pathophysiological configuration capable of producing angiographic appearances of high-grade stenosis. Recognition of this entity is critical to avoid inappropriate endovascular interventions and to guide the development of tailored surgical strategies. Further radiological and surgical studies are warranted to validate this concept and refine diagnostic criteria. Declarations Author Contribution Kadir Yıldırım, Aymer Coşar and Mehmet Erkan Üstün wrote the main manuscript text and prepared figures . All authors reviewed the manuscript. References Del Corso L, Moruzzo D, Conte B et al (1998) Tortuosity, kinking, and coiling of arteries. Angiology 49:361–371 Pancera P, Ribul M, Presciuttini B (2000) Dolichoarteriopathies of the carotid arteries. Angiology 51:739–746 Weibel J, Fields WS (1965) Tortuosity, coiling, and kinking of the internal carotid artery. Neurology 15:7–18 Metz H, Murray-Leslie RM, Bannister RG et al (1961) Kinking of the carotid artery. Lancet 1:424–426 Aleksic M, Schütz G, Gerth S et al (2004) Hemodynamic relevance of carotid kinking. 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Radiology 185:289–292 Hope MD, Hope TA, Crook SE et al (2010) 4D flow MRI. Radiology 255:725–732 Cloud GC, Markus HS (2003) Diagnosis and management of vertebral artery stenosis. QJM 96:27–54 Pelz DM, Lownie SP, Fox AJ (1990) Vertebral artery origin stenosis. AJNR 11:1009–1016 Kieffer E, Koskas F, Bahnini A et al (1997) Surgical repair of vertebral artery origin lesions. J Vasc Surg 25:529–540 George B, Laurian C (1986) Vertebral artery compression. Neurosurgery 19:571–576 Hennerici M, Rautenberg W, Schwartz A (1987) Vertebral artery atherosclerosis. Stroke 18:889–896 Osborn AG (1999) Diagnostic Cerebral Angiography, 2nd edn. Lippincott Williams & Wilkins Krings T, Mandell DM, Kiehl TR et al (2011) Intracranial arterial anatomy. Radiology 258:676–696 Schievink WI (2001) Spontaneous arterial dissections. N Engl J Med 344:898–906 Lasjaunias P, Berenstein A, ter Brugge KG (2001) Surgical Neuroangiography. Springer van den Heuvel MP, Hulshoff Pol HE (2010) Exploring the brain network. Nat Rev Neurosci 11:157–169 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8633418","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":576771351,"identity":"e909c821-ede1-4f94-bcc0-bde39747022f","order_by":0,"name":"Kadir 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3","display":"","copyAsset":false,"role":"figure","size":226979,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e2A:\u003c/strong\u003e Cervical magnetic resonance angiography; the white arrow shows the stenosis over 70% while the other vertebral artery is hypoplastic.\u003c/p\u003e","description":"","filename":"Figure2A.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8633418/v1/05ef5be0e849895913904712.jpg"},{"id":100854510,"identity":"b83e5ab6-93d8-4cf5-b24c-95827386fd58","added_by":"auto","created_at":"2026-01-22 06:52:47","extension":"jpg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":59850,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e2B:\u003c/strong\u003eCervical magnetic resonance angiography; the white arrow shows the stenosis over 70% while the other vertebral artery has a grade 2 kinking at C6 level.\u003c/p\u003e","description":"","filename":"Figure2B.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8633418/v1/c56d11c63850ee4b201d80a7.jpg"},{"id":101652154,"identity":"ab6fe088-fb23-4de3-81d8-65b4fd44b203","added_by":"auto","created_at":"2026-02-02 09:28:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":789335,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8633418/v1/0d7ffdf5-d7ed-477b-8ac2-8da9a81b22f4.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Vertebral Artery Origin Interarterial Kinking: A Distinct Anatomical–Pathophysiological Mechanism Mimicking High- Grade Stenosis","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eDolicoarteriopathies of the vertebral and carotid arteries\u0026mdash;including elongation, coiling, and kinking\u0026mdash;are well-recognized contributors to cerebrovascular insufficiency and ischemic events [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Kinking is traditionally defined as an abnormal angulation occurring along the course of a single artery and is commonly classified according to the degree of angular deviation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In moderate and severe forms, such angulations may significantly impair blood flow and increase the risk of ischemia [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe vertebral artery, particularly its V1 segment, is uniquely vulnerable due to its anatomical relationship with the subclavian artery, surrounding fibrous bands, and osseous structures of the thoracic outlet [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Vertebrobasilar insufficiency arising from V1 pathology represents a major cause of neurogenic vertigo and may also manifest with gait instability, ataxia, and other posterior circulation symptoms [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough endovascular and surgical techniques for VA-origin stenosis have evolved substantially, diagnostic challenges remain. Angiographic imaging primarily evaluates luminal caliber and often assumes that high-grade narrowing reflects intrinsic stenotic disease [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. However, this assumption may overlook complex three-dimensional arterial relationships that produce functional rather than fixed stenosis [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our surgical experience, we repeatedly observed a configuration in which the vertebral artery exhibited an abnormal angulation relative to the subclavian artery at its origin. This angulation, occurring between two distinct arterial structures rather than within a single vessel, consistently appeared as high-grade stenosis on preoperative MR or CT angiography. These findings suggest the presence of a distinct anatomical\u0026ndash;pathophysiological mechanism not encompassed by classical definitions of vertebral artery kinking.