Bow Hunter's Stroke

This section is compiled by Frank M. Painter, D.C.
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Vascular Ultrasound Measurements After Atlas Orthogonal Chiropractic Care
in a Patient With Bow Hunter Syndrome

J Chiropractic Medicine 2018 (Dec);   17 (4):   231–236 ~ FULL TEXT

Bow hunter syndrome (BHS) is also known as bow hunter stroke and rotational vertebral artery syndrome. Bow hunter syndrome is a rare cause of vertebrobasilar insufficiency; the mechanism was first postulated in cadaveric studies of the early to mid–20th century. [1, 2] Sorensen coined the term in 1978 based on the symptoms occurring with the activity of archery. [3] Bow hunter syndrome is most commonly a result of a mechanical compression of the vertebral artery (VA), except for rare cases where compression results from intrinsic vascular problems such as atherosclerosis. [4] The resultant occlusion or stenosis of the VA occurs with head rotation and typically in the dominant VA. Because the occlusion is dynamic, the symptoms are typically transient, dependent on head position. The most commonly reported symptoms are syncope, near-syncope, drop attack, vertigo, dizziness, and impaired vision. Other less commonly reported symptoms include dysarthria, dysphasia, diplopia, nystagmus, numbness, paresthesia, nausea, headache, neck pain, arm pain, tinnitus, and ataxia. [4–6] Transient vision loss (TVL) and blindness have also been reported in some cases. [4, 5, 7–9] Bow hunter syndrome studies are limited to case studies and case series. The largest overview of BHS to date was published by Jost and Daily [7] in 2015, in which 126 cases were described and categorized and in which a variety of causes, sites of stenosis, and treatment regimens are described. The condition can result in permanent neurologic deficit if left undiagnosed. [10]

Bow Hunter's Stroke Due To Instability at the Uncovertebral C3/4 Joint
European Spine Journal 2011 (Jul);   20 Suppl 2:   S266–170 ~ FULL TEXT

Bow hunter's stroke is typically due to mechanical compression or stretching of the dominant vertebral artery (VA) during contralateral head rotation against the bony elements of the atlas and axis. We report a case of vertebrobasilar insufficiency due to bilateral vertebral artery occlusion at the left C3-4 and the right C1-2 junction on rightward head rotation. A 64-year-old man experienced ischemic symptoms during 90° head rotation to the right with complete resolution of symptoms after returning his head to the neutral position. Dynamic cervical angiography with rightward head rotation showed severe compression of the right VA at the transverse foramen of C3-4 and mechanical stenosis of the left VA at the C1-2 level. During head rotation, the flow of the right VA was decreased more than the left side. Cervical 3-D computed tomography (CT) on rightward head rotation demonstrated displacement of the uncovertebral C3-4 joint, with excessive rotation of the C3 vertebral body. Based on these findings, instability at C3-4 was suspected to be the main cause of the vertebrobasilar insufficiency. Anterior discectomy and fusion at the C3/4 level were performed. Postoperatively, the patient experienced complete resolution of symptoms, and dynamic cervical angiography showed disappearance of the compression of the right VA. To our knowledge, this is the first reported case of bow hunter's stroke diagnosed by dynamic cerebral angiography and cervical 3-D CT without angiography, and treated by anterior decompression and fusion without decompression of the VA.

Bow Hunter's Stroke Caused by a Severe Facet Hypertrophy of C1-2
J Korean Neurosurg Soc. 2010 (Feb);   47 (2):   134–6

Bow hunter's stroke is a rare symptomatic vertebrobasilar insufficiency in which vertebral artery (VA) is mechanically occluded during head rotation. Various pathologic conditions have been reported as causes of bow hunter's stroke. However, bow hunter's stroke caused by facet hypertrophy of C1-2 has not been reported. A 71-year-old woman presented with symptoms of vertebrobasilar insufficiency. Spine computed tomography showed massive facet hypertrophy on the left side of C1-2 level. A VA angiogram with her head rotated to the right revealed significant stenosis of left VA. C1-2 posterior fixation and fusion was performed to prevent serious neurologic deficit from vertebrobasilar stroke.

A Case of Bow Hunter's Stroke Treated with Endovascular Surgery
No Shinkei Geka 2006 (Feb);   34 (2):   189–192

Bow hunter's stroke results from vertebrobasilar insufficiency due to a mechanical occlusion or stenosis of the vertebral artery caused by head rotation. We report here a case of bow hunter's stroke that was successfully treated with endovascular surgery. A 69-year-old male complained of intractable vertigo when he rotated his head to the right side. Neuroradiological studies proved that the symptom was attributed to the mechanical severe stenosis of the left vertebral artery at the C1-C2 level on head rotation, in addition to the atherosclerotic stenosis at the origin of the right vertebral artery.

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

Spine 2002 (Dec 1);   27 (23):   E495–498

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 degrees 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.

Acute Traumatic Stroke: A Case of Bow Hunter's Stroke in a Child
Eur J Emerg Med 1998;   5 (2) Jun:   259–263

Acute traumatic stroke of the cerebellum is rarely seen in children. In adults, chiropractical manipulation, yoga exercises, bow hunting and cervical trauma have all been associated with vertebrobasillar damage and subsequent stroke due to cerebellar infarction.

A Case of Juvenile Bow Hunter's Stroke
No To Shinkei 2000;   52 (5) May:   431–434

Bow hunter's stroke results from vertebrobasilar insufficiency caused by mechanical occlusion or stenosis of the vertebral artery at the C 1-2 level on head rotation. Commonly it is seen in elder people with cervical spondylosis. Here we reports a case of bow hunter's stroke in a 25-year-old male who complained of visual disturbance and syncope on rotation of the head 90 degrees or more to the left.

Bow Hunter's Stroke Associated with an Aberrant Course of the Vertebral Artery – A Case Report
Neurol Med Chir 1999;   39 (12) Nov:   867–869

Bow hunter's stroke may be caused by atlantoaxial arterial anomalies, so accurate preoperative evaluation of the region is necessary to avoid anatomical confusion at surgery.

A Case of Bow Hunter's Stroke Caused by Bilateral Vertebral Artery
Occlusive Change on Head Rotation to the Right

No Shinkei Geka 1998;   26 (5) May:   417–422

We report a case of bow hunter's stroke caused by simultaneous bilateral vertebral artery occlusive changes at the right C3-4 and the left C1-2 level on head rotation to the right side.

Bow Hunter's Stroke Caused by Simultaneous Occlusion of Both Vertebral Arteries
Acta Neurochir 1999;   141 (8):   895–896

Usefulness of Three-dimensional CT for Bow Hunter Stroke
Acta Neurochir 1997;   139 (3):   265–266


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