Endovascular Treatment of Bow Hunter’s Syndrome Presenting With Acute Vertebral Artery Occlusion: A Case Report

BackgroundBow Hunter's Syndrome (BHS) is a rare condition in which dynamic vertebral artery (VA) compression during neck rotation induces transient symptoms, such as vertigo, whereas major arterial occlusion is extremely uncommon. There is no standardized treatment for BHS, and management includes conservative, surgical, and rarely endovascular approaches. We report a unique case of BHS with acute VA occlusion successfully treated by mechanical thrombectomy followed by elective stent placement.Case ReportAn 87-year-old woman presented with right gaze deviation, dysarthria, right hemiparesis, and sensory disturbance. Magnetic resonance imaging showed acute infarcts in the left pons and cerebellum, while magnetic resonance angiography showed poor visualization from the VA to the basilar artery. Emergency cerebral angiography showed VA occlusion, and subsequent thrombectomy was performed, which resulted in successful recanalization. Post-recanalization angiography showed residual stenosis at the V3 segment and an anomalous course of the VA running caudal to the posterior arch of the atlas. A dynamic ultrasonographic examination with neck rotation showed occlusion of the VA, which confirmed the diagnosis of BHS. Stent placement was planned because compression of the left VA was confirmed to be caused by soft tissue rather than by bony structures. Balloon angioplasty showed resistance to external compression. Subsequently, a balloon-expandable stent was successfully deployed using a distal access catheter and a stiff micro guidewire. Follow-up imaging confirmed VA patency with preserved flow during head rotation. The patient showed neurological improvement without recurrence during 6 months of follow-up.ConclusionWe report a rare case of BHS presenting with acute VA occlusion treated effectively with endovascular therapy. BHS should be considered as a potential cause of large-vessel occlusion in posterior circulation stroke when abnormal arterial courses are identified. In selected cases, stent placement may be a feasible therapeutic option depending on the compressive structure.