Stroke as the initial presentation of Takayasu's arteritis: A case report

Ischemic stroke as the first clinical manifestation of an initially undiagnosed case of Takayasu arteritis in a young woman from Ethiopia: A case report

Takayasu arteritis (TAK) is a rare large-vessel vasculitis of unknown etiology that leads to arterial wall thickening, stenosis, and occlusion, which may complicate cerebrovascular ischemic events. Ischemic stroke is a potentially devastating complication of TAK at a young age, but the occurrence is still rarely reported in Ethiopia. Although it occurs late in the course of the condition, it may be the initial presentation and suggest an unfavorable prognosis. Herein, we address the case of a 25-year-old woman who presented to a university hospital while on follow-up after 2 years of stroke with deterioration in clinical symptoms, absent brachial artery pulses, and unrecordable blood pressure in both arms. At the time of admission in 2021, the contrast brain computed tomography scan revealed an ischemic infarction in the right middle cerebral artery territory. However, the etiology of the stroke could not be defined at that time due to ambiguity in the clinical picture and the inability of clinicians to incorporate TAK into the differential diagnosis, resulting in a delay in the early diagnosis of the case. Two years later, in 2023, she underwent computed tomography angiography and was diagnosed to have TAK based on American College of Rheumatology criteria, with Numano type IIb angiographic extent of disease, ischemic stroke, and stage II systemic hypertension. The patient was treated by a field of experts. This case highlights the need to consider TAK in the differential diagnosis of stroke in young patients in the absence of traditional risk factors; appropriate tests should be performed to confirm or rule out this diagnosis, and management should be modified accordingly.

Takayasu arteritis presenting as a stroke in young: a case report

Introduction

Takayasu arteritis is a large-vessel vasculitis predominantly seen in young women. Lack of signs and symptoms in the early stage of the disease often delays the diagnosis and thus leads to significant morbidity and mortality. One severe complication that may arise is a significant narrowing of blood vessels, potentially leading to life-threatening ischemic repercussions.

Case presentation

The authors present a case of a 29-year-old female who presented to our ER with features of left-sided hemiparesis and right-sided facial deviation. Computed tomography angiography and Carotid Doppler helped in making the diagnosis of Takayasu arteritis. She was managed with prednisolone and mycophenolate mofetil. She has been on a regular follow-up for the last year and is currently stable.

Conclusion

Even being a rare scenario, stroke can be the initial presentation of Takayasu arteritis. Early diagnosis and management in young patients are vital in keeping the disease at bay and preventing physical, mental, and socio-economic adversities.

A Case of Takayasu's Arteritis Presenting With Acute Middle Cerebral Artery Stroke Managed With Aortic-Common Carotid Artery (CCA) Bypass Surgery

Takayasu's arteritis (TA) is a rare inflammatory disorder that affects large arteries, particularly the aorta and its main branches. TA is also known as a pulseless disease because it diminishes blood flow to the limbs and organs. The patient was a 17-year-old female whose prior medical history included a diagnosis of TA. She had been experiencing multiple syncopal episodes up to three times daily, lasting 10 seconds each. She was being managed outpatient with immunologic therapy and warfarin. She initially presented to a children's hospital with abdominal pain and an asymmetrical smile and was found to have a ruptured ovarian cyst. This case demonstrated that life-threatening complications of TA can occur as a result of otherwise unrelated and common circumstances. The patient was managed medically and then proceeded to surgery. The case further highlights the multidisciplinary team approach between medical and surgical specialties and weighing the risks and benefits of complications for the patient's long-term care. Early diagnosis and prompt initiation of appropriate therapy are essential for better outcomes. Clinicians should be aware of the nonspecific symptoms of TA and consider it in the differential diagnosis of young patients presenting with systemic symptoms and arterial insufficiency. The initial presentation of middle cerebral artery stroke in young women has been documented in prior literature, but most published cases present the medical management of the disease. Our patient's case was unique because medical management was insufficient, with surgical management pursued due to persistent symptomatic hypotension. The inciting event of this case, an ovarian rupture with retroperitoneal hemorrhage, represents a unique burden to watershed infarctions in this patient group. Further research is needed to understand the pathogenesis of TA better and to develop more effective treatment strategies for this challenging disease.

Clinical characteristics and outcomes in patients with Takayasu arteritis coexisting with myocardial ischemia and neurological symptoms: A multicenter, long-term, follow-up study

Background

The incidence of coexisting myocardial ischemia and neurological symptoms in Takayasu arteritis (TA) is currently unknown. There is no standardized treatment algorithm in complex cases involving the coronary and intracranial arteries.

