Endovascular Coil Embolization for Recurrent Bow Hunter's Stroke

[Repeated Bow hunter's stroke by artery-to-artery embolism from the vertebral artery dissecting aneurysm formed by head rotation: A case report]

A 55-year-old woman suffered from diplopia and occipital pain after shoveling snow. She was diagnosed with the right vertebral artery dissecting aneurysm at the level of the axial vertebra and repeatedly had cerebral infarctions in the posterior circulation. She had subluxation of the atlantoaxial vertebra as an underlying disease. Right vertebral angiogram with the head rotated to the left showed the right vertebral artery occlusion and left vertebral angiogram with the head rotated to the right showed stenosis at the C1-C2 level, leading to the diagnosis of Bow hunter's stroke. After wearing a cervical collar and taking 100 ‍mg of aspirin, she had no recurrence of cerebral infarction and later underwent C1-C2 posterior fusion to prevent the recurrence of cerebral infarction. She finished taking aspirin 6 months after the surgery, and there has been no recurrence of cerebral infarction. We report here a case of Bow hunter's stroke, a rare disease, with good clinical outcomes after C1-C2 posterior fusion.

A synovial cyst-induced vertebral artery dissection in bow hunter's stroke: illustrative case

BACKGROUND

Bow hunter's stroke (BHS) is a rare condition characterized by occlusion of the vertebral artery (VA) due to a head rotation. BHS typically results from neck hyperrotation, often due to anatomical factors. The authors present a case of BHS in a young male patient exacerbated by os odontoideum (OD), resulting in atlantoaxial dislocation, which ultimately led to VA dissection.

OBSERVATIONS

A man in his 20s presented with persistent dizziness and nausea and initially received a diagnosis of a brain infarction. However, imaging revealed VA dissection caused by an OD with an associated synovial cyst. Surgical intervention, specifically atlantoaxial posterior fixation, resolved the instability and allowed for natural regression of the synovial cysts, preventing further vascular events. In this case, the OD with atlantoaxial dislocation was identified as the causative factor for BHS. The coexistence of a synovial cyst was a unique finding, likely triggered by chronic irritation caused by the OD.

LESSONS

This case emphasizes the importance of thorough cervical spinal evaluation in young patients presenting with posterior circulation stroke. https://thejns.org/doi/10.3171/CASE2487.

Safety and efficacy of dynamic catheter-directed cerebral digital subtraction angiography for diagnosis of bowhunter syndrome spectrum disorders: A systematic review of the literature

INTRODUCTION

Dynamic catheter-directed cerebral digital subtraction angiography (dcDSA) is the gold standard for diagnosing dynamic vascular occlusion syndromes such as bowhunter syndrome (BHS). Nonetheless, concerns about its safety exist and no standardized protocols have been published to date.

METHODS

We describe our methodology and insights regarding the use of dcDSA in patients with BHS. We also perform a systematic literature review to identify cases of typical and atypical presentations of BHS wherein dcDSA was utilized and report on any procedural complications related to dcDSA.

RESULTS

Our study included 104 cases wherein dcDSA was used for the diagnosis of BHS. There were 0 reported complications of dcDSA. DcDSA successfully established diagnosis in 102 of these cases. Thirty-eight cases were deemed atypical presentations of BHS. Fourteen patients endorsed symptoms during neck flexion/extension. In eight cases, there was dynamic occlusion of bilateral vertebral arteries during a single maneuver. Three patients had multiple areas of occlusion along a single vertebral artery (VA). An anomalous entry of the VA above the C6 transverse foramen was observed in four patients. One patient had VA occlusion with neutral head position and recanalization upon contralateral lateral head tilt.

CONCLUSION

Our study highlights the safety and diagnostic benefits of dcDSA in characterizing the broad spectrum of BHS pathology encountered in clinical practice. This technique offers a powerful means to evaluate changes in cerebral blood flow and cervical arterial morphology in real time, overcoming the constraints of static imaging methods. Our findings pave the way for further studies on dcDSA to enhance cross-sectional imaging methods for the characterization of BHS and other dynamic vascular occlusion syndromes.