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Dynamic bilateral vertebral arteriography. A-C: DSA of the right VA at the neutral position of the head and neck. The hemispheric (arrows) and vermian (arrowheads) branches of the right PICA are demonstrated by injection of the right VA. A: Anterior-posterior view. B: Lateral view. C: Lateral view of 3D-rotation angiography with the volume-rendering method. D-H: Dynamic DA of the right VA. No stenosis is seen in the right VA at the neutral position (D), rotation of the neck to the right (E) and to the left (F), and head tilt to the left (H). Occlusion of the right VA is demonstrated at C4 level during head tilt to the right (G). I-K: Dynamic DSA of the left VA during head tilt to the right. I and J: Anterior-posterior view. K: Lateral view. The distal portion of the right VA is opacified in a retrograde fashion from the left VA (I), and both PICA hemispheric (arrows) and vermian (arrowheads) branches are subsequently shown (J and K).
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BACKGROUND
Bow hunter’s syndrome or stroke (BHS) is characterized by rotational vertebrobasilar insufficiency elicited by rotation of the neck. It is caused by dynamic and reversible occlusion of the vertebral artery (VA). Reversible symptoms of rotational vertebrobasilar insufficiency are described as bow hunter’s syndrome, although brain infarcti...
Contexts in source publication
Context 1
... nausea, and vomiting. MRA revealed an identical right VA occlusion with no new infarction on DWI. During subsequent dynamic digital subtraction angiography (DSA) and DA procedures with the patient's head in the neutral position, the nondominant right VA and the vermian and hemispheric branches of the right PICA were injected without stenosis ( Fig. 4A-D). No severe stenosis or occlusion was revealed in the right VA when the neck was rotated to the right (Fig. 4E) or left (Fig. 4F) or when the neck was flexed or extended. However, the right VA was occluded by an osteophyte at the C4 level when his head was tilted to the right, which elicited no complaints of dizziness, nausea, or ...
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... dynamic digital subtraction angiography (DSA) and DA procedures with the patient's head in the neutral position, the nondominant right VA and the vermian and hemispheric branches of the right PICA were injected without stenosis ( Fig. 4A-D). No severe stenosis or occlusion was revealed in the right VA when the neck was rotated to the right (Fig. 4E) or left (Fig. 4F) or when the neck was flexed or extended. However, the right VA was occluded by an osteophyte at the C4 level when his head was tilted to the right, which elicited no complaints of dizziness, nausea, or vomiting (Fig. 4G). A similar occlusion was not induced by head tilt to the left (Fig. 4H). No stenosis or occlusion ...
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... subtraction angiography (DSA) and DA procedures with the patient's head in the neutral position, the nondominant right VA and the vermian and hemispheric branches of the right PICA were injected without stenosis ( Fig. 4A-D). No severe stenosis or occlusion was revealed in the right VA when the neck was rotated to the right (Fig. 4E) or left (Fig. 4F) or when the neck was flexed or extended. However, the right VA was occluded by an osteophyte at the C4 level when his head was tilted to the right, which elicited no complaints of dizziness, nausea, or vomiting (Fig. 4G). A similar occlusion was not induced by head tilt to the left (Fig. 4H). No stenosis or occlusion was demonstrated ...
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... 4A-D). No severe stenosis or occlusion was revealed in the right VA when the neck was rotated to the right (Fig. 4E) or left (Fig. 4F) or when the neck was flexed or extended. However, the right VA was occluded by an osteophyte at the C4 level when his head was tilted to the right, which elicited no complaints of dizziness, nausea, or vomiting (Fig. 4G). A similar occlusion was not induced by head tilt to the left (Fig. 4H). No stenosis or occlusion was demonstrated in the dominant left VA on dynamic DA. The distal right VA was demonstrated in a retrograde fashion by injection of the left VA when the patient's head was tilted to the right (Fig. 4I), and both the vermian and ...