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eBetween 2016 and 2024, 115 patients with vertebrobasilar insufficiency attributable to V1 segment pathology underwent surgical treatment. Sixty-five patients had kinking in the mid-V1 segment, while 50 demonstrated high-grade stenosis of the V1 segment [\u003cspan additionalcitationids=\"CR19\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAmong the stenotic group, 32 patients exhibited\u0026thinsp;\u0026ge;\u0026thinsp;70% stenosis at the vertebral artery origin on preoperative cervical MR or CT angiography and were selected for surgical exploration based on symptom severity and imaging findings.\u003c/p\u003e \u003cp\u003e The study was conducted in accordance with the Declaration of Helsinki and approved by the institutional ethics committee 10/02/2025 (80576354-050-99/664). Written informed consent was obtained from all patients or their legal representatives.\u003c/p\u003e \u003cp\u003eIntraoperative findings revealed three distinct mechanisms underlying VA-origin stenosis. External compression by fibrotic bands was identified in 3 patients, consistent with previously described extrinsic compression mechanisms [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Atherosclerotic plaque extension from the subclavian artery accounted for stenosis in 2 patients, in line with classical atheromatous disease patterns [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the remaining 27 patients (84%), no intrinsic stenosis or external compression was present. Instead, the vertebral artery demonstrated a pronounced upward or lateral deviation at its origin, resulting in an angular relationship with the subclavian artery. This configuration produced a functional narrowing that appeared angiographically indistinguishable from true stenosis. Importantly, this did not represent a kink within the vertebral artery itself but rather an angulation between two separate arterial axes.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eTERMINOLOGICAL DEFINITION\u003c/h2\u003e \u003cp\u003eBased on consistent intraoperative findings, we use the term \u003cb\u003evertebral artery origin interarterial kinking\u003c/b\u003e to describe the pathological angulation occurring between the subclavian artery and the vertebral artery at its origin. Unlike classical vertebral artery kinking\u0026mdash;which involves deformation within a single vessel\u0026mdash;this entity reflects a geometric mismatch between two distinct arterial structures at their junction.\u003c/p\u003e \u003cp\u003eThis terminology emphasizes the anatomical and functional distinction of this mechanism from previously described dolicoarteriopathies and facilitates clearer communication in both surgical and radiological contexts [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRADIOLOGICAL–SURGICAL DISCORDANCE\u003c/h3\u003e\n\u003cp\u003eStandard MR and CT angiography reliably detect luminal narrowing but are limited in differentiating intrinsic stenosis from angulation-related functional narrowing [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In vertebral artery origin interarterial kinking, static imaging fails to capture the three-dimensional geometry and dynamic flow alterations at the arterial junction.\u003c/p\u003e \u003cp\u003eThis limitation explains the frequent discrepancy between radiological appearance and intraoperative findings observed in our series. Similar radiological\u0026ndash;surgical discordance has been described in other vascular territories where geometric deformation rather than luminal disease predominates [\u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe present study describes a distinct anatomical\u0026ndash;pathophysiological configuration at the vertebral artery origin that may mimic high-grade stenosis on conventional angiographic imaging. Unlike classical vertebral artery kinking, which involves angulation within a single arterial segment, the mechanism observed in this series arises from an angular relationship between two separate arterial structures\u0026mdash;the subclavian artery and the vertebral artery\u0026mdash;at their junction. This distinction is not merely semantic but has important diagnostic and therapeutic implications.\u003c/p\u003e \u003cp\u003eOne potential point of debate is whether this configuration represents a truly new pathological entity or a previously unrecognized variant of known dolicoarteriopathies. While it may be argued that vertebral artery origin interarterial kinking constitutes a subtype of kinking, existing classification systems are based exclusively on intravascular angular deformation within a single vessel. They do not account for interarterial geometry at branching points. The consistent intraoperative identification of this configuration, coupled with its high prevalence (84%) among surgically explored VA-origin stenoses in our series, supports the concept that this mechanism represents a distinct anatomical\u0026ndash;functional phenomenon rather than an incidental variation.