Bilateral bow-hunter's stroke caused by sleeping in prone position: A case of recurrent posterior circulation infarction

Objectives Bow hunter's stroke (BHS) is a condition characterized by temporary vertebrobasilar insufficiency caused by mechanical compression or occlusion of the vertebral artery when the head is rotated, leading to transient neurological symptoms such as dizziness, vertigo, nystagmus, dysarthria, and potentially stroke. Therefore, a situation in which the head remains rotated for an extended period is a significant risk factor for BHS.

Materials and Methods We present a case of a 25-year-old woman who experienced three recurrent cerebral infarctions in the posterior circulation area after sleeping in a prone position with her head rotated.

Results The first infarction occurred in the right thalamus, followed by bilateral cerebellar infarctions, and finally, an infarction in the left cerebellar hemisphere. Carotid Doppler ultrasonography revealed blood flow interruption in the left vertebral artery due to head rotation, and digital subtraction angiography showed that rotation of the head to one side resulted in blood flow disruption of the contralateral vertebral artery in both right and left rotation. A C1-2 posterior fixation surgery was performed to stabilize the atlas and axis using screws and rods, with no recurrence observed thereafter.

Conclusions When encountering a young patient with recurrent posterior circulation infarctions upon awakening, it is crucial to inquire about the patient's sleeping position, such as prone positioning, to assess for potential vertebral artery stenosis or occlusion due to head rotation.