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... the neck was rotated to the right (Fig. 4E) or left (Fig. 4F) or when the neck was flexed or extended. However, the right VA was occluded by an osteophyte at the C4 level when his head was tilted to the right, which elicited no complaints of dizziness, nausea, or vomiting (Fig. 4G). A similar occlusion was not induced by head tilt to the left (Fig. 4H). No stenosis or occlusion was demonstrated in the dominant left VA on dynamic DA. The distal right VA was demonstrated in a retrograde fashion by injection of the left VA when the patient's head was tilted to the right (Fig. 4I), and both the vermian and hemispheric branches of the right PICA were subsequently opacified ( Fig. 4J and ...
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... no complaints of dizziness, nausea, or vomiting (Fig. 4G). A similar occlusion was not induced by head tilt to the left (Fig. 4H). No stenosis or occlusion was demonstrated in the dominant left VA on dynamic DA. The distal right VA was demonstrated in a retrograde fashion by injection of the left VA when the patient's head was tilted to the right (Fig. 4I), and both the vermian and hemispheric branches of the right PICA were subsequently opacified ( Fig. 4J and K). The man was asymptomatic while his head was tilted to the right for more than 1 ...
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... to the left (Fig. 4H). No stenosis or occlusion was demonstrated in the dominant left VA on dynamic DA. The distal right VA was demonstrated in a retrograde fashion by injection of the left VA when the patient's head was tilted to the right (Fig. 4I), and both the vermian and hemispheric branches of the right PICA were subsequently opacified ( Fig. 4J and K). The man was asymptomatic while his head was tilted to the right for more than 1 ...
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... nondominant right VA in the other. 9,10 The affected nondominant right VA was stenotic at C4-C5 or C5-C6 in the neutral position but completely occluded with head rotation to the right. 9,10 However, in our patient, repeated cerebellar infarction was not a wake-up stroke, and the nondominant right VA was not stenotic in the neutral head position (Fig. 4D), although complete occlusion of the right VA was induced by head tilt to the right (Fig. 4G). BHS induced by head tilt is an extremely rare condition. 6,15 Treatment for BHS includes conservative treatment and surgery. Conservative treatment includes the avoidance of head rotation, cervical collars, and/or antiplatelet or ...
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... or C5-C6 in the neutral position but completely occluded with head rotation to the right. 9,10 However, in our patient, repeated cerebellar infarction was not a wake-up stroke, and the nondominant right VA was not stenotic in the neutral head position (Fig. 4D), although complete occlusion of the right VA was induced by head tilt to the right (Fig. 4G). BHS induced by head tilt is an extremely rare condition. 6,15 Treatment for BHS includes conservative treatment and surgery. Conservative treatment includes the avoidance of head rotation, cervical collars, and/or antiplatelet or anticoagulation therapy. 4,6,16 Conservative management with antiplatelet agents may be considered the ...
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Methods: Data from adult patients (>18 years) admitted to the emergency department from August 2019 to February...
Citations
... The predominant symptoms included Vertigo, presyncope/syncope, gait instability and visual defect. Specifically, 16 patients reported dizziness [2,8,[12][13][14]16,19,21,[24][25][26]29,31,32,35,36], 11 experienced presyncope or syncope [7,13,15,17,18,20,23,27,30,33,34], 4 had gait disturbances [2,8,18,33], and 4 noted visual changes [6,21,26,28]. ...
... Vertebral artery stenosis was mainly observed at the C4-C5 [8,14,16,21,26,28,29,31,34,35] and C5-C6 levels [1,6,7,15,[22][23][24]29,30,32], with 10 cases reported at each level. Six cases occurred at C3-C4 [12,17,19,20,24,25] and four between C1-C2 [2,27,33,36]. ...
... As for occipital bone -C1 [18], C2-C3 [24] and C6-C7 [13], one case was reported at each level. There was no notable difference observed in the side of blood flow impairment, with 15 cases of stenosis occurring on the left side [2,8,12,[16][17][18][19][20][21]25,29,[32][33][34]36], 13 on the right side [1,6,7,[13][14][15]22,23,27,28,30,31,35], and 2 cases involving both sides [24,26]. ...
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.
