JAMA Otol Logo Orlando 2013 AHNS Meeting Location
American Head & Neck Society
Annual Meeting, April 10-11, 2013
JW Marriott Grande Lakes
Orlando, Florida

During the
Combined Otolaryngology Spring Meeting
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Presentation: P045
Topic: Clinical - Gen. Head & Neck Surgery
Type: Poster
Date: Wednesday - Thursday, April 10 - 11, 2013
Session: Designated Poster viewing times
Authors: Maria C Buniel, MD, Shannon Kraft, MD, Gary M Nesbit, MD, Helmi L Lutsep, MD, Joshua S Schindler, MD, Bronwyn E Hamilton, MD
Institution(s): Oregon Health and Science University, Portland, OR USA

PURPOSE: Dynamic vertebral artery occlusion from head rotation and extension (Bow-hunter’s syndrome) is a rare entity, with few case reports found in the literature. In the classic syndrome, occlusion occurs at the atlanto-axial junction with head rotation. We describe a case of dynamic vertebral artery occlusion with head flexion due to compression of an aberrant vertebral artery by the ipsilateral superior cornu of the thyroid cartilage.

METHODS: We discuss the pertinent clinical features, radiographic findings, management of the case, and review the literature on dynamic vertebral artery compression.

SUMMARY: A 55 year-old female presented with nausea, vomiting and vertigo after several hours of looking down while working on a deck at her home. Six hours later, she developed slurred speech, numbness of her right face, and vertical diplopia. Initial computed tomography (CT) head revealed no intracranial abnormalities or evidence of stroke. Speech and vision abnormalities eventually resolved over the course of 4-6 hours. Subsequent neck CT angiography showed high-grade stenosis of the right vertebral artery (VA) prior to insertion into the foramen transversarium at C3. The contralateral VA entered the foramen transversarium more inferiorly at C6. There was an occlusive thrombus noted within the basilar tip of the artery, which extended into the left posterior cerebral artery (PCA). The PCAs reconstituted via a patent circle of Willis. Magnetic resonance imaging (MRI) 48 hours after initial presentation demonstrated multifocal regions of T2 hyperintensity in the right cerebellar hemisphere with evidence of restricted diffusion consistent with an acute ischemic infaction. Dynamic carotid angiogram further characterized significant narrowing of the right vertebral artery at C4 during neck flexion due to compression by the ipsilateral superior cornu of the thyroid cartilage. This resolved when the neck was extended.

The patient presented five months after her stroke for evaluation for definitive management of her unique problem. Consultation with neurology and neuroradiology colleagues led to the conclusion that her symptoms resulted from acute occlusion of the right vertebral artery from the ipsilateral superior cornu of the thyroid cartilage resulting in a thromboembolic event. The patient was given the options of medical management, vertebral artery stenting or resection of the superior cornu of the thyroid cartilage. The patient elected for laryngoplasty, given the low morbidity of such a procedure. The patient tolerated the procedure well. At two month follow-up, repeat arteriogram demonstrated resolution of dynamic vertebral artery compression. The patient no longer complains of near syncope with head flexion and her disequilibrium has improved.

DISCUSSION: While there are several case reports of vertebral artery compression with head rotation, recurrent stroke risk could not be predicted given the paucity of long-term outcomes for such a rare phenomenon. Only one other case of thyroid cartilage compression of the VA has been reported in the literature, but the patient declined surgical intervention. To our knowledge, this is the only case of dynamic vertebral artery compression by the thyroid cartilage managed with laryngoplasty.

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