Abstract
BACKGROUNDThe authors recently reported a series of children with vertebral artery (VA) compression during head turning who presented with recurrent posterior circulation stroke. Whether VA compression occurs during head positioning for cranial surgery is unknown.OBSERVATIONSThe authors report a case of a child with incidental rotational occlusion of the VA observed during surgical head positioning for treatment of an intracranial arteriovenous fistula. Intraoperative angiography showed dynamic V3 occlusion at the level of C2 with distal reconstitution via a muscular branch “jump” collateral, supplying reduced flow to the V4 segment. She had no clinical history or imaging suggesting acute or prior stroke. Sequential postoperative magnetic resonance imaging scans demonstrated signal abnormality of the left rectus capitus muscle, suggesting ischemic edema.LESSONSThis report demonstrates that rotational VA compression during neurosurgical head positioning can occur in children but may be asymptomatic due to the presence of muscular VA–VA “jump” collaterals and contralateral VA flow. Although unilateral VA compression may be tolerated by children with codominant VAs, diligence when rotating the head away from a dominant VA is prudent during patient positioning to avoid posterior circulation ischemia or thromboembolism.
Highlights
The authors recently reported a series of children with vertebral artery (VA) compression during head turning who presented with recurrent posterior circulation stroke
We present a case of Rotational vertebral arteriopathy/occlusion (RVAO) incidentally noted during intraoperative digital subtraction angiography (DSA) in a young girl undergoing surgical ligation of an intracranial pial arteriovenous fistula (AVF)
This report describes the incidental detection of RVAO due to craniocervical positioning in neurological surgery in a child
Summary
The authors recently reported a series of children with vertebral artery (VA) compression during head turning who presented with recurrent posterior circulation stroke. Intraoperative angiography showed dynamic V3 occlusion at the level of C2 with distal reconstitution via a muscular branch “jump” collateral, supplying reduced flow to the V4 segment She had no clinical history or imaging suggesting acute or prior stroke. A related phenomenon, sometimes called “bow hunter’s syndrome,” presents with symptoms of posterior circulation insufficiency due to dynamic narrowing of the vertebral artery (VA) during head rotation (typically to the contralateral side).[1] Pediatric RVAO may present with stuttering or recurrent transient ischemic attacks or strokes, classically in young boys.[2,3] Confirmatory diagnosis requires catheter digital subtraction angiography (DSA) with images obtained in the neutral and rotated head position.[4] In select cases, surgical untethering of ligamentous bands or bony excrescences with or without fusion of the C1–C2 articulation can alleviate symptoms and prevent further neurological injury.[5]. Transient RVAO due to surgical head positioning has not been reported previously in the literature, to our knowledge, and suggests the importance of careful head positioning for pediatric neurosurgery to gain access to the intracranial pathology and to preserve physiological brain perfusion
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
