Rotation Vertebral Artery Syndrome

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Continuing Education Activity

Rotational vertebral artery syndrome, or "bow hunter syndrome," is a very rare diagnosis that is easily missed. Furthermore, symptoms are very nonspecific and caused by underlying anatomic abnormalities or derangements. This activity serves to examine the underlying pathology of this rare cause of vertebrobasilar insufficiency and highlights the role of the interprofessional team in the evaluation and management of patients with this condition.


  • Review the relevant anatomy associated with rotational vertebral artery syndrome.
  • Outline the pathogenesis of rotational vertebral artery syndrome.
  • Explain the difficulty in the diagnosis of rotational vertebral artery syndrome as the underlying cause of vertebrobasilar insufficiency.
  • Summarize the importance of an interprofessional team approach in diagnosing and treating rotational vertebral artery syndrome.


Rotational vertebral artery syndrome, or colloquially "bow hunter syndrome," is a rare cause of vertebrobasilar insufficiency. In patients with bow hunter syndrome, rotation of the head and neck can lead to compression of the vertebral artery at the atlantoaxial or subaxial levels in the spine. The name "bow hunter syndrome" is derived from a patient who developed Wallenberg syndrome (a lateral medullary infarction) during archery practice due to poor circulation with his head turned for extended periods.[1]

Understanding the anatomy of the vertebral artery is critical to the pathogenesis of bow hunter syndrome. The vertebral arteries originate from the subclavian arteries. They generally enter deep into the transverse process of C6 in most cases (C7 in 7.5% of cases) and ascend through the transverse foramen of each cervical vertebrae. After ascending through the transverse foramen of the atlas (C1), the vertebral arteries travel along the posterior arch of C1 and into the suboccipital triangle, where they enter the foramen magnum.[2]


As a result of the vertebral arteries' complex course along the posterior arch of the atlas (C1), it is susceptible to compression and occlusion due to rotation of the head. Disk herniation, osteophytes, spondylotic changes, vertebral artery dissection, cervical spondylosis, and any other anatomical or surgical derangements in the cervical-occipital region may result in vertebral artery occlusion. Musculotendinous compression can cause this condition in association with thoracic outlet syndrome. Osteophytes and bone spurs are the most common causes of occlusion.[3][4][5][6][7][8]


Rotational vertebral artery syndrome usually presents in patients aged 50 to 79, with a predilection for men at a ratio of approximately 2 to 1. Old age, hypertension, osteoarthritis, hyperlipidemia, diabetes, smoking, and coronary artery disease are other risk factors found to be associated with its diagnosis.[1][3][4][9]

History and Physical

The clinical presentation of rotational vertebral artery syndrome varies from patient to patient. Typically, they will have a history ranging from transient ischemic attacks to devastating strokes of the posterior circulation that are evoked by head rotation and generally resolve with derotation of the neck. Most commonly, patients report dizziness, syncope, impaired vision/nystagmus, nausea, Horner syndrome, and other motor and sensory deficits that occur with head rotation. Unfortunately, the reported clinical findings most common are not specific to bow hunter's syndrome but rather are commonplace in disorders of the neurovestibular system.[1][9][10]


Patients with a suspected vascular disorder affecting the vertebrobasilar system should undergo computed tomography angiography (CTA) or magnetic resonance imaging (MRI)/magnetic resonance angiography (MRA) to assess for abnormal bony structures, infarction lesions, and vertebral artery stenosis. Diagnostic confirmation is digital subtraction angiography, which in true bow hunter's syndrome, will show normal arteries in neutral head alignment and stenotic arteries or vascular occlusion with head rotation. These vascular studies are considered the gold standard in confirming the diagnosis of bow hunter's syndrome.[1] Furthermore, electrophysiologic exams such as motor evoked potentials, somatosensory evoked potentials (SSEPs), and brain stem auditory evoked response serve as baseline information preceding and following surgical intervention.[11][12]

Treatment / Management

Rotational vertebral artery syndrome is rare, and there is not one single consensus on the best course of treatment. Conservative management with avoidance of head and neck rotation using a brace or collar is one option, while adjunct anticoagulation therapy may improve morbidity.

Most patients are offered conservative treatment initially and undergo surgical intervention if symptoms fail to improve. Decompression and fusion of the cervical spine, generally at C1-C2 or occiput-C2, may be employed.[1][13][14]

Cornelius et al. described a case of bow hunter's syndrome caused by dynamic vertebral artery stenosis. The patient in question had a history of focal dissection, and after failing conservative management, he received treatment with coil embolization of his right vertebral artery.[15] As there are many potential causes of dynamic vertebral artery compression, surgical treatment is targeted to each patient's specific pathology and is not standardizable across all patients.

