Anatomical variants of the vertebral artery: insights from cadaveric and radiological studies-a review

Shrikrishna H. Basagoudanavar; Deepa Gadwal

doi:10.18203/2349-3933.ijam20253359

Authors

Shrikrishna H. Basagoudanavar Department of ENT, All India Institute of Medical Sciences, Bibinagar, Hyderabad, Telangana, India
Deepa Gadwal Department of Anatomy, All India Institute of Medical Sciences, Bibinagar, Hyderabad, Telangana, India

DOI:

https://doi.org/10.18203/2349-3933.ijam20253359

Keywords:

Vertebral artery, Anatomical variation, Hypoplasia, Fenestration, Cadaver, Radiological imaging

Abstract

Vertebral artery (VA) anatomical variations pose significant clinical challenges in neurosurgical, diagnostic, and endovascular interventions. This review aims to consolidate cadaveric and radiological evidence to map the morphologic spectrum and prevalence of such variants. A comprehensive search strategy was applied to PubMed using Boolean terms, retrieving 446 articles. Following strict inclusion criteria, 31 studies were selected. The most common variant identified was the origin of the left VA from the aortic arch, observed in 13 studies with a frequency range of 0.79%–9.3%. Entry level variations at cervical vertebrae C3–C7, hypoplasia (16.1%–59.3%), duplication (~0.16%), fenestration (~0.4%), and other anomalies such as triplication and abnormal origins from the brachiocephalic or common carotid artery were also reported. Course-related anomalies including tortuosity and anomalous trajectories further highlight the importance of preoperative imaging. Radiological studies offered population-level data, while cadaveric studies revealed detailed morphological nuances. Geographic variation in findings underscores the role of ethnicity and embryological development. The findings emphasize the need for standardized nomenclature, enhanced imaging protocols, and greater awareness among clinicians to mitigate intraoperative risks and improve patient outcomes.

Metrics

Metrics Loading ...

References

Dzierżanowski J, Szarmach A, Baścik B, Czapiewski P, Muc A, Piskunowicz M, et al. Intracranial region of the vertebral artery: morphometric study in the context of clinical usefulness. Folia Morphol (Warsz). 2017;76(3):379-87. DOI: https://doi.org/10.5603/FM.a2017.0021

Tellioglu AM, Durum Y, Gok M, Polat AG, Karaman CZ, Karakas S. Evaluation of Morphologic and Morphometric Characteristic of Foramen Transversarium on 3-Dimensional Multidetector Computed Tomography Angiography. Turk Neurosurg. 2018;28(4):557-62.

Chao Q, Hu Y, Zhao B, Sun Y, Shu H, Wang D, et al. Anatomic characteristics of the vertebrobasilar artery: A three-dimensional reconstruction study based on computed tomography angiography. Med (Baltimore). 2025;104(12):e41931. DOI: https://doi.org/10.1097/MD.0000000000041931

Tasdemir R, Cihan OF. Multidetector computed tomography evaluation of origin, V2 segment variations and morphology of vertebral artery. Folia Morphol (Warsz). 2023;82(2):274-81. DOI: https://doi.org/10.5603/FM.a2022.0030

Paşaoğlu L. Vertebrobasilar system computed tomographic angiography in central vertigo. Med (Baltimore). 2017;96(12):e6297. DOI: https://doi.org/10.1097/MD.0000000000006297

Omotoso BR, Harrichandparsad R, Moodley IG, Satyapal KS, Lazarus L. An anatomical investigation of the proximal vertebral arteries (V1, V2) in a select South African population. Surg Radiol Anat. 2021;43(6):929-41.

Bueno HF, Nimchinsky EA. Mapping of Anatomic Variants of the Proximal Vertebral Artery in Relation to Embryology. AJNR Am J Neuroradiol. 2023;44(8):943-50. DOI: https://doi.org/10.3174/ajnr.A7942

Li X, Guan L, Zilundu PLM, Chen J, Chen Z, Ma M, et al. The applied anatomy and clinical significance of the proximal, V1 segment of vertebral artery. Folia Morphol (Warsz). 2019;78(4):710-9. DOI: https://doi.org/10.5603/FM.a2019.0039

Zhang H, Chai W, Wang S, Wang Y, Li H. Persistent first intersegmental artery (PFIA) visualized by three-dimensional computed tomography angiography in Chinese population. Int J Surg. 2018;52:233-6. DOI: https://doi.org/10.1016/j.ijsu.2018.02.038

Wang S, Ren WJ, Zheng L, Sun ST, Zhang BH, Chen Y, et al. Anatomical Variations of the Vertebral Artery: Analysis by Three-Dimensional Computed Tomography Angiography in Chinese Population. Orthop Surg. 2021;13(5):1556-62. DOI: https://doi.org/10.1111/os.13047

Li S, Li Y, Bai M, Zhang C. Three-Dimensional Time-of-Flight Magnetic Resonance Angiography Detection of Duplication of the Vertebral Artery in a Large Chinese Population. Med Sci Monit. 2016;22:3771-7. DOI: https://doi.org/10.12659/MSM.897503

Omotoso BR, Harrichandparsad R, Moodley IG, Satyapal KS, Lazarus L. An anatomical investigation of the proximal vertebral arteries (V1, V2) in a select South African population. Surg Radiol Anat. 2021;43(6):929-41. DOI: https://doi.org/10.1007/s00276-021-02712-x

