Takayasu’s Arteritis - An Unusual Cause of Stroke in a Young Patient
A 28-year-old male with no significant past medical history presented to a community emergency department with acute onset of a dense right hemiplegia and aphasia. While at work the patient had a witnessed collapse to the ground. 911 was called.\nA family member reported that the patient had been complaining of headaches and, back and shoulder pain for two weeks. No other systemic symptoms predated the patient’s presentation. The patient had a history of mild intermittent asthma and used an albuterol metered dose inhalers as needed. There was no known family history of cardiac, cerebrovascular or autoimmune disease.\nOn presentation, the patient was acutely ill appearing. There were no visible signs of trauma. He had a blood pressure of 111/62 mmHg in the right upper extremity and 173/105 mmHg in the left upper extremity. His heart rate was 115 beats-per-minute and his respiratory rate was 14 breaths per minute with an oxygen saturation of 98% on 3L nasal cannula. He had loud bruits heard over the carotid and subclavian arteries as well as the abdominal aorta. There was a 3/6 systolic ejection murmur noted over the entire precordium. He was non-verbal, not following commands, and did not open his eyes spontaneously. He had extensor posturing to noxious stimuli on the right side.\nThe patient was intubated for airway protection and taken emergently for a non-contrast brain computed tomography (CT) that revealed a dense middle cerebral artery (MCA) sign on the left corresponding to a thrombus without acute hemorrhage, infarct or mass effect (). The patient was administered alteplase within a 4.5 hour window without any immediate change in his clinical status.\nA chest, neck and brain CT angiogram was performed, which showed marked wall thickening involving the left common carotid artery with complete occlusion of the distal left common carotid artery and MCA (). Also seen was occlusion of the right common carotid and vertebral arteries with extensive collaterals, as well as inflammatory changes surrounding the aorta and subclavian vessels. No dissection of the aorta or its branches was visualized. A brain magnetic resonance image (MRI) was performed demonstrating an evolving infarct involving the left deep basal ganglia, thalamus and cerebral cortex (). There was restricted diffusion weighted signal of the left cerebral cortex signifying viable tissue with ongoing ischemia. As the patient had already received thrombolytic therapy and failed to improve, a neurosurgical consult was obtained and the patient was taken to the interventional suite where a thrombectomy, clot retrieval and angioplasty of the left common carotid and MCA thrombus was performed to allow for reperfusion ().\nLaboratory testing revealed an erythrocyte sedimentation rate (ESR) of 103 mm/hour (normal 0–15 mm/hr) and a C-reactive protein (CRP) of 51 (normal < 10). The patient’s complete blood count, chemistries, coagulation profiles, hypercoagulable studies, electrocardiogram, and chest radiograph were normal.\nGiven the clinical exam, laboratory results and the findings on the CT angiogram, the presumptive diagnosis of Takayasu’s arteritis was made. The patient was started on high dose steroids and methotrexate. He subsequently had normalization of his ESR and CRP and had marked clinical improvement by time of discharge.