scholarly journals Bow hunter syndrome in rheumatoid arthritis: illustrative case

2021 ◽  
Vol 2 (3) ◽  
Author(s):  
Brian P. Curry ◽  
Vijay M. Ravindra ◽  
Jason H. Boulter ◽  
Chris J. Neal ◽  
Daniel S. Ikeda
Keyword(s):  
Rheumatoid Arthritis ◽  
Cervical Spine ◽  
Vertebral Artery ◽  
Hunter Syndrome ◽  
Left Vertebral Artery ◽  
Illustrative Case ◽  
Vertebrobasilar Insufficiency ◽  
Vascular Insufficiency ◽  
Vertebral Artery Compression ◽  
Spine Disease

BACKGROUND Rheumatoid arthritis (RA) frequently features degeneration and instability of the cervical spine. Rarely, this degeneration manifests as symptoms of bow hunter syndrome (BHS), a dynamic cause of vertebrobasilar insufficiency. OBSERVATIONS The authors reviewed the literature for cases of RA associated with BHS and present a case of a man with erosive RA with intermittent syncopal episodes attributable to BHS as a result of severe extrinsic left atlantooccipital vertebral artery compression from RA-associated cranial settling. A 72-year-old man with RA-associated cervical spine disease who experienced gradual, progressive functional decline was referred to a neurosurgery clinic for evaluation. He also experienced intermittent syncopal events and vertiginous symptoms with position changes and head turning. Vascular imaging demonstrated severe left vertebral artery compression between the posterior arch of C1 and the occiput as a result of RA-associated cranial settling. He underwent left C1 hemilaminectomy and C1–4 posterior cervical fusion with subsequent resolution of his syncope and vertiginous symptoms. LESSONS This is an unusual case of BHS caused by cranial settling as a result of RA. RA-associated cervical spine disease may rarely present as symptoms of vascular insufficiency. Clinicians should consider the possibility, though rare, of cervical spine involvement in patients with RA experiencing symptoms consistent with vertebral basilar insufficiency.

Rotational vertebrobasilar insufficiency as a component of thoracic outlet syndrome resulting in transient blindness

1994 ◽  
Vol 81 (4) ◽  
pp. 617-619 ◽  
Author(s):  
James J. Sell ◽  
Jesse R. Rael ◽  
William W. Orrison
Keyword(s):  
Vertebral Artery ◽  
Thoracic Outlet Syndrome ◽  
Head Rotation ◽  
Cortical Blindness ◽  
Left Vertebral Artery ◽  
Vertebrobasilar Insufficiency ◽  
Content Type ◽  
Aged Woman ◽  
Extrinsic Compression ◽  
Vertebral Artery Compression

✓ Cases of unilateral vertebral artery compression associated with thoracic outlet syndrome infrequently result in symptoms and, of those that do, most involve the brain stem. Reports of transient blindness resulting from this condition are even more rare. The authors describe the case of a middle-aged woman who presented with transient blindness when she turned her head excessively to the left. She also exhibited other less severe brainstem symptoms. Arteriography demonstrated occlusion of the left vertebral artery only when her head was rotated to the left. Surgical exploration revealed entrapment of the left vertebral artery by a tight anterior scalene muscle, release of which resulted in complete resolution of her symptoms. Both neurosurgeons and radiologists need to be aware that extrinsic compression of the vertebral artery precipitated by head rotation may sometimes result in transient cortical blindness.

scholarly journals Fusion for subaxial bow hunter’s syndrome results in remote osseous remodeling of the hyperostotic growth responsible for vertebral artery compression

2021 ◽  
Vol 12 ◽  
pp. 104
Author(s):  
Daniel Satoshi Ikeda ◽  
Charles A. Miller ◽  
Vijay M. Ravindra
Keyword(s):  
Cervical Spine ◽  
Vertebral Artery ◽  
Complete Resolution ◽  
Dynamic Compression ◽  
Diffuse Idiopathic Skeletal Hyperostosis ◽  
Head Rotation ◽  
Vertebrobasilar Insufficiency ◽  
The Right ◽  
Vertebral Artery Compression ◽  
Hunter's Syndrome

Background: The authors present a previously unreported case of a patient with diffuse idiopathic skeletal hyperostosis (DISH) who developed bow hunter’s syndrome (BHS) or positional vertebrobasilar insufficiency. In addition, the authors demonstrate angiographic evidence of remote osseous remodeling after segmental fusion without direct decompression of the offending bony growth. BHS is a rare, yet well established, cause of posterior circulation ischemia and ischemic stroke. Several etiologies such as segmental instability and spondylosis have been described as causes, however, DISH has not been associated with BHS before this publication. Case Description: A 77-year-old man who presented with BHS was found to have cervical spine changes consistent with DISH, and angiography confirmed right vertebral artery (VA) stenosis at C4–5 from a large pathological elongation of the right C5 lateral mass. Head rotation resulted in occlusion of the VA. The patient underwent an anterior cervical discectomy and fusion and reported complete resolution of his symptoms. A delayed angiogram and CT of the cervical spine demonstrated complete resolution of the baseline stenosis, no dynamic compression, and remote osseous remodeling of the growth, respectively. Conclusion: This case represents the first publication in the literature of DISH as a causative etiology of BHS and of angiographic data demonstrating resolution of a compressive osseous pathology without direct decompression in BHS.

