Cerebrovascular accident in patients with giant cell arteritis: A systematic review and meta-analysis of cohort studies

Cranial involvement in giant cell arteritis

Since its first clinical description in 1890, extensive research has advanced our understanding of giant cell arteritis, leading to improvements in both diagnosis and management for affected patients. Imaging studies have shown that the disease frequently extends beyond the typical cranial arteries, also affecting large vessels such as the aorta and its proximal branches. Meanwhile, advances in comprehending the underlying pathophysiology of giant cell arteritis have given rise to numerous potential therapeutic agents, which aim to minimise the need for glucocorticoid treatment and prevent flares. Classification criteria for giant cell arteritis, as well as recommendations for management, imaging, and treat-to-target have been developed or updated in the last 5 years, and current research encompasses a broad spectrum covering basic, translational, and clinical research. In this Series paper, we aim to discuss the current understanding of giant cell arteritis with cranial manifestations, describe the clinical approach to this condition, and explore future directions in research and patient care.

Stroke frequency, associated factors, and clinical features in primary systemic vasculitis: a multicentric observational study

OBJECTIVES

The cerebral vessels may be affected in primary systemic vasculitis (PSV), but little is known about cerebrovascular events (CVEs) in this population. This study aimed to determine the frequency of CVEs at the time of diagnosis of PSV, to identify factors associated with CVEs in PSV, and to explore features and outcomes of stroke in patients with PSV.

METHODS

Data from adults newly diagnosed with PSV within the Diagnostic and Classification Criteria in VASculitis (DCVAS) study were analysed. Demographics, risk factors for vascular disease, and clinical features were compared between patients with PSV with and without CVE. Stroke subtypes and cumulative incidence of recurrent CVE during a prospective 6-month follow-up were also assessed.

RESULTS

The analysis included 4828 PSV patients, and a CVE was reported in 169 (3.50%, 95% CI 3.00-4.06): 102 (2.13% 95% CI 1.73-2.56) with stroke and 81 (1.68% 95% CI 1.33-2.08) with transient ischemic attack (TIA). The frequency of CVE was highest in Behçet's disease (9.5%, 95% CI 5.79-14.37), polyarteritis nodosa (6.2%, 95% CI 3.25-10.61), and Takayasu's arteritis (6.0%, 95% CI 4.30-8.19), and lowest in microscopic polyangiitis (2.2%, 95% CI 1.09-3.86), granulomatosis with polyangiitis (2.0%, 95% CI 1.20-3.01), cryoglobulinaemic vasculitis (1.9%, 95% CI 0.05-9.89), and IgA-vasculitis (Henoch-Schönlein) (0.4%, 95% CI 0.01-2.05). PSV patients had a 11.9% cumulative incidence of recurrent CVE during a 6-month follow-up period.

CONCLUSION

CVEs affect a significant proportion of patients at time of PSV diagnosis, and the frequency varies widely among different vasculitis, being higher in Behçet's. Overall, CVE in PSV is not explained by traditional vascular risk factors and has a high risk of CVE recurrence.

[Management of cardiovascular comorbidities in immune-mediated inflammatory diseases]

Patients with chronic inflammatory and autoimmune diseases are at increased cardiovascular risk, which is the cause of persistent excess mortality despite increasingly effective specific treatment of the inflammatory and/or autoimmune disease. This increased cardiovascular risk is multifactorial, associated with accelerated atherosclerosis related to systemic inflammation, but also secondary to traditional cardiovascular risk factors and to the therapies used to control systemic inflammation. This justifies a coordinated, personalized management of cardiovascular risk in patients with chronic inflammatory and autoimmune diseases, based not only on the treatment of their disease to achieve the lowest level of activity, but also on the screening and management of their cardiovascular comorbidities and modifiable cardiovascular risk factors.

Giant-cell arteritis related strokes: scoping review of mechanisms and rethinking treatment strategy?

