Positional occlusion/stasis of vertebral arteries in a case of cervical rheumatoid arthritis presenting with multiple posterior circulation infarcts: a case report with angiographic demonstration.

Abstract

A case report of rheumatoid arthritis involving cervical spine, who presented with multiple posterior circulation infarcts, and pertinent literature review are presented. To describe a rare positional occlusion/stasis of vertebral arteries, which resolved following application of cervical traction. The likely mechanism of above findings is proposed. The mechanism of vertebrobasilar insufficiency with changes in head position in patients with rheumatoid arthritis can result from a number of causes; however, bilateral compromise of vertebral arteries during head extension had been described only once. There is no report of vertebral artery angiogram in any individual following application of traction and relief of compromise in extension. A 45-year-old man had rheumatoid arthritis for the last 10 years and presented with symptoms of posterior circulation infarcts. Cervical spine radiographs revealed "mobile" atlantoaxial dislocation and atlantoaxial impaction. Magnetic resonance imaging confirmed odontoid erosions, lateral masses destruction, atlantoaxial dislocation, and atlantoaxial impaction. Angiogram showed occlusion of the left vertebral artery and transient stasis of the right vertebral artery distal to foramen transversarium of C2 vertebra in extension position. The left vertebral artery had narrowing in the same segment in the neutral position. Following traction, repeat angiogram showed no occlusion or narrowing of either vertebral artery in any position. Transoral odontoidectomy and occipitocervical fusion were performed. The patient had no fresh deficits following surgery. We described a rare case of positional occlusion/stasis of vertebral arteries associated with rheumatoid arthritis, in which angiography following cervical traction showed complete resolution.