Introduction A rare subset of strokes described in the literature occurs from dynamic compression of extracranial cerebral arteries. In these conditions, certain movements cause temporary mechanical occlusion of the vertebral or carotid arteries from nearby anatomical structures ultimately resulting in cerebral hypoperfusion and neurological symptoms. Here, the authors report three isolated cases of recurrent ischemic strokes from extrinsic compression of cerebral arteries, with two cases consistent with bow hunter syndrome and the third case with vascular Eagle syndrome.
Results Case #1: A 60-year-old male with a history of recurrent, cryptogenic PICA infarcts presented with new cerebellar infarcts. Imaging revealed a diminutive left VA coursing outside of the transverse foramina between the posterior vertebral osteophytes and the horn of the thyroid cartilage. Dynamic cerebral angiogram revealed occlusion of the left VA at C5-C6 with neck flexion that resolved upon neck extension. After confirming sufficient contralateral circulation with the balloon occlusion test, the left VA was sacrificed with coil embolization. The patient remains asymptomatic 2 years following the procedure.
Case #2: A 39-year-old retired military pilot with a history of a right VA dissection and recurrent cryptogenic posterior circulation strokes presented with an acute midbrain infarct. Imaging revealed an acute infarct in the left inferior colliculus and chronic bilateral cerebellar infarcts. His right VA traversed between the superior horn of the thyroid cartilage and the transverse process of the right C5 vertebral body. Dynamic cerebral angiogram confirmed focal occlusion of the right VA with neck turning. The patient underwent surgery to resect the affected portions of the thyroid cartilage and the C5 vertebral body. His postoperative course was unremarkable and was discharged the following day.
Case #3: A 47-year-old male presented with left hemiplegia, hemineglect, and slurred speech for 10 hours. Imaging revealed occlusion of the right ICA and occlusion distal right M2 with presence of bilateral elongated, jagged styloid processes. The right ICA thrombus was successfully aspirated. Two days later, the patient presented with new right cerebral infarcts with a long segment dissecting pseudoaneurysm of the right ICA and a short dissecting pseudoaneurysm of the left ICA. The presence of bilateral pseudoaneurysms with his elongated styloid processes raised suspicion for vascular Eagle syndrome.
Conclusion These cases illustrate an uncommon stroke etiology from dynamic extrinsic compression of extracranial cerebral arteries. Considering such a cause should be taken into account in patients presenting with recurrent, cryptogenic strokes.
Disclosures J. Choi: None. R. Zhang: None. S. Tsappidi: None. Y. Zhang: None. F. Hui: None. S. Brown: None.
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