We report a case of bow hunter's stroke caused by simultaneous bilateral vertebral artery occlusive changes at the right C3-4 and the left C1-2 level on head rotation to the right side. The pathogenesis and surgical treatment for this particular case are discussed. A 61-year-old male with cervical spondylosis repeatedly experienced vertebrobasilar insufficiency when he rotated his head over 60 degree from the mid-position to the right side. Bilateral vertebral angiography demonstrated severe compression of the right vertebral artery by a lateral osteophyte and instability at the C3-4 level accompanied with the mechanical stenosis of the left vertebral artery at the C1-2 level only at the time of turning his head to the right. As the surgical treatment we performed osteophytectomy of the right uncovertebral joint at the C3-4 level in addition to anterior decompression with fusion using hydroxyapatite spacer and titanium plate at that level. Postoperatively, the patient had no ischemic episodes and there was angiographical resolution of the rotational stenosis at the C3-4 level. For the clinical manifestation of bow hunter's stroke on head rotation, it is indispensable that simultaneous severe occlusive changes present on bilateral vertebral arteries. In case of a vertebral occlusive change caused by lateral osteophyte at the unstable vertebral joint, anterior decompression and fusion with osteophytectomy may be a wiser approach than arterial decompression or posterior fusion at the C1-2 level to another vertebral artery occlusive lesion.