Abstract 2225: Vertebral Artery Stenting for the Treatment of Bow Hunter Syndrome: a report of four cases.

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
M Ziad Darkhabani ◽  
Matthew Thompson ◽  
Marc A Lazzaro ◽  
Asif Taqi ◽  
Osama O Zaidat
Keyword(s):  
Vertebral Artery ◽  
Symptomatic Relief ◽  
Rare Condition ◽  
Head Rotation ◽  
Hunter Syndrome ◽  
Outcome Data ◽  
Left Vertebral Artery ◽  
Neutral Position ◽  
Vertebrobasilar Insufficiency ◽  
Vertebral Artery Stenting

Background: Bow Hunter syndrome is a rare condition that results from vertebrobasilar insufficiency secondary to mechanical occlusion or stenosis of the vertebral artery due to head rotation. Traditionally, surgical intervention with C1-C2 fusion or decompression of the vertebral artery was the mainstay of therapy. Endovascular intervention was rarely described for the treatment of bow hunter syndrome. Methods: The neurointerventional database between July 2005 and October 2010 was reviewed for identification of all cases of bow hunter syndrome that were treated with vertebral artery stenting. We report clinical, technical and outcome data on four patients with bow hunter syndrome who were treated with vertebral artery stenting. Results: Vertebral artery stenting was performed in the V2 segment (C2-C6) of the vertebral arteries in all four patients without significant technical difficulties. All patients reported symptomatic relief with minor or no residual stenosis on dynamic digital subtraction angiography. Conclusion: Vertebral artery stenting for the treatment of Bow Hunter syndrome is feasible, safe, and clinically effective. Endovascular techniques might offer an alternative and a minimally invasive therapy for the treatment of bow hunter syndrome. Figure 1 . Case #1. (A) Selective left subclavian angiogram showing the left vertebral artery with head in neutral position. (B) Narrowing of the V2 segment with head turned to the left. (C) Post-stenting of the V1 (origin) and V2 segments with head turned to the left.

scholarly journals Left Vertebral Artery to Common Carotid Artery Transposition in a Patient With Bilateral Vertebral Insufficiency: 3-Dimensional Operative Video

2020 ◽  
Vol 19 (3) ◽  
pp. E301-E302
Author(s):  
Sirin Gandhi ◽  
Claudio Cavallo ◽  
Justin R Mascitelli ◽  
Michael J Nanaszko ◽  
Xiaochun Zhao ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Vertebral Artery ◽  
Common Carotid Artery ◽  
Suture Technique ◽  
Posterior Circulation ◽  
Left Vertebral Artery ◽  
Vertebrobasilar Insufficiency ◽  
Subclavian Steal ◽  
Bypass Patency ◽  
Patient Consent

Abstract Extracranial vertebral artery (VA) atherosclerosis is responsible for 14% to 32% of posterior circulation infarctions.1 In the posterior circulation, narrowing of the VA > 30% is significantly associated with strokes. Subclavian artery (SCA) atherosclerosis can produce subclavian steal. Retrograde VA flow around an occluded SCA decreases blood flow to the posterior circulation and causes vertebrobasilar insufficiency (VBI). Flow augmentation to the posterior circulation can be achieved by VA endarterectomy, arterial stenting, VA-common carotid artery (CCA) transposition, or bypass using an interposition graft.2,3 This video illustrates microsurgical revascularization of the proximal VA with VA-CCA transposition. A 58-yr-old man with a prior stroke and chronic right VA occlusion presented with dysarthria and gait instability. Angiographic evaluation confirmed complete midcervical right VA occlusion and left SCA occlusion proximal to VA origin, with subclavian steal. After obtaining patient consent and a failed attempt at endovascular recanalization of the left SCA, a left VA-CCA end-to-side transposition was performed. Neck dissection exposed the left CCA. The thyrocervical trunk served as a landmark to identify the SCA, which was traced proximally to the VA origin. After proximal occlusion, the VA was transected and “fish-mouthed” for end-to-side anastomosis to CCA. An intraluminal, continuous suture technique was used to sew the back walls of this anastomosis. Postoperative computed tomography angiography confirmed bypass patency. Collateral circulation through the thyrocervical and costocervical trunks likely supplied the left arm, and no cerebral, or limb, ischemic symptoms were noted on follow-up. VA-CCA transposition is an uncommon technique for safe and effective revascularization of symptomatic, medically refractory VBI caused by VA occlusion or, as in this case, SCA occlusion with secondary subclavian steal. Used with permission from Barrow Neurological Institute, Phoenix, Arizona.

