{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T01:19:49Z","timestamp":1787707189670,"version":"build-2784847793"},"reference-count":16,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"8","license":[{"start":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T00:00:00Z","timestamp":1787529600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Neurosurg Case Lessons"],"published-print":{"date-parts":[[2026,8,24]]},"abstract":"<jats:sec>\n                    <jats:title>BACKGROUND<\/jats:title>\n                    <jats:p>Rotational vertebrobasilar ischemia, also known as bow hunter\u2019s syndrome (BHS), is an underrecognized cause of posterior circulation stroke. Fewer than 200 cases have previously been documented, with most involving unilateral dynamic compression of the vertebral artery by adjacent bony structures that are subsequently treated with surgical decompression.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>OBSERVATIONS<\/jats:title>\n                    <jats:p>The authors report a case of bilateral BHS involving the craniocervical junction in a 37-year-old patient who presented with multiple posterior circulation ischemic events. Dynamic angiography revealed that his left vertebral artery was occluded by head turn to the right, and his right vertebral artery became stenotic during head turn to the left. The patient had multiple anomalies of the craniocervical junction; however, no direct bony vertebral artery compression was seen. Therefore, occiput\u2013C3 fusion was performed to prevent dynamic vertebral artery kinking on neck rotation and thus further stroke.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>LESSONS<\/jats:title>\n                    <jats:p>BHS can present with bilateral vertebral artery kinking in rare cases. Particularly at the craniocervical junction, vertebrobasilar ischemia can occur in the presence of tortuous vertebral artery anatomy and vertebral anomalies without obvious bony compression. Dynamic catheter and CT angiography are essential diagnostic studies, and occipitocervical fusion can be useful if no direct bony compression is identified.<\/jats:p>\n                    <jats:p>\n                      <jats:ext-link xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" ext-link-type=\"uri\" xlink:href=\"https:\/\/thejns.org\/doi\/10.3171\/CASE26286\">https:\/\/thejns.org\/doi\/10.3171\/CASE26286<\/jats:ext-link>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/case26286","type":"journal-article","created":{"date-parts":[[2026,8,19]],"date-time":"2026-08-19T00:01:21Z","timestamp":1787097681000},"source":"Crossref","is-referenced-by-count":0,"title":["Bilateral bow hunter\u2019s syndrome at the craniocervical junction: illustrative case"],"prefix":"10.3171","volume":"12","author":[{"given":"John M.","family":"Bernabei","sequence":"first","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arati","family":"Patel","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hunter","family":"Yamada","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mahmoud M.","family":"Elguindy","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lee A.","family":"Tan","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel M. S.","family":"Raper","sequence":"additional","affiliation":[{"name":"Department of Neurological Surgery, University of California, San Francisco, California"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1754","reference":[{"issue":"5","key":"bib1","series-title":"World Neurosurg","first-page":"733","article-title":"Diagnosis and management of bow hunter\u2019s syndrome: 15-year experience at Barrow Neurological Institute","volume":"82","author":"Zaidi","year":"2014","unstructured":"Zaidi HAAlbuquerque FCChowdhry SAZabramski JMDucruet AFSpetzler RF.Diagnosis and management of bow hunter\u2019s syndrome: 15-year experience at Barrow Neurological Institute. World Neurosurg. 