Recurrent CT perfusion imaging abnormalities in a patient with bow hunter's syndrome

Bow hunter's syndrome is a rare syndrome of dynamic compression of the vertebral artery leading to recurrent posterior circulation stroke and/or transient ischaemic attack. The artery is compressed by the transverse process of a cervical vertebra or other structures. We describe a man in his 20s who had recurrent posterior circulation strokes confirmed on CT perfusion imaging before a dynamic left vertebral artery stenosis was found on neck manoeuvres during digital subtraction angiography. A diagnosis of bow hunter's syndrome was made. As conservative management had failed, the patient had surgical resection of the large occipital condylar bony spur, which was causing the compression. There has been no further recurrence since surgery at 12 months. Bow hunter's syndrome is a rare disorder that requires a high index of suspicion in patients with recurrent symptoms. The use of CT perfusion imaging can increase diagnostic certainty in the setting of bow hunter's syndrome.