KIMMERLE ANOMALY AS A DYNAMIC CRANIOCERVICAL NEUROVASCULAR COMPRESSION SYNDROME: AN INTEGRATIVE REVIEW AND PROPOSED DIAGNOSTIC–THERAPEUTIC FRAMEWORK

Аннотация

Background. Kimmerle anomaly, also termed ponticulus posticus or arcuate foramen, is an osseous bridge over the vertebral artery groove of the atlas. Although usually incidental, it may become clinically relevant when the V3 segment of the vertebral artery, periarterial sympathetic plexus, venous plexus, or C1–C2 neural structures are constrained during head rotation. 
Materials and methods. A structured literature synthesis was conducted using biomedical publications, emphasizing systematic reviews, meta-analyses, computed-tomography studies, surgical reports published through July 2026. Evidence was organized according to morphology, dynamic vascular behavior, symptom reproducibility, collateral circulation, and treatment response. 
Results. Reported  prevalence  varies  because  of  population  differences  and  imaging methodology;  modern  CT-based  analyses  identify  ponticulus  posticus  as  a  common  anatomical variant. In practice, morphology alone does not establish causality. The strongest evidence of clinical significance is concordance between a compatible posterior-circulation or suboccipital syndrome, reproducible positional symptoms, structural narrowing around the V3 segment, and demonstrable flow reduction during provocative testing. Thin-slice CT defines osseous anatomy, CT angiography or MR angiography evaluates vascular relationships, duplex or transcranial Doppler provides dynamic screening, and rotational digital subtraction angiography remains the reference test when necessary. 
Conclusion. Clinically  significant  Kimmerle  anomaly  should  be  regarded  as  a  dynamic craniocervical neurovascular compression syndrome. Conservative management is appropriate for most  patients,  whereas  microsurgical  decompression  or  stabilization  should  be  reserved  for hemodynamically verified, refractory cases.
Keywords: Kimmerle anomaly; ponticulus posticus; arcuate foramen; vertebral artery; V3 segment; rotational vertebral artery syndrome; Bow Hunter syndrome; CT angiography; dynamic ultrasonography; craniovertebral junction.