Cervical ribs or malformed first ribs are found in 1 % of normal population and constitute 4.5% of patients with thoracic outlet syndrome. They predominantly cause neurologic symptoms in upper limb while vascular symptoms caused by them are rare involving only 2% of these patients. The vascular symptoms caused by cervical ribs predominantly involve the distal upper limb and are due to thromboembolism from the proximal subclavian artery disease due to chronic trauma and aneurysm formation. Such phenomenon has also been described in other acquired conditions causing subclavian disease like malunited fracture of the clavicle. Right sided stroke in these patients have been rarely but consistently reported in the literature since long, but all the reported patients had history of upper limb vascular symptoms before the cerebral event. Presentation with carotid stroke without significant upper limb symptoms has not been described.

A 18 year old male patient presented to us with history of sudden onset weakness of left upper limb and deviation of face towards right 2 months back which started with loss of consciousness. NCCT done at that time showed right basal ganglia and adjacent frontal opercular region infarct. Patient was extensively investigated for all the causes of stroke in young for 2 months and was then sent to department of Neuroradiology for DSA to investigate vascular causes. The angiogram revealed narrowing of right MCA and non visualization of ascending frontal branches of right MCA suggesting thromboembolic episode in the past. During angiography a cervical rib was also noted on the right side causing mild narrowing of right subclavian artery with post stenotic dilatation. Angiogram during abduction revealed complete occlusion of the subclavian artery and filling of the right axillary artery from the collaterals. Combination of well formed cervical rib causing subclavian stenosis and post stenotic dilatation with evidence of thromboembolism on cerebral DSA was highly suggestive of cervical rib as the cause of stroke in this patient. Right subclavian artery showed only minimal dilatation and was not explored as thrombus was not evident either on angiography or Doppler.