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Bow Hunter’s Syndrome in the Setting of Contralateral Vertebral Artery Stenosis: Evaluation and Treatment Options

Horowitz, Michael MD*†; Jovin, Tudor MD; Balzar, Jeff PhD*; Welch, William MD*; Kassam, Amin MD

Case Reports

Study Design. A case report.

Objective. To illustrate a rare case of bow hunter’s syndrome in a patient with significant contralateral vertebral artery (VA) occlusive disease.

Summary of Background Data. Bow hunter’s syndrome is an uncommon condition in which the VA is symptomatically occluded during neck rotation. This case is interesting in that the patient had what appeared to be a normal right VA and occluded left VA when the head was in the neutral position. When the head was rotated 45° to the left, the patient’s right VA was occluded (bow hunter’s finding), and it became apparent that the left VA was not completely occluded (as it appeared in the neutral position angiogram) but rather was 90% stenosed. The complete occlusion appearance in the neutral position was an angiographic phenomenon caused by competitive flow through the open right VA. When the patient rotated his head to the left, he occluded his right VA and had insufficient blood flow through the left VA, thus creating a symptomatic ischemic state.

Methods. This case was studied using dynamic computed tomography imaging, single-photon emission computed tomography, transcranial Doppler ultrasound, brain stem auditory evoked potentials, and dynamic range-of-motion cerebral angiography

Results. The patient demonstrated bow hunter’s syndrome as documented on clinical examination and history. Transcranial Doppler studies, dynamic computed tomography scanning, and cerebral/cervical angiography confirmed the diagnosis and revealed an interesting angiographic pattern, which explained the patient’s symptoms and findings only when angiographic flow patterns were taken into consideration.

Conclusions. Bow hunter’s syndrome should be suspected when a patient presents with reproducible vertebrobasilar symptoms on rotating the neck. Quantitative documentation using imaging and electroneurophysiologic tests is important when assessing this subjective process. Careful evaluation of the angiographic imagescan often help explain an odd flow pattern and provide the physician with a range of treatment options.

From the Departments of *Neurosurgery, †Radiology, ‡Neurology, and §Otolaryngology,

University of Pittsburgh Medical Center–Presbyterian University Hospital, Pittsburgh, Pennsylvania.

Device status/drug statement: This report does not contain information about medical device(s)/drug(s).

Conflict of interest: No funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this report.

Address reprint requests to: Michael Horowitz, MD, Department of Neurosurgery, University of Pittsburgh Medical Center, Suite B400, 200 Lothrop Street, Pittsburgh, PA 15213-2582. E-mail:

© 2002 Lippincott Williams & Wilkins, Inc.