Giant cell arteritis presenting as multiple ischaemic strokes: a successful case of endovascular treatment
  • Ana Órfão
    Department of Internal Medicine III, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
  • Carolina Saca
    Department of Internal Medicine IV, Immune-Mediated Systemic Diseases Unit (Unidade de Doenças Imunomediadas Sistémicas – UDIMS), Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
  • Inês Alexandre
    Nephrology, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
  • Ana Maria Oliveira
    Intensive Care, Hospital de Vila Franca de Xira, Vila Franca de Xira, Portugal
  • João Fernandes Serôdio
    Department of Internal Medicine IV, Immune-Mediated Systemic Diseases Unit (Unidade de Doenças Imunomediadas Sistémicas – UDIMS), Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
  • João Barreira
    Stroke Unit, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
  • Teresa Mesquita
    Stroke Unit, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal

Keywords

Giant cell arteritis, intracranial stenosis, ischemic stroke, vascular imaging, endovascular treatment

Abstract

Giant cell arteritis (GCA) may manifest with aggressive intracranial stenosis resistant to medical therapy, and patients may develop refractory neurologic deficits and cerebral infarcts, making GCA a life-threatening condition.
We report the case of a 68-year-old woman recently diagnosed with GCA, medicated with prednisolone 60 mg daily. Two weeks later, the patient was admitted to our Stroke Unit after a sudden episode of global aphasia. Magnetic resonance angiography showed two recent ischaemic lesions, besides an erythrocyte sedimentation rate of 17 mm/hour. A cerebral angiography revealed bilateral stenosis and dilation in the petrous, cavernous and supraclinoid segments of internal carotid arteries (ICA). The patient was started on intravenous methylprednisolone pulses (250 mg daily for five days). Computed tomography (CT) angiography and Doppler ultrasound showed severe vascular disease affecting multiple territories, without significant intracranial involvement. The hypothesis of GCA with extracranial vasculitic involvement was considered as the aetiology of ischaemic cerebral infarctions in multiple territories and, given the severity of the disease, it was decided to add tocilizumab. Despite this, the patient evolved with significant worsening neurological deficits and a CT scan confirmed the presence of new vascular events. Endovascular treatment (EVT) with balloon angioplasty was conducted on both ICAs, with improved calibre and downstream filling. After that, the patient presented sustained clinical improvement, without recurrence of any ischaemic events at the one-year follow-up.
This clinical case stands out for the importance of EVT as an effective therapy in patients with medically refractory GCA with symptomatic intracranial stenosis, improving their prognosis.

