Supplementary Material for: Yoga Causing Vertebrobasilar Ischemia with Neuro-Ophthalmic Presentation: A Case Report

Introduction:
We present a case of a woman experiencing blurry vision and dizziness consistent with vertebrobasilar insufficiency during yoga confirmed with dynamic transcranial Doppler ultrasound. This is the first case identifying yoga as a cause of vertebrobasilar ischemia leading to neuro-ophthalmic findings and documenting the use of dynamic imaging to confirm vertebrobasilar ischemia during symptomatic positioning.
Case Presentation: A 56-year-old female with a past medical history of ADHD, dysthymia, allergic rhinitis, vertigo, and abnormal uterine bleeding presented to neuro-ophthalmology clinic for evaluation of transient painless bilateral “shadowing” of vision over the past year. The patient’s symptoms began two years prior with vertigo. She was treated with Epley maneuvers which resolved the vertigo. A year later, she had an acute vision change described as a shadow or blurriness in the center of her vision which lasted ten minutes. At the time, she was unable to identify a trigger. She was referred to neuro-ophthalmology clinic for further evaluation of her visual episodes, which tended to occur during yoga and were accompanied by dizziness, especially in the “upward-facing dog” pose. She subsequently underwent a dynamic transcranial Doppler ultrasound during head-turning maneuvers and yoga poses, which showed posterior cerebral artery reduction in velocity indicating vertebral artery compression. She was counseled on starting aspirin and avoiding triggers for VBI including yoga and chiropractic manipulations.
Conclusion: Neck hyperextension or rotation may lead to vertebrobasilar ischemia. Physicians should consider yoga as a potential cause of neck hyperextension leading to vertebrobasilar ischemia. This case represents the first report of yoga with a neuro-ophthalmic presentation of vertebrobasilar insufficiency confirmed by dynamic imaging.