\u003c/p\u003e \u003cp\u003eAnother critical issue concerns the apparent discrepancy between radiological and intraoperative findings. Cervical MR angiography and CT angiography are optimized for evaluating luminal caliber and fixed stenotic lesions; however, they are inherently limited in depicting three-dimensional arterial geometry and dynamic flow alterations at vascular junctions. In the cases presented, angulation-related functional narrowing at the vertebral artery origin produced angiographic appearances indistinguishable from true high-grade stenosis. This radiological\u0026ndash;surgical discordance highlights an intrinsic limitation of static imaging rather than an interpretive error and underscores the need for heightened clinical suspicion in selected patients. Advanced imaging techniques incorporating dynamic or flow-based assessment may help bridge this gap in the future, although such methods are not yet routinely available.\u003c/p\u003e \u003cp\u003eFrom a clinical perspective, recognition of vertebral artery origin interarterial kinking is particularly important in treatment planning. Lesions interpreted as fixed stenoses on angiography are often considered candidates for endovascular intervention. However, when the underlying mechanism is angular misalignment rather than intrinsic luminal disease, angioplasty or stenting may not only fail to resolve symptoms but may also increase the risk of arterial injury, dissection, or occlusion due to altered vessel geometry. In this context, surgical exploration provides both diagnostic clarification and an opportunity for definitive management tailored to the underlying anatomical configuration.\u003c/p\u003e \u003cp\u003eThe relatively limited sample size of the present study may raise concerns regarding the generalizability of these findings. It should be emphasized that the aim of this report is not to establish epidemiological prevalence but to describe and define a recurrent intraoperative observation encountered within a well-characterized surgical population. As is often the case in vascular and skull base surgery, recognition of new anatomical or pathophysiological mechanisms frequently originates from surgical experience and is subsequently refined through broader validation. The present study provides a conceptual framework intended to stimulate further investigation rather than to offer definitive conclusions.\u003c/p\u003e \u003cp\u003eTaken together, these findings suggest that vertebral artery origin interarterial kinking represents an underrecognized mechanism of vertebrobasilar insufficiency. Its identification challenges the assumption that all angiographic stenoses at the VA origin reflect intrinsic disease and emphasizes the importance of integrating radiological findings with detailed anatomical and surgical assessment. Increased awareness of this entity may help prevent inappropriate treatment selection and contribute to the development of more precise diagnostic and therapeutic strategies.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIntraoperative observations continue to reveal vascular mechanisms not readily apparent on preoperative imaging. Vertebral artery origin interarterial kinking represents a distinct anatomical\u0026ndash;pathophysiological configuration capable of producing angiographic appearances of high-grade stenosis. Recognition of this entity is critical to avoid inappropriate endovascular interventions and to guide the development of tailored surgical strategies. Further radiological and surgical studies are warranted to validate this concept and refine diagnostic criteria.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eKadir Yıldırım, Aymer Coşar and Mehmet Erkan \u0026Uuml;st\u0026uuml;n wrote the main manuscript text and prepared figures . All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDel Corso L, Moruzzo D, Conte B et al (1998) Tortuosity, kinking, and coiling of arteries. Angiology 49:361\u0026ndash;371\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePancera P, Ribul M, Presciuttini B (2000) Dolichoarteriopathies of the carotid arteries. Angiology 51:739\u0026ndash;746\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWeibel J, Fields WS (1965) Tortuosity, coiling, and kinking of the internal carotid artery. Neurology 15:7\u0026ndash;18\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMetz H, Murray-Leslie RM, Bannister RG et al (1961) Kinking of the carotid artery. Lancet 1:424\u0026ndash;426\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAleksic M, Sch\u0026uuml;tz G, Gerth S et al (2004) Hemodynamic relevance of carotid kinking. J Vasc Surg 39:55\u0026ndash;61\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDelcker A, Diener HC (1994) Vertebral artery kinking and ischemia. Stroke 25:150\u0026ndash;152\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCagnie B, Danneels L, Van Tiggelen D et al (2005) The anatomy of the thoracic outlet. Clin Anat 18:53\u0026ndash;61\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTubbs RS, Shoja MM, Loukas M (2016) Bergman\u0026rsquo;s Comprehensive Encyclopedia of Human Anatomic Variation. Wiley\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLang J, Samii M (1995) Skull Base and Related Structures, 2nd