Abstract Details

Title Hiding in Plain Sight: Dynamic DSA Reveals a Spectrum of Vertebral Artery Compression in Posterior Circulation Stroke – A Community-based Case Series

Topic Cerebrovascular Disease and Interventional Neurology

Presentation(s) P1 - Poster Session 1 (8:00 AM-9:00 AM)

Poster/Presentation
Number 4-012

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.

Authors/Disclosures
Mehrdad Emami, MD PRESENTER	Dr. Emami has nothing to disclose.
Michael T. Caton, Jr., MD	Dr. Caton has nothing to disclose.
Michael F. Waters, MD, PhD, FAAN (Mount Sinai Scholl of Medicine)	Dr. Waters has nothing to disclose.

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