{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,4]],"date-time":"2026-08-04T23:06:09Z","timestamp":1785884769326,"version":"3.56.0"},"reference-count":92,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"4","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["FOC"],"published-print":{"date-parts":[[2015,4]]},"abstract":"<jats:p>\n                    The craniocervical junction (CCJ) functions within a complicated regional anatomy necessary to protect and support vital neurovascular structures. In select instances, vascular pathology can be attributed to this complicated interplay of motion and structure found within this narrow space. The authors report 3 cases of complex vascular pathology related to motion at the CCJ and detail the management of these cases. Two cases involved posterior circulation vascular compression syndromes, and one case involved a vascular anomaly and its relation to aneurysm formation and rupture. The patient in Case 1 was a 66-year-old man with a history of syncopal episodes resulting from the bilateral vertebral artery becoming occluded when he rotated his head. Successful microsurgical decompression at the skull base resulted in patent bilateral vertebral artery V\n                    <jats:sub>3<\/jats:sub>\n                    segments upon head movement in all directions. The patient in Case 2 was a 53-year-old woman who underwent elective resection of a right temporal meningioma and who experienced postoperative drowsiness, dysphagia, and mild right-arm ataxia. Subsequent MRI demonstrated bilateral posterior inferior cerebel-lar artery (PICA) strokes. Cerebral angiography showed a single PICA, of extradural origin, supplying both cerebellar hemispheres. The PICA exhibited dynamic extradural compression when the patient rotated her head; the bilateral PICA strokes were due to head rotation during surgical positioning. In Case 3, a 37-year-old woman found unconscious in her home had diffuse subarachnoid hemorrhage and evidence of a right PICA aneurysm. A right far-lateral craniectomy was performed for aneurysm clipping, and she was found to have a dissecting aneurysm with an associated PICA originating extradurally. There was a shearing phenomenon of the extradural PICA along the dura of the foramen magnum, and this microtraumatic stress imposed on the vessel resulted in a dissecting aneurysm. This series of complex and unusual cases highlights the authors\u2019 understanding of vascular pathology of the CCJ and its management.\n                  <\/jats:p>","DOI":"10.3171\/2015.1.focus14826","type":"journal-article","created":{"date-parts":[[2015,4,1]],"date-time":"2015-04-01T13:05:25Z","timestamp":1427893525000},"page":"E6","source":"Crossref","is-referenced-by-count":6,"title":["Motion-related vascular abnormalities at the craniocervical junction: illustrative case series and literature review"],"prefix":"10.3171","volume":"38","author":[{"given":"Vijay M.","family":"Ravindra","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jayson A.","family":"Neil","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marcus D.","family":"Mazur","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Min S.","family":"Park","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"William T.","family":"Couldwell","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Philipp","family":"Taussky","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"key":"b1-focus14826","first-page":"519","article-title":"Vertebrobasilar occlusion disease, in Barnett HJ, Mohr JP, Stein BM (eds):Stroke: Pathophysiology, Diagnosis, and Management, ed 3","author":"Amarenco","year":"1998"},{"key":"b2-focus14826","series-title":"Neuroradiology","first-page":"117","article-title":"Rotational obstructions of the vertebral artery at the atlantoaxial joint","volume":"9","author":"Barton","year":"1975"},{"key":"b3-focus14826","first-page":"1209","article-title":"Surgical management of aneurysms of the vertebral