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References

  • Farina N, Tomelleri A, Campochiaro C, Dagna L. Giant cell arteritis: Update on clinical manifestations, diagnosis, and management. Eur J Intern Med 2023;107:17–26.
  • N. Simonsen CZ, Speiser L, Hansen IT, Jayne D, von Weitzel-Mudersbach P. Endovascular Treatment of Intracerebral Giant Cell Arteritis. Front Neurol 2020;11:287.
  • Serôdio JF, Trindade M, Favas C, Alves JD. Extra-Cranial Involvement in Giant Cell Arteritis. In: Chaudhry AI, editor. Giant-Cell Arteritis [Internet]. IntechOpen; 2022.
  • Prieto-González S, Arguis P, García-Martínez A, Espígol-Frigolé G, Tavera-Bahillo I, Butjosa M, et al. Large vessel involvement in biopsy-proven giant cell arteritis: prospective study in 40 newly diagnosed patients using CT angiography. Ann Rheum Dis 2012;71:1170–1176.
  • Blockmans D, de Ceuninck L, Vanderschueren S, Knockaert D, Mortlemans L, Bobbaers H. Repetitive 18F-fluorodeoxyglucose positron emission tomography in giant cell arteritis: a prospective study of 35 patients. Arthritis Rheum 2006;55:131–137.
  • Bull Haaversen AC, Brekke LK, Kermani TA, Molberg O, Diamantopoulos AP. Extended ultrasound examination identifies more large vessel involvement in patients with giant cell arteritis. Rheumatology (Oxford) 2023;62:1887–1894.
  • Siemonsen S, Brekenfeld C, Holst B, Kaufmann-Buehler A-K, Fiehler J, Bley TA. 3T MRI reveals extra- and intracranial involvement in giant cell arteritis. AJNR Am J Neuroradiol 2015;36:91–97.
  • Wong J, Chan S, Shetty A. A Case of Giant Cell Arteritis Presenting As Catastrophic Posterior Circulation Stroke: A Diagnostic Dilemma. Cureus 2022;14(8):e27961.
  • Caton MT Jr, Mark IT, Narsinh KH, Baker A, Cooke DL, Hetts SW, et al. Endovascular Therapy for Intracranial Giant Cell Arteritis: Systematic Review, Technical Considerations and the Effect of Intra-arterial Calcium Channel Blockers. Clin Neuroradiol 2022;32:1045–1056.
  • Gonzalez-Gay MA, Vazquez-Rodriguez TR, Gomez-Acebo I, Pego-Reigosa R, Lopez-Diaz MJ, Vazquez-Triñanes MC, et at. Strokes at time of disease diagnosis in a series of 287 patients with biopsy-proven giant cell arteritis. Medicine (Baltimore) 2009;88:227–235.
  • Salvarani C, Della Bella C, Cimino L, Macchioni P, Formisano D, Bajocchi G, et al. Risk factors for severe cranial ischaemic events in an Italian population-based cohort of patients with giant cell arteritis. Rheumatology (Oxford) 2009;48:250–253.
  • Soriano A, Muratore F, Pipitone N, Boiardi L, Cimino L, Salvarani C. Visual loss and other cranial ischaemic complications in giant cell arteritis. Nat Rev Rheumatol 2017;13:476–484.
  • Stone JH, Tuckwell K, Dimonaco S, Klearman M, Aringer M, Blockmans D, et al. Trial of Tocilizumab in Giant-Cell Arteritis. N Engl J Med 2017;377:317–328.
  • Chatterjee S, Flamm SD, Tan CD, Rodriguez ER. Clinical diagnosis and management of large vessel vasculitis: giant cell arteritis. Curr Cardiol Rep 2014;16:498.
  • Both M, Aries PM, Müller-Hülsbeck S, Jahnke T, Schäfer PJ, Gross WL, et al. Balloon angioplasty of arteries of the upper extremities in patients with extracranial giant-cell arteritis. Ann Rheum Dis 2006;65:1124–1130.
  • Nuenninghoff DM, Hunder GG, Christianson TJH, McClelland RL, Matteson EL. Incidence and predictors of large-artery complication (aortic aneurysm, aortic dissection, and/or large-artery stenosis) in patients with giant cell arteritis: a population-based study over 50 years. Arthritis Rheum 2003;48:3522–3531.
  • Takatsuki K, Kojima Y, Ikeuchi Y, Kitayama J, Tanaka A, Inoue Y. Intracranial vascular stenosis in giant cell arteritis successfully treated by two balloon angioplasty procedures. Mod Rheumatol Case Rep 2022;7:166–171.
  • Lago A, Tembl JI, Fortea G, Morales L, Nieves C, Campins M, et al. Stroke and temporal arteritis: A study of 6 cases. Neurologia (Engl Ed) 2020;35:75–81.
  • Togo M, Kono T, Hoshi T, Imamura H, Todo K, Adachi H, et al. Successful endovascular therapy for multiple intracranial arterial stenosis associated with medically intractable giant cell arteritis. J Neurol Sci 2018;384:104–106.
  • Guerrero AM, Sierra-Hidalgo F, Calleja P, Navia P, Campollo J, Díaz-Guzmán J. Intracranial internal carotid artery angioplasty and stenting in giant cell arteritis. J Neuroimaging 2015;25:307–309.
  • Neutel D, Biscoito L, Campos J, e Melo TP, Albuquerque L. Giant cell arteritis with symptomatic intracranial stenosis and endovascular treatment. Neurol Sci 2014;35:609–610.
  • Dementovych N, Mishra R, Shah QA. Angioplasty and stent placement for complete occlusion of the vertebral artery secondary to giant cell arteritis. J Neurointerv Surg 2012;4:110–113.
  • Chausson N, Olindo S, Signaté A, Cohen-Ténoudji P, Aveillan M, Saint-Vil M, et al. Angioplastie carotidienne bilatérale chez une patiente avec infarctus cérébral sur maladie de Horton [Bilateral intracerebral angioplasty in a patient with stroke caused by giant cell arteritis]. Rev Neurol (Paris) 2010;166:328–332.
  • Steiger R, Walchhofer L-M, Rietzler A, Mair KJ, Knoflach M, Glodny B, et al. Cerebral Phosphorus Magnetic Resonance Spectroscopy in a Patient with Giant Cell Arteritis and Endovascular Therapy. Case Rep Radiol 2018;2018:7806395.
  • Espígol-Frigolé G, Gomez-Choco M, Obach V, Sanroman L, Prieto-González S, Argelich R, et al. Percutaneous transluminal angioplasty of internal carotid and vertebral arteries in giant cell arteritis: report of 2 cases. APMIS 2009;117(suppl.):104–105.
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    Published: 2024-02-08
    Issue: 2024: Vol 11 No 3 (view)


    How to cite:
    1.
    Órfão A, Saca C, Alexandre I, Oliveira AM, Fernandes Serôdio J, Barreira J, Mesquita T. Giant cell arteritis presenting as multiple ischaemic strokes: a successful case of endovascular treatment. EJCRIM 2024;11 doi:10.12890/2024_004296.

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