A 16-year-old male presented with right-sided numbness, dysphagia, and right peripheral vision loss after working out during football practice. In the emergency room (ER) his right-sided visual field defect persisted, with anomia and alexia. He stated that he had experienced intermittent episodes and discreet events over the past year including weakness, numbness, and vision loss.
He had a computerized tomography scan of the head, which revealed areas of hypodensity in the left temporoparietal region suggestive of stroke. This finding was confirmed by magnetic resonance imaging, which revealed multiple strokes of different ages. Specifically, he had an acute stroke in the left temporoparietal region, along with subacute strokes in the right thalamus, spanning the corpus callosum and left cerebellum. The patient was then admitted to the pediatric intensive care unit (PICU) for observation and further workup. A cerebral angiogram revealed a focal dissection of the distal right VA with a small nonocclusive thrombus proximal to the dissection. The only suspicious event from the patient's history was a wrestling incident in the locker rooms a few days before the onset of stroke. He was followed by neurology and hematology/oncology, and had workups to rule out vasculitis, metabolic, hypercoagulable, and cardiac embolic sources, all of which were negative. Anticoagulation with enoxaparin was then initiated, and the patient was discharged home with instructions to avoid weight lifting and contact sports.
Approximately 3 months after his initial presentation and completing his 3-month course of anticoagulation with therapeutic enoxaparin, the patient experienced new transient neurological symptoms of headache, blurred vision, and confusion. Incidentally, he began weightlifting a week prior to the onset of his new symptoms. Magnetic resonance imaging of the brain revealed a subacute stroke in the left medial cerebellum, and a new area of encephalomalacia, suspicious for a stroke, in the parietal region near the vertex that occurred after his initial hospitalization. The patient was then admitted for further evaluation.
A dynamic cerebral angiogram was performed and revealed that the patient had a Bow Hunter's type phenomenon, with dynamic occlusion of the right VA in the chin up position looking to the left [Figure 1].
A dynamic computerized tomography angiogram performed with the patient's head in rotated position showed a near complete occlusion of the V3 segment of the right VA resulting from an anomalous spur emanating from his right occipital condyle that pinched off his VA between the C1 ring and this condylar spur [Figure 2]. This was determined to be the etiology of the dissection. Therefore, the patient was managed by neck immobilization via a cervical collar, and we initiated aspirin 81 mg and coumadin with an INR goal of 2-3. At this time, the plan was to allow the dissection flap to heal and then bring the patient back for elective surgical decompression of the condylar spur. 
However, 2 weeks after the treatment modality of immobilization and pharmacotherapy, the patient presented with a transient ischemic attack. He reported right hemibody numbness and tingling. His INR at that point was subtherapeutic, first at 1.8 then at 1.6. A magnetic resonance imaging and magnetic resonance angiography of the head and neck revealed persistent narrowing of the V3 segment of the VA to 50%, with new strokes noted in the occipital lobe, right cerebellum, and a thrombus in the left P2-3 segment of the left posterior cerebral artery.
Since the patient had further thrombotic episodes due to the dissection, he was admitted and placed on 325 mg aspirin, clopidrogrel (300 mg load followed by 75 mg daily), and a heparin infusion. After a thorough discussion of all treatment options, including stenting of the artery, surgery to drill off the spur, or continued medical therapy, the decision was made to proceed with coil embolization/sacrifice of the right VA so as to prevent further thromboembolic events as well as to avoid the future need for surgical decompression of the anomalous occipital condyle process. The right VA was sacrificed with coil embolization and trapping of a 4 mm thrombus over the dissected segment [Figure 3]. The patient tolerated the procedure without complication and was subsequently discharged home. 
During his initial postoperative clinic visit, one week status-post right VA sacrifice, his cervical collar was discontinued. During his 5 week postoperative clinic visit, he reported no further episodes of seizures, paresthesias, headache, or neck pain. He was doing well on aspirin 81 mg with a plan to continue antiplatelet therapy indefinitely
Three months status-post right VA sacrifice, the patient had a baseline right homonymous hemianopsia and a mild nystagmus, especially with right lateral gaze, but was otherwise doing well and denied any symptoms. He had increased his level of activity and started weightlifting but was not cleared for contact sports.