Rotational Vertebrobasilar Ischemia: Hemodynamic Assessment and Surgical Treatment

Neurosurgery ◽  
2005 ◽  
Vol 56 (1) ◽  
pp. 36-45 ◽  
Author(s):  
Marcelo D. Vilela ◽  
Robert Goodkin ◽  
David A. Lundin ◽  
David W. Newell
Keyword(s):  
Surgical Treatment ◽  
Vertebral Artery ◽  
Transcranial Doppler ◽  
Posterior Circulation ◽  
Long Term Results ◽  
Vertebrobasilar Insufficiency ◽  
Head Turning ◽  
Vertebrobasilar Ischemia ◽  
Hemodynamic Assessment ◽  
Vertebral Artery Compression

Abstract OBJECTIVE: Rotational vertebrobasilar insufficiency is a severe and incapacitating condition. Proper investigation and management are essential to reestablish normal posterior circulation hemodynamics, improve symptoms, and prevent stroke. We present a series of 10 patients with rotational vertebrobasilar ischemia who were treated surgically and emphasize the importance of transcranial Doppler in the diagnosis and management of this condition. METHODS: All patients presented with symptoms of vertebrobasilar insufficiency induced by head turning. Transcranial Doppler documented a significant decrease in the posterior cerebral artery velocities during head turning that correlated with the symptoms in all patients. A dynamic cerebral angiogram was performed to demonstrate the site and extent of vertebral artery compression. RESULTS: The surgical technique performed was tailored to each individual patient on the basis of the anatomic location, pathogenesis, and mechanism of the vertebral artery compression. Five patients underwent removal of osteophytes at the level of the subaxial cervical spine, one patient had a discectomy, two patients had a decompression only at the level of C1–C2, and two patients had a decompression and fusion at the C1–C2 level. CONCLUSION: The transcranial Doppler is extremely useful to document the altered hemodynamics preoperatively and verify the return of normal posterior circulation velocities after the surgical decompression in patients with rotational vertebrobasilar ischemia. Surgical treatment is very effective, and excellent long-term results can be expected in the vast majority of patients after decompression of the vertebral artery.

scholarly journals Ruptured vertebrobasilar junction aneurysm unmasking subclavian steal syndrome

2020 ◽  
Vol 11 ◽  
pp. 419
Author(s):  
Vivek Murumkar ◽  
Shumyla Jabeen ◽  
Sameer Peer ◽  
Aravinda Hanumanthapura Ramalingaiah ◽  
Jitender Saini
Keyword(s):  
Vertebral Artery ◽  
Subclavian Artery ◽  
Subclavian Steal Syndrome ◽  
Left Vertebral Artery ◽  
Vertebrobasilar Insufficiency ◽  
Subclavian Steal ◽  
Subclavian Artery Occlusion ◽  
Retrograde Filling ◽  
Vertebrobasilar Junction ◽  
Steal Syndrome

Background: Subclavian steal occurs due to stenosis or occlusion of the subclavian artery or innominate artery proximal to the origin of the vertebral artery. Often asymptomatic, the condition may be unmasked due to symptoms of vertebrobasilar insufficiency triggered by strenuous physical exercise involving the affected upper limb. The association of vertebrobasilar junction (VBJ) aneurysms with subclavian steal syndrome has been rarely reported. Hereby, we present a case of VBJ aneurysm associated with subclavian steal treated successfully with endovascular coiling. Case Description: A 65-year-old female presented in the emergency department with acute severe headache and vomiting with no focal neurological deficits. Non-contrast computed tomography of the brain showed modified Fischer Grade 3 subarachnoid hemorrhage. Subsequent digital subtraction angiogram (DSA) showed VBJ aneurysm directed inferiorly with the left subclavian artery occlusion. There was retrograde filling of the left vertebral artery on right vertebral injection, confirming the diagnosis of subclavian steal. Balloon assisted coiling of the VBJ aneurysm was performed while gaining access through the stenotic left vertebral artery ostium which provided a more favorable hemodynamic stability to the coil mass. Conclusion: Subclavian steal exerting undue hemodynamic stress on vertebrobasilar circulation can be an etiological factor for the development of the flow-related aneurysms. Access to the VBJ aneurysms may be feasible through the stenosed vertebral artery if angioplasty is performed before the coiling of the aneurysm.