Stroke is a rare and severe complication of giant cell arteritis (GCA). Although early diagnosis and treatment initiation are essential, the mechanism of stroke is often related to vasculitis complicated by arterial stenosis and occlusion. Its recurrence is often attributed to early steroid resistance or late GCA relapse, so immunosuppressive treatment is often reinforced. However, many questions concerning the mechanisms of stroke remain elusive, and no review to date has examined the whole data set concerning GCA-related stroke. We therefore undertook this scoping review. GCA-related stroke does not necessarily display general signs and inflammatory parameters are sometimes normal, so clinicians should observe caution. Ischemic lesions often show patterns predating watershed areas and are associated with stenosis or thrombosis of the respective arteries, which are often bilateral. Lesions predominate in the siphon in the internal carotid arteries, whereas all the vertebral arteries may be involved with a predominance in the V3-V4 segments. Ultrasonography of the cervical arteries may reveal edema of the intima (halo sign), which is highly sensitive and specific of GCA, and precedes stenosis. The brain arteries are spared although very proximal arteritis may rarely occur, if the patient has microstructural anatomical variants. Temporal artery biopsy reveals the combination of mechanisms leading to slit-like stenosis, which involves granulomatous inflammation and intimal hyperplasia. The lumen is sometimes occluded by thrombi (<15%), suggesting that embolic lesions may also occur, although imaging studies have not provided strong evidence for this. Moreover, persistence of intimal hyperplasia might explain persisting arterial stenosis, which may account for delayed stroke occurring in watershed areas. Other possible mechanisms of stroke are also discussed. Overall, GCA-related stroke mainly involves hemodynamic mechanisms. Besides early diagnosis and treatment initiation, future studies could seek to establish specific preventive or curative treatments using angioplasty or targeting intimal proliferation.

Pole to pole

An otherwise asymptomatic 67-year-old man presented to his ophthalmologist complaining of acute painless "dark area on the right." Visual acuity was preserved, and a single cotton-wool spot was noted in each retina. An inferior right quadrantanopia was evident on automated visual fields, and computerized tomography of the brain confirmed a left occipital stroke. Acute phase markers were elevated, and temporal artery biopsy was consistent with a diagnosis of giant cell arteritis. Isolated retinal cotton wool spots, even in the absence of systemic signs and symptoms, may be suggestive of giant cell arteritis.

Giant cell arteritis-related cerebrovascular ischemic events: a French retrospective study of 271 patients, systematic review of the literature and meta-analysis

BACKGROUND

Cerebrovascular ischemic events (CIE) are among the most severe complications of giant cell arteritis (GCA). Heterogeneity between different studies in the definition of GCA-related CIE leads to uncertainty regarding their real prevalence. The aim of our study was to evaluate the prevalence and describe the characteristics of GCA-related CIE in a well-phenotyped cohort completed by a meta-analysis of the existing literature.

METHODS

In this retrospective study performed in the Lille University Hospital, all consecutive patients with GCA according to American College of Rheumatology (ACR) diagnostic criteria were included from January 1, 2010, to December 31, 2020. A systematic review of the literature using MEDLINE and EMBASE was performed. Cohort studies of unselected GCA patients reporting CIE were included in the meta-analysis. We calculated the pooled summary estimate of GCA-related CIE prevalence.

RESULTS

A total of 271 GCA patients (89 males, mean age 72 ± 9 years) were included in the study. Among them, 14 (5.2%) presented with GCA-related CIE including 8 in the vertebrobasilar territory, 5 in the carotid territory, and 1 patient having multifocal ischemic and hemorrhagic strokes related to intra-cranial vasculitis. Fourteen studies were included in the meta-analysis, representing a total population of 3553 patients. The pooled prevalence of GCA-related CIE was 4% (95% CI 3-6, I2 = 68%). Lower body mass index (BMI), vertebral artery thrombosis on Doppler US (17% vs 0.8%, p = 0.012), vertebral arteries involvement (50% vs 3.4%, p < 0.001) and intracranial arteries involvement (50% vs 1.8%, p < 0.001) on computed tomography angiography (CTA) and/or magnetic resonance angiography (MRA), and axillary arteries involvement on positron emission computed tomography (PET/CT) (55% vs 20%, p = 0.016) were more frequent in GCA patients with CIE in our population.

CONCLUSIONS

The pooled prevalence of GCA-related CIE was 4%. Our cohort identified an association between GCA-related CIE, lower BMI, and vertebral, intracranial, and axillary arteries involvement on various imaging modalities.

Prevalence and impact of cerebrovascular risk factors in patients with giant cell arteritis: An observational study from the Spanish national registry

OBJECTIVE

To assess the prevalence and impact of cerebrovascular risk factors (CRF) on cerebrovascular events (CVE) in patients with giant cell arteritis (GCA).

METHODS

Analysis of the patients diagnosed with GCA identified in the Spanish Hospital Discharge Database between 2016 and 2018.

