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Takeshima Y, Motoyama Y, Nakagawa I, Eura N, Saito K, Sugie K, Nakase H. Embolic stroke induced by rotational persistent 1st intersegmental artery compression. Br J Neurosurg 2023; 37:1835-1838. [PMID: 34180319 DOI: 10.1080/02688697.2021.1940854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
A 45-year-old man suffered multiple cerebral infarctions in the vertebrobasilar artery territory, followed by second stroke against conservative treatment. Radiological examinations revealed intra-arterial defect in left persistent 1st intersegmental artery (PFIA) at C1 level, suggesting mural thrombus, and mechanical compression of left PFIA at the level with head rotation to the right clearly revealed by reconstructed 3-dimensional radiological images, but no findings of atlantoaxial instability. One month after the second stroke, posterior fixation was performed. Postoperative course was uneventful without subsequent stroke for 24 months. This unique case demonstrated that PFIA might associate with cerebral stroke as a clinical condition of bow hunter's stroke even in middle age. Reconstructed 3-dimensional radiological images might be useful for clear demonstration of the pathophysiology in this complex clinical entity.
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Affiliation(s)
- Yasuhiro Takeshima
- Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Yasushi Motoyama
- Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
| | - Nobuyuki Eura
- Neurology, Nara Medical University School of Medicine, Kashihara, Japan
| | - Kozue Saito
- Neurology, Nara Medical University School of Medicine, Kashihara, Japan
| | - Kazuma Sugie
- Neurology, Nara Medical University School of Medicine, Kashihara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan
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Bukhari MK, Alghamdi SA. Ischemic Stroke Secondary to Dynamic Vertebral Artery Stenosis: Case Report and Review of the Literature. Cureus 2021; 13:e20167. [PMID: 35003995 PMCID: PMC8724019 DOI: 10.7759/cureus.20167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2021] [Indexed: 11/24/2022] Open
Abstract
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.
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Rotational vertebral artery occlusion ("bow hunter syndrome"). EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2021; 30:1440-1450. [PMID: 33389200 DOI: 10.1007/s00586-020-06680-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/23/2020] [Accepted: 11/25/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE To review the literature, analyze and discuss diagnostic and treatment options for the Bowhunter Syndrome. A clinical case of idiopathic rotatory C1-C2 subluxation causing dynamic vertebral artery occlusion is presented. METHODS Literature review between 1960 and 2019, discussion of diagnostic methods and treatment options. Description of diagnostic and treatment methods in the aforementioned case. RESULTS We present a patient with dynamic left vertebral artery occlusion associated with idiopathic rotatory C1-C2 subluxation. A dynamic Angio-CT showed rotatory C1-C2 subluxation with significant flow reduction at the left vertebral artery at the exit of the C2 transverse foramen until the V3 segment when the head rotated towards the right. Due to clinical and radiological worsening in the following months, posterior C1-C2 arthrodesis was performed, with the disappearance of the symptoms. There are 193 cases reported with dynamic vertebral artery occlusion, but in only two, the etiology was primary rotational atlantoaxial instability. The most prevalent etiology was degenerative. CONCLUSION Rotatory vertebral artery occlusion is a rare condition presented mostly in adults, aged 50-70 years. Vertebrobasilar insufficiency is triggered by the rotation of the head to the contralateral side of the dominant vertebral artery. Dynamic subtraction angiography is considered the diagnostic gold-standard method, but dynamic Angio-CT scan, Angio-MRI, or Doppler ultrasonography are less invasive options. The treatment options are conservative or surgical. Endovascular surgery is another option in specific cases.