A 72-Year-Old Female With Bow Hunter Syndrome: A Rare Surgical Approach to C4-5 Vertebral Artery Decompression: 2-Dimensional Operative Video

2020 ◽  
Vol 19 (3) ◽  
pp. E310-E310
Author(s):  
Michael J Gigliotti ◽  
Jacob Joseph ◽  
Byron Gregory Thompson ◽  
Paul Park
Keyword(s):  
Vertebral Artery ◽  
Dynamic Testing ◽  
Hunter Syndrome ◽  
Operative Intervention ◽  
Vertebrobasilar Insufficiency ◽  
Symptomatic Disease ◽  
Ct Angiogram ◽  
Preoperative Ct ◽  
The Right ◽  
Operative Neurosurgery

Abstract Bow hunter syndrome is defined as vertebrobasilar insufficiency due to mechanical occlusion of the vertebral artery during head and neck rotation. In many cases, this is due to osteophyte formation, disc herniation, cervical spondylosis, tendinous bands, or tumors. Symptomatic disease may vary from inducing transient vertigo to posterior circulation stroke. Although digital subtraction angiography is the gold standard in diagnosis, the underlying pathology in bow hunter syndrome may be detected with doppler ultrasound, computed tomography (CT) angiogram, magnetic resonance imaging and angiogram, and diagnostic angiography with dynamic testing. In this case, a 72-yr-old female with a recent right-sided cerebellar stroke underwent operative intervention to decompress the right vertebral artery at C4-C5 in order to relieve symptomatic bow hunter syndrome. Preoperative CT angiogram revealed bilateral significant stenosis of the vertebral arteries at the C4-C5 level with follow-up diagnostic angiogram revealing complete occlusion of the right vertebral artery with the head rotated right (compared to 80% occlusion observed when the patient's head was rotated left). Prior to the procedure, the patient experienced lightheadedness, diaphoresis, dizziness, and a sensation of facial flushing exacerbated by rotating her head to the right. To relieve her symptoms, operative intervention was undertaken. To access the lateral osteophytes originating from the uncovertebral joint, a C4-5 discectomy is utilized. The vertebral artery was decompressed, and a standard anterior cervical fusion was performed. Postoperatively, the patient was stable and was discharged 1 d after surgery. Postoperative imaging showed adequate decompression of the right vertebral artery at the level of C4-5.  The authors confirm that they have obtained, prior to submission, a written release from the patient authorizing use of this surgical video to be submitted and published in the journal Operative Neurosurgery, as well as consent to perform the procedure.

Microvascular anatomy of foramen caecum medullae oblongatae

1991 ◽  
Vol 75 (2) ◽  
pp. 299-304 ◽  
Author(s):  
Asim Mahmood ◽  
Manuel Dujovny ◽  
Maximo Torche ◽  
Ljubisa Dragovic ◽  
James I. Ausman
Keyword(s):  
Vertebral Artery ◽  
Basilar Artery ◽  
Foramen Magnum ◽  
Left Vertebral Artery ◽  
Anterior Inferior Cerebellar Artery ◽  
Outer Diameter ◽  
Vertebrobasilar Insufficiency ◽  
High Concentration ◽  
Content Type ◽  
Fine Print

✓ The foramen caecum (FC) is a triangular-shaped fossa situated in the midline on the base of the brain stem, at the pontomedullary junction. Although this area is known to have a very high concentration of brainstem perforating vessels, its microvascular anatomy has not been studied in detail. The purpose of this study was to detail the microvasculature of this territory. Twenty unfixed brains were injected with silicone rubber solution and dissected under a microscope equipped with a camera. The origin, course, outer diameter, and branching pattern of the perforators were examined. The total number of perforators found in the 20 brains was 287, with an average (± standard deviation) of 14.35 ± 1.24 perforators per brain (range seven to 28). Their origin was as follows: right vertebral artery in 52 perforators (18.11%); left vertebral artery in 35 (12.19%); basilar artery below the anterior inferior cerebellar artery (AICA) in 139 (48.43%); basilar artery above the AICA in 46 (16.02%); AICA in 10 (3.48%); and anterior spinal artery in five (1.74%). Most of the perforators arose as sub-branches of larger trunks; their average outer diameter was 0.16 ± 0.006 mm while that of trunks was 0.35 ± 0.02 mm. These anatomical data are important for those wishing 1) to study the pathophysiology of vascular insults to this area caused by atheromas, thrombi, and emboli; 2) to plan vertebrobasilar aneurysm surgery; 3) to plan surgery for vertebrobasilar insufficiency; and 4) to study foramen magnum neoplasms.

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