and posterior inferior cerebellar artery complex, in Schmidek HH, Roberts DW (eds):Operative Neurosurgical Techniques: Indications, Methods, and Results, ed 5","volume":"1","author":"Bertalanffy","year":"2006"},{"key":"b4-focus14826","series-title":"Surg Neurol","first-page":"406","article-title":"Aneurysms from extracranial, extradurally originating posterior inferior cerebellar arteries: a rare case report","volume":"72","author":"Bhat","year":"2009"},{"key":"b5-focus14826","series-title":"Surg Neurol","first-page":"625","article-title":"Rotational vertebral artery insufficiency resulting from cervical spondylosis: case report and review of the literature","volume":"65","author":"Bulsara","year":"2006"},{"key":"b6-focus14826","series-title":"Neurology","first-page":"2011","article-title":"Dominant vertebral artery occlusion during ipsilateral head tilt","volume":"76","author":"Choi"},{"key":"b7-focus14826","series-title":"Stroke","first-page":"1817","article-title":"Rotational vertebral artery occlusion: mechanisms and long-term outcome","volume":"44","author":"Choi","year":"2013"},{"key":"b8-focus14826","series-title":"Neurosurg Rev","first-page":"127","article-title":"Bow-hunter\u2019s syndrome caused by dynamic vertebral artery stenosis at the craniocervical junction\u2014a management algorithm based on a systematic review and a clinical series","volume":"35","author":"Cornelius","year":"2012"},{"key":"b9-focus14826","series-title":"J Neuroimaging","first-page":"184","article-title":"Rotational vertebrobasilar insufficiency due to dynamic compression of the dominant vertebral artery by the thyroid cartilage and occlusion of the contralateral vertebral artery at C1-2 level","volume":"18","author":"Dabus","year":"2008"},{"key":"b10-focus14826","series-title":"Neuroradiology","first-page":"514","article-title":"Rotational vertebrobasilar insufficiency secondary to vertebral artery occlusion from fibrous band of the longus coli muscle","volume":"32","author":"Dadsetan","year":"1990"},{"key":"b11-focus14826","series-title":"J Stroke Cerebrovasc Dis","first-page":"908.e1","article-title":"Vertebral artery stenting for the treatment of bow hunter\u2019s syndrome: report of 4 cases","volume":"21","author":"Darkhabani","year":"2012"},{"key":"b12-focus14826","series-title":"Neurosurgery","first-page":"93","article-title":"Surgical correction of lesions affecting the second portion of the vertebral artery","volume":"19","author":"Diaz","year":"1986"},{"key":"b13-focus14826","series-title":"Stroke","first-page":"1452","article-title":"Vertebrobasilar ischemia after neck motion","volume":"22","author":"Frisoni","year":"1991"},{"key":"b14-focus14826","series-title":"Neurol Med Chir (Tokyo)","first-page":"1020","article-title":"Rotational stenosis of the first segment of the vertebral artery through compression by the cervical sympathetic chain\u2014case report","volume":"28","author":"Fujimoto","year":"1988"},{"key":"b15-focus14826","series-title":"Interv Neuroradiol","first-page":"304","article-title":"Treatment of ruptured vertebral artery dissecting aneurysms. A short report","volume":"20","author":"Hamasaki","year":"2014"},{"key":"b16-focus14826","series-title":"J Clin Neurosci","first-page":"209","article-title":"Bow hunter\u2019s syndrome secondary to bilateral dynamic vertebral artery compression","volume":"22","author":"Healy","year":"2015"},{"key":"b17-focus14826","series-title":"JAMA","first-page":"475","article-title":"Mechanical occlusion of the vertebral artery. A new clinical concept","volume":"196","author":"Husni","year":"1966"},{"key":"b18-focus14826","series-title":"Brain","first-page":"319","article-title":"The cervical portion of the vertebral artery; a clinico-pathological study","volume":"79","author":"Hutchinson","year":"1956"},{"key":"b19-focus14826","series-title":"J Neurosurg","first-page":"1031","article-title":"Rotational occlusion of the vertebral artery caused by transverse process hyperrotation