Asymptomatic rotational vertebral artery compression in a child due to head positioning for cranial surgery: illustrative case

M. Travis Caton, Kazim Narsinh, Amanda Baker, Adib A. Abla, Jarod L. Roland, Van V. Halbach, Christine K. Fox, Heather J. Fullerton, Steven W. Hetts

Research output: Contribution to journalArticlepeer-review

2 Scopus citations


BACKGROUND The authors recently reported a series of children with vertebral artery (VA) compression during head turning who presented with recurrent posterior circulation stroke. Whether VA compression occurs during head positioning for cranial surgery is unknown. OBSERVATIONS The authors report a case of a child with incidental rotational occlusion of the VA observed during surgical head positioning for treatment of an intracranial arteriovenous fistula. Intraoperative angiography showed dynamic V3 occlusion at the level of C2 with distal reconstitution via a muscular branch “jump” collateral, supplying reduced flow to the V4 segment. She had no clinical history or imaging suggesting acute or prior stroke. Sequential postoperative magnetic resonance imaging scans demonstrated signal abnormality of the left rectus capitus muscle, suggesting ischemic edema. LESSONS This report demonstrates that rotational VA compression during neurosurgical head positioning can occur in children but may be asymptomatic due to the presence of muscular VA–VA “jump” collaterals and contralateral VA flow. Although unilateral VA compression may be tolerated by children with codominant VAs, diligence when rotating the head away from a dominant VA is prudent during patient positioning to avoid posterior circulation ischemia or thromboembolism.

Original languageEnglish
Article numberCASE2085
JournalJournal of Neurosurgery: Case Lessons
Issue number3
StatePublished - Jan 2021
Externally publishedYes


  • bow hunter’s syndrome
  • pediatric neurosurgery
  • pediatric stroke
  • vertebral artery
  • vertebral artery compression


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