title: Repeated vertebrobasilar thromboembolism in a patient with severe upper cervical instability because of rheumatoid arthritis.
abstract: BACKGROUND
  Although many reports have examined upper cervical rheumatoid arthritis (RA) and spinal cord disorders resulting from RA lesions, few cases of thromboembolic events in the vertebrobasilar system associated with RA lesions of the upper cervical spine have been reported.
  
  
  OBJECTIVE
  We encountered a rare case of repeated vertebrobasilar thromboembolism with severe upper cervical instability resulting from RA. Furthermore, we obtained clinical images of the vertebrobasilar system just before and after the first thromboembolic event. We thus present the case of a patient with RA who recovered without surgery from repeated vertebrobasilar thromboembolism that might have been caused by severe upper cervical instability.
  
  
  METHODS
  Case report.
  
  
  METHODS
  A 59-year-old man with a 14-year history of RA experienced nuchal pain because of severe atlantoaxial and vertical subluxations. While awaiting surgery, he developed left Wallenberg syndrome because of occlusion in the left vertebral artery (VA). Five days later, he displayed impaired consciousness and symptoms of right Wallenberg syndrome. Emergency magnetic resonance angiography showed occlusion in the basilar artery. After thrombolytic therapy, he gradually recovered.
  
  
  RESULTS
  Because we presumed that the patient's recurrent thrombus formation resulted from kinking of the right VA caused by severe instability of the upper cervical spine, we planned to treat him surgically despite his impaired consciousness and tracheostomy. However, the anesthesiologist would not approve surgery because the patient had high-risk conditions. The cervical spine was thus realigned and immobilized in a halo apparatus for 3 months to achieve stability. Now, more than 5 years after these events, the patient has experienced no more thromboembolic events and his condition has remained stable, without need for surgery.
  
  
  CONCLUSIONS
  Repeated vertebrobasilar thromboembolism in patients with RA may sometimes be caused by severe upper cervical instability that can be treated without surgery.
authors.affiliation: Department of Orthopaedic Surgery, Osaka University, Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka 565-0871, Japan. ko-osk@umin.ac.jp
authors.forename: Kazuya
authors.initials: K
authors.lastname: Oshima
authors.forename: Hironobu
authors.initials: H
authors.lastname: Sakaura
authors.forename: Motoki
authors.initials: M
authors.lastname: Iwasaki
authors.forename: Akio
authors.initials: A
authors.lastname: Nakura
authors.forename: Ryutaro
authors.initials: R
authors.lastname: Fujii
authors.forename: Hideki
authors.initials: H
authors.lastname: Yoshikawa
mesh_terms: D001172:Arthritis, Rheumatoid / Q000150:complications* / Q000000981:diagnostic imaging; D001268:Atlanto-Axial Joint / Q000000981:diagnostic imaging / Q000293:injuries*; D006801:Humans; D004204:Joint Dislocations / Q000000981:diagnostic imaging / Q000628:therapy*; D007593:Joint Instability / Q000000981:diagnostic imaging / Q000209:etiology* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009984:Orthopedic Fixation Devices; D011859:Radiography; D013923:Thromboembolism / Q000150:complications* / Q000000981:diagnostic imaging / Q000628:therapy*; D015912:Thrombolytic Therapy; D016896:Treatment Outcome