Rotational Vertebral Artery Research Articles

Tumor-induced rotational vertebral artery occlusion in the upper cervical spine: illustrative case

BACKGROUND Rotational vertebral artery occlusion, or bow hunter’s syndrome (BHS), is a rare but clinically important cause of vertebrobasilar insufficiency. Extrinsic compression of the artery is usually caused by osteophytes, fibrous bands, or lateral disc herniation and typically occurs in the setting of anatomical variations, leading to dynamic compromise of the posterior circulation. Neoplastic causes of BHS are rare. OBSERVATIONS The authors present the case of a 72-year-old man with a left vertebral artery–dominant posterior circulation and isolated small right vertebral artery terminating in the posterior inferior cerebellar artery (PICA). He developed progressively worsening dynamic insufficiency of his right PICA circulation due to compression of the right vertebral artery at C2 from an intradural-extradural dumbbell-shaped lesion. This patient was successfully treated via surgical debulking of the lesion and cervical spine fixation and experienced no neurological deficits postoperatively. LESSONS This neoplastic change represents an exceedingly rare presentation for BHS, which warrants further study on its etiology and treatment. https://thejns.org/doi/10.3171/CASE24415

The use of dynamic magnetic resonance angiography in the diagnosis of rotational vertebral artery syndrome

AbstractBackgroundRotational vertebral artery (VA) syndrome represents a rare mechanical vasculopathy that can lead to vertebrobasilar insufficiency and ischemic stroke.ObjectiveWe describe a 10‐year‐old boy with a history of chronic morning emesis who presented with acute onset dizziness, gait instability, and vomiting and was diagnosed with acute ischemic posterior circulation stroke.InterpretationContrast‐enhanced magnetic resonance angiography (MRA) of the head and neck with dynamic positioning demonstrated loss of flow‐related enhancement with head tilted to the left, conferring a diagnosis of rotational VA syndrome. He started aspirin monotherapy and subsequently underwent C1 laminectomy, with both radiographic and clinical improvement on follow‐up.ConclusionDynamic contrasted‐enhanced MRA imaging can serve as a noninvasive alternative to digital subtraction angiography in the diagnosis of rotational VA syndrome and should be considered in suspected cases of pediatric rotational arteriopathy.

Bow Hunter's syndrome surgical approach and outcome: Two new cases and literature review.

Bow Hunter's syndrome (BHS) is a rare entity known as rotational vertebral artery occlusion syndrome. Classically, it presents with nausea, vertigo, and dizziness elicited by extension or rotation of the neck. There are several management approach modalities, including surgical and nonsurgical alternatives. We conducted an electronic database search on PubMed and Scopus. The search was performed on February 18, 2024, using a combination of keywords related to Bow Hunter Syndrome regarding management. From the latter query, 97 results followed, from which we included 76 and excluded 21 due to the information being irrelevant to our study and non-retrievable publications. A total of 121 patients were retrieved. The mean age of presentation was 50 years, with a female-to-male ratio of 3:1. There were 108 adult cases, and only 13 were pediatric and adolescents. Symptoms were elicited by right rotation (46%). The most affected levels were C1-C2 (44%). The anterior approach was the most common (40%) and had a better outcome (84%), followed by the posterior (30%), which had more cases with partial recovery (19% vs. 16%). BHS management is still challenging as there are many factors that we must consider when deciding on the approach. There is inconclusive evidence on the proper management of these patients. Although the suggestions found in our review and our experience are valuable, no definitive management ensures a good quality of life and outcome for these patients. Further research is needed on this topic.

Bow hunter’s syndrome due to an anomalous right vertebral artery origin and contralateral absence: a case report and literature review

BackgroundBow Hunter’s syndrome (BHS), also known as rotational vertebral artery occlusion (RVAO), is a rare condition characterized by dynamic vertebrobasilar insufficiency due to position-dependent occlusion of the vertebral artery (VA). In the existing literature, most cases of BHS are attributed to osteophytic compression originating from the occipital condyle or within the transverse foramen, often accompanied by anatomical abnormalities of the VA. However, cases presenting solely with VA anomalies in the absence of any cervical vertebral structural abnormality are rare. This case report presents a unique instance of BHS in a 56-year-old male, attributed to the anomalous origin of the right VA and the absence of the left VA, without cervical structural abnormalities.Case presentationThe patient exhibited symptoms like episodic dizziness and vertigo, which were exacerbated by rightward head rotation and alleviated upon returning to a neutral position. Diagnostic evaluation, including digital subtraction angiography, revealed that the right VA originated from the right common carotid artery and compression-induced stenosis of the right VA during head rotation. Conservative management, including avoidance of certain head movements and anti-arteriosclerosis medication, led to symptom resolution over a two-year follow-up period.ConclusionsThis report contributes to the understanding of BHS by highlighting a rare vascular anomaly presentation and incorporates a review of 14 similar case reports in the literature describing that an anatomical abnormality of the VA is mainly responsible for the pathology of BHS in the absence of cervical vertebral anomalies, thus emphasizing the need for careful diagnostic and management strategies.

