Surgical Treatment of Rotational Vertebral Artery Syndrome Induced by Spinal Tumor: A Case Report and Literature Review

Safety and efficacy of dynamic catheter-directed cerebral digital subtraction angiography for diagnosis of bowhunter syndrome spectrum disorders: A systematic review of the literature

INTRODUCTION

Dynamic catheter-directed cerebral digital subtraction angiography (dcDSA) is the gold standard for diagnosing dynamic vascular occlusion syndromes such as bowhunter syndrome (BHS). Nonetheless, concerns about its safety exist and no standardized protocols have been published to date.

METHODS

We describe our methodology and insights regarding the use of dcDSA in patients with BHS. We also perform a systematic literature review to identify cases of typical and atypical presentations of BHS wherein dcDSA was utilized and report on any procedural complications related to dcDSA.

RESULTS

Our study included 104 cases wherein dcDSA was used for the diagnosis of BHS. There were 0 reported complications of dcDSA. DcDSA successfully established diagnosis in 102 of these cases. Thirty-eight cases were deemed atypical presentations of BHS. Fourteen patients endorsed symptoms during neck flexion/extension. In eight cases, there was dynamic occlusion of bilateral vertebral arteries during a single maneuver. Three patients had multiple areas of occlusion along a single vertebral artery (VA). An anomalous entry of the VA above the C6 transverse foramen was observed in four patients. One patient had VA occlusion with neutral head position and recanalization upon contralateral lateral head tilt.

CONCLUSION

Our study highlights the safety and diagnostic benefits of dcDSA in characterizing the broad spectrum of BHS pathology encountered in clinical practice. This technique offers a powerful means to evaluate changes in cerebral blood flow and cervical arterial morphology in real time, overcoming the constraints of static imaging methods. Our findings pave the way for further studies on dcDSA to enhance cross-sectional imaging methods for the characterization of BHS and other dynamic vascular occlusion syndromes.

Bow hunter’s syndrome successfully treated with a posterior surgical decompression approach: A case report and review of literature

BACKGROUND

Bow hunter’s syndrome (BHS) is a rare but surgically treatable cause of vertebrobasilar insufficiency due to dynamic rotational occlusion of the vertebral artery. Typically, patients present with posterior circulation transient ischaemic symptoms such as presyncope, syncope, vertigo, diplopia, and horizontal nystagmus, but irreversible deficits, including medullary and cerebellar infarctions, have also been described.

CASE SUMMARY

A 70-year-old patient presented an acute onset of vertigo and gait instability triggered by right head rotation. His medical history included previous episodes of unilateral left neck and occipital pain followed by light-headedness, sweating, and blurred vision when turning his head, and these episodes were associated with severe degenerative changes in the atlanto-dens and left atlanto-axial facet joints and right rotation of the C2 cervical vertebrae. Brain magnetic resonance imaging revealed the presence of acute bilateral cerebellar ischaemic lesions, while static vascular imaging did not reveal any vertebral artery abnormalities. Dynamic ultrasonography and angiography were performed and confirmed the presence of a dynamic occlusion of the vertebral artery V3-V4 segment when the head was rotated to the right secondary to left C1-C2 bone spur compression. Surgical decompression led to complete resolution of paroxysmal symptoms without neurological sequelae.

CONCLUSION

BHS should be considered in cases of repeated posterior circulation transient ischaemic attack or ischaemic stroke, particularly when associated with high cervical spine abnormalities.

Ischemic Stroke Secondary to Dynamic Vertebral Artery Stenosis: Case Report and Review of the Literature

Ischemic stroke secondary to dynamic vertebral artery stenosis or occlusion, also known as “bow hunter's syndrome,” is a rare stroke mechanism. We report a case of a 24-year-old man with multiple hereditary exostosis (MHE) diagnosed at childhood. His first presentation to a neurologist was due to neck pain and clinical syndrome suggestive of ischemia in the vertebrobasilar territory. A therapeutic occlusion was done successfully without complication. The patient was discharged two days later on aspirin alone. In follow up one year later he continued to be symptom free. Moreover, this stroke mechanism has been reported extensively in the literature in isolation or secondary to many underlying diseases. In total, there are 168 cases reported in the published English literature, in either case reports or small series. In this review, we found that by far, vertebral artery occlusion at the atlanto-axial (C1-2) level dominated most reported cases. The most frequent presentation that led to further investigation was syncope or pre-syncope provoked by head rotation to one side. To our knowledge, there is no previous report of any stroke syndrome related to MHE before our case. In this paper, we report the first case secondary to MHE and review the literature up to date since the first reported case in 1952.

Diagnosis, Management, and Treatment Options: A Cervical Spine Osteochondroma Meta-Analysis

Osteochondroma is described as a capped benign bony neoplasm that forms on the outer surface of bone. These tumors affect nearly 6 million people per year. Although osteochondromas most often involve the appendicular skeleton, many involve the spine, with many cases located in the cervical spine. When osteochondromas involve the spine, they can present with a variety of symptoms, including pain, radiculopathy, and myelopathy, which may necessitate surgical treatment. Spinal osteochondromas can be classified into 2 types: multiple osteochondromas in the context of patients with multiple hereditary exostosis (MHE) and solitary osteochondroma or solitary exostosis (SE). Previous reviews have captured only some of the available literature on cervical osteochondromas and have generally focused on either SE or those associated with MHE. The purpose of our review was to provide an extensive review of all previously reported cervical osteochondromas and to compare osteochondroma characteristics, clinical presentation, and outcomes in the context of MHE and SE.

Subaxial Vertebral Artery Rotational Occlusion Syndrome: An Overview of Clinical Aspects, Diagnostic Work-Up, and Surgical Management

Extrinsic compression of the subaxial vertebral artery (VA) may cause rotational occlusion syndrome (ROS) and contribute to vertebrobasilar insufficiency potentially leading to symptoms and in severe cases, to posterior circulation strokes. The present literature review aimed to report the main clinical findings, diagnostic work-up, and surgical management of the subaxial VA-ROS, the diagnosis of which can be difficult and is often underestimated. An illustrative case is also presented. A thorough literature search was conducted to retrieve manuscripts that have discussed the etiology, diagnosis, and treatment of ROS. Total 41 articles were selected based on the best match and relevance and mainly involved case reports and small cases series. The male/female ratio and average age were 2.6 and 55.6±11 years, respectively. Dizziness, visual disturbances, and syncope were the most frequent symptoms in order of frequency, while C5 and C6 were the most affected levels. Osteophytes were the cause in >46.2% of cases. Dynamic VA catheter-based angiography was the gold standard for diagnosis along with computed tomography angiography. Except in older patients and those with prohibitive comorbidities, anterior decompressive surgery was always performed, mostly with complete recovery, and zero morbidity and mortality. A careful neurological evaluation and dynamic angiographic studies are crucial for the diagnosis of subaxial VA-ROS. Anterior decompression of the VA is the cure of this syndrome in almost all cases.