Objective

This study aimed to describe the clinical characteristics and outcomes in patients with TA coexisting with myocardial ischemia and neurological symptoms.

Methods

We retrospectively collected and assessed 1,580 patients with TA, and enrolled patients with myocardial ischemia and neurological symptoms from January 2002 to December 2021 in several hospitals. The incidence, clinical features, management strategy, and prognosis of these patients were evaluated.

Results

Ninety-four (5.9%, 94/1,580) patients with TA coexisting with myocardial ischemia and neurological symptoms were included in the present study. Imaging results showed that the subclavian arteries were the most frequently affected arteries and 37 patients had intracranial vascular abnormalities, comprising the basilar artery (6.1%, 17/279), middle cerebral artery (2.5%, 7/279), anterior cerebral artery (2.9%, 8/279), and posterior cerebral artery (1.9%, 5/279). Among patients with neurological symptoms, 25 patients underwent percutaneous transluminal angioplasty and 20 patients underwent stent implantation. The most common site of stenosis was the ostial and proximal segments of the coronary artery, with 142 lesions among 188 (75.5%) lesions. Thirty-eight patients adopted interventional therapy, 21 patients underwent surgical treatment, and the remaining 35 patients received conservative treatment. There were 20 (21.27%, 20/94) late deaths during a mean follow-up of 57.79 months. The mortality rate in the conservative treatment group was significantly higher than that in the interventional therapy and surgical treatment groups.

Conclusion

Patients with TA involving both the coronary and intracranial vessels are not rare. Stenosis and occlusion lesions most frequently involve the ostia and proximal segment of the arteries. Severe vascular lesions should be revascularized as soon as possible. These patients should be supplemented with glucocorticoids, antiplatelet, nitrates, and statins.

Point-of-care ultrasound for stroke patients in the emergency room

Stroke requires rapid determination of the cause to provide timely and appropriate initial management. Various ultrasonographic techniques have been evaluated as ways to determine the cause of stroke; among them, carotid artery ultrasonography is particularly useful since it provides considerable information within a short time period when used to evaluate a specific site. In the emergency room, carotid artery ultrasonography can be used to diagnose internal carotid artery stenosis, predict an occluded vessel, and infer the cause of ischemic stroke. Additionally, carotid artery ultrasonography can diagnose different conditions including subclavian artery steal syndrome, bow hunter's stroke, Takayasu's arteritis, moyamoya disease, and dural arteriovenous fistula. Furthermore, patients with ischemic stroke with a pulse deficit or hypotension must be differentiated from acute type A aortic dissection, which requires emergency surgery; carotid artery ultrasonography can immediately differentiate between the two conditions by identifying the intimal flap of the common carotid artery. The following article provides an overview of carotid artery ultrasonography performed as point-of-care ultrasound in the emergency room in patients with suspected stroke.

Bridging Therapy for Acute Stroke as the Initial Manifestation of Takayasu Arteritis: A Case Report and Review of Literature

Takayasu arteritis (TA) is a chronic inflammatory disease involving the aorta and its principal branches. Acute ischaemic stroke (AIS) as the initial manifestation of TA is uncommon. There is little evidence on the efficacy of bridging therapy for AIS induced by TA. A 23-year-old Chinese woman with a suspected stroke presented to our hospital with sudden onset of right-sided weakness, right facial palsy, and aphasia that occurred 1 hour ago. After physical and ancillary examinations, recombinant tissue plasminogen activator was administered to the patient, which led to partial recovery. Her neurological function deteriorated with a large salvageable ischaemic penumbra on computed tomography perfusion. Cerebrovascular angiography showed multiple stenoses in the brachiocephalic trunk, the beginning of the right common carotid artery (CCA), and the bilateral subclavian arteries, as well as occlusion of the left CCA and its branches. Mechanical thrombectomy of the left middle cerebral artery was performed immediately. Percutaneous transluminal balloon angioplasty of the left CCA followed by stent implantation of the proximal left CCA was then performed. A diagnosis of TA was made based on the findings. The patient’s neurological deficit fully recovered with immunosuppressants at the 3 month-follow-up. We report a rare case of a patient with TA initially presenting with AIS treated with bridging therapy with full recovery of neurological function. Bridging therapy should be taken into consideration for AIS in patients with TA. Further study is needed in this regard.