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Mori M, Yamahata H, Yamaguchi S, Niiro T, Atsuchi M, Kasuya J, Tokimura H, Arita K. Bow-hunter's syndrome due to left C7 schwannoma in a patient with bilateral absence of the posterior inferior cerebellar artery. J Orthop Sci 2019; 24:939-944. [PMID: 28456352 DOI: 10.1016/j.jos.2017.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 03/31/2017] [Accepted: 04/08/2017] [Indexed: 12/12/2022]
Affiliation(s)
- Masanao Mori
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Hitoshi Yamahata
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan.
| | - Satoshi Yamaguchi
- Department of Neurosurgery, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - Tadaaki Niiro
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | | | - Junji Kasuya
- Atsuchi Neurosurgical Hospital, Kagoshima, Japan
| | - Hiroshi Tokimura
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
| | - Kazunori Arita
- Department of Neurosurgery, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan
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Favorable Long-Term Outcomes for Positional Vertebral Artery Occlusion with Treatment Strategy Prioritizing Spinal Fusion Surgery. World Neurosurg 2018; 114:e792-e799. [DOI: 10.1016/j.wneu.2018.03.089] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 03/10/2018] [Accepted: 03/12/2018] [Indexed: 11/22/2022]
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Takeshima Y, Shigematsu H, Konishi K, Nakagawa I, Motoyama Y, Nakase H. Posterior atlantoaxial fusion using a C2 transverse foramen-penetrating screw: A technical note. Surg Neurol Int 2017; 8:262. [PMID: 29184713 PMCID: PMC5680663 DOI: 10.4103/sni.sni_57_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Accepted: 03/05/2017] [Indexed: 11/19/2022] Open
Abstract
Background: Although recent development of screw instrumentation techniques for rigid fixation of the atlantoaxial joint has increased surgical options, patients in whom screws of any type cannot be safely placed are sometimes encountered. We present a unique surgical technique for C1-2 transarticular screw placement utilizing a novel trajectory. Methods: A 35-year-old male with a history of Down's syndrome and cognitive dysfunction with hyperkinesis spontaneously developed rapid onset of tetraparesis and gait disturbance. Radiographs of the cervical spine revealed atlantoaxial subluxation (AAS) that could not be reduced. Computed tomography (CT) of the head showed multiple subacute cerebral infarctions in the territory of the right vertebral artery (VA). Three-dimensional CT angiography of the craniovertebral junction additionally confirmed right VA occlusion at the C2/3 level, a left C2 origin of the posterior inferior cerebellar artery, and hypoplasia of the bilateral C2 pedicles/C2 lamina. Because traditional screw-placement was not feasible, we performed a unique atlantoaxial fusion utilizing a C2 transverse foramen-penetrating screw with iliac bone grafting performed under neuronavigation. Results: The postoperative course was uneventful, and the patient regained the ability to ambulate, returning to his previous level of function. The CT of the cervical spine 12 months postoperatively showed rigid bony C1-C2 fusion, without recurrence of stroke. Conclusion: We introduced a novel C1-C2 transarticular screw-placement technique in which the trajectory went through the ipsilateral VA foramen due to already extent VA occlusion.
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Affiliation(s)
- Yasuhiro Takeshima
- Department of Neurosurgery, Nara Medical University Hospital, Kashihara, Nara, Japan
| | - Hideki Shigematsu
- Department of Orthopedics, Nara Medical University Hospital, Kashihara, Nara, Japan
| | - Kengo Konishi
- Department of Radiation, Nara Medical University Hospital, Kashihara, Nara, Japan
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University Hospital, Kashihara, Nara, Japan
| | - Yasushi Motoyama
- Department of Neurosurgery, Nara Medical University Hospital, Kashihara, Nara, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University Hospital, Kashihara, Nara, Japan
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Abstract
STUDY DESIGN Retrospective cohort study of the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2012. OBJECTIVE Minimizing the morbidity of posterior cervical fusion can be improved with identification of patient risk factors. SUMMARY OF BACKGROUND DATA Posterior cervical fusion is an effective technique for treating a variety of pathology. Stability and neurological improvement have been well documented. The increasing frequency of these procedures necessitates further investigation into the factors that may negatively impact perioperative care. METHODS The American College of Surgeons National Surgical Quality Improvement Program was queried for all patients undergoing posterior cervical fusion in 2011 and 2012. Preoperative and intraoperative variables were investigated for correlation to complications, readmissions, prolonged intubation, reintubation, and reoperation. A frailty-based score was used to assess preoperative risk. Regression models for prediction were performed. RESULTS The study identified 5627 patients of posterior cervical fusion in 2011 and 2012. Of these, 2029 patients (36.1%) had any of our identified complications. Transfusion was the most common in 1482 (26.3%) patients. Excluding transfusion, the complication rate was 9.8%. Prolonged intubation greater than 48 hours occurred in 83 (1.5%) patients. Reintubation occurred in 72 (1.3%) patients. Readmission occurred in 398 (7.8%) patients. Reoperation was necessary in 273 (4.9%) patients with postoperative infection being the most common reason. The frailty-based score was shown to be predictive of any of the above events (P < 0.0001). The majority of patients (54.9%) in the group that had complications was found to have a frailty score of 1 or higher. CONCLUSION The predictors for any event included female sex, increased surgical time, combined anterior-posterior procedures, preoperative inpatient status, diabetes, smoking, American Society of Anesthesiologists class 3 or higher, and increasing age. The frailty-based score is a viable option to predict morbidity in posterior cervical fusion.Level of Evidence: 3.
