• Peter Kan, Parham Yashar, David J Langer, Adnan H Siddiqui, and Elad I Levy.
• Department of Neurosurgery, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA.
• World Neurosurg. 2012 Nov 1;78(5):553.e15-7.

BackgroundBow hunter's syndrome is a rare cause of vertebrobasilar insufficiency arising from mechanical compression of the vertebral artery (VA) during rotation of the head. Surgical treatment usually involves direct decompression of the VA at the site of compression. We describe what is to our knowledge the first reported case of a posterior inferior cerebellar artery (PICA)-to-PICA in situ bypass for treatment of Bow hunter's-type ischemia in a patient with a VA dissection.Case DescriptionThe patient was a 41-year-old man who developed disabling symptoms of vertebrobasilar insufficiency after trauma when he rotated his head to the right. Dynamic angiography demonstrated a chronic dissection and stasis of flow in the right VA when his head was rotated to the right, with no obvious site of focal compression. The right VA ended in the PICA and the left VA was of good caliber. A single-photon emission computed tomography study with acetazolamide challenge confirmed brainstem ischemia and poor cerebrovascular reserve. He ultimately underwent a PICA-to-PICA in situ bypass to revascularize his right PICA territory with complete symptom resolution.ConclusionsThe PICA-to-PICA in situ bypass is a useful option in the treatment of Bow hunter's-type ischemia in the absence of focal structural compression of the VA or VA stenosis.Copyright © 2012 Elsevier Inc. All rights reserved.

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