Dynamic imaging of the craniovertebral junction is mandatory in patients with posterior circulation strokes

The course of the vertebral artery after exiting from the C1 foramen transversarium and prior to entering the dura lends itself to compression in C1-2 instability. However, atlantoaxial dislocation presenting with vertebrobasilar insufficiency and posterior circulation stroke (PCS) is rare.

In this retrospective study, we identified 96 patients with PCS who had complete radiological data. Ten (10.4%) patients had craniovertebral junction (CVJ) anomalies, of which six underwent surgery and four were managed conservatively. The clinical and functional outcomes were measured in the two groups.

Left-sided strokes were seen in 7/10 patients, the majority of whom had left dominant vertebral arteries. The mean age at presentation in those with CVJ anomalies was 27.2 ± 12.8 years that was significantly lower than those without CVJ anomalies, 52.2 ± 14.5 years (p ≤ 0.001). The etiologies of PCS in those < 50 years were CVJ anomalies (30%), atherosclerosis (30%) and vasculitis (27%); however, the overwhelming majority of strokes in the > 50 year age group was atherosclerosis (91%). Postoperatively, there were no recurrent strokes in the operated patients, who also obtained significant clinical improvement on the modified Rankin Scale, Nurick Scale and modified McCormick Scale as compared to those who did not undergo surgery.

Early diagnosis and surgical treatment of CVJ instability prevent recurrent strokes and improve outcomes in patients with PCS. Physicians and spine surgeons need to be sensitized regarding CVJ anomalies as a cause of PCS enabling early diagnosis with dynamic imaging particularly in the younger age group. These slides can be retrieved under Electronic Supplementary Material.