Dynamic vertebral artery occlusion aka bow hunter syndrome causing posterior fossa stroke in a young adult: a case report

BackgroundBow Hunter syndrome (BHS) is a rare, but important cause of posterior circulation stroke. It is also known as Rotational vertebral artery syndrome and is caused by transient dynamic vertebro-basilar insufficiency on movement of the neck in the presence of certain soft tissue or bone anomalies in the cranio-vertebral region.Case presentationWe present a case of Bow hunter syndrome in an 18-year-old adult male who presented with vomiting, occipital headache and loss of balance, with findings of posterior circulation stroke on imaging. Medical causes of young stroke, including vasculitis and clotting disorders were ruled out, following which a diagnostic conventional angiography and CT angiography was performed. The cause of vascular compromise in our case was the presence of vertebral anomalies, in particular, the presence of a partial ponticulus posticus with formation of an incomplete arcuate foramen. He was treated with cervical spine immobilisation and C1–C2 fixation. In addition, our patient had a single posterior inferior cerebellar artery (PICA) on the side of the dynamic insufficiency, which lead to bilateral cerebellar infarcts. Our case is unique because it demonstrates a combination of osseous and vascular developmental anomalies resulting in posterior circulation stroke.ConclusionsThough uncommon, BHS should be considered in the list of differentials in otherwise unexplained cases of posterior circulation stroke. Conventional angiography with dynamic manoeuvres is the modality of choice for documenting the rotational vertebral artery occlusion.

Review of Thyroid Cartilage Compression of the Vertebral Artery

Thyroid cartilage compression of the Vertebral Artery (VA) has been implicated as a rare cause of Rotational Vertebral Artery Occlusion (RVAO). 10 cases have been reported in the literature. This has a higher tendency to affect males and younger patients than other forms of stroke. Patients present with multiple episodes prior to diagnosis. Radiologic studies prove crucial for confirming this condition. An aberrant VA course appears to be a necessary factor. All cases suffer from right side VA compression by the superior thyroid cornu. Conservative therapy with antiplatelet treatment is employed commonly. Most patients have definitive treatment with surgical resection of the right superior thyroid cornu. Theories proposed for these characteristics include VA dominance, structural variability in the thyroid cartilage between genders and also variable thyroid cartilage ossification. Given these findings, we propose the term “thyro-vertebral artery syndrome” for this condition.

Ponticulus Posticus, a Rare Cause of Bowhunter’s Syndrome a Rotational Vertebral Artery Syndrome

Bowhunters are a rare cause of posterior circulation stroke. We present the case of a young male presenting with giddiness and vomiting episodes on the rotation of the head. An infarct was seen in the left posterior inferior cerebellar artery area. Radiological imaging comprising computerized tomography, dynamic digital subtraction angiography, and three-dimensional craniovertebral junction model showed dysplastic C1 arch with ponticulus posticus causing dynamic compression of the vertebral artery. The patient underwent resection of the bony dysplasia on the left C1 arch with unilateral fixation of the C1-C2 joint. On follow-up, the patient was found to be completely symptom-free with no further similar episodes of vertebrobasilar insufficiency on head turning.

Abstract Number ‐ 76: Bow hunter’s syndrome‐ a rare case of hearing loss associated with co‐dominant vertebral artery compression

