Images in Neurosurgery
An 11-year-old boy presents with multiple intermittent episodes of right-sided tongue numbness, left hemiparesis, and paresthesias. Workup for vertebral artery dissection was inconclusive; aspirin was initiated for antiplatelet therapy. Patient suffered an additional episode of visual disturbances and extreme lethargy, subsequently returning to baseline. A second formal diagnostic angiogram was completed that included dynamic head turning, revealing complete occlusion of the right vertebral artery with head turning to the left. C1-2 fusion was completed to limit motion and intermittent occlusion. Patient has been asymptomatic postoperatively.
Figure 1: CT angiogram reconstruction of the right vertebral artery shows normal vasculature without evidence of dissection or stenosis.
Figure 2: Time-of-flight MR angiogram demonstrates appropriate flow through right vertebral artery.
Figure 3: With head in neutral position, digital subtraction angiogram shows patent right vertebral artery.
Figure 4: Head turning to the left causes complete occlusion of the right vertebral artery consistent with Bowhunter’s syndrome.
Figure 5: With head returned to neutral position, right vertebral artery recanalizes with good distal flow.