BACKGROUND: Bow hunter's syndrome (BHS), also known as rotational vertebral 
artery occlusion syndrome, is rare. Occasionally, it combines with 
dissection/pseudoaneurysm of the ipsilateral VA.
METHODS: We report a case of BHS combined with ipsilateral VA 
dissection/pseudoaneurysm and review eight similar cases reported in the 
literature. Their aetiology, clinical and imaging features, treatment, and 
prognosis were analysed.
RESULTS: Nine patients (seven male, two female; average age 22.0 ± 4.5 years) 
were enrolled. Visual symptoms comprised the most common clinical finding 
(66.7%, 7/9). Clinical symptoms were not related to neck rotation in seven 
patients (77.8%). Eight patients (88.9%) had multiple, scattered, new and old 
infarctions of the posterior circulation revealed on computed 
tomography/magnetic resonance imaging (CT/MRI) scans. Dissection/pseudoaneurysm 
was found in the ipsilateral VA - usually subtle and localised in the atlas, 
axis, and occipital bone - in all nine patients. Seven patients (66.7%) had 
special causes for the syndrome (i.e. congenital bone dysplasia). Altogether, 
87.5% (7/8) experienced recurrence with cerebral infarction after antithrombotic 
therapy alone. Aetiologically targeted treatment, including surgical 
decompression or vertebral fixation, was performed in seven patients (77.8%).
CONCLUSION: Young patients presenting with cryptogenic stroke in the posterior 
circulation and localised, subtle dissection/pseudoaneurysm of the ipsilateral 
VA around the atlanto-axial joint should undergo carotid ultrasonography with a 
neck rotation test or dynamic CT angiography/MR angiography/digital subtraction 
angiography, if necessary, to rule out/diagnose BHS.