• Aria Mahtabfar, Jacob Mazza, Daniel Franco, Glenn A Gonzalez, Kevin Hines, Nohra Chalouhi, Pascal Jabbour, James Harrop, and Joshua Heller.
• Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA. Electronic address: Aria.Mahtabfar@jefferson.edu.
• World Neurosurg. 2021 Jan 1; 145: 178-182.

BackgroundRheumatoid arthritis (RA) is a chronic inflammatory polyarthropathy that affects many synovial joints favoring the hands, knees, and vertebral articulations. Joint laxity manifests as subaxial instability, atlantoaxial instability, and cranial settling (CS).Case DescriptionA 70-year-old woman with past medical history of RA, Hashimoto's thyroiditis, osteoporosis, history of C1-2 fusion for instability 15 years prior, with subsequent revision cervicothoracic fusion for degeneration, and trauma 2 years prior presents with new onset headache, nausea, and vomiting of 36-hour duration. Neurologic examination was only notable for mild right dysmetria. Workup revealed acute hemorrhage in the posterior fossa with migration of the right rod implant and screw tulip, as a result of CS. The patient underwent occipital-cervical fusion with removal of the migratory hardware.ConclusionsIntracranial rod migration and hemorrhage secondary to CS is a rare complication that must be brought to the attention of surgeons operating on patients with RA.Copyright © 2020 Elsevier Inc. All rights reserved.

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