Introduction Bow hunter’s syndrome (BHS), also known as rotational vertebral artery syndrome, refers to symptomatic vertebrobasilar insufficiency (VBI) caused by mechanical compression and severe stenosis or occlusion of the vertebral artery (VA) during neck and head rotation. Etiologies include bony spurs and osteophytes, or hypertrophic muscles and ligaments compressing typically on the dominant vertebral artery. Upon turning their head, patients experience posterior circulation symptoms such as vertigo, dizziness, syncope, nausea, tinnitus, or headache. These patients are at risk of stroke due to repetitive mechanical damage to the vessel and thromboembolism. [1] We present a rare case of BHS associated with hearing loss that was caused by bony spurs compressing on a left co‐dominant vertebral artery seen on turning head to both sides. Methods A woman in her 50s presented with sporadic progressive episodes of dizziness which started about 4 years. In addition, she reported experiencing episodic tinnitus in her left ear, frequent headaches, neck pain, and syncopal episodes. She was diagnosed with severe left ear sensorineural hearing loss (SNHL). Vestibular therapy and multiple neuropathic medications (nortriptyline, gabapentin) only provided her with minimal relief. Results Examination showed left SNHL and neck tenderness. X‐ray of cervical spine showed bony hypertrophy adjacent to the dens and inferior to the anterior arch of C1, suggestive of large osteoarthritic bony spurs. CT angiogram showed narrowing of the left vertebral artery at C1 due to severe hypertrophic arthropathy of the lateral mass articulation. It also showed impingement of the left VA in the left transverse foramen. The intradural portion of the VA (V4) appeared to be co‐dominant with normal size. Dynamic cerebral angiogram revealed near occlusion of the left VA at the level of C1‐C2 with head to the right. Left VA remained patent in neutral position, and experienced reduction in flow with head rotation to the left. The dynamic stenosis of VA caused by mechanical compression upon head turn leading to VBI, and reversal of stenosis when rotating head to neutral position was consistent with diagnosis of Bow hunters syndrome. Conclusions This case report highlights a rare presentation of VBI caused by dynamic stenosis of VA as a sequela of mechanical compression of a co‐dominant VA upon head turn to both sides. Only about 2% of the BHS patients experience symptoms during head turn to both sides [2], which was the finding in our patient. Furthermore, this case illustrates an association between BHS and SNHL. Hearing loss is previously described in vertebral artery atresia [3]; however, we present a novel association between acquired BHS and SNHL. Although we could not prove the causality, the coexistence of the two conditions in this patient may help to elicit further clinical consideration and evaluation in patients with SNHL of unknown etiology.

A Case of Rotational Vertebral Artery Syndrome after Vertebral Artery Dissection

Rotational vertebral artery syndrome (RVAS), also called Bow-Hunter syndrome, is characterized by position-aggravated reversible vertebra-basillarischemia. By rotating the head to one side, the mechanical compression of a dominant vertebral artery (VA) in the setting of a hypoplastic contralateral VA might cause tinnitus, vertigo and syncope. A 60-year-old male experienced recurrent tinnitus and vertigo while rotating the head to the right side. Neck CT images showed no abnormal structures near the course of both VAs. In 3-phase dynamic neck CT angiography, a focal vertebral artery dissection was identified at the right C6 transverse foramen. Close observation and anticoagulation therapy were started to prevent thrombo-embolic complications. Herein, we report a case of RVAS with vertebral artery dissection with a review of the literatures.

A Case of Rotational Vertebral Artery Occlusion Syndrome with a Rare Mechanism

A Case of Rotational Vertebral Artery Occlusion Syndrome with a Rare Mechanism

Atlanto-occipital ligament calcification: a novel imaging finding in pediatric rotational vertebral artery occlusion

We describe a 2-year-old girl with bow hunter syndrome complicated by vertebral artery dissection and multiple ischemic infarcts. Pediatric bow hunter syndrome is a rare and likely under-recognized disorder. Interestingly, our patient had atlanto-occipital ligament calcification on CT scan, an imaging finding that has not been reported in association with bow hunter syndrome and one that might help increase recognition of this dynamic disorder of the posterior circulation.

Rotatory Vertebral Artery Syndrome in Foramen Magnum Stenosis

Rotatory vertebral artery syndrome (RVAS) is characterized by recurrent attacks of vertigo, nystagmus, and syncope induced by compression of the vertebral artery during head rotation. A 60-year-old man with atlas vertebrae fracture presented recurrent attacks of positional vertigo. Left-beat, upbeat and count clock-wise torsional nystagmus occurred after lying down and bilateral head roll (HR) showing no latency or fatigue. Magnetic resonance imaging revealed foramen magnum stenosis (FMS) and dominancy of right vertebral artery (VA). The flow of the right VA on transcranial Doppler decreased significantly during left HR. The slower the velocity was, the more the nystagmus was aggravated. RVAS can be evoked by FMS causing compression of the VA. And the nystagmus might be aggravated according to the blood flow insufficiency. Keywords: Rotational vertebral artery compression; Foramen magnum stenosis; Central positional nystagmus 중심 단어: íšŒì „ì„±ì²™ì¶”ë™ë§¥ì••, 대공협착, 중추성자세안진