RESULTS

8,474 hospital admissions from patients diagnosed with GCA were identified. 3.4% of the admissions were motivated by CVE (stroke in 2.8% and transient ischemic attack in 0.6%). When compared with the admissions due to other causes, the patients who suffered from CVE presented a higher rate of male sex (36.2% vs 43.5%, p=0.007), hypertension (66.9% vs 74.4%, p=0.004), diabetes (27.6% vs 33.7%, p=0.016) and atherosclerosis (6.6% vs 10.2%, p=0.0.017). After adjustment, male sex (OR=1.35, 95% CI 1.06-1.72) and mainly hypertension (OR=1.44, 95% CI 1.11-1.90) were associated with a higher risk of CVE.

CONCLUSION

Hypertension, along with male sex, was the strongest risk factor for cerebrovascular events in GCA patients. In these high-risk patients, antiplatelet therapy should be re-considered and evaluated in prospective studies.

The incidence and characteristics of giant cell arteritis in Hispanics and the associated outcomes of ischemic ocular events and stroke

Giant cell arteritis (GCA) is a large vessel vasculitis whereby up to half of all patients show ocular involvement, highlighting the importance of treating GCA before it leads to irreversible blindness. Most of the research published for GCA and associated adverse ocular events are based on majority Caucasian populations establishing the current belief that Hispanics have a much lower incident of GCA. We sought to investigate the incidence of GCA in Hispanics and characterize associated ocular events, stroke rates, and comorbid diseases. We conducted a retrospective cohort study of GCA-coded medical records in self-identified Hispanics assessed at the University Medical Center Hospital in El Paso, Texas. From 2000 to 2019, there were 68 new cases of GCA in the Hispanics which represents an average incidence of 0.062% with a 95% confidence interval of [0.05, 0.09] of Hispanics over the age of 50 admitted to University Medical Center hospital. Of the subjects diagnosed with GCA, the majority had ocular involvement such as blurry vision (47.06%), ocular pain (26.47%), and blindness (14.71%). We did not observe a history of stroke had a statistically significant difference associated with GCA with ophthalmic disease compared to GCA without ophthalmic disease. Polymyalgia rheumatica (PMR) was identified in only 2.94% of the Hispanic subjects with GCA. Major conclusions in our study advocate Hispanics with GCA are prevalent and unique in its associations with other comorbid diseases. Unlike non-Hispanic White populations, Hispanic subjects with GCA do not show an association with PMR nor an increased association with stroke.

Cardiovascular risk in vasculitis

The present review summarizes the burden, risk factors, biomarkers of and therapeutic consideration for cardiovascular disease in systemic vasculitis. Ischemic heart disease (IHD) and stroke are intrinsic features of Kawasaki disease, Takayasu arteritis, Giant Cell Arteritis (GCA), and Behcet's disease. The risk of IHD and stroke is increased in anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) and cryoglobulinemic vasculitis. Behcet's disease could present with venous thromboembolism. The risk of venous thromboembolism is increased in AAV, polyarteritis nodosa, and GCA. The risk of cardiovascular events is greatest at or immediately after the diagnosis of AAV or GCA, therefore, controlling vasculitis disease activity is of utmost importance. Traditional as well as disease-related risk factors drive the heightened cardiovascular risk in vasculitis. Aspirin or statins reduce the risk of IHD or stroke in GCA or the risk of IHD in Kawasaki Disease. Venous thromboembolism in Behcet's disease should be treated with immunosuppressive therapy rather than with anticoagulation.

Cardiovascular Disease in Large Vessel Vasculitis: Risks, Controversies, and Management Strategies

Takayasu's arteritis (TAK) and giant cell arteritis (GCA) are the 2 most common primary large vessel vasculitides (LVV). They share common vascular targets, clinical presentations, and histopathology, but target a strikingly different patient demographic. While GCA predominantly affects elderly people of northern European ancestry, TAK preferentially targets young women of Asian heritage. Cardiovascular diseases (CVD), including ischemic heart disease, cerebrovascular disease, aortic disease, and thromboses, are significantly increased in LVV. In this review, we will compare and contrast the issue of CVD in patients with TAK and GCA, with respect to prevalence, risk factors, and mechanisms of events to gain an understanding of the relative contributions of active vasculitis, vascular damage, and accelerated atherosclerosis. Controversies and possible mitigation strategies will be discussed.

