title: Fusion surgery for recurrent cerebellar infarctions due to bilateral atlantoaxial rotational vertebral artery occlusion.
abstract: METHODS
  Case report and literature review.
  
  
  OBJECTIVE
  To describe a unique case of recurrent cerebral embolisms with "bilateral" atlantoaxial rotational vertebral artery occlusion (RVAO), and review the literature on this rare entity.
  
  
  BACKGROUND
  The few reports of bilateral bow hunter's stroke (BHS) contain either RVAO at the subaxial level, and BHS associated with bilateral RVAO at the atlantoaxial level has never been reported. The treatment strategy for this entity is controversial.
  
  
  METHODS
  An 18-year-old female experienced a cerebellar embolism in the left superior cerebellar artery area, followed by a second cerebral embolism in the right posterior inferior cerebellar artery area. Blood analysis showed no coagulation or autoimmune abnormalities. Transesophageal echocardiography ruled out a patent foramen ovale. Vertebral angiography and 3-dimensional computed tomography angiography with neck rotation clearly showed vertebral artery occlusion at the atlantoaxial level. For preventing a recurrence of thromboembolic event, surgical intervention was chosen.
  
  
  RESULTS
  The patient underwent posterior atlantoaxial fixation with an iliac bone graft 2 months after the previous cerebellar infarction. Her postoperative course was uneventful. At 22 months of follow-up, she had no neurological deficits or further infarctions. Bony fusion was radiologically confirmed and 3-dimensional computed tomography angiography with neck rotation showed good patency of vertebral arteries.
  
  
  CONCLUSIONS
  To our knowledge, the 7 published reports of bilateral BHS or RVAO involve double causes both the atlantoaxial and subaxial levels, but 1 unspecified case. Because of the difficulty to identify the proper affected side in the case of bilateral atlantoaxial BHS with certainty, fusion surgery may be suitable for the reliable treatment.
  
  
  METHODS
  N/A.
authors.affiliation: From the Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan.
authors.forename: Yasuhiro
authors.initials: Y
authors.lastname: Takeshima
authors.forename: Fumihiko
authors.initials: F
authors.lastname: Nishimura
authors.forename: Young-Su
authors.initials: YS
authors.lastname: Park
authors.forename: Hiroyuki
authors.initials: H
authors.lastname: Nakase
mesh_terms: D000293:Adolescent; D001268:Atlanto-Axial Joint / Q000601:surgery*; D020520:Brain Infarction / Q000209:etiology / Q000601:surgery*; D002526:Cerebellar Diseases / Q000209:etiology / Q000601:surgery*; D005260:Female; D006801:Humans; D012399:Rotation; D013123:Spinal Fusion; D016896:Treatment Outcome; D014715:Vertebrobasilar Insufficiency / Q000150:complications / Q000601:surgery*