Angioplasty and stent placement for complete occlusion of the vertebral artery secondary to giant cell arteritis

Abstract

Giant cell arteritis (GCA) is the most common form of systemic vasculitis in adults. Patients usually present with headache and visual symptoms, and have an elevated erythrocyte sedimentation rate. It has been reported that 3-4% of patients with GCA develop ischemic events secondary to vertebral artery stenosis or occlusion. The mainstay of therapy of GCA is high dose steroid and/or methotrexate. A case is described of a patient who initially presented with intermittent double vision, mild headache and unremarkable MRI and MR angiography of the head and neck. The patient was diagnosed and treated for ocular myasthenia. The patient was readmitted 2 months later with imbalance and worsening headache, and workup suggested bilateral cerebellar infarction, complete occlusion of the left vertebral artery and a high grade stenosis of the right vertebral artery. Erythrocyte sedimentation rate and C reactive protein were elevated. Temporal artery biopsy demonstrated changes consistent with GCA. During the course of the treatment with corticosteroids and immunosuppressant, the patient developed dysarthria, left facial droop and left hemiplegia, and was found to have complete occlusion of both vertebral arteries. The patient was emergently taken for revascularization of the occluded segment using angioplasty and stent placement. The patient had significant improvement of neurological symptoms within 3 days after the procedure and continued to improve during hospitalization. Endovascular treatment of vasculitis affecting the intracranial vessels is not yet established. Our experience with successful treatment of complete occlusion of the vertebral artery secondary to GCA using endovascular intracranial angioplasty and stent placement is reported.

Intracranial Internal Carotid Artery Angioplasthy and Stenting in Giant Cell Arteritis

“…To date, only two cases of endovascular treatment on patients with GCA with intracranial stenosis have been described. Chausson et al described a case of GCA with preocclusive bilateral carotid stenosis in which they carried out angioplasty and stenting. Shah et al reported another case with complete occlusion of the V4 segment of the right vertebral artery treated with angioplasty and stenting.…”

Fatal Spontaneous Bilateral Vertebral Artery Dissection in Giant Cell Arteritis (GCA)

“…Treatment is challenging and, in addition to established medical treatment strategies of GCA and ischemic stroke, may necessitate rescue endovascular treatment. While clinically not successful in our patient, neurological improvement after angioplasty and stenting has been reported in a similar clinical situation [4]. Arterial dissection was found to be causative for acute bilateral vertebral artery occlusion in our patient.…”

“…The vertebrobasilar circulation is affected most frequently [1][2][3]. The reported cases were similar in the clinical presentation with typical clinical symptoms of GCA (age >50 years, new onset of headache, elevated inflammatory parameters and some with jaw claudication and/or visual deterioration) and a subsequent neurological worsening [3][4][5]. The majority of events occur before or early after initiation of corticosteroid treatment [2,3].…”

Endovascular Treatment of Intracerebral Giant Cell Arteritis

“…We have only found balloon dilatation and stenting described before in three single cases (11)(12)(13). The use of stent retrievers in the treatment of cerebral vasospasm in patients with subarachnoid hemorrhage has been described recently (14) and the technique was adopted in cases due to failure of performing balloon angioplasty.…”