Recurrent embolic strokes associated with vertical atlantoaxial subluxation in a patient with rheumatoid arthritis: a case report and review of literature

J Stroke Cerebrovasc Dis. 2013 Nov;22(8):e676-81. doi: 10.1016/j.jstrokecerebrovasdis.2013.07.010. Epub 2013 Aug 2.


We report a 78-year-old woman with rheumatoid arthritis who developed recurrent embolic cerebellar strokes associated with vertical atlantoaxial subluxation (AAS). On contrast angiography, the bilateral vertebral arteries (VAs) were occluded between the C1 and C2 levels, and the distal parts of bilateral VA were supplied by the collateral circulations. Dynamic cerebral angiography and carotid duplex ultrasonography showed that blood flow was substantially decreased in the left VA and left posterior inferior cerebellar artery on cervical anteflexion. It is suggested that vertical AAS reduced the blood flow of collateral circulation in the left VA with cervical anteflexion and might be a cause of recurrent ischemic stroke.

Keywords: Atlantoaxial subluxation; angiography; carotid duplex ultrasonography; recurrent embolic stroke.

Publication types

  • Case Reports
  • Review

MeSH terms

  • Aged
  • Arthritis, Rheumatoid / complications*
  • Arthritis, Rheumatoid / diagnosis
  • Atlanto-Axial Joint*
  • Carotid Arteries / diagnostic imaging
  • Carotid Arteries / physiopathology*
  • Cerebral Angiography / methods
  • Cerebrovascular Circulation*
  • Collateral Circulation*
  • Diffusion Magnetic Resonance Imaging
  • Female
  • Head Movements
  • Hemodynamics
  • Humans
  • Intracranial Embolism / diagnosis
  • Intracranial Embolism / etiology*
  • Intracranial Embolism / physiopathology
  • Joint Dislocations / diagnosis
  • Joint Dislocations / etiology*
  • Magnetic Resonance Angiography
  • Recurrence
  • Stroke / diagnosis
  • Stroke / etiology*
  • Stroke / physiopathology
  • Tomography, X-Ray Computed
  • Ultrasonography, Doppler, Duplex
  • Vertebrobasilar Insufficiency / complications
  • Vertebrobasilar Insufficiency / physiopathology