J Korean Orthop Assoc.  2020 Feb;55(1):85-89. 10.4055/jkoa.2020.55.1.85.

Bow Hunter's Syndrome Caused by Bilateral Dynamic Occlusion of the Subaxial Vertebral Arteries during Neck Extension

• Yi J
• Han HS

• KMID: 2470773
• DOI: http://doi.org/10.4055/jkoa.2020.55.1.85

Abstract

Bow hunter's syndrome is a rare disease that shows the symptoms of vertebrobasilar insufficiency resulting from a dynamic obstruction or stenosis of the vertebral arteries during neck movement. This paper reports a case of a 59-year-old male who visited the emergency room with diplopia, tinnitus, and gait disturbance. Magnetic resonance imaging and angiography revealed a multiple cerebellar infarct, total obstruction of the right vertebral artery, and dynamic obstruction of the left vertebral artery during neck extension. As the infarction worsened, a thrombectomy was done. Posterior decompression and fusion at C5-6 were performed for the left vertebral artery. The left vertebral arterial patency was confirmed by intraoperative and postoperative angiography. No recurrence of the symptoms was observed for six months after surgery. Physicians need to pay attention to the diagnosis of vertebrobasilar insufficiency caused by an obstruction of the vertebral arteries during neck extension in cervical instability patients.

Keyword

bow hunter's syndrome; vertebrobasilar insufficiency; endovascular therapy; surgical therapy; cervical spondylosis

MeSH Terms

Angiography
Constriction, Pathologic
Decompression
Diagnosis
Diplopia
Emergency Service, Hospital
Gait
Humans
Infarction
Magnetic Resonance Imaging
Male
Middle Aged
Mucopolysaccharidosis II*
Neck*
Rare Diseases
Recurrence
Spondylosis
Thrombectomy
Tinnitus
Vertebral Artery*
Vertebrobasilar Insufficiency

Figure

• 

  Figure 1 Initial transfemoral cerebral angiography images show occlusion of the vertebral arteries. (A) The right vertebral artery is completely occluded at the C5-6 disc level (arrow). (B) The left vertebral artery is partially occluded by the C6 superior articular process (arrow).

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  Figure 2 Preoperative computed tomography angiography shows a blockade of circulation at the transverse foramina. (A) The right superior articular process completely occludes the right vertebral artery (arrow). (B) The left superior articular process occludes approximately 80% of the left C5 transverse foramen (arrow).

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  Figure 3 Intraoperative microscopy images show that the defect produced by left total facetectomy at C5 (white asterisk)-6 (black asterisk) was repaired by an interpositional bone graft using an auto iliac bone block (arrow).

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  Figure 4 Intraoperative transfemoral cerebral angiography images show undisrupted blood flow of the left vertebral artery.

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  Figure 5 Postoperative computed tomography angiography shows complete resection of the left C6 superior articular process (asterisk) and successful decompression of the left vertebral artery. Interpositional bone block appears beautiful (arrow).

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