and unilateral apophyseal joint subluxation. Case report","volume":"86","author":"Kawaguchi","year":"1997"},{"key":"b20-focus14826","series-title":"Neurosurgery","first-page":"672","article-title":"Vertebral artery occlusion at the narrowed \u201cscalenovertebral angle\u201d: mechanical vertebral occlusion in the distal first portion","volume":"16","author":"Kojima","year":"1985"},{"key":"b21-focus14826","series-title":"Neurosurgery","first-page":"427","article-title":"Rotational vertebral artery occlusion: a mechanism of vertebrobasilar insufficiency","volume":"41","author":"Kuether","year":"1997"},{"issue":"4 Suppl","key":"b22-focus14826","series-title":"Neurosurgery","first-page":"367","article-title":"Far-lateral approach to the craniocervical junction","volume":"57","author":"Lanzino","year":"2005"},{"key":"b23-focus14826","series-title":"Neurosurgery","first-page":"1066","article-title":"Rotational vertebral artery occlusion-series of 9 cases","volume":"67","author":"Lu","year":"2010"},{"key":"b24-focus14826","series-title":"J Neurosurg","first-page":"581","article-title":"Vertebrobasilar insufficiency secondary to vertebral artery occlusion from a fibrous band. Case report","volume":"56","author":"Mapstone","year":"1982"},{"key":"b25-focus14826","series-title":"Neurosurgery","first-page":"1393","article-title":"Bow Hunter\u2019s stroke caused by a nondominant vertebral artery occlusion: case report","volume":"41","author":"Matsuyama","year":"1997"},{"key":"b26-focus14826","series-title":"J Neurosurg","first-page":"619","article-title":"Comparison of C1-2 posterior fusion and decompression of the vertebral artery in the treatment of bow hunter\u2019s stroke","volume":"86","author":"Matsuyama","year":"1997"},{"key":"b27-focus14826","series-title":"Cerebrovascular Surgery","first-page":"529","article-title":"Vertebral artery insufficiency and cervical spondylosis","author":"Nagashima","year":"1985"},{"key":"b28-focus14826","series-title":"J Neurol","first-page":"1775","article-title":"Rotational vertebral artery syndrome due to compression of nondominant vertebral artery terminating in posterior inferior cerebellar artery","volume":"258","author":"Noh","year":"2011"},{"key":"b29-focus14826","series-title":"Acta Neurochir (Wien)","first-page":"391","article-title":"Vertebral artery decompression in a patient with rotational occlusion","volume":"150","author":"Petridis","year":"2008"},{"key":"b30-focus14826","series-title":"J Am Med Assoc","first-page":"600","article-title":"Cerebellar and spinal injuries after chiropractic manipulation","volume":"133","author":"Pratt-Thomas","year":"1947"},{"issue":"3 Suppl","key":"b31-focus14826","series-title":"Neurosurgery","first-page":"S29","article-title":"The cerebellar arteries","volume":"47","author":"Rhoton","year":"2000"},{"key":"b32-focus14826","series-title":"Neurology","first-page":"216","article-title":"Intermittent downbeat nystagmus due to vertebral artery compression","volume":"43","author":"Rosengart","year":"1993"},{"key":"b33-focus14826","series-title":"N Engl J Med","first-page":"898","article-title":"Spontaneous dissection of the carotid and vertebral arteries","volume":"344","author":"Schievink","year":"2001"},{"key":"b34-focus14826","series-title":"Neurology","first-page":"968","article-title":"Vertebral artery compression in cervical spondylosis: Arteriographic demonstration during life of vertebral artery insufficiency due to rotation and extension of the neck","volume":"10","author":"Sheehan","year":"1960"},{"key":"b35-focus14826","series-title":"Neurosurgery","first-page":"259","article-title":"Bow hunter\u2019s stroke","volume":"2","author":"Sorensen","year":"1978"},{"key":"b36-focus14826","series-title":"Neurology","first-page":"1376","article-title":"Rotational vertebral artery occlusion syndrome with vertigo due to \u201clabyrinthine excitation.