Rotational vertebral artery occlusion: Case report and review of literature

Rotational vertebral artery occlusion (RVAO) classically involves transient, position-dependent vertebrobasilar insufficiency (VBI) that occurs when an extra-vascular lesion (e.g. osteophyte or fibromuscular band) compresses a dominant vertebral artery with turning of the head to one side. Our patient presented with VBI associated vertigo, dizziness, and lightheadedness that occurred when her head was turned to the right. RVAO was initially suggested by transcranial Doppler ultrasound (TCD) changes that were not supported by initial catheter angiography. After her symptoms worsened over a course of two years, the diagnosis was confirmed with repeat angiography with head rotation. Further imaging with computed tomography and magnetic resonance demonstrated spondylosis at the C5-C6 vertebrae and an osteophyte near the C5 transverse foramen, which caused position-dependent extra-vascular compression. She was treated with surgical decompression and anterior discectomy and fusion at C5-C6. The unique anatomical pathology of this case combined with the diagnostic discrepancy between early TCD and angiography make it an interesting contribution to the otherwise limited body of literature on RVAO.

Abstract WP387: Diagnosis and Surgical Management of Rotational Vertebral Artery Occlusion in Children

Background: Rotational vertebral artery occlusion (RVAO) is associated with significant posterior circulation morbidity, recurrence, and lacks evidenced based treatment recommendations. Upper cervical spine abnormalities, lack of traumatic history, and dynamic vessel imaging aid in diagnosis and treatment options. Here, we evaluate our cohort of children with RVAO for associated musculoskeletal, angiographic, and arterial tortuosity factors in light of management strategies and outcomes. Methods: Five pediatric patients with RVAO were evaluated with dynamic arterial compression with either CT based angiography or digital subtraction angiography. Solitary factors such as ponticulous posticus, hypermobility comorbidities, 3D-print models and arterial tortuosity index were examined in relation to management strategies. Results: Musculoskeletal abnormalities were associated in all cases presenting with evidence of dynamic angiographic compression. Not all cases had evidence angiographic compression. A mild elevation in arterial tortuosity index was observed. All five patients were managed with treatment approaches including antiplatelet/coagulation therapies, vertebral artery decompression, and/or posterior cervical fusion. Conclusion: Treatment strategies relied on identifiable compression factors associated with the level of vertebral artery dissection. In children, upper cervical bony abnormalities and dynamic compression at the VA3 level are common to RVAO diagnosis. Further examination of arterial tortuosity as an index in understanding the susceptibility of children towards RVAO is required.

“Cervical Vertigo-Pathophysiology and Management: An Update”

There are many myths about cervical vertigo. Cervical vertigo is defined as vertigo from the cervical spine. In this review article, we outline the basic science and clinical evidence for cervical vertigo according to the current literature. So far, there are 4 different hypotheses explaining the vertigo of a cervical origin, including proprioceptive cervical vertigo, Barre-Lieou syndrome, rotational vertebral artery vertigo, and migraine-associated cervicogenic vertigo. Proprioceptive cervical vertigo and rotational vertebral artery vertigo have survived with time. Barre-Lieou syndrome once was discredited, but it has been resurrected recently by increased scientific evidence. Diagnosis depends mostly on patients' subjective feelings, lacking positive signs, specific laboratory examinations and clinical trials, and often relies on limited clinical experiences of clinicians. Neurological, vestibular, and psychosomatic disorders must first be excluded before the dizziness and unsteadiness in cervical pain syndromes can be attributed to a cervical origin. Treatment for cervical vertigo is challenging. Manual therapy is recommended for treatment of proprioceptive cervical vertigo. Anterior cervical surgery and percutaneous laser disc decompression are effective for the cervical spondylosis patients accompanied with Barre- Lieou syndrome. As to rotational vertebral artery vertigo, a rare entity, when the exact area of the arterial compression is identified through appropriate tests such as computed tomography angiography (CTA), magnetic resonance angiography (MRA), or digital subtraction angiography (DSA). Decompressive surgery should be the chosen treatment.