Differential Diagnosis

Rotational vertebral artery syndrome presents with nonspecific symptoms consistent with vertebrobasilar deficiency. Most commonly, patients report dizziness, syncope, impaired vision/nystagmus, nausea, Horner syndrome, and other motor and sensory deficits that occur with head rotation. Patients often present with symptoms of transient ischemic attacks and strokes, which can have a plethora of underlying causes. 

As mentioned briefly above, bow hunter syndrome was initially described in a patient who developed symptoms analogous to lateral medullary syndrome, normally caused by an infarct of the vertebral artery or the posterior inferior cerebellar artery. Lateral medullary syndrome, or Wallenberg syndrome, is characterized by ipsilateral pain and temperature sensation loss in the face and contralateral loss of pain and temperature sensation in the body accompanied by gait ataxia/vertigo, nystagmus, nausea/vomiting, and dysphagia.[16]

Other diagnoses in the differential are sick sinus syndrome and hypersensitivity baroreceptor syndrome.


Choi et al. reported that of 19 patients with rotational vertebral artery syndrome managed conservatively, no patient developed a posterior circulation stroke over 37.5 months of follow-up. Furthermore, four patients had resolution of symptoms during the follow-up period.[17]

Conversely, a review by Rastogi et al. reported only a 37% favorable outcome incidence for patients managed conservatively.[9]


Repeated transient ischemic attacks and strokes of the vestibular system can result in decreased balance, syncope, dizziness, and long-term neurological deficits. Furthermore, falls associated with these attacks can result in other injuries. Patients who require cervical fusion lose significant motion in the neck, with the atlantoaxial joint being responsible for 55% of rotation and 15% of flexion and extension.

Deterrence and Patient Education

Patients who note episodes of dizziness, syncope, nausea, loss of balance, and other neurological symptoms accompanying rotation of the head should be evaluated for rotational vertebral artery syndrome by a medical professional, as symptoms are nonspecific and could indicate numerous different pathologies. Patients diagnosed with bow hunter syndrome can usually be managed non-operatively with neck immobilization and anticoagulation. Still, they should undergo careful monitoring under the supervision of a medical specialist.

Enhancing Healthcare Team Outcomes

Rotational vertebral artery syndrome is a treatable condition that can have significant morbidity if not managed appropriately. As such, it is best managed by an interprofessional team approach. Furthermore, it represents a diagnostic challenge as there are many causes of vertebral basilar deficiency and other pathologies that may mimic its symptoms. Therefore, practitioners whose patients exhibit symptoms of cerebellar ischemia should be sent for evaluation by a specialist in neurology to obtain a correct diagnosis. Neurosurgeons, vascular surgeons, and/or orthopedic spine surgeons can all play a role in the surgical management of rotational vertebral artery syndrome if a patient fails non-operative management.

Nurses and medical support staff must work together and communicate clearly between medical team members to execute the plan of management to optimize patient outcomes. As the consequences of mismanagement of bow hunter syndrome can be severe, medical professionals must be both educated and prepared to provide the highest quality of patient care.



Steven M. Kane




Duan G, Xu J, Shi J, Cao Y. Advances in the Pathogenesis, Diagnosis and Treatment of Bow Hunter's Syndrome: A Comprehensive Review of the Literature. Interventional neurology. 2016 Jun:5(1-2):29-38. doi: 10.1159/000444306. Epub 2016 Mar 4     [PubMed PMID: 27610119]

Level 3 (low-level) evidence


Peng CW, Chou BT, Bendo JA, Spivak JM. Vertebral artery injury in cervical spine surgery: anatomical considerations, management, and preventive measures. The spine journal : official journal of the North American Spine Society. 2009 Jan-Feb:9(1):70-6. doi: 10.1016/j.spinee.2008.03.006. Epub 2008 May 27     [PubMed PMID: 18504163]


Jost GF, Dailey AT. Bow hunter's syndrome revisited: 2 new cases and literature review of 124 cases. Neurosurgical focus. 2015 Apr:38(4):E7. doi: 10.3171/2015.1.FOCUS14791. Epub     [PubMed PMID: 25828501]

Level 3 (low-level) evidence


Zaidi HA, Albuquerque FC, Chowdhry SA, Zabramski JM, Ducruet AF, Spetzler RF. Diagnosis and management of bow hunter's syndrome: 15-year experience at barrow neurological institute. World neurosurgery. 2014 Nov:82(5):733-8. doi: 10.1016/j.wneu.2014.02.027. Epub 2014 Feb 16     [PubMed PMID: 24549025]