\u201d","volume":"54","author":"Strupp","year":"2000"},{"key":"b37-focus14826","series-title":"Headache","first-page":"187","article-title":"Headache and neck pain: the warning symptoms of vertebral artery dissection","volume":"34","author":"Sturzenegger","year":"1994"},{"key":"b38-focus14826","series-title":"Stroke","first-page":"1776","article-title":"Dynamic transcranial Doppler assessment of positional vertebrobasilar ischemia","volume":"25","author":"Sturzenegger","year":"1994"},{"key":"b39-focus14826","first-page":"E1097","article-title":"Extracranial aneurysm of the posterior inferior cerebellar artery with an aberrant origination: case report","volume":"61","author":"Tabatabai","year":"2007"},{"key":"b40-focus14826","series-title":"Neurology","first-page":"331","article-title":"Syndrome of vertebral artery compression","volume":"7","author":"Tissington Tatlow","year":"1957"},{"key":"b41-focus14826","series-title":"Neurol Med Chir (Tokyo)","first-page":"90","article-title":"Simultaneous bilateral vertebral artery occlusion in the lower cervical spine manifesting as bow hunter\u2019s syndrome","volume":"48","author":"Tsutsumi","year":"2008"},{"issue":"1 Suppl","key":"b42-focus14826","series-title":"J Neurosurg","first-page":"90","article-title":"Bow hunter stroke caused by cervical disc herniation. Case report","volume":"96","author":"Vates","year":"2002"},{"key":"b43-focus14826","series-title":"Neurosurgery","first-page":"36","article-title":"Rotational vertebrobasilar ischemia: hemodynamic assessment and surgical treatment","volume":"56","author":"Vilela","year":"2005"},{"key":"b44-focus14826","series-title":"AJNR Am J Neuroradiol","first-page":"96","article-title":"Rotational vertebral artery occlusion at C1-C2","volume":"6","author":"Yang","year":"1985"},{"key":"b45-focus14826","series-title":"Acta Neurol Taiwan","first-page":"69","article-title":"A case of bow hunter\u2019s stroke caused by non-dominant vertebral artery","volume":"14","author":"Yeh","year":"2005"},{"key":"b46-focus14826","series-title":"World Neurosurg","first-page":"733","article-title":"Diagnosis and management of bow hunter\u2019s syndrome: 15-year experience at Barrow Neurological Institute","volume":"82","author":"Zaidi","year":"2014"},{"key":"b1-focus14826","first-page":"519","article-title":"Vertebrobasilar occlusion disease, in Barnett HJ, Mohr JP, Stein BM (eds):Stroke: Pathophysiology, Diagnosis, and Management, ed 3","author":"Amarenco","year":"1998"},{"key":"b2-focus14826","series-title":"Neuroradiology","first-page":"117","article-title":"Rotational obstructions of the vertebral artery at the atlantoaxial joint","volume":"9","author":"Barton","year":"1975"},{"key":"b3-focus14826","first-page":"1209","article-title":"Surgical management of aneurysms of the vertebral and posterior inferior cerebellar artery complex, in Schmidek HH, Roberts DW (eds):Operative Neurosurgical Techniques: Indications, Methods, and Results, ed 5","volume":"1","author":"Bertalanffy","year":"2006"},{"key":"b4-focus14826","series-title":"Surg Neurol","first-page":"406","article-title":"Aneurysms from extracranial, extradurally originating posterior inferior cerebellar arteries: a rare case report","volume":"72","author":"Bhat","year":"2009"},{"key":"b5-focus14826","series-title":"Surg Neurol","first-page":"625","article-title":"Rotational vertebral artery insufficiency resulting from cervical spondylosis: case report and review of the literature","volume":"65","author":"Bulsara","year":"2006"},{"key":"b6-focus14826","series-title":"Neurology","first-page":"2011","article-title":"Dominant vertebral artery occlusion during ipsilateral head tilt","volume":"76","author":"Choi"},{"key":"b7-focus14826","series-title":"Stroke","first-page":"1817","article-title":"Rotational vertebral artery occlusion: mechanisms and long-term outcome","volume":"44","author":"Choi","year":"2013"},{"key":"b8-focus14826","series-title":"Neurosurg Rev","first-page":"127","article-title":"Bow-hunter\u2019s syndrome caused by dynamic vertebral artery stenosis at the craniocervical