ObjectiveVascular geometry is influenced by several factors during its growth and development. Here, we compared the differences in vertebrobasilar geometry among residents of a plateau region at different altitudes and investigated the relationship between vascular geometry and altitude.MethodsData of some adults in the plateau region who experienced vertigo and headache as the main symptoms but had no evident abnormalities found during imaging examination were collected. They were divided into three groups based on an altitude gradient: group A (1,800–2,500 masl), group B (2,500–3,500 masl), and group C (over 3,500 masl). They underwent head–neck energy-spectrum computed tomography angiography with a gemstone spectral imaging scanning protocol. The following indices were observed: (1) vertebrobasilar geometric configurations (walking, tuning fork, lambda, and no confluence), (2) vertebral artery (VA) hypoplasia, (3) the bending number of bilateral VA intracranial segment, (4) length and tortuosity of the basilar artery (BA), and (5) anteroposterior (AP)–mid–BA angle, BA–VA angle, lateral–mid–BA angle, and VA–VA angle.ResultsOf the 222 subjects, 84 of them were included in group A, 76 in group B, and 62 in group C. The number of participants in walking, tuning fork, lambda, and no confluence geometries was 93, 71, 50, and 8, respectively. As altitude increased, the tortuosity of the BA also increased (1.05 ± 0.06 vs. 1.06 ± 0.08 vs. 1.10 ± 0.13,P= 0.005), as did the lateral–mid–BA angle (23.18° ± 9.53° vs. 26.05° ± 10.10° vs. 31.07° ± 15.12°,P= 0.007) and the BA–VA angle (32.98° ± 17.85° vs. 34.51° ± 17.96° vs. 41.51° ± 19.22°,P= 0.024). There was a relatively weak positive correlation between the altitude and the tortuosity of the BA (rs= 0.190,P= 0.005), the lateral–mid–BA angle (rs= 0.201,P= 0.003), and the BA–VA angle (rs= 0.183,P= 0.006) which showed a significant difference. Compared with groups A and B, there were more multibending groups and fewer oligo-bending groups in group C (P< 0.001). There was no difference found in the vertebral artery hypoplasia, actual length of the BA, VA–VA angle, and AP–mid–BA angle among the three groups.ConclusionAs the altitude increased, the tortuosity of the BA and the sagittal angle of the vertebrobasilar arterial system also increased. The increase in altitude can lead to changes in vertebrobasilar geometry.