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Atypical presentation of rotational vertebral artery insufficiency: illustrative case
Journal article   Open access

Atypical presentation of rotational vertebral artery insufficiency: illustrative case

Pranish A. Kantak, Sarv Priya, Girish Bathla, Mario Zanaty and Patrick W. Hitchon
Journal of Neurosurgery: Case Lessons, Vol.1(9)
03/01/2021
DOI: 10.3171/CASE20169
PMCID: PMC9241253
PMID: 35854706
url
https://doi.org/10.3171/CASE20169View
Published (Version of record) Open Access

Abstract

BACKGROUND Rotational vertebral artery insufficiency (RVAI), also known as bow hunter’s syndrome, is an uncommon cause of vertebrobasilar insufficiency that leads to signs of posterior circulation ischemia during head rotation. RVAI can be subdivided on the basis of the anatomical location of vertebral artery compression into atlantoaxial RVAI (pathology at C1-C2) or subaxial RVAI (pathology below C2). Typically, RVAI is only seen with contralateral vertebral artery pathologies, such as atherosclerosis, hypoplasia, or morphological atypia. OBSERVATIONS The authors present a unique case of atlantoaxial RVAI due to rotational instability, causing marked subluxation of the C1-C2 facet joints. This case is unique in both the mechanism of compression and the lack of contralateral vertebral artery pathology. The patient was successfully treated with posterior C1-C2 instrumentation and fusion. LESSONS When evaluating patients for RVAI, neurosurgeons should be aware of the variety of pathological causes, including rotational instability from facet joint subluxation. Due to the heterogeneous nature of the pathologies causing RVAI, care must be taken to decide if conservative management or surgical correction is the right course of action. Because of this heterogeneous nature, there is no set guideline for the treatment or management of RVAI.

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