junction\u2014a management algorithm based on a systematic review and a clinical series","volume":"35","author":"Cornelius","year":"2012"},{"key":"b9-focus14826","series-title":"J Neuroimaging","first-page":"184","article-title":"Rotational vertebrobasilar insufficiency due to dynamic compression of the dominant vertebral artery by the thyroid cartilage and occlusion of the contralateral vertebral artery at C1-2 level","volume":"18","author":"Dabus","year":"2008"},{"key":"b10-focus14826","series-title":"Neuroradiology","first-page":"514","article-title":"Rotational vertebrobasilar insufficiency secondary to vertebral artery occlusion from fibrous band of the longus coli muscle","volume":"32","author":"Dadsetan","year":"1990"},{"key":"b11-focus14826","series-title":"J Stroke Cerebrovasc Dis","first-page":"908.e1","article-title":"Vertebral artery stenting for the treatment of bow hunter\u2019s syndrome: report of 4 cases","volume":"21","author":"Darkhabani","year":"2012"},{"key":"b12-focus14826","series-title":"Neurosurgery","first-page":"93","article-title":"Surgical correction of lesions affecting the second portion of the vertebral artery","volume":"19","author":"Diaz","year":"1986"},{"key":"b13-focus14826","series-title":"Stroke","first-page":"1452","article-title":"Vertebrobasilar ischemia after neck motion","volume":"22","author":"Frisoni","year":"1991"},{"key":"b14-focus14826","series-title":"Neurol Med Chir (Tokyo)","first-page":"1020","article-title":"Rotational stenosis of the first segment of the vertebral artery through compression by the cervical sympathetic chain\u2014case report","volume":"28","author":"Fujimoto","year":"1988"},{"key":"b15-focus14826","series-title":"Interv Neuroradiol","first-page":"304","article-title":"Treatment of ruptured vertebral artery dissecting aneurysms. A short report","volume":"20","author":"Hamasaki","year":"2014"},{"key":"b16-focus14826","series-title":"J Clin Neurosci","first-page":"209","article-title":"Bow hunter\u2019s syndrome secondary to bilateral dynamic vertebral artery compression","volume":"22","author":"Healy","year":"2015"},{"key":"b17-focus14826","series-title":"JAMA","first-page":"475","article-title":"Mechanical occlusion of the vertebral artery. A new clinical concept","volume":"196","author":"Husni","year":"1966"},{"key":"b18-focus14826","series-title":"Brain","first-page":"319","article-title":"The cervical portion of the vertebral artery; a clinico-pathological study","volume":"79","author":"Hutchinson","year":"1956"},{"key":"b19-focus14826","series-title":"J Neurosurg","first-page":"1031","article-title":"Rotational occlusion of the vertebral artery caused by transverse process hyperrotation and unilateral apophyseal joint subluxation. Case report","volume":"86","author":"Kawaguchi","year":"1997"},{"key":"b20-focus14826","series-title":"Neurosurgery","first-page":"672","article-title":"Vertebral artery occlusion at the narrowed \u201cscalenovertebral angle\u201d: mechanical vertebral occlusion in the distal first portion","volume":"16","author":"Kojima","year":"1985"},{"key":"b21-focus14826","series-title":"Neurosurgery","first-page":"427","article-title":"Rotational vertebral artery occlusion: a mechanism of vertebrobasilar insufficiency","volume":"41","author":"Kuether","year":"1997"},{"issue":"4 Suppl","key":"b22-focus14826","series-title":"Neurosurgery","first-page":"367","article-title":"Far-lateral approach to the craniocervical junction","volume":"57","author":"Lanzino","year":"2005"},{"key":"b23-focus14826","series-title":"Neurosurgery","first-page":"1066","article-title":"Rotational vertebral artery occlusion-series of 9 cases","volume":"67","author":"Lu","year":"2010"},{"key":"b24-focus14826","series-title":"J Neurosurg","first-page":"581","article-title":"Vertebrobasilar insufficiency secondary to vertebral artery occlusion from a fibrous band. Case report","volume":"56","author":"Mapstone","year":"1982"},{"key":"b25-focus14826","series-title":"Neurosurgery","first-page":"1393","article-title":"Bow