• Yasuhiro Takeshima, Fumihiko Nishimura, Young-Su Park, and Hiroyuki Nakase.
• From the Department of Neurosurgery, Nara Medical University School of Medicine, Kashihara, Japan.
• Spine. 2014 Jun 15;39(14):E860-3.

Study DesignCase report and literature review.ObjectiveTo describe a unique case of recurrent cerebral embolisms with "bilateral" atlantoaxial rotational vertebral artery occlusion (RVAO), and review the literature on this rare entity.Summary Of Background DataThe few reports of bilateral bow hunter's stroke (BHS) contain either RVAO at the subaxial level, and BHS associated with bilateral RVAO at the atlantoaxial level has never been reported. The treatment strategy for this entity is controversial.MethodsAn 18-year-old female experienced 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 with neck rotation clearly showed vertebral artery occlusion at the atlantoaxial level. For preventing a recurrence of thromboembolic event, surgical intervention was chosen.ResultsThe patient underwent posterior atlantoaxial 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 3-dimensional computed tomography angiography with neck rotation showed good patency of vertebral arteries.ConclusionTo our knowledge, the 7 published reports of bilateral BHS or RVAO involve double causes both the atlantoaxial and subaxial levels, but 1 unspecified case. Because of the difficulty to identify the proper affected side in the case of bilateral atlantoaxial BHS with certainty, fusion surgery may be suitable for the reliable treatment.Level Of EvidenceN/A.

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