Intraoperative High-Resolution 2-Dimensional and 3-Dimensional Angiography in Cervical Decompression for Subaxial Bow...

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.^3-5Table 1 presents a summary of previously reported subaxial BHS cases. During decompression, intraoperative VA patency confirmation is essential because static postoperative imaging cannot reliably exclude residual dynamic compression, and delayed confirmation may necessitate reoperation.^6,7 We present 2 cases of subaxial rotational occlusion syndrome (subaxial BHS) treated with anterior cervical decompression and intraoperative angiography in a hybrid operating suite (Video 1). Case 1 is an 80-year-old woman with neck pain, dizziness, tinnitus, near-syncope, and ocular symptoms on leftward head rotation; computed tomography/dynamic angiography showed left VA narrowing at C4-5 from spondylotic compression. Case 2 is a 57-year-old woman with prior Eagle syndrome with vertigo, nausea, and blurred vision on left neck rotation; magnetic resonance angiography demonstrated focal left V2 stenosis at C5-6 from uncovertebral osteophytes and incidental distal VA fenestration. Both underwent anterior V2 exposure, ultrasonic drilling of osteophytes, Gore-Tex/fibrin glue reinforcement, and anterior cervical discectomy and fusion (C4-5 and C5-6) to eliminate residual rotational motion at the decompressed segment. Intraoperative biplane angiography via left radial access (Isovue-300; 6 mL at 6 mL/s per 2-dimensional run; 18 mL at 3 mL/s for 3-dimensional acquisition) with simulated head turning, performed 10-15 minutes after hemostasis under general anesthesia, supplemented by 3-dimensional 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 3, and complete symptom resolution was confirmed at 6 weeks.