Diagnostic and therapeutic approach to adult central nervous system vasculitis

The clinical manifestations of central nervous system (CNS) vasculitis are highly variable. In the absence of a positive CNS biopsy, CNS vasculitis is particularly suspected when markers of both vascular disease and inflammation are present. To facilitate the clinical and therapeutic approach to this rare condition, CNS vasculitis can be classified according to the size of the involved vessels. Vascular imaging is used to identify medium vessel disease. Small vessel disease can only be diagnosed with a CNS biopsy. Medium vessel vasculitis usually presents with focal neurological signs, while small vessel vasculitis more often leads to cognitive deficits, altered level of consciousness and seizures. Markers of CNS inflammation include cerebrospinal fluid pleocytosis or elevated protein levels, and vessel wall, parenchymal or leptomeningeal enhancement. The broad range of differential diagnoses of CNS vasculitis can be narrowed based on the disease subtype. Common mimickers of medium vessel vasculitis include intracranial atherosclerosis and reversible cerebral vasoconstriction syndrome. The diagnostic workup aims to answer two questions: is the neurological presentation secondary to a vasculitic process, and if so, is the vasculitis primary (i.e., primary angiitis of the CNS) or secondary (e.g., to a systemic vasculitis, connective tissue disorder, infection, malignancy or drug use)? In primary angiitis of the CNS, glucocorticoids and cyclophosphamide are most often used for induction therapy, but rituximab may be an alternative. Based on the available evidence, all patients should receive maintenance immunosuppression. A multidisciplinary approach is necessary to ensure an accurate and timely diagnosis and to improve outcomes for patients with this potentially devastating condition.

Predictive models for thromboembolic events in giant cell arteritis: A US veterans health administration population-based study

Giant cell arteritis (GCA) that affects older patients is an independent risk factor for thromboembolic events. The objective of this study was to identify predictive factors for thromboembolic events in patients with GCA and develop quantitative predictive tools (prognostic nomograms) for pulmonary embolism (PE) and deep venous thrombosis (DVT). A total of 13,029 patients with a GCA diagnosis were included in this retrospective study. We investigated potential predictors of PE and DVT using univariable and multivariable Cox regression models. Nomograms were then constructed based on the results of our Cox models. We also assessed the accuracy and predictive ability of our models by using calibration curves and cross-validation concordance index. Age, inpatient status at the time of initial diagnosis of GCA, number of admissions before diagnosis of GCA, and Charlson comorbidity index were each found to be independent predictive factors of thromboembolic events. Prognostic nomograms were then prepared based on these predictors with promising prognostic ability. The probability of developing thromboembolic events over an observation period of 5 years was estimated by with time-to-event analysis using the method of Kaplan and Meier, after stratifying patients based on predicted risk. The concordance index of the time-to-event analysis for both PE and DVT was &gt; 0.61, indicating a good predictive performance. The proposed nomograms, based on specific predictive factors, can accurately estimate the probability of developing PE or DVT among patients with GCA.

A Case of Giant Cell Arteritis Presenting As Catastrophic Posterior Circulation Stroke: A Diagnostic Dilemma

Giant cell arteritis (GCA) is an immune-mediated systemic vasculitis usually seen in the older population. We describe a case of a 75-year-old woman who presented with jaw claudication and temporal headache. A colour duplex ultrasonography and later biopsy of the temporal arteries confirmed GCA and she was commenced on oral steroids. She was subsequently readmitted with a new worsening vision of both eyes and confusion. Her brain images revealed acute bilateral vertebral artery thrombus with haemorrhagic transformation. She was loaded on intravenous steroids. The next day she developed vomiting, bilateral visual loss and a cardiac arrest from ventricular fibrillation. Following the return of spontaneous circulation, she was taken to the cardiac catheterisation laboratory for a coronary angiogram, which showed diffuse thrombus at the apical left anterior descending artery. A bedside echocardiogram revealed a sizable left ventricular thrombus. She was managed with heparin and antiplatelet therapy.

This case presented a complex diagnostic dilemma to the medical team as vasculitis, atherosclerosis, and cardiac emboli could have contributed to her stroke and visual loss. This patient also had some vascular risk factors for occlusive cerebrovascular disease, potentially suggesting a clinical event with multiple aetiologies.

Stroke and visual loss are rare but serious complications of GCA, which require a high index of suspicion and early treatment with corticosteroids to improve prognosis. Although a temporal artery biopsy remains to be the definitive diagnostic modality for GCA, the use of radiological investigations in the diagnosis of GCA is increasingly common. A non-invasive colour duplex ultrasonography of the temporary arteries could be used to assess GCA in highly suspected patients. Echocardiograms and contrast-enhanced body imaging should be performed in patients with suspected or established GCA to assess for secondary thromboembolic and vascular complications.