Hunter\u2019s stroke caused by a nondominant vertebral artery occlusion: case report","volume":"41","author":"Matsuyama","year":"1997"},{"key":"b26-focus14826","series-title":"J Neurosurg","first-page":"619","article-title":"Comparison of C1-2 posterior fusion and decompression of the vertebral artery in the treatment of bow hunter\u2019s stroke","volume":"86","author":"Matsuyama","year":"1997"},{"key":"b27-focus14826","series-title":"Cerebrovascular Surgery","first-page":"529","article-title":"Vertebral artery insufficiency and cervical spondylosis","author":"Nagashima","year":"1985"},{"key":"b28-focus14826","series-title":"J Neurol","first-page":"1775","article-title":"Rotational vertebral artery syndrome due to compression of nondominant vertebral artery terminating in posterior inferior cerebellar artery","volume":"258","author":"Noh","year":"2011"},{"key":"b29-focus14826","series-title":"Acta Neurochir (Wien)","first-page":"391","article-title":"Vertebral artery decompression in a patient with rotational occlusion","volume":"150","author":"Petridis","year":"2008"},{"key":"b30-focus14826","series-title":"J Am Med Assoc","first-page":"600","article-title":"Cerebellar and spinal injuries after chiropractic manipulation","volume":"133","author":"Pratt-Thomas","year":"1947"},{"issue":"3 Suppl","key":"b31-focus14826","series-title":"Neurosurgery","first-page":"S29","article-title":"The cerebellar arteries","volume":"47","author":"Rhoton","year":"2000"},{"key":"b32-focus14826","series-title":"Neurology","first-page":"216","article-title":"Intermittent downbeat nystagmus due to vertebral artery compression","volume":"43","author":"Rosengart","year":"1993"},{"key":"b33-focus14826","series-title":"N Engl J Med","first-page":"898","article-title":"Spontaneous dissection of the carotid and vertebral arteries","volume":"344","author":"Schievink","year":"2001"},{"key":"b34-focus14826","series-title":"Neurology","first-page":"968","article-title":"Vertebral artery compression in cervical spondylosis: Arteriographic demonstration during life of vertebral artery insufficiency due to rotation and extension of the neck","volume":"10","author":"Sheehan","year":"1960"},{"key":"b35-focus14826","series-title":"Neurosurgery","first-page":"259","article-title":"Bow hunter\u2019s stroke","volume":"2","author":"Sorensen","year":"1978"},{"key":"b36-focus14826","series-title":"Neurology","first-page":"1376","article-title":"Rotational vertebral artery occlusion syndrome with vertigo due to \u201clabyrinthine excitation.\u201d","volume":"54","author":"Strupp","year":"2000"},{"key":"b37-focus14826","series-title":"Headache","first-page":"187","article-title":"Headache and neck pain: the warning symptoms of vertebral artery dissection","volume":"34","author":"Sturzenegger","year":"1994"},{"key":"b38-focus14826","series-title":"Stroke","first-page":"1776","article-title":"Dynamic transcranial Doppler assessment of positional vertebrobasilar ischemia","volume":"25","author":"Sturzenegger","year":"1994"},{"key":"b39-focus14826","first-page":"E1097","article-title":"Extracranial aneurysm of the posterior inferior cerebellar artery with an aberrant origination: case report","volume":"61","author":"Tabatabai","year":"2007"},{"key":"b40-focus14826","series-title":"Neurology","first-page":"331","article-title":"Syndrome of vertebral artery compression","volume":"7","author":"Tissington Tatlow","year":"1957"},{"key":"b41-focus14826","series-title":"Neurol Med Chir (Tokyo)","first-page":"90","article-title":"Simultaneous bilateral vertebral artery occlusion in the lower cervical spine manifesting as bow hunter\u2019s syndrome","volume":"48","author":"Tsutsumi","year":"2008"},{"issue":"1 Suppl","key":"b42-focus14826","series-title":"J Neurosurg","first-page":"90","article-title":"Bow hunter stroke caused by cervical disc herniation. 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