Bow Hunter's syndrome surgical approach and outcome: Two new cases and literature review

Abstract

Background: Bow Hunter's syndrome (BHS) is a rare entity known as rotational vertebral artery occlusion syndrome. Classically, it presents with nausea, vertigo, and dizziness elicited by extension or rotation of the neck. There are several management approach modalities, including surgical and nonsurgical alternatives.

Methods: We conducted an electronic database search on PubMed and Scopus. The search was performed on February 18, 2024, using a combination of keywords related to Bow Hunter Syndrome regarding management. From the latter query, 97 results followed, from which we included 76 and excluded 21 due to the information being irrelevant to our study and non-retrievable publications.

Results: A total of 121 patients were retrieved. The mean age of presentation was 50 years, with a female-to-male ratio of 3:1. There were 108 adult cases, and only 13 were pediatric and adolescents. Symptoms were elicited by right rotation (46%). The most affected levels were C1-C2 (44%). The anterior approach was the most common (40%) and had a better outcome (84%), followed by the posterior (30%), which had more cases with partial recovery (19% vs. 16%).

Conclusion: BHS management is still challenging as there are many factors that we must consider when deciding on the approach. There is inconclusive evidence on the proper management of these patients. Although the suggestions found in our review and our experience are valuable, no definitive management ensures a good quality of life and outcome for these patients. Further research is needed on this topic.

Keywords: Artery; Bow; Insufficiency; Management; Occlusion; Vertebral.

Graph 1:

Approach and outcome comparison.

Figure 1:

3D XPER-computed tomography angiogram, right head rotation. The lateral view confirms contrast stagnation in the late phases at the C1 vertebral groove. Axial view confirms the atlantoaxial joint is stable. RVA: Right vertebral artery, R-Rot: Right head rotation.

Figure 2:

Microsurgical view after vertebral artery decompression. A right hemilaminectomy of C1 and the lateral superior portion of the transverse foramen was opened to allow VA foramen decompression. VA: Vertebral artery.

Figure 3:

2D DSA angiogram, right vertebral artery (VA); (a and b) AP and lateral view during the arterial phase with a neutral position. (c) Right VA injection, arterial phase. (d) Capillary phase left VA. (e) XPER computed tomography angiogram with head rotation.

Figure 4:

(a and b) Microsurgical view during vertebral artery (VA) liberation. (c) Microsurgical view after VA liberation. Postoperative angio computed tomography with left head rotation showed the decompression of the VA in C1 and C2 and the opening of the vertebral foramina.

Graph 2:

Common age of presentation. YRS: Years.