An Updated Review of Cardiovascular Events in Giant Cell Arteritis

Giant cell arteritis (GCA) is a systemic vasculitis with a direct and indirect increased risk of acute and chronic vascular events, affecting large and medium vessels, and responsible for most of the morbidity and mortality of this disease. We aimed in this review to provide an updated synthesis of knowledge regarding cardiovascular events observed in GCA. By definition, GCA patients are over 50 and often over 70 years old, and subsequently also present age-related cardiovascular risk factors. In addition, the systemic and vascular inflammation as well as glucocorticoids (GC) probably contribute to an accelerated atherosclerosis and to vascular changes leading to arterial stenoses and aortic dilations and/or dissections. GCA-related ischemic complications, especially ophthalmologic events, stroke or myocardial infarcts are mostly observed within the first months after the diagnosis, being mainly linked to the vasculitic process. Conversely, aortic complications, including dilations or dissections, generally occur several months or years after the diagnosis, mainly in patients with large-vessel vasculitis. In these patients, other factors such as atherosclerosis, GC-related endothelial damage and vascular wall remodeling/healing probably contribute to the vascular events. GCA management includes the detection and treatment of these previous and newly induced cardiovascular risk factors. Hence, the use of cardiovascular treatments (e.g., aspirin, anticoagulation, statins, anti-hypertensive treatments) should be evaluated individually. Aortic structural changes require regular morphologic evaluations, especially in patients with previous aortitis. The initial or secondary addition of immunosuppressants, especially tocilizumab, an anti-IL-6 receptor antibody, is discussed in patients with GCA-related cardiovascular complications and, more consensually, to limit GC-mediated comorbidities.

Giant cell arteritis complicated by tongue necrosis and bilateral cerebellar ischaemic stroke

Giant cell arteritis (GCA) typically presents with headache, scalp tenderness or visual disturbance. Other symptoms include orofacial pain, constitutional symptoms and ischaemic stroke. An 81-year-old woman with a background of type-2 diabetes and hypertension presented with headache, oral pain and right visual loss. Examination showed hypertension, nodular temporal arteries, reduced visual acuity and suspected oral candida. Inflammatory markers were raised and she was diagnosed with GCA and commenced on corticosteroids. During treatment she developed tongue ulceration, then acute vertigo and incoordination with nystagmus and ataxia. Neuroimaging confirmed bilateral, cerebellar ischaemic strokes and temporal artery biopsy was consistent with GCA. With corticosteroids and secondary prevention of stroke measures she is now functionally independent. Oral pain is an uncommon symptom of GCA and delays in recognition may lead to catastrophic consequences. Clinicians should be aware of uncommon presentations and to optimise additional ischaemic stroke risk-factors.

Real-life analysis of the causes of death in patients consecutively followed for giant cell arteritis in a French centre of expertise

OBJECTIVES

To describe, in a real-life setting, the direct causes of death in a cohort of consecutive patients with GCA.

METHODS

We retrospectively analysed the deaths that occurred in a cohort of 470 consecutive GCA patients from a centre of expertise between January 2000 and December 2019. Among the 120 patients who died, we retrieved data from the medical files of 101 patients.

RESULTS

Cardiovascular events were the dominant cause of death (n = 41, 41%) followed by infections (n = 22, 22%), geriatric situations (i.e. falls or senile deterioration; n = 17, 17%) and cancers (n = 15, 15%). Patients in each of these four groups were compared with the other deceased patients pooled together. Patients who died from cardiovascular events were more frequently male (46 vs 27%; P = 0.04) with a past history of coronary artery disease (29 vs 8%; P = 0.006). Patients who died from infections mostly had ongoing glucocorticoid treatment (82 vs 53%; P = 0.02) with higher cumulative doses (13 994 vs 9150 mg; P = 0.03). Patients who died from geriatric causes more frequently had osteoporosis (56 vs 17%; P = 0.0009) and had mostly discontinued glucocorticoid treatment (76 vs 33%; P = 0.001). The predictive factors of death in multivariate analysis were a history of coronary disease [hazard ratio (HR) 2.39; 95% CI 1.27, 4.21; P = 0.008], strokes at GCA diagnosis (HR 2.54; 95% CI 1.05, 5.24; P = 0.04), any infection during follow-up (HR 1.93; 95% CI 1.24, 2.98; P = 0.004) and fever at GCA diagnosis (HR 1.99; 95% CI 1.16, 3.28; P = 0.01).

CONCLUSION

Our study provides real-life insight on the cause-specific mortality in GCA patients.

Giant cell arteritis: what is new in the preclinical and early clinical development pipeline?

