Child's Nervous System

, Volume 26, Issue 12, pp 1669–1674

Rotational vertebral artery occlusion in a child with multiple strokes: a case-based update

  • Hansel M. Greiner
  • Todd A. Abruzzo
  • Marielle Kabbouche
  • James L. Leach
  • Mario Zuccarello
Case-Based Update



Rotational vertebral artery occlusion (RVAO), sometimes known as “Bow hunter syndrome,” is an important and diagnostically challenging cause of posterior circulation stroke in children. It is caused by impingement of osseous and/or ligamentous structures on the vertebral artery.


We review the differential diagnosis and recommended workup for posterior circulation stroke in children. The anatomical cause for pediatric RVAO is most commonly an anomalous bone formation of the rostral vertebral column. Many bony anomalies have been associated with RVAO, including the “ponticulus posticus,” a common anomaly of the C1 vertebrae. The definitive diagnosis of RVAO is made with dynamic angiography, and surgical decompression of the vertebral artery prevents recurrent strokes.

Illustrative case

We report a 15-year-old boy with recurrent posterior circulation ischemic strokes caused by an anomalous ossification of the C1 vertebrae. Three-dimensional (3D) and multiplanar reconstructed CT images showed the anomalous C1 ossification, and cervicocerebral digital subtraction angiography (DSA) revealed an associated vertebral artery (VA) dissection. The patient was initially managed by head immobilization in a hard collar and anticoagulation for 3 months. After healing of the dissection that was confirmed angiographically, dynamic DSA demonstrated reversible occlusion of the VA during contralateral head turn. Surgical decompression of the VA was performed and confirmed by intra-operative DSA with head turning.


RVAO is an important diagnosis in children with posterior circulation stroke. Our case demonstrates the need for high clinical suspicion and careful analysis of 3D cervical spine CT images in children with posterior circulation stroke.


Pediatric stroke Bow hunter syndrome Rotational vertebral artery syndrome Ponticulus posticus Dynamic angiography 