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KAGEYAMA H, YOSHIMURA S, IIDA T, SHIRAKAWA M, UCHIDA K, TOMOGANE Y, MIYAJI Y. Juvenile Cerebral Infarction Caused by Bow Hunter's Syndrome during Sport: Two Case Reports. Neurol Med Chir (Tokyo) 2016; 56:580-3. [PMID: 27053329 PMCID: PMC5027241 DOI: 10.2176/nmc.cr.2015-0351] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 03/01/2016] [Indexed: 01/14/2023] Open
Abstract
We report two cases of juvenile cerebral infarction caused by bow hunter's syndrome (BHS) during sport. Case 1 was a 17-year-old male who developed a partial visual field defect after playing basketball. BHS was diagnosed because cervical ultrasonography demonstrated occlusion of the vertebral artery when the neck was rotated. After C1-2 posterior fixation was performed, his symptoms resolved. Case 2 was an 18-year-old male with recurrent visual disturbance after playing handball. Cerebral infarction occurred repeatedly despite antiplatelet therapy. After 3 years, vertebral artery dissection was diagnosed and stenting was performed, but his symptoms did not resolve. BHS was diagnosed when he was examined at our department. C1-2 posterior fixation was performed and his symptoms resolved. In these two cases, BHS was caused by sporting activity. For accurate diagnosis and treatment of BHS, neuroimaging with cervical rotation is mandatory.
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Affiliation(s)
- Hiroto KAGEYAMA
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo
| | - Shinichi YOSHIMURA
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo
| | - Tomoko IIDA
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo
| | - Manabu SHIRAKAWA
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo
| | - Kazutaka UCHIDA
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo
| | - Yusuke TOMOGANE
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo
| | - Yuki MIYAJI
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo
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Posterior atlantoaxial fusion as treatment option for extracranial vertebral artery dissecting aneurysm: a case report and literature review. Acta Neurochir (Wien) 2016; 158:1741-4. [PMID: 27383200 DOI: 10.1007/s00701-016-2891-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/23/2016] [Indexed: 10/21/2022]
Abstract
Symptomatic extracranial vertebral artery (VA) dissection may need surgery. We describe such a case successfully treated with atlantoaxial fusion based on its rare dynamic angiographic findings. A 27-year-old woman suffered from repeated brainstem and cerebellar infarctions from a left extracranial VA dissecting aneurysm. Dynamic angiography showed the dissecting aneurysm of the V3 segment in the neutral head position, and deflation of the aneurysm during rightward head rotation. She underwent posterior atlantoaxial fusion, and the lesion was repaired with no subsequent ischemia. Posterior atlantoaxial fusion can be an option for some extracranial VA dissections with preserving its anterograde blood flow.