Introduction: Giant Cell Arteritis (GCA) is the most common systemic vasculitis worldwide. For decades, glucocorticoids have represented the mainstay of treatment, at the expense of toxic systemic effects owing to prolonged courses of high-dose treatment regimens. The search for effective drugs permitting lower glucocorticoid treatment regimens in GCA has been afrustrating one. The recent successful therapeutic application of tocilizumab, an interleukin-6 receptor inhibitor, has transformed the treatment of GCA and catalyzed research exploring other promising therapeutic targets.Areas covered: This review explores emerging drugs in preclinical and clinical development for the management of GCA, in addition to synthesizing data on the current standard of care therapeutic agents. Drug therapies were identified by search of MEDLINE and PubMed in addition to trials from registries (clinicaltrials.gov, clinicaltrialsregister.eu, pubmed.gov) from theyear 2010.Expert opinion: Tocilizumab has revolutionized the treatment of GCA. However, much remains to be learned about its optimal usage in GCA and asubstantial minority of pa tients do not achieve sustained glucocorticoid-free remission. Numerous exciting new agents are under investigation to fill this treatment gap in GCA, with the GM-CSF inhibitor mavrilimumab, and IL-12/23 blockade with ustekinumab providing promise through targeting the GCA pathogenic pathway in its proximal portion.

Stroke secondary to giant-cell arteritis: A literature review

Stroke is a leading cause of death and disability worldwide. In addition to the classical etiologies of stroke as atherosclerosis and cardioembolism there are many unusual, rare causes, which require a high level of clinical suspicion and further investigations for correct and early diagnosis and adequate treatment. Giant-cell arteritis or temporal arteritis, the most frequent vasculitis in the elderly population is one of the uncommon causes of stroke. In the setting of giant-cell arteritis, stroke more likely affects the vertebrobasilar territory and is the main cause of mortality. Duplex ultrasound examination is a routine investigation for stroke patients and may be key to the diagnosis if the classical hypoechoic ‘halo sign’ is recognized at the level of vertebral arteries. In this situation the ultrasound evaluation of temporal arteries and temporal artery biopsy are mandatory. The Giant-cell arteritis-related stroke is a rare condition; therefore, there are no evidence-based guidelines or standard recommendations for the treatment. In the present review, the main characteristics of giant-cell arteritis-related stroke are discussed.

Giant Cell Arteritis and Cardiac Comorbidity

Giant cell arteritis (GCA) is a large vessel vasculitis with a pathogenesis that involves two CD4 T-helper cell lineages, Th1 and Th17. The goal of GCA treatment is to achieve clinical remission and prevent complications, especially vision loss. Despite recent advances in treatment and diagnostic modalities for GCA, there continues to be a gap in the medical literature in addressing treatment and follow-up for patients with GCA after clinical remission is achieved. Of the most important issues to address in this patient population by rheumatologists and primary care physicians alike, is that of cardiovascular disease (CVD) risks in GCA patients associated with the vasculitis and its mainstay of treatment with high-dose glucocorticoids over a prolonged period of time. Physicians must be aware of the CVD events that have been observed in a higher proportion compared to the general population in GCA patients, including strokes, thoracic aortic aneurysms and dissections, myocardial infarctions, and peripheral vascular disease. This review will focus on the risk of CVD in GCA patients, with recommendations for management and follow-up.

Beyond Giant Cell Arteritis and Takayasu's Arteritis: Secondary Large Vessel Vasculitis and Vasculitis Mimickers

PURPOSE OF REVIEW

To provide an overview of mimickers of large vessel vasculitis (LVV), by the main presenting manifestation, i.e., systemic, vascular, and cranial manifestations.

RECENT FINDINGS

The main differential diagnoses in patients with giant cell arteritis (GCA) and Takayasu arteritis (TAK) presenting with systemic manifestations (i.e., fever, anorexia, weight loss, night sweats, arthralgia/myalgia, and/or increased inflammatory indexes) are neoplastic, infectious, or other inflammatory conditions. In patients with vascular manifestations (such as peripheral ischemia, vascular stenoses, or aneurysms), atherosclerosis and non-inflammatory vascular diseases should be excluded. In those presenting with predominant cranial symptoms (i.e., temporal headache, jaw claudication, scalp tenderness, transient or permanent vision loss), other causes of headache, cerebrovascular accidents, optic neuropathy, and neuromuscular syndromes need to be considered. The diagnosis of LVV maybe challenging, especially when patients present with atypical or incomplete clinical forms. In these cases, a multidisciplinary approach is strongly recommended.

