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Case Reports
. 2013 Nov 20:4:148.
doi: 10.4103/2152-7806.121647. eCollection 2013.

An unusual case of pediatric bow hunter's stroke

Tony I Anene-Maidoh  1 , Rafael A Vega, Gregory L Fautheree, John F Reavey-Cantwell
Affiliations
Case Reports

An unusual case of pediatric bow hunter's stroke

Tony I Anene-Maidoh et al. Surg Neurol Int. .

Abstract

Background: Bow Hunter's syndrome/stroke is defined as symptomatic, vertebrobasilar insufficiency provoked by physiologic head rotation. It is a diagnostically challenging cause of posterior circulation stroke in children. While there have been prior reports of this rare disorder, we describe an exceptional case of pediatric Bow Hunter's stroke resulting from a near complete occlusion the right vertebral artery (VA) secondary to an anomalous spur emanating from the right occipital condyle. Surgical and endovascular options and approaches are also detailed herein.

Case description: A 16-year-old male presented with multiple posterior circulation ischemic strokes. A dynamic computerized tomography angiogram performed with the patient's head in a rotated position revealed a near complete occlusion of the V3 segment of the right VA from a bone spur arising from his occipital condyle. The spur caused a focal dissection of the distal right VA with associated thrombus. He was initially managed with a cervical collar, antiplatelet therapy with aspirin 81 mg and anticoagulation with coumadin (INR goal 2-3) for 3 months. Despite the management plan, he had a subsequent thromboembolic event and a right VA sacrifice with coil embolization was then performed. At the 3-month follow-up, the patient was doing well with no reports of any subsequent strokes.

Conclusion: We report the first reported pediatric case of Bow Hunter's stroke due to dynamic right VA occlusion from an occipital condylar bone spur. The vascular compression from this spur led to a right VA dissection and thrombus formation and ultimately caused multiple posterior circulation thromboembolic strokes. Endovascular treatment options including vessel sacrifice should be considered in cases that have failed maximal medical management.

Keywords: Bow Hunter's syndrome; coil embolization; endovascular surgery; stroke; vertebral artery.

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Figures

Figure 1
Figure 1
(a) Cerebral angiogram of the right vertebral artery showing a normal course and flow of the artery. (b) Dynamic right vertebral artery angiogram with the head turned showing complete flow obstruction
Figure 2
Figure 2
(a-d) Computerized tomography angiogram of the head and neck demonstrating both the aberrant right condylar bone spur (arrow) and its close proximity to the right vertebral artery
Figure 3
Figure 3
(a) Cerebral angiogram of the right vertebral artery demonstrating a dissection and associated thrombus (arrow) secondary to intermittent condylar bone spur compression. (b) Cerebral angiogram of the left vertebral artery. The right vertebral artery has been occluded with coil embolization both proximally and distally, trapping the thrombus. The right PICA is preserved through a right AICA-PICA variant
See this image and copyright information in PMC

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