Bilateral arcuate foramen decompression for posterior circulation stroke in a child-case report and literature review.
Hogg F, Smith L, D'Arco F, Thompson D • Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery • 2026
Arcuate foramen (AF)-related vertebral artery compression represents a rare but potentially treatable cause of paediatric posterior circulation stroke, and surgical decompression may be considered when AF is identified following careful assessment of cervical spine anatomy.
Key Findings
Results
A 15-year-old boy with bilateral arcuate foramen underwent successful bilateral surgical vertebral artery decompression after presenting with posterior circulation infarction from vertebral artery dissection.
The patient presented with posterior circulation infarction secondary to vertebral artery dissection associated with bilateral arcuate foramen of the C1 vertebra.
Surgery utilized 3D-printed intraoperative guides for operative planning and execution.
Intraoperative neurophysiological monitoring remained stable throughout the procedure with no complications.
Postoperative recovery was uneventful.
At 7-month follow-up, the patient remained stroke-free with complete resolution of headaches and hypertension.
Results
A literature review identified 10 papers comprising 106 patients who underwent surgical decompression for arcuate foramen-related vertebral artery compression.
The review was conducted using PubMed and Google Scholar.
Ten papers were identified in total.
The 106 patients across these papers all underwent surgical decompression for AF-related vertebral artery compression.
The predominant surgical approach used across reported cases was a posterior midline approach.
Documentation of surgical technique for vertebral artery decompression in such cases was described as limited.
Background
The arcuate foramen is a well-described congenital anomaly of the C1 vertebra that may cause vertebral artery compression leading to posterior circulation stroke in children.
Posterior circulation stroke resulting from vertebral artery dissection in children is described as rare.
Compression of the vertebral artery within the arcuate foramen is identified as a potential mechanism for vertebral artery dissection.
The arcuate foramen is characterized as a congenital anomaly of the C1 vertebra.
The authors note that careful assessment of cervical spine anatomy should be performed in cases of paediatric posterior circulation stroke.
Conclusions
Surgical decompression of the vertebral artery at the arcuate foramen is presented as a viable treatment option for AF-related vertebral artery compression in pediatric patients.
The authors conclude that AF-related vertebral artery compression represents 'a rare but potentially treatable cause of paediatric posterior circulation stroke.'
Surgical decompression may be considered when arcuate foramen is identified in the context of paediatric posterior circulation stroke.
Use of 3D-printed intraoperative guides was employed as an adjunct for operative planning and execution in the described case.
The posterior midline approach was the predominant technique identified in the literature review.
What This Means
This paper reports on a rare cause of stroke in children: a bony abnormality at the top of the spine called an arcuate foramen (AF), which can compress an artery supplying the back of the brain (the vertebral artery) and cause it to tear, leading to stroke. The authors describe a 15-year-old boy who had this abnormality on both sides of his spine, suffered a stroke as a result, and was successfully treated with surgery to decompress both vertebral arteries. Surgeons used custom 3D-printed guides to help plan and carry out the operation safely. Seven months after surgery, the patient had no further strokes and his headaches and high blood pressure had completely resolved.
The authors also reviewed all previously published cases of surgery for this condition and found 10 studies covering 106 patients, most of whom were treated through a surgical approach from the back of the neck. This research suggests that the arcuate foramen should be looked for when children suffer strokes affecting the back of the brain, as it may be an underlying and surgically correctable cause. The use of modern tools like 3D printing for surgical planning may help improve safety and precision in these technically challenging operations.
This condition is considered rare, and there is currently limited published guidance on how to perform surgery for it. This case and the accompanying literature review add to the small body of evidence suggesting that, when identified, surgical decompression can be performed safely and may prevent future strokes in affected children.
Hogg F, Smith L, D'Arco F, Thompson D. (2026). Bilateral arcuate foramen decompression for posterior circulation stroke in a child-case report and literature review.. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery. https://doi.org/10.1007/s00381-026-07431-5