Clinical and Radiographic Features of Giant Cell Arteritis With Intracranial Involvement

Objective

Giant cell arteritis (GCA) is a large‐vessel vasculitis that primarily affects the aorta and its branches. Extracranial branches of the carotid artery are frequently affected; however, intracranial involvement in GCA is rare.

Methods

A retrospective medical record review was performed to identify all patients with intracranial GCA (IC‐GCA) from January 1996 through May 2018.

Results

Nine patients with IC‐GCA were included (78% male; mean age, 72.1 years [SD: 7.9]). All patients met ACR criteria for GCA. The median time from onset of GCA to intracranial involvement was 0.6 months (interquartile range: 0.1‐5.1). All patients had neurologic symptoms, 89% had an ischemic cerebrovascular event. Transient or permanent vision loss was frequent (56% of patients). IC‐GCA was diagnosed by cranial imaging in all nine patients. Intracranial vasculitis most commonly affected the internal carotid artery (100%), followed by the vertebral artery (67%), posterior cerebral artery (67%), middle cerebral artery (44%), anterior cerebral artery (33%), and posterior inferior cerebral artery (11%). Intracranial vessel stenosis was present in 89%, occlusion in 33%, wall thickening in 33%, and dilation in 11%.

All patients received glucocorticoids. Additional therapeutic agents included cyclophosphamide (67%) and tocilizumab (22%). Despite treatment, five patients had rapid deterioration and mortality. Comparing IC‐GCA patient survival to the expected rates from the US population, the standardized mortality ratio (95% CI) for IC‐GCA was 58.1 (18.9‐135.6).

Conclusion

Although rare, IC‐GCA is associated with significant morbidity and mortality. It occurs predominantly in men and presents with ischemic cerebrovascular events. Current treatment strategies appear to be of limited efficacy for IC‐GCA.

Neurological Involvement in Primary Systemic Vasculitis

Primary systemic vasculitis can affect every structure in both the central and peripheral nervous system, causing varied neurological manifestations of neurological dysfunction. Early recognition of the underlying causes of the neurological symptoms can facilitate timely treatment and improve the prognosis. This review highlights the clinical manifestations of primary systemic vasculitis in the nervous system.

Ischemic stroke in giant-cell arteritis: French retrospective study

Acute cerebrovascular ischemic events are a rare and severe complication of giant cell arteritis (GCA). We aimed to determine the prevalence of GCA-related stroke, the overall survival and the relapse-free survival in patients with GCA. A multicentric retrospective analysis was performed on 129 patients with GCA diagnosed between September 2010 and October 2018 in two University Hospitals. Among 129 GCA patients, 18 (16%) presented an acute ischemic cerebrovascular event. Patients with stroke were older (83 [67-96] years versus 76 [58-96]; p = 0.014) and more frequently males (61% versus 30%; p = 0.014) than those without stroke. The frequency of anterior ischemic optic neuropathy was higher in patients with stroke (n = 6, 33%) than patients without stroke (n = 12, 11%)(p = 0.02). Overall survival was significantly decreased in GCA patients with stroke (4.4 months), comparatively to patients without stroke (221.7 months; log rank test = 0.006). The 3-years relapse-free survival was decreased in patients with stroke (8.42 versus78.0 months; log rank = 0.0001), as well as the time with sustained remission (78 versus 139 months; log rank test = 0.0004). This study shows the prevalence and risk factors of ischemic stroke in GCA.

Giant-cell arteritis-related mortality in France: A multiple-cause-of-death analysis

OBJECTIVES

Giant-cell arteritis (GCA) is a large vessel vasculitis. Data regarding mortality are controversial. We describe the mortality data of the French death certificates for the period of 2005 to 2014.

METHODS

Using multiple-cause-of-death (MCOD) analysis, we calculated age-adjusted mortality rates for GCA, examined differences in mortality rates according to age and gender and analyzed the underlying causes of death (UCD).

RESULTS

We analyzed 4628 death certificates listing a diagnosis of GCA as UCD or non-underlying cause of death (NUCD). The mean age of death was 86 (±6.8) years. The overall age-standardized mortality rate among GCA patients was 7.2 per million population. Throughout the study period, the mean age of death was significantly increased (r = 0.17, p < .0001) in both genders. There was no significant difference with age repartition of death in the general population (p = .26). When GCA was listed as the UCD, most frequent associated diseases were cardiovascular (79%) and infectious diseases (35%). When GCA was reported as the NUCD, the listed UCD was a cardiovascular event in 40% of cases, neoplasm in 13%, neurodegenerative disorder in 11% and infectious disease in 10%. When GCA was the UCD or NUCD, an age-adjusted observed/expected ratio > 1 in GCA-associated mortality compared with the general population mortality was observed for tuberculosis, pneumonia and cardiovascular diseases.

