Rotational vertebral artery occlusion, also known as bow hunter's syndrome, is a 
well-documented surgically amenable cause of vertebrobasilar insufficiency. 
Traditionally, patients have been imaged using dynamic rotational angiography. 
The authors sought to determine whether intraoperative indocyanine green (ICG) 
angiography could reliably assess the adequacy of surgical decompression of the 
vertebral artery (VA). The authors report two patients who presented with 
multiple transient episodes of syncope provoked by turning their head to the 
right. Rotational dynamic angiography revealed a dominant VA that became 
occluded with head rotation to the right side. The patients underwent successful 
surgical decompression of the VA via an anterior cervical approach. 
Intraoperative ICG angiography demonstrated patency of the VA with head 
rotation. This was further confirmed by intraoperative dynamic catheter 
angiography. To our knowledge, we present the first two cases of the use of ICG 
combined with intraoperative dynamic rotational angiography to document the 
adequacy of surgical decompression of the VA in a patient with rotational 
vertebral artery occlusion. Intraoperative ICG angiography is a useful adjunct 
and may potentially supplant the need for intraoperative catheter angiography.