edn. Schattauer\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaloh RW (1990) Vertebrobasilar insufficiency. Neurol Clin 8:331\u0026ndash;348\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrad A, Baloh RW (1989) Vertigo of vascular origin. Neurology 39:784\u0026ndash;788\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaplan LR (1996) Posterior circulation ischemia. Lancet 347:615\u0026ndash;620\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQureshi AI, Alexandrov AV, Tegeler CH (2007) Guidelines for screening of extracranial carotid and vertebral artery disease. Stroke 38:199\u0026ndash;203\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaturvedi S, Bruno A, Feasby T et al (2005) Carotid artery stenosis. Lancet 365:1467\u0026ndash;1476\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJenkins JS, White CJ (2010) Vertebral artery stenosis. Circulation 122:178\u0026ndash;182\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarks MP, Pelc NJ, Ross MR (1992) Functional MR angiography. Radiology 185:289\u0026ndash;292\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHope MD, Hope TA, Crook SE et al (2010) 4D flow MRI. Radiology 255:725\u0026ndash;732\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCloud GC, Markus HS (2003) Diagnosis and management of vertebral artery stenosis. QJM 96:27\u0026ndash;54\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePelz DM, Lownie SP, Fox AJ (1990) Vertebral artery origin stenosis. AJNR 11:1009\u0026ndash;1016\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKieffer E, Koskas F, Bahnini A et al (1997) Surgical repair of vertebral artery origin lesions. J Vasc Surg 25:529\u0026ndash;540\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeorge B, Laurian C (1986) Vertebral artery compression. Neurosurgery 19:571\u0026ndash;576\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHennerici M, Rautenberg W, Schwartz A (1987) Vertebral artery atherosclerosis. Stroke 18:889\u0026ndash;896\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOsborn AG (1999) Diagnostic Cerebral Angiography, 2nd edn. Lippincott Williams \u0026amp; Wilkins\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrings T, Mandell DM, Kiehl TR et al (2011) Intracranial arterial anatomy. Radiology 258:676\u0026ndash;696\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchievink WI (2001) Spontaneous arterial dissections. N Engl J Med 344:898\u0026ndash;906\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLasjaunias P, Berenstein A, ter Brugge KG (2001) Surgical Neuroangiography. Springer\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003evan den Heuvel MP, Hulshoff Pol HE (2010) Exploring the brain network. Nat Rev Neurosci 11:157\u0026ndash;169\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"vertebral artery, dolicoarteriopathies, kinking, stenosis, vertebrobasilar insufficiency","lastPublishedDoi":"10.21203/rs.3.rs-8633418/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8633418/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eMultiple pathological mechanisms may lead to vertebral artery (VA) stenosis at its origin. Vertebrobasilar insufficiency, a major cause of neurogenic vertigo, may also present with ataxia and other posterior circulation symptoms. Classical vertebral artery kinking is defined as angulation within a single arterial segment; however, alternative mechanisms may exist that are not adequately captured by this definition.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eBetween 2016 and 2024, 115 patients with vertebrobasilar insufficiency due to V1 segment pathology underwent surgical treatment. Sixty-five patients exhibited kinking in the mid-V1 segment, while 50 demonstrated high-grade stenosis of the V1 segment. Among these, 32 patients showed\u0026thinsp;\u0026ge;\u0026thinsp;70% stenosis at the vertebral artery origin on preoperative cervical MR or CT angiography and underwent surgical exploration.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIntraoperatively, 3 patients had external compression by fibrotic bands, and 2 had atherosclerotic plaques extending from the subclavian artery. In the remaining 27 patients (84%), the apparent stenosis was caused by an upward or lateral angulation between the subclavian artery and the vertebral artery at its origin, producing a functional high-grade stenosis without intrinsic luminal disease.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eVertebral artery origin interarterial kinking represents a distinct anatomical\u0026ndash;pathophysiological configuration that may mimic true stenosis on angiographic imaging. Recognition of this mechanism is essential to avoid inappropriate endovascular interventions and to guide appropriate surgical management.\u003c/p\u003e","manuscriptTitle":"Vertebral Artery Origin Interarterial Kinking: A Distinct Anatomical–Pathophysiological Mechanism Mimicking High- Grade Stenosis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-22 06:52:42","doi":"10.21203/rs.3.rs-8633418/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"848fbe99-2186-4bee-897a-9b7f8936ca20","owner":[],"postedDate":"January 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-07T10:18:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-22 06:52:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8633418","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8633418","identity":"rs-8633418","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}