Intraoperative High Resolution 2D and 3D Angiography in Cervical Decompression for Sub-Axial Bow Hunter's Syndrome.

Abstract

Bow hunter's syndrome (BHS) causes vertebrobasilar insufficiency when head rotation compresses the vertebral artery (VA).^1,2 Although classically craniocervical, subaxial cases from osteophytic V2 compression lack standardized management with treatments ranging from decompression to stenting.^3-5 During decompression, intraoperative VA patency confirmation is essential, as static postoperative imaging cannot reliably exclude residual dynamic compression, and delayed confirmation may necessitate reoperation.^6,7 We present two cases of subaxial rotational occlusion syndrome (subaxial BHS) treated with anterior cervical decompression and intraoperative angiography in a hybrid operating suite. Case 1: an 80-year-old woman with neck pain, dizziness, tinnitus, near-syncope, and ocular symptoms on leftward head rotation; CT/dynamic angiography showed left VA narrowing at C4-C5 from spondylotic compression. Case 2: a 57-year-old woman with prior Eagle syndrome with vertigo, nausea, and blurred vision on left neck rotation; MRA demonstrated focal left V2 stenosis at C5-C6 from uncovertebral osteophytes and incidental distal VA fenestration. Both underwent anterior V2 exposure, ultrasonic drilling of osteophytes, Gore-Tex/fibrin glue reinforcement, and ACDF (C4-C5; C5-C6) to eliminate residual rotational motion at the decompressed segment. Intraoperative biplane angiography via left radial access (Isovue 300; 6 mL at 6 mL/sec per 2D run; 18 mL at 3 mL/sec for 3D acquisition) with simulated head turning, performed 10-15 minutes after hemostasis under general anesthesia, supplemented by 3D rotational angiography in Case 2 to characterize the VA fenestration, showed no head-turning compression and confirmed complete VA patency.^8,9 Both were discharged on postoperative day three and complete symptom resolution was confirmed at 6 weeks.