Bow hunter stroke caused by cervical disc herniation

Case report

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✓ Bow hunter stroke, which is characterized by transient vertebrobasilar ischemia brought on by head turning, is an unusual condition usually caused by structural abnormalities at the craniocervical junction. The authors present a case in which compression of the left vertebral artery (VA) at the C4–5 level was caused by a laterally herniated intervertebral disc. A 56-year-old man presented with a 6-month history of dizziness and syncope when he turned his head 45° or more to the left. Transcranial Doppler (TCD) ultrasonography demonstrated decreased blood flow through the left VA, and angiography revealed an occlusion of the left VA at the C4–5 level, both when the patient turned his head to the left. Via an anterior cervical approach, the VA canal was unroofed through the transverse foramina to decompress the left VA at C4–5; intraoperatively, the left VA was found to be compressed by a laterally herniated cervical disc fragment. To the best of the authors' knowledge this is the first report of a laterally herniated cervical disc causing bow hunter stroke. The use of TCD may be of value in the diagnosis and management of the disorder, and herniated cervical disc must be included in the roster of potential causes for this rare disease.

Article Information

Address correspondence to: G. Edward Vates, M.D., Ph.D., Department of Neurological Surgery, University of California at San Francisco, 505 Parnassus Avenue, M779, San Francisco, California 94143. email: vatese@neurosurg.ucsf.edu.

© AANS, except where prohibited by US copyright law.

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Figures

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    A: Digital-subtraction anteroposterior left-side VA angiogram demonstrating normal findings with the patient in the supine position. B: Anteroposterior right-sided VA angiogram revealing normal findings with the patient in the supine position. C: Anteroposterior angiogram demonstrating complete occlusion of the left VA when the patient's head is turned to the left by 70°. D: Anteroposterior angiogram revealing adequate filling of the right VA when the patient's head is turned to the left but with significant compression at the C-1 posterior loop of the right VA (black arrow). E: Anteroposterior angiogram (same as in C but without digital subtraction and with only 45° of turning). Compression of the left VA at the C4–5 level can be seen. F: Postoperative anteroposterior angiogram revealing no compression of the left VA at the C4–5 level after removal of the herniated disc fragment and unroofing of the VA canal at the C4–5 level. The patient's head is turned 90°.

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    Intraoperative photograph obtained through the operating microscope, demonstrating the complete decompression of the VA. The VA now sits in a trough freed from external compression, with short white arrows indicating the medial edge of the trough drilled from the C4–5 levels and the long white arrow showing the direction of flow in the left VA.

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    Postoperative axial CT scans through C-4 (A) and C-5 (B), demonstrating the extent of osseous resection accomplished during surgery.

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