CONCLUSION

In this analysis of French death certificates mentioning GCA, we observed a stable standardized mortality rate between 2005 and 2014. The most frequent associated diseases were cardiovascular diseases and infections.

Mortality causes and trends associated with giant cell arteritis: analysis of the French national death certificate database (1980-2011)

Objectives

Comprehensive analyses of cause-specific death patterns in GCA are sparse. We studied the patterns and time trends in GCA-related mortality using a large death certificate database.

Methods

We obtained multiple-cause-of-death data from the French national death certificate database for 1980-2011. GCA-associated deaths were defined as decedents ⩾55 years old with GCA listed as an underlying or non-underlying cause of death. Time trends of death rates were analysed and the mean age at death with GCA and in the general population ⩾55 years old were calculated. Standardized mortality odds ratios (SMORs) were calculated for 17 selected causes of death (based on 2000-11 data).

Results

The analyses pertained to approximately 15 000 death certificates listing GCA (including approximately 6300 for 2000-11). Annual standardized death rates for GCA increased to a peak in 1997 and then decreased (Spearman's correlation test, both P < 0.0001). Mean age at death was higher for GCA than for general population decedents (Student's t-test, P < 0.0001). GCA deaths were frequently or strongly associated with aortic aneurysm and dissection (1.85% of death certificates, SMOR: 3.09, 95% CI: 2.48, 3.82), hypertensive disease (20.78%, SMOR: 2.22, 95% CI: 1.97, 2.50), diabetes mellitus (11.27%, SMOR: 1.96, 95% CI: 1.72, 2.23), certain infectious and parasitic diseases (12.12%, SMOR: 1.76, 95% CI: 1.55, 2.00) and ischaemic heart disease (16.54%, SMOR: 1.45, 95% CI: 1.35, 1.64).

Conclusion

GCA is associated with increased risk of dying from large-vessel disease, other cardiovascular diseases and potentially treatment-related co-morbidities. These findings help provide better insights into the outcomes of GCA.

Giant Cell Arteritis: Practical Pearls and Updates

PURPOSE OF REVIEW

The purpose of this review is to summarize recent updates and distill practical points from the literature which can be applied to the care of patients with suspected and confirmed giant cell arteritis (GCA).

RECENT FINDINGS

Contemporary thinking implicates a fundamental failure of T regulatory cell function in GCA pathophysiology, representing opportunity for novel therapeutic avenues. Tocilizumab has become the first Food and Drug Administration-approved treatment for GCA following demonstration of efficacy and safety in a phase 3 clinical trial. There have been significant parallel advances in both our understanding of GCA pathophysiology and treatment. Tocilizumab, and other agents currently under investigation in phase 2 and 3 clinical trials, presents a new horizon of hope for both disease remission and avoidance of glucocorticoid-related complications.

Efficacy of early rehabilitation therapy on movement ability of hemiplegic lower extremity in patients with acute cerebrovascular accident

This study aims to investigate the efficacy of early rehabilitation therapy on the movement ability of hemiplegic lower extremity in patients with acute cerebrovascular accident (CVA).A total of 86 patients who suffered from acute CVA were selected and divided into 2 groups, according to random number tables: control group, and research group. Patients in the control group received routine primary therapy, while patients in the research group received rehabilitation based on the basic therapy. The recovery of hemiplegic limb movement ability and the improvement of daily living ability before and after treatment were evaluated using the simplified Fugl-Meyer assessment (FMA), neurologic deficit scale (NDS), and Barthel index (BI). After treatment, the clinical efficacy and satisfaction degree for treatment were compared.The FMA, NDS, and BI of patients in these 2 groups were distinctly ameliorated after treatment (P <.05). After treatment, the ameliorated degrees of FMA, NDS, and BI in the research group were obviously superior to those in the control group, and the differences were statistically significant (P <.05). The total efficacy and satisfaction degree in the research group were evidently higher than those in the control group after early rehabilitation therapy, and the differences were statistically significant (P <.05).Early rehabilitation therapy can significantly ameliorate the movement ability of hemiplegic lower extremity in patients with acute CVA. Its therapeutic effect is remarkable. Hence, it is worthy of popularizing in clinical practice.