Combined use of intraoperative indocyanine green and dynamic angiography in rotational vertebral artery occlusion

Rotational vertebral artery occlusion, also known as bow hunter’s syndrome, is a well-documented surgically amenable cause of vertebrobasilar insufficiency. Traditionally, patients have been imaged using dynamic rotational angiography. The authors sought to determine whether intraoperative indocyanine green (ICG) angiography could reliably assess the adequacy of surgical decompression of the vertebral artery (VA). The authors report two patients who presented with multiple transient episodes of syncope provoked by turning their head to the right. Rotational dynamic angiography revealed a dominant VA that became occluded with head rotation to the right side. The patients underwent successful surgical decompression of the VA via an anterior cervical approach. Intraoperative ICG angiography demonstrated patency of the VA with head rotation. This was further confirmed by intraoperative dynamic catheter angiography. To our knowledge, we present the first two cases of the use of ICG combined with intraoperative dynamic rotational angiography to document the adequacy of surgical decompression of the VA in a patient with rotational vertebral artery occlusion. Intraoperative ICG angiography is a useful adjunct and may potentially supplant the need for intraoperative catheter angiography.

A Case of Rotational Vertebral Artery Syndrome.

A Case of Rotational Vertebral Artery Syndrome.

A Case of Rotational Vertebral Artery Syndrome Diagnosed with Color Doppler-Assisted Carotid Duplex Sonography Imaging

A Case of Rotational Vertebral Artery Syndrome Diagnosed with Color Doppler-Assisted Carotid Duplex Sonography Imaging

Pathogenesis, Diagnosis, and Treatment of Cervical Vertigo

Cervical vertigo is characterized by vertigo from the cervical spine. However, whether cervical vertigo is an independent entity still remains controversial. In this narrative review, we outline the basic science and clinical evidence for cervical vertigo according to the current literature. So far, there are 4 different hypotheses explaining the vertigo of a cervical origin, including proprioceptive cervical vertigo, Barré-Lieou syndrome, rotational vertebral artery vertigo, and migraine-associated cervicogenic vertigo. Proprioceptive cervical vertigo and rotational vertebral artery vertigo have survived with time. Barré-Lieou syndrome once was discredited, but it has been resurrected recently by increased scientific evidence. Diagnosis depends mostly on patients’ subjective feelings, lacking positive signs, specific laboratory examinations and clinical trials, and often relies on limited clinical experiences of clinicians. Neurological, vestibular, and psychosomatic disorders must first be excluded before the dizziness and unsteadiness in cervical pain syndromes can be attributed to a cervical origin. Treatment for cervical vertigo is challenging. Manual therapy is recommended for treatment of proprioceptive cervical vertigo. Anterior cervical surgery and percutaneous laser disc decompression are effective for the cervical spondylosis patients accompanied with BarréLiéou syndrome. As to rotational vertebral artery vertigo, a rare entity, when the exact area of the arterial compression is identified through appropriate tests such as magnetic resonance angiography (MRA), computed tomography angiography (CTA) or digital subtraction angiography (DSA) decompressive surgery should be the chosen treatment. Key words: Cervical vertigo, dizziness, whiplash injury, neck pain, cervical spondylosis, manual therapy, vestibular rehabilitation, vertebrobasilar insufficiency

Subaxial Rotational Vertebral Artery Syndrome

A case report on rotational vertebral artery syndrome (RVAS) and surgical treatment. To illustrate a safe treatment option of RVAS with diminished risk of iatrogenic damage to the vertebral artery. RVAS is an uncommon cause of symptomatic transient vertebrobasilar insufficiency induced by physiological head rotation with temporary significant external compression of the dominant subaxial vertebral artery. Previous reports state that the treatment of choice consists of decompression of the vessel with resection of the anterior rim of the transverse process and any fibrotic sheet or intertransverse muscle, if necessary, combined with an anterior cervical discectomy and fusion (ACDF) with uncus resection. This is a case report on RVAS and its surgical treatment. The diagnosis of RVAS due to an osteophyte of the uncinate process at level C5/C6 was confirmed using computed tomographic angiography. We performed a classic ACDF using the contralateral approach with complete resection of the uncovertebral joint at the pathologic site. In our case, the symptoms of transient vertebrobasilar insufficiency induced by head rotation completely resolved postoperatively, and computed tomographic angiography images at 3 months postoperatively showed good bony ingrowth and restoration of vertebral artery patency during extreme rotation. Classic ACDF with complete resection of the uncovertebral joint is a safe treatment option for RVAS in the subaxial cervical spine. Fusion at the pathologic level will eliminate rotation and prevent further formation of osteophytes at the operated level. Unroofing of the vertebral artery seems not always necessary, diminishing the surgical risk.