Endovascular Treatment for Bow Hunter's Syndrome: Case Report

Abstract

Introduction: Bow hunter's syndrome is a unique clinical entity caused by mechanical occlusion of the vertebral artery on head rotation. Although it is usually treated by direct surgical intervention, we report successful treatment using endovascular stent placement for contralateral vertebral artery stenosis.

Case Description: A 56-year-old man presented with repeated vertigo and loss of consciousness caused by turning his head to the left. Right vertebral angiogram showed no abnormalities with the head in the neutral position. However, with the head rotated 60° to the left, the right vertebral artery was completely occluded at the C1-2 level. A three-dimensional angiogram with bone window clearly demonstrated vertebral artery compression at the C1-2 level by the bony structure. The left subclavian angiogram revealed severe stenosis at the origin of the left vertebral artery. Left vertebral artery angioplasty followed by stent placement was successfully performed under local anesthesia. The patient showed an uneventful postoperative course and his preoperative symptoms disappeared. At 6 months postoperatively, a left subclavian angiogram showed good patency of the stented left vertebral artery and the patient showed no recurrent symptoms.

Conclusion: Vertebral artery stenting is a useful and less invasive option in the treatment of bow hunter's syndrome in the setting of contralateral vertebral artery stenosis.

Key words

vertebral artery stenosis - stents - angioplasty - vertebrobasilar insufficiency - endovascular treatment

References

• 1 Barton JW, Margolis MT. Rotational obstruction of the vertebral artery at the atlantoaxial joint.  Neuroradiology. 1975;  9 117-120
• 2 Sorensen BF. Bow hunter's stroke.  Neurosurgery. 1978;  2 259-261
• 3 Hanakita J, Miyake H, Nagayasu S. et al . Angiographic examination and surgical treatment of bow hunter's stroke.  Neurosurgery. 1988;  23 228-232
• 4 Horowitz M, Jovin T, Balzar J. et al . Bow hunter's syndrome in the setting of contralateral vertebral artery stenosis: evaluation and treatment options.  Spine. 2002;  27 E495-498
• 5 Matsuyama T, Morimoto T, Sakaki T. Bow Hunter's stroke caused by a nondominant vertebral artery occlusion: case report.  Neurosurgery. 1997;  41 1393-1395
• 6 Fox MW, Piepgras DG, Bartleson JD. Anterolateral decompression of the atlantoaxial vertebral artery for symptomatic positional occlusion of the vertebral artery. Case report.  J Neurosurg. 1995;  83 737-740
• 7 Matsuyama T, Morimoto T, Sakaki T. Comparison of C1-2 posterior fusion and decompression of the vertebral artery in the treatment of bow hunter's stroke.  J Neurosurg. 1997;  86 619-623
• 8 Seki T, Hida K, Akino M. et al . Anterior decompression of the atlantoaxial vertebral artery to treat bow hunter's stroke: technical case report.  Neurosurgery. 2001;  49 1474-1476
• 9 Whitmore RG, Simon SL, Hurst RW. et al . Bow hunter's syndrome caused by accessory cervical ossification: posterolateral decompression and the use of intraoperative Doppler ultrasonography.  Surg Neurol. 2007;  67 169-171
• 10 Husni EA, Storer J. The syndrome of mechanical occlusion of the vertebral artery; further observations.  Angiology. 1967;  18 106-116
• 11 Albuquerque FC, Fiorella D, Han P. et al . A reappraisal of angioplasty and stenting for the treatment of vertebral origin stenosis.  Neurosurgery. 2003;  53 607-616
• 12 Hanel RA, Brasiliense LBC, Spetzler RF. Microsurgical revascularization of proximal vertebral artery: A single-center, single-operator analysis.  Neurosurgery. 2009;  64 1043-1050 , discussion 1051

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