A 75-year-old male presented with the left upper limb weakness. The brain magnetic resonance images (MRI) and MR angiography (MRA) showed evidence of multiple embolic infarctions from the right VA to the right cerebellum, right parieto-occipital junction, and right occipital lobe. The cervical MRI documented significant spinal stenosis and contrast-enhanced computed tomography (CE-CT) revealed a large lateral right-sided C5-C6 osteophyte. 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 [-]. 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 [ and ]. Patency and sufficient blood flow through the right VA were confirmed intraoperatively utilizing indocyanine green video angiography []. As the preoperative MRI had also demonstrated spinal canal stenosis at C4-C5, an additional C4-C5 ACDF was performed. Following these decompressions, threaded titanium cages filled with bone graft substitutes were inserted into the C4/5 and C5/6 intervertebral spaces []. The patient’s postoperative course was uneventful. Sufficient right-sided C5-C6 osteophyte resection and right VA decompression were confirmed on the postoperative CECT and 3D-CTA []. The postoperative MRA documented right VA patency along with no further evidence of cerebellar infarctions awhile []. 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 [].