&NA;Substantial controversy has surrounded the diagnosis and management of vertebrobasilar ischemic events, with no consensus on the value of medical or surgical treatment of patients symptomatic with brain stem ischemia who have angiographically proven vertebral artery lesions. This report presents our experience with the surgical treatment of 12 of 88 patients with angiographically verifield lesions in the vertebral artery who were symptomatic for 1 to 12 months before their evaluation. None experienced symptomatic relief with antiplatelet agents, nor did the administration of anticoagulants in 4 of the patients provide any benefit. The lesions included bilateral vertebral artery occlusion with distal reconstitution through muscular collaterals in 6 patients, unilateral vertebral artery hypoplasia with contralateral long‐tailed lesions from the vertebral artery origin to C‐5 in 3 patients, and severe bilateral vertebral artery origin lesions extending beyond the C‐5 level in 3 patients. A vertebral endarterectomy and vertebral‐carotid transposition in the second portion of the artery were successfully used to reestablish flow and obtain symptomatic relief in 10 of the 12 cases; 1 of these procedures had to be redone because of a persistent stenosis at C‐4. Another patient had a saphenous vein graft from the common carotid to the vertebral artery at C‐5. The remaining patient had an anastomosis of the distal external carotid to the vertebral artery at C‐3, but this failed and an anastomosis of the occipital artery to the anterior inferior cerebellar artery had to be completed to reestablish flow. We think that operation offers a possible means to reestablish flow and to obtain symptomatic relief for patients with symptoms of brain stem ischemia who have severe angiographic lesions in the first two portions of the vertebral artery. (Neurosurgery19:93‐100, 1986)