Ding D, Mehta GU, Medel R, Liu KC. Utility of intraoperative angiography during subaxial foramen transversarium decompression for bow hunter's syndrome. Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences. 2013 Jun:19(2):240-4     [PubMed PMID: 23693050]


Anaizi AN, Sayah A, Berkowitz F, McGrail K. Bow hunter's syndrome: the use of dynamic magnetic resonance angiography and intraoperative fluorescent angiography. Journal of neurosurgery. Spine. 2014 Jan:20(1):71-4. doi: 10.3171/2013.9.SPINE121019. Epub 2013 Oct 18     [PubMed PMID: 24138059]


Thomas B, Barreau X, Pointillart V, Sibon I, Renou P. Endovascular Embolization of a Nondominant Vertebral Artery Compressed by an Osteophyte to Prevent Recurrence of Vertebrobasilar Infarctions. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2015 Sep:24(9):e257-9. doi: 10.1016/j.jstrokecerebrovasdis.2015.05.033. Epub 2015 Jul 6     [PubMed PMID: 26159645]


Healy AT, Lee BS, Walsh K, Bain MD, Krishnaney AA. Bow hunter's syndrome secondary to bilateral dynamic vertebral artery compression. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 2015 Jan:22(1):209-12. doi: 10.1016/j.jocn.2014.05.027. Epub 2014 Jul 25     [PubMed PMID: 25070633]


Rastogi V, Rawls A, Moore O, Victorica B, Khan S, Saravanapavan P, Midivelli S, Raviraj P, Khanna A, Bidari S, Hedna VS. Rare Etiology of Bow Hunter's Syndrome and Systematic Review of Literature. Journal of vascular and interventional neurology. 2015 Jul:8(3):7-16     [PubMed PMID: 26301025]

Level 1 (high-level) evidence


Velat GJ, Reavey-Cantwell JF, Ulm AJ, Lewis SB. Intraoperative dynamic angiography to detect resolution of Bow Hunter's syndrome: Technical case report. Surgical neurology. 2006 Oct:66(4):420-3; discussion 423     [PubMed PMID: 17015129]

Level 3 (low-level) evidence


Ikeda DS, Villelli N, Shaw A, Powers C. Bow hunter's syndrome unmasked after contralateral vertebral artery sacrifice for aneurysmal subarachnoid hemorrhage. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 2014 Jun:21(6):1044-6. doi: 10.1016/j.jocn.2013.10.005. Epub 2013 Oct 23     [PubMed PMID: 24308952]


Whitmore RG, Simon SL, Hurst RW, Nisenbaum HL, Kasner SE, Zager EL. Bow hunter's syndrome caused by accessory cervical ossification: posterolateral decompression and the use of intraoperative Doppler ultrasonography. Surgical neurology. 2007 Feb:67(2):169-71     [PubMed PMID: 17254879]


Go G, Hwang SH, Park IS, Park H. Rotational Vertebral Artery Compression : Bow Hunter's Syndrome. Journal of Korean Neurosurgical Society. 2013 Sep:54(3):243-5. doi: 10.3340/jkns.2013.54.3.243. Epub 2013 Sep 30     [PubMed PMID: 24278656]


Yoshimura K, Iwatsuki K, Ishihara M, Onishi Y, Umegaki M, Yoshimine T. Bow hunter's stroke due to instability at the uncovertebral C3/4 joint. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2011 Jul:20 Suppl 2(Suppl 2):S266-70. doi: 10.1007/s00586-010-1669-2. Epub 2011 Jan 30     [PubMed PMID: 21279658]


Cornelius JF, George B, N'dri Oka D, Spiriev T, Steiger HJ, Hänggi D. Bow-hunter's syndrome caused by dynamic vertebral artery stenosis at the cranio-cervical junction--a management algorithm based on a systematic review and a clinical series. Neurosurgical review. 2012 Jan:35(1):127-35; discussion 135. doi: 10.1007/s10143-011-0343-4. Epub 2011 Jul 26     [PubMed PMID: 21789571]

Level 1 (high-level) evidence


Sorensen BF. Bow hunter's stroke. Neurosurgery. 1978 May-Jun:2(3):259-61     [PubMed PMID: 732978]


Choi KD, Choi JH, Kim JS, Kim HJ, Kim MJ, Lee TH, Lee H, Moon IS, Oh HJ, Kim JI. Rotational vertebral artery occlusion: mechanisms and long-term outcome. Stroke. 2013 Jul:44(7):1817-24. doi: 10.1161/STROKEAHA.113.001219. Epub 2013 May 21     [PubMed PMID: 23696552]