We present a case of Bowhunter’s in a patient who underwent extensive evaluation. Asking about the relationship between symptoms and head position may have allowed us to reach the diagnosis more quickly.

An uncommon cause of syncope is dynamic rotational occlusion of the vertebral artery (VA), also known as Bowhunter’s Syndrome. Torsion of the neck compresses the vessel, causing dizziness, syncope, and even thrombotic stroke.

74-year-old male, history of hypertension, diabetes and alcohol use disorder presented to ED with syncope. Lightheadedness and tunnel vision accompanied syncope with several days of diarrhea and heavy alcohol consumption. Review of systems were otherwise negative.

Vitals signs were stable. Fractures of the left maxilla and orbit were found. Physical exam revealed a 4/6 holosystolic murmur at the right second intercostal space. Neurologic examination was unremarkable. ECG showed normal sinus rhythm with RBBB of indeterminate age with prolonged QT interval. Labs showed anemia and hypokalemia.

An echocardiogram was unimpressive; and he received blood products for anemia. Correction of his macrocytic anemia and hypokalemia improved his lightheadedness, but the dizziness persisted. On further questioning, he noted that his symptoms returned when he turned his head to the right. A CT scan revealed bilateral foraminal stenosis with facet hypertrophy at C6-C7. A CTA showed osteophyte compression of the right VA at C4-C5. Dynamic CTA with head rotated to the right and extended demonstrated significant stenosis of the VA at the C4-C5 level. The patient underwent a C4-C5 facetectomy and a C3-C6 fusion, eliminating his symptoms.

Bowhunter’s Syndrome, although an uncommon etiology of syncope, should not be missed. Inquiring about effects of head position on a patient’s symptoms may be both revealing and helpful in lowering healthcare costs. Dynamic CTA may be warranted in similar clinical circumstances.