Hiding in Plain Sight: Dynamic DSA Reveals a Spectrum of Vertebral Artery Compression in Posterior Circulation Stroke – A Community-based Case Series
Objective:
To describe a spectrum of vertebral artery compression detected through dynamic digital subtraction angiography (DSA) in patients with posterior circulation stroke and inconclusive standard vascular imaging.
Background:
Posterior circulation strokes without clear etiologies on CTA or MRA are frequently attributed to cardioembolic or hypercoagulable causes, leading to under-recognition of dynamic vascular pathologies such as Bow Hunter’s Syndrome (BHS). BHS encompasses vertebrobasilar insufficiency secondary to head-position–dependent vertebral artery compression, ranging from mild kinking to complete occlusion. Vertebral artery pseudoaneurysm may serve as a marker of dynamic pathology warranting targeted evaluation.
Design/Methods:
We retrospectively reviewed three patients presenting with posterior circulation infarcts over one year at a community hospital whose initial CTA and MRA were inconclusive. All underwent negative hypercoagulable and cardioembolic evaluations. Each subsequently received catheter-based dynamic DSA with head-turning maneuvers to assess for rotational vascular compromise.
Results:
Case 1: A 41-year-old man with bilateral cerebellar and thalamic infarcts had partial compression of a left V3 pseudoaneurysm during rotation.
Case 2: A 45-year-old man with recurrent cerebellar infarcts demonstrated dynamic kinking and flow reduction of the dominant right vertebral artery with rightward head turn, reproducing dizziness.
Case 3: A 61-year-old woman with recurrent posterior circulation strokes despite optimal medical therapy showed complete occlusion of the right vertebral artery at 60° contralateral rotation, associated with a 6 mm pseudoaneurysm.
These cases illustrate a continuum of BHS pathology—from partial compression to dynamic kinking to complete occlusion with pseudoaneurysm formation.
Conclusions:
Detection of three such cases within one year at a thrombectomy-capable community hospital underscores that dynamic vertebral artery compression is likely underdiagnosed. Recognition of pseudoaneurysm as a potential marker of mechanical stress and incorporation of dynamic vascular testing into stroke evaluation may improve diagnostic accuracy and prevent recurrent ischemic events.
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