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Duan G, Xu J, Shi J, Cao Y. Advances in the Pathogenesis, Diagnosis and Treatment of Bow Hunter's Syndrome: A Comprehensive Review of the Literature. INTERVENTIONAL NEUROLOGY 2016; 5:29-38. [PMID: 27610119 DOI: 10.1159/000444306] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Bow hunter's syndrome (BHS), also known as rotational vertebral artery (VA) occlusion syndrome, is a rare yet treatable type of symptomatic vertebrobasilar insufficiency resulting from mechanical occlusion or stenosis of the VA during head and neck rotation or extension. The symptoms of BHS range from transient vertigo to posterior circulation stroke. The underlying pathology is dynamic stenosis or compression of the VA by abnormal bony structures with neck rotation or extension in many cases, such as osteophyte, disc herniation, cervical spondylosis, tendinous bands or tumors. Imaging approaches, such as Doppler sonography, computed tomography and angiography, as well as magnetic resonance imaging and angiography, are widely used in the diagnosis and evaluation of this syndrome. Digital subtraction angiography with head rotation remains the gold standard diagnostic method. Conservative management, surgery and endovascular procedures are the three major treatment methods for BHS, whereas some symptomatic patients may need operative treatment including surgery and endovascular procedures when conservative management is not adequate.
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Affiliation(s)
- Guangxin Duan
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiaping Xu
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jijun Shi
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Yongjun Cao
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, China; Jiangsu Key Laboratory of Translational Research and Therapy for Neuro-Psycho-Diseases, Institute of Neuroscience, Soochow University, Suzhou, China
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Yu Z, Yu S, Liu R. Letter to the Editor: Bow hunter's syndrome: surgery or conservative therapy? Neurosurg Focus 2015; 39:E6. [PMID: 26646930 DOI: 10.3171/2015.7.focus15331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Zhe Yu
- Chinese PLA General Hospital, Beijing, China
| | | | - Ruozhuo Liu
- Chinese PLA General Hospital, Beijing, China
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Rheumatoid arthritis-induced lateral atlantoaxial subluxation with multiple vertebrobasilar infarctions. Spine (Phila Pa 1976) 2015; 40:E186-9. [PMID: 25384055 DOI: 10.1097/brs.0000000000000701] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Case report. OBJECTIVE To highlight the probability that lateral atlantoaxial subluxation (AAS) exists in patients with rheumatoid arthritis (RA) and induces vertebrobasilar infarctions that are more foregrounded than compressive myelopathy. SUMMARY OF BACKGROUND DATA Although lateral subluxation is a well-known subtype of AAS, a case of cerebral ischemia associated with lateral AAS has not been reported before. METHODS A 52-year-old male with a 6-year history of RA had a sudden onset of visual field defect and mild right cerebellar ataxia. Head magnetic resonance imaging revealed acute multiple infarctions in the vertebrobasilar area, and magnetic resonance angiography revealed stenosis of the left vertebral artery (VA). Lateral radiograph of the cervical spine in the neutral position revealed atlanto-occipital assimilation and anterior AAS. T2-weighted sagittal images on cervical magnetic resonance imaging revealed high signal intensity in the spinal cord at C1-C2. Cerebral angiography revealed right VA occlusion and severe stenosis of the left V3 segment of VA. Three-dimensional computed tomography angiography of the craniovertebral junction revealed lateral AAS, which was due to severe erosive changes of the facet joints, and the left V3 portion was stenosed by a bony component. During conservative therapy, the patient experienced left occulomotor nerve palsy due to a second stroke. RESULTS Two months later, the patient underwent occipitocervical posterior fusion with an iliac bone graft. His postoperative course was uneventful, and the left VA stenosis disappeared. At the 45-month follow-up, he had no further infarctions. Bony fusion was radiologically confirmed, and 3-dimensional computed tomography angiography revealed good patency of the affected left VA. CONCLUSION In patients with RA, the potential risk of AAS should be recognized. Lateral AAS in particular may induce cerebral ischemia by positional VA occlusion in advanced stages of the disease. LEVEL OF EVIDENCE N/A.
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