  1. 1.
    Agrawal N, Johnston SC, Wu YW, Sidney S, Fullerton HJ (2009) Imaging data reveal a higher pediatric stroke incidence than prior US estimates. Stroke 40:3415–3421CrossRefPubMedGoogle Scholar
  2. 2.
    Brandt T, Baloh RW (2005) Rotational vertebral artery occlusion: a clinical entity or various syndromes? Neurology 65:1156–1157CrossRefPubMedGoogle Scholar
  3. 3.
    Broderick J, Talbot GT, Prenger E, Leach A, Brott T (1993) Stroke in children within a major metropolitan area: the surprising importance of intracerebral hemorrhage. J Child Neurol 8:250–255CrossRefPubMedGoogle Scholar
  4. 4.
    Cho YJ (2009) Radiological analysis of ponticulus posticus in Koreans. Yonsei Med J 50:45–49CrossRefPubMedGoogle Scholar
  5. 5.
    Choi KD, Shin HY, Kim JS, Kim SH, Kwon OK, Koo JW, Park SH, Yoon BW, Roh JK (2005) Rotational vertebral artery syndrome: oculographic analysis of nystagmus. Neurology 65:1287–1290CrossRefPubMedGoogle Scholar
  6. 6.
    Cushing KE, Ramesh V, Gardner-Medwin D, Todd NV, Gholkar A, Baxter P, Griffiths PD (2001) Tethering of the vertebral artery in the congenital arcuate foramen of the atlas vertebra: a possible cause of vertebral artery dissection in children. Dev Med Child Neurol 43:491–496CrossRefPubMedGoogle Scholar
  7. 7.
    Dadsetan MR, Skerhut HE (1990) Rotational vertebrobasilar insufficiency secondary to vertebral artery occlusion from fibrous band of the longus coli muscle. Neuroradiology 32:514–515CrossRefPubMedGoogle Scholar
  8. 8.
    Ganesan V, Chong WK, Cox TC, Chawda SJ, Prengler M, Kirkham FJ (2002) Posterior circulation stroke in childhood: risk factors and recurrence. Neurology 59:1552–1556PubMedGoogle Scholar
  9. 9.
    Golomb MR, Fullerton HJ, Nowak-Gottl U, Deveber G (2009) Male predominance in childhood ischemic stroke: findings from the international pediatric stroke study. Stroke 40:52–57CrossRefPubMedGoogle Scholar
  10. 10.
    Hasan I, Wapnick S, Tenner MS, Couldwell WT (2002) Vertebral artery dissection in children: a comprehensive review. Pediatr Neurosurg 37:168–177CrossRefPubMedGoogle Scholar
  11. 11.
    Haynes MJ, Cala LA, Melsom A, Mastaglia FL, Milne N, McGeachie JK (2005) Posterior ponticles and rotational stenosis of vertebral arteries. A pilot study using Doppler ultrasound velocimetry and magnetic resonance angiography. J Manipulative Physiol Ther 28:323–329CrossRefPubMedGoogle Scholar
  12. 12.
    Lu DC, Gupta N, Mummaneni PV (2009) Minimally invasive decompression of a suboccipital osseous prominence causing rotational vertebral artery occlusion. Case report. J Neurosurg Pediatr 4:191–195CrossRefPubMedGoogle Scholar
  13. 13.
    Matsuyama T, Morimoto T, Sakaki T (1997) Comparison of C1-2 posterior fusion and decompression of the vertebral artery in the treatment of bow hunter’s stroke. J Neurosurg 86:619–623CrossRefPubMedGoogle Scholar
  14. 14.
    Nemecek AN, Newell DW, Goodkin R (2003) Transient rotational compression of the vertebral artery caused by herniated cervical disc. Case report. J Neurosurg 98:80–83PubMedGoogle Scholar
  15. 15.
    Saito K, Hirano M, Taoka T, Nakagawa H, Kitauchi T, Tanizawa E, Yoshida K, Sakurai Y, Tamura K, Nakase H, Yoshioka A, Sakaki T, Kichikawa K, Ueno S (2008) Artery-to-artery embolism with a mobile mural thrombus due to rotational vertebral artery occlusion. J Neuroimaging 20(3):284–286CrossRefPubMedGoogle Scholar
  16. 16.
    Shimizu T, Waga S, Kojima T, Niwa S (1988) Decompression of the vertebral artery for bow-hunter’s stroke. Case report. J Neurosurg 69:127–131CrossRefPubMedGoogle Scholar
  17. 17.
    Velat GJ, Reavey-Cantwell JF, Ulm AJ, Lewis SB (2006) Intraoperative dynamic angiography to detect resolution of Bow Hunter’s syndrome: technical case report. Surg Neurol 66:420–423, discussion 423CrossRefPubMedGoogle Scholar
  18. 18.
    Vilela MD, Goodkin R, Lundin DA, Newell DW (2005) Rotational vertebrobasilar ischemia: hemodynamic assessment and surgical treatment. Neurosurgery 56:36–43, discussion 43–35PubMedGoogle Scholar
  19. 19.
    Young JP, Young PH, Ackermann MJ, Anderson PA, Riew KD (2005) The ponticulus posticus: implications for screw insertion into the first cervical lateral mass. J Bone Joint Surg Am 87:2495–2498CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Hansel M. Greiner
    • 1
  • Todd A. Abruzzo
    • 2
    • 5
  • Marielle Kabbouche
    • 1
  • James L. Leach
    • 3
  • Mario Zuccarello
    • 4
  1. 1.Department of NeurologyCincinnati Children’s Hospital Medical CenterCincinnatiUSA
  2. 2.Pediatric Interventional NeuroradiologyCincinnati Children’s Hospital Medical CenterCincinnatiUSA
  3. 3.Pediatric NeuroradiologyCincinnati Children’s Hospital Medical CenterCincinnatiUSA
  4. 4.Department of Neurosurgery, Mayfield ClinicUniversity of CincinnatiCincinnatiUSA
  5. 5.Mayfield ClinicUniversity of CincinnatiCincinnatiUSA

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