2014;82(5):733-738. doi:10.1016\/j.wneu.2014.02.027"},{"issue":"4","key":"bib2","series-title":"Neurosurg Focus","first-page":"E7","article-title":"Bow hunter\u2019s syndrome revisited: 2 new cases and literature review of 124 cases","volume":"38","author":"Jost","year":"2015","unstructured":"Jost GFDailey AT.Bow hunter\u2019s syndrome revisited: 2 new cases and literature review of 124 cases. Neurosurg Focus. 2015;38(4):E7. doi:10.3171\/2015.1.FOCUS14791"},{"issue":"6","key":"bib3","series-title":"Eur Spine J","first-page":"1440","article-title":"Rotational vertebral artery occlusion (\u201cbow hunter syndrome\u201d)","volume":"30","author":"Schulz","year":"2021","unstructured":"Schulz RDonoso RWeissman K.Rotational vertebral artery occlusion (\u201cbow hunter syndrome\u201d). Eur Spine J. 2021;30(6):1440-1450. doi:10.1007\/s00586-020-06680-5"},{"issue":"7","key":"bib4","series-title":"Neurology","first-page":"329","article-title":"Pearls & Oy-sters: bow hunter syndrome: a rare cause of posterior circulation stroke","volume":"91","author":"Jadeja","year":"2018","unstructured":"Jadeja NNalleballe K.Pearls & Oy-sters: bow hunter syndrome: a rare cause of posterior circulation stroke. Neurology. 2018;91(7):329-331. doi:10.1212\/WNL.0000000000006009"},{"issue":"10","key":"bib5","series-title":"J Neurol Neurosurg Psychiatry","first-page":"1131","article-title":"Bow hunter\u2019s syndrome: an unusual case of bilateral dynamic occlusion of vertebral arteries","volume":"92","author":"Toluian","year":"2021","unstructured":"Toluian TVolterra DGioppo ARigamonti P.Bow hunter\u2019s syndrome: an unusual case of bilateral dynamic occlusion of vertebral arteries. J Neurol Neurosurg Psychiatry. 2021;92(10):1131-1132. doi:10.1136\/jnnp-2021-326462"},{"issue":"1","key":"bib6","series-title":"J Clin Neurosci","first-page":"209","article-title":"Bow hunter\u2019s syndrome secondary to bilateral dynamic vertebral artery compression","volume":"22","author":"Healy","year":"2015","unstructured":"Healy ATLee BSWalsh KBain MDKrishnaney AA.Bow hunter\u2019s syndrome secondary to bilateral dynamic vertebral artery compression. J Clin Neurosci. 2015;22(1):209-212. doi:10.1016\/j.jocn.2014.05.027"},{"issue":"5-6","key":"bib7","series-title":"World Neurosurg","first-page":"799.E1","article-title":"Rare case of bilateral vertebral artery stenosis caused by C4-5 spondylotic changes manifesting with bilateral bow hunter\u2019s syndrome","volume":"79","author":"Fleming","year":"2013","unstructured":"Fleming JBVora TKHarrigan MR.Rare case of bilateral vertebral artery stenosis caused by C4-5 spondylotic changes manifesting with bilateral bow hunter\u2019s syndrome. World Neurosurg. 2013;79(5-6):799.E1-799.E5. doi:10.1016\/j.wneu.2012.06.022"},{"issue":"1","key":"bib8","series-title":"Neurosurgery","article-title":"Rotational vertebrobasilar ischemia: hemodynamic assessment and surgical treatment","volume":"56","author":"Vilela","year":"2005","unstructured":"Vilela MDGoodkin RLundin DANewell DW.Rotational vertebrobasilar ischemia: hemodynamic assessment and surgical treatment. Neurosurgery. 2005;56(1):36-43. doi:10.1227\/01.NEU.0000146441.93026.CE"},{"issue":"3","key":"bib9","series-title":"Radiol Case Rep","first-page":"597","article-title":"Bow hunter\u2019s syndrome in a patient with vertebral artery atresia, an arcuate foramen, and unilateral deafness: a case report","volume":"12","author":"Simpkin","year":"2017","unstructured":"Simpkin CTDavis KEDavis BSVosko AMJorgensen ME.Bow hunter\u2019s syndrome in a patient with vertebral artery atresia, an arcuate foramen, and unilateral deafness: a case report. Radiol Case Rep. 2017;12(3):597-601. doi:10.1016\/j.radcr.2017.04.001"},{"issue":"7","key":"bib10","series-title":"Stroke","first-page":"1817","article-title":"Rotational vertebral artery occlusion: mechanisms and long-term outcome","volume":"44","author":"Choi","year":"2013","unstructured":"Choi KDChoi JHKim JSRotational vertebral artery occlusion: mechanisms and long-term outcome. Stroke. 2013;44(7):1817-1824. doi:10.1161\/STROKEAHA.113.001219"},{"issue":"4","key":"bib11","series-title":"Oper Neurosurg","first-page":"E363","article-title":"Atlanto-occipital decompression of vertebral artery for a variant of bow hunter\u2019s syndrome: 2-dimensional operative video","volume":"21","author":"Khan","year":"2021","unstructured":"Khan NRElarjani TChen SHMiskolczi LStrasser SMorcos JJ.Atlanto-occipital decompression of vertebral artery for a variant of bow hunter\u2019s syndrome: 2-dimensional operative video. Oper Neurosurg. 2021;21(4):E363-E364. doi:10.1093\/ons\/opab231"},{"issue":"3","key":"bib12","series-title":"Oper Neurosurg","first-page":"E310","article-title":"A 72-year-old female with bow hunter syndrome: a rare surgical approach to C4-5 vertebral artery decompression: 2-dimensional operative video","volume":"19","author":"Gigliotti","year":"2020","unstructured":"Gigliotti MJJoseph JThompson BGPark P.A 72-year-old female with bow hunter syndrome: a rare surgical approach to C4-5 vertebral artery decompression: 2-dimensional operative video. Oper Neurosurg. 2020;19(3):E310. doi:10.1093\/ons\/opaa011"},{"key":"bib13","series-title":"World Neurosurg","first-page":"284","article-title":"C2-C3 anterior cervical arthrodesis in the treatment of bow hunter\u2019s syndrome: case report and review of the literature","volume":"118","author":"Schunemann","year":"2018","unstructured":"Schunemann VKim JDornbos DNimjee SM.C2-C3 anterior cervical arthrodesis in the treatment of bow hunter\u2019s syndrome: case report and review of the literature. World Neurosurg. 2018;118:284-289. doi:10.1016\/j.wneu.2018.07.129"},{"issue":"6","key":"bib14","series-title":"Oper Neurosurg","first-page":"E83","article-title":"Microsurgical treatment of bowhunter\u2019s syndrome: 3-dimensional operative video","volume":"15","author":"Agarwal","year":"2018","unstructured":"Agarwal VBarrow DL.Microsurgical treatment of bowhunter\u2019s syndrome: 3-dimensional operative video. Oper Neurosurg. 2018;15(6):E83. doi:10.1093\/ons\/opy059"},{"issue":"8","key":"bib15","series-title":"Clin Neurol Neurosurg","first-page":"1520","article-title":"Rotational vertebral artery occlusion associated with occipitoatlantal assimilation, atlantoaxial subluxation, and basilar impression","volume":"115","author":"Inamasu","year":"2013","unstructured":"Inamasu JNakatsukasa M.Rotational vertebral artery occlusion associated with occipitoatlantal assimilation, atlantoaxial subluxation, and basilar impression. Clin Neurol Neurosurg. 2013;115(8):1520-1523. doi:10.1016\/j.clineuro.2012.12.005"},{"issue":"9","key":"bib16","series-title":"Neurol Med Chir (Tokyo)","first-page":"696","article-title":"Bow hunter\u2019s stroke associated with atlantooccipital assimilation\u2014case report","volume":"39","author":"Sakai","year":"1999","unstructured":"Sakai KTsutsui THunter B.Bow hunter\u2019s stroke associated with atlantooccipital assimilation\u2014case report. Neurol Med Chir (Tokyo). 1999;39(9):696-700. doi:10.2176\/nmc.39.696"}],"container-title":["Journal of Neurosurgery: Case Lessons"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-case-lessons\/12\/8\/article-CASE26286.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-case-lessons\/12\/8\/article-CASE26286.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-case-lessons\/12\/8\/article-CASE26286.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T00:38:07Z","timestamp":1787704687000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-case-lessons\/12\/8\/article-CASE26286.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,24]]},"references-count":16,"journal-issue":{"issue":"8"},"URL":"https:\/\/doi.org\/10.3171\/case26286","relation":{},"ISSN":["2694-1902"],"issn-type":[{"value":"2694-1902","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,24]]}}}