Three Pediatric cases of Bow hunter's Syndrome

Background: Bow hunter’s syndrome is a rare condition in which the vertebral artery is compressed during head rotation, potentially leading to recurrent vessel injury, dissection, and stroke. If gone unrecognized and left untreated, this syndrome can result in recurrent strokes. This case series describes three pediatric males diagnosed with bow hunter’s syndrome subsequently treated with cervical spinal fusion.

Case information: Three previously healthy male patients (median age: 8) with posterior circulation strokes were treated at a single institution. Demographics, stroke score, and treatments are summarized in Table 1. Two patients experienced recurrent strokes while the third underwent endovascular thrombectomy for an acute basilar artery occlusion. Acute medical treatment otherwise included anticoagulation and neck stabilization with cervical collar due to clinical suspicion of bow hunter's syndrome. The diagnosis was subsequently confirmed via dynamic conventional angiography performed with neck rotation. All three patients received an occiput to C3 vertebra fusion. Follow up imaging performed 3 months post fusion showed no evidence of additional strokes.

Conclusions: Bow hunter’s syndrome is a rare cause of posterior circulation strokes amongst children and should be included in the differential diagnosis of likely patients given the high likelihood of stroke recurrence. The diagnostic gold standard is dynamic conventional angiography to confirm vertebral artery compression. Cervical spine stabilization to limit neck rotation and anticoagulation may help reduce the risk of stroke recurrence until neurosurgical intervention can be pursued. Further studies are necessary to follow the long term outcomes of patients treated with cervical spinal fusion and develop a standard of care for bow hunter’s syndrome.