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Bow-hunter’s syndrome caused by dynamic vertebral artery stenosis at the cranio-cervical junction—a management algorithm based on a systematic review and a clinical series

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Abstract

Bow hunter's syndrome (BHS) is defined as symptomatic, vertebro-basilar insufficiency caused by mechanical occlusion of the vertebral artery (VA) at the atlanto-axial level during head rotation. In the literature, about 40 cases have been reported. However, due to the rarity of this pathology, there are no guidelines for diagnosis and treatment. Conservative, surgical, and endovascular concepts have been proposed. In order to work out an algorithm, we performed a systematic review of the literature and a retrospective analysis of patients, which have been treated in our institutions over the last decade. The clinical series was comprised of five patients. The symptoms ranged from transient vertigo to posterior circulation stroke. Diagnosis was established by dynamic angiography. In all patients, the VA was decompressed; one patient required additional fusion. The clinical and radiological results were good, and the treatment-related morbidity was low. The literature review demonstrated that Bow hunter's syndrome is a rare pathology but associated with a pathognomonic and serious clinical presentation. The gold standard of diagnosis is dynamic angiography, and patients were well managed with tailored vertebral artery decompression. By this management, clinical and radiological results were excellent and the treatment-related morbidity was low.

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Acknowledgements

We would like to thank Lili Laleva for the art work and Tad Dobrowolski for linguistic help.

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Correspondence to Jan Frederick Cornelius.

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Comments

Ernst Delwel, Rotterdam, The Netherlands

The authors have produced a well-written and educative article on the Bow Hunter's Syndrome (BHS). They performed a review of the literature and present the results of five patients which they have operated.

Typical for BHS is symptomatic compression of the (dominant) vertebral artery (VA) at the atlanto-axial level by contra-lateral rotation of the head. Dynamic DSA is indicated for the diagnosis and shows occlusion of the VA during contra-lateral rotation of the head. In all cases, there is insufficient collateral blood flow from the anterior circulation. The BHS might lead to thromboembolic complications, but the exact natural history of the syndrome is not well known. In literature, a total of 34 patients were identified who were operated for the BHS: 11 fusions, 17 posterior vascular decompressions, and 6 anterior vascular decompressions. The authors favor the anterolateral decompression as it offers the possibility to identify and subsequently cut fibrous bands which might add to the compression of the VA at the atlanto-axial level. In all five cases operated by the authors, the patients recovered uneventful and the syndrome was cured. The effect of vascular decompression was checked intra- or postoperatively.

As the natural history of the BHS is not exactly known and conservative therapy has been described in literature as a reasonable option, to my opinion, surgery should only be performed in a center with high competence in vascular and complex spinal procedures to minimize the surgical risks. If possible, intra-operative control of the decompression of the VA might be useful.

The authors are to be complimented with their very instructive article and excellent surgical results in their five cases of BHS.

Carlo Schaller, Geneva, Switzerland

The authors report on a very rare neurovascular problem: Bow hunter's syndrome. Symptomatology may be very vague, and thus, this syndrome may be overlooked easily in routine clinical practice. This may in part be due to the fact that occlusion of the VA is transient only due to temporary rotation of the head, and that this position may be normalized by the patients themselves without paying too much of attention. It is potentially dangerous, however, as it may cause brainstem infarction occasionally.

In addition to a review of existing literature on the matter, the authors report on their own five patients, and they provide a diagnostic algorithm for the evaluation of these patients. All except for one of their patients were treated via an anterolateral approach for decompression of the VA at the C1/C2 junction. They recommend to add a posterior approach plus internal fixation in case of instability in the C1/C2 joint. They stress the importance of detailed follow-up as there is evidence from the (scarce) literature of a high rate of failure, possibly due to postoperative scarring, or—in case of posterior approaches—due to missed anterolateral ligaments.

Their paper is enriched by clear illustrations concerning patient positioning, surgical approach, and technique of decompression. The potential role of endovascular stenting, especially in case of concomitant proximal VA stenosis is discussed as well. This underlines the importance that such patients should be treated in dedicated neurovascular centers with all the necessary experts and equipment to treat potential complications.

The authors are to be commended for their clear and comprehensive description of this rare clinico-pathological entity and for their excellent description of the surgical technique. It is hoped that this article will help to avoid missing such patients in the neurosurgical practice of the readership of this journal.

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Cornelius, J.F., George, B., N’dri Oka, D. et al. Bow-hunter’s syndrome caused by dynamic vertebral artery stenosis at the cranio-cervical junction—a management algorithm based on a systematic review and a clinical series. Neurosurg Rev 35, 127–135 (2012). https://doi.org/10.1007/s10143-011-0343-4

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