Giant Cell Arteritis as a Cause of First-Ever Stroke

Wiszniewska, Małgorzata; Devuyst, G.; Bogousslavsky, Julien

doi:10.1159/000104482

Cited by 52 publications

(31 citation statements)

References 34 publications

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“…In patients with giant cell arteritis, 50%-75% of strokes occur in the vertebrobasilar circulation (compared with 15%-20% of strokes in patients without giant cell arteritis). 6,10 Our patient developed bilateral occlusion of the vertebral arteries, which was confirmed by cerebral angiography. This occurs in only 0.1%-0.2% of patients with cerebrovascular disease.…”

Section: Investigationssupporting

confidence: 55%

“…Giant cell arteritis is often overlooked as a possible cause of stroke, because it is reportedly the cause of firstever stroke in only 0.11% of patients. 6 Because the diagnosis of giant cell arteritis was not ini- A B Practice tially considered in our patient, we missed the significance of his weight loss and headache, and an erythrocyte sedimentation rate was not initially ordered.…”

Section: Discussionmentioning

confidence: 94%

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An atypical presentation of giant cell arteritis

Zwicker¹,

Atkins²,

Lum³

et al. 2011

Canadian Medical Association Journal

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A n 85-year-old man presented to the emergency department with difficulty walking, dizziness and double vision that had lasted for one week. He had previously experienced several weeks of temporal headache and weight loss. Abnormal findings on neur o logic examination included upbeat nystagmus, gaze palsy when looking to the right and gait ataxia.Diffusion-weighted magnetic resonance imaging (MRI) showed multiple, small, acute and subacute infarcts in the pons, cerebellar hemispheres and occipital lobes. A computed tomography (CT) angiogram showed bilateral concentric thickening of the walls of the vertebral arteries extracranially (Figure 1) with irregular, concentric stenoses of these arteries from the subclavian artery to the upper cervical vertebrae. The radiologic differential diagnosis included bilateral dissection of the vertebral arteries, but it did not include giant cell arteritis. Our patient was given treatment with intravenous heparin, followed by warfarin for the presumed dissection. After four weeks in hospital, he was discharged to a stroke rehabilitation facility.Six weeks after being discharged from hospital, the patient was readmitted with a decreased level of consciousness, dysarthria and worsening ataxia. A diffusion-weighted MRI showed new infarcts in the pons, cerebellum and midbrain. A magnetic resonance angiogram showed severely diminished blood flow in his basilar artery, as well as extensive multifocal areas of diminished flow within the vertebral arteries. A new, moderately severe, area of stenosis within the petrous portion of his left internal carotid artery was evident (Figure 2).The rapid progression of changes in the large vessels led to the consideration of vasculitis as a possible diagnosis. Our patient's erythrocyte sedi mentation rate was 30 mm/h (the upper limit of normal varies between laboratories, but it is 6 mm/h at our institution) and his C-reactive protein level was 25 (normal < 8) mg/L. When adjusted for age, the erythrocyte sedimentation rate could be interpreted as normal (upper limit of normal of the the age-adjusted rate for men is calculated as age in years ÷ 2; for women, it is calculated as [age in years + 10] ÷ 2). 1 His hemoglobin level was normal, and laboratory markers of systemic vasculitis were negative.Given the initial involvement of large, extracranial arteries, our patient's advanced age and his continued weight loss, giant cell arteritis rather than primary central nervous system angiitis became our working diagnosis. Treatment Practice CMAJ • Given the wide spectrum