Buffoli B, Verzeletti V, Hirtler L, Rezzani R, Rodella LF. Retroesophageal right subclavian artery associated with a bicarotid trunk and an ectopic origin of vertebral arteries. Surg Radiol Anat. 2021;43(9):1491-5. DOI: https://doi.org/10.1007/s00276-021-02746-1

Dean CJ, Labagnara K, Lee AK, Yun DJ, Dong Z, Mishall PL, et al. Bilateral vertebral arteries entering the C4 foramen transversarium with the left vertebral artery originating from the aortic arch. Folia Morphol (Warsz). 2023;82(3):721-5. DOI: https://doi.org/10.5603/FM.a2022.0059

Magklara EP, Pantelia ET, Solia E, Panagouli E, Piagkou M, Mazarakis A, et al. Vertebral artery variations revised: origin, course, branches and embryonic development. Folia Morphol (Warsz). 2021;80(1):1-12. DOI: https://doi.org/10.5603/FM.a2020.0022

Wang L, Zhang J, Xin S. Morphologic features of the aortic arch and its branches in the adult Chinese population. J Vasc Surg. 2016;64(6):1602-1608.e1. DOI: https://doi.org/10.1016/j.jvs.2016.05.092

Park GS, Park JS. Anatomical differences of the vertebrobasilar artery between normal subjects and patients with cerebral infarction. Medicine (Baltimore). 2024;103(32):e39105. DOI: https://doi.org/10.1097/MD.0000000000039105

Eid N, Ito Y, Futaki S, Kondo Y. Complete right- and left-sided thoracic ducts associated with aberrant left vertebral artery: unreported case with surgical implications. Folia Morphol (Warsz). 2018;77(1):156-60. DOI: https://doi.org/10.5603/FM.a2017.0055

Takata K, Ueda M, Takeuchi K, Komiya H, Yoshikawa D, Kanai S, et al. Diagnosis of C5 segmental vertebral artery using magnetic resonance angiography. Surg Radiol Anat. 2025;47(1):132. DOI: https://doi.org/10.1007/s00276-025-03640-w

Tapia-Nañez M, Landeros-Garcia GA, Sada-Treviño MA, Pinales-Razo R, Quiroga-Garza A, Fernandez-Rodarte BA, et al. Morphometry of the aortic arch and its branches. A computed tomography angiography-based study. Folia Morphol (Warsz). 2021;80(3):575-82. DOI: https://doi.org/10.5603/FM.a2020.0098

Rusu MC, Jianu AM, Monea MD, Ilie AC. Two cases of combined anatomical variations: maxillofacial trunk, vertebral, posterior communicating and anterior cerebral atresia, linguofacial and labiomental trunks. Folia Morphol (Warsz). 2022;81(1):237-46. DOI: https://doi.org/10.5603/FM.a2021.0007

Czuba ME, Frączek MJ, Ciuk K, Polak J, Gabryś P, Brzegowy P, et al. Coexistence of posterior cerebral circulation anatomical variations and basilar artery aneurysms: Case-control study. Folia Med Cracov. 2020;60(3):75-84.

Ostrowski P, Bonczar M, Yika ADC, Czekańska H, Batko J, Wojciechowski W, et al. The occipital-vertebral anastomosis revisited. Folia Morphol (Warsz). 2023;82(3):615-23. DOI: https://doi.org/10.5603/FM.a2022.0101

Tatit RT, Pacheco C, Aguiar P, Isolan GR, Campero A, Barbo M, et al. The Posterior Inferior Cerebellar Artery (PICA): An Anatomical and Clinical Analysis. Turk Neurosurg. 2022;32(2):244-250. DOI: https://doi.org/10.5137/1019-5149.JTN.33441-20.3

Wang J, Chong Y, Jiang C, Dai Y, Liang W, Ding L. Microvascular decompression for hemifacial spasm involving the vertebral artery. Acta Neurochir (Wien). 2022;164(3):827-32. DOI: https://doi.org/10.1007/s00701-021-05076-8

Mohan A, Mielke-Maday H, Delgado-Lebron J. Cervical spinal cord infarction due to impingement of an anomalous right vertebral artery by thoracic osteophyte. Spinal Cord Ser Cases. 2021;7(1):95. DOI: https://doi.org/10.1038/s41394-021-00457-8

Vitošević F, Vitošević Z, Rasulić L. The right vertebral artery arising from the right common carotid artery: report of a rare case. Surg Radiol Anat. 2020;42(10):1263-6. DOI: https://doi.org/10.1007/s00276-020-02514-7

Peng CW, Chou BT, Bendo JA, Spivak JM. Vertebral artery injury in cervical spine surgery: anatomical considerations, management, and preventive measures. Spine J. 2009;9(1):70-6. DOI: https://doi.org/10.1016/j.spinee.2008.03.006

Lee KS, Kim GS, Jung Y, Jeong IS, Na KJ, Oh BS, et al. Supraclavicular transposition of aberrant left vertebral artery for hybrid treatment of aortic arch aneurysm: a case report. J Cardiothorac Surg. 2017;12(1):9. DOI: https://doi.org/10.1186/s13019-017-0574-8

Keser N, Kula O, Is M, Yardimcioglu I. Prevalence of Anomalously Originating Occipital Artery in a Group of Turkish Individuals: A Retrospective Study using Angiography. Turk Neurosurg. 2019;29(3):335-9. DOI: https://doi.org/10.5137/1019-5149.JTN.23232-18.1

Kandregula S, Guthikonda B. Vertebral Artery Course Variations and Implications in Craniovertebral Junction Surgeries. Neurol India. 2021;69(2):241-2. DOI: https://doi.org/10.4103/0028-3886.314593