Bow Hunters syndrome: an unusual case of bilateral dynamic occlusion of vertebral arteries

Case description

A 54-year-old man came to our attention complaining of occasional tinnitus and blurred vision for 2 years, particularly when driving, the symptoms were linked to rightward head rotation.

Neurological examination highlighted the occurrence of the reported symptoms at the neck right torsion beyond 45° after about 10 s.

After a preliminary Echo-colour Doppler, the patient underwent a dynamic contrast-enhanced MR angiography (CE-MRA) of the supra-aortic trunks. In a neutral position, vertebral artery (VA) blood flow and calibre were regular with no evidence of dominance; scans performed a in rightward head rotation beyond 60° showed a bilateral dynamic stenosis of VAs, in particular at the C5–C6 level on the right, and at the C2 level on the left (figure 1).

For diagnostic confirmation, a dynamic digital subtraction angiography (dDSA) was performed, adding selective injections of VAs at different degrees of right neck rotation. dDSA confirmed the CE-MRA findings, leading to the diagnosis…

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