• Yasuhiro Takeshima, Fumihiko Nishimura, Young-Su Park, and Hiroyuki Nakase.
• Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan.
• Spine. 2014 Apr 11.

Structured Abstract:Study Design. Case report and literature review.Objective. To describe an unique case of recurrent cerebral embolisms with bilateral atlanto-axial rotational vertebral artery occlusion (RVAO), and review the literature on this rarely entity.Summary of Background Data. The few reports of bilateral bow hunter's stroke (BHS) contain either RVAO at subaxial level, and BHS associated with bilateral RVAO at the atlanto-axial level has never been reported. The treatment strategy for this entity is controversial.Methods. An 18-year-old girl suffered a cerebellar embolism in the left superior cerebellar artery area, followed by a second cerebral embolism in the right posterior inferior cerebellar artery area. Blood analysis showed no coagulation or autoimmune abnormalities. Transesophageal echocardiography ruled out a patent foramen ovale. Vertebral angiography and 3-dimensional computed tomography angiography (3D-CTA) with neck rotation clearly showed vertebral artery occlusion at the atlanto-axial level. For preventing a recurrence of thromboembolic event, surgical intervention was chosen.Results. The patient underwent posterior atlanto-axial fixation with an iliac bone graft 2 months after the previous cerebellar infarction. Her postoperative course was uneventful. At 22 months of follow-up, she had no neurological deficits or further infarctions. Bony fusion was radiologically confirmed and 3D-CTA with neck rotation showed good patency of vertebral arteries.Conclusion. To our knowledge, the seven published reports of bilateral BHS or RVAO involve double etiologies both the atlanto-axial and subaxial levels, but one unspecified cases. Because of the difficulty to identify the proper affected side in the case of bilateral atlanto-axial BHS with certainty, fusion surgery may be suitable for the reliable treatment.

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