• Victoria Schunemann, Jeeho Kim, David Dornbos, and Shahid M Nimjee.
• Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
• World Neurosurg. 2018 Oct 1; 118: 284-289.

BackgroundBow hunter's syndrome (BHS) or rotational vertebral artery occlusion is a rare syndrome of vertebrobasilar insufficiency due to compression or occlusion of the contralateral vertebral artery with cervical axial rotation. Compression at the C2-C3 level, the junction between the axial and subaxial spine, has not been described. Management can include medical treatment with antiplatelet medications, surgical fusion, or vertebral artery decompression.Case DescriptionThe patient presented with dizziness and loss of consciousness with axial head rotation to the left. Dynamic digital subtraction angiography revealed occlusion of the right vertebral artery with the head turning to the left, with concurrent symptom onset. The left vertebral artery largely ended in the posterior inferior cerebellar artery. The patient underwent C2-C3 anterior cervical discectomy and fusion without vertebral artery decompression. His postoperative course was uneventful, with complete symptom resolution. Follow-up dynamic angiography demonstrated a patent right vertebral artery with axial head rotation to the left.ConclusionsThis case report demonstrates that even high cervical etiology for BHS can be successfully managed from an anterior approach. At present, no consensus has been reached for the treatment of BHS. A review of the current data demonstrated that anterior approaches without decompression are slightly safer than posterior approaches, with a smaller risk of vertebral artery injury. Depending on the anatomic variant and the pathophysiology of vertebral compression, an anterior approach without decompression provides a feasible alternative for the treatment of symptomatic BHS.Copyright © 2018 Elsevier Inc. All rights reserved.

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