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RA Cervical Vascular Complication — SCE Rheumatology MCQ

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HardRheumatology EmergenciesRA Cervical Vascular ComplicationSCE Rheumatology

A 59-year-old man with longstanding seropositive erosive rheumatoid arthritis has known atlantoaxial and vertical subluxation. He reports recurrent brief episodes of vertigo and diplopia precipitated by turning his head. He now presents with an acute lateral medullary syndrome, and MRI shows multiple posterior-circulation infarcts. Which vascular mechanism most likely links his cervical rheumatoid disease to these neurological events?

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Correct answer: E — Dynamic vertebral artery compression or kinking from atlantoaxial instability causing vertebrobasilar thromboembolism

The correct answer is E. Destructive rheumatoid disease at C1–C2 can produce atlantoaxial rotational or translational instability, mechanically compressing or kinking the V3 segment of the vertebral artery. Positional occlusion and endothelial injury may cause vertebrobasilar insufficiency or recurrent thromboembolism. Head-rotation-provoked vertigo or diplopia followed by posterior-circulation infarction is particularly characteristic. Carotid compression would produce anterior-circulation deficits, not a lateral medullary syndrome. Direct extension of rheumatoid synovitis does not characteristically cause basilar arteritis, and retro-odontoid pannus does not anatomically obstruct the cerebral venous sinuses. Cranial settling may compress the brainstem or vertebral arteries but is not an established direct cause of intracranial aneurysm formation.

Reference: Yoshimatsu Y et al. Vertebrobasilar Infarction Due to Bow Hunter's Syndrome in a Patient with Rheumatoid Arthritis: A Case Report. Journal of UOEH. 2021;43(3):349–353. https://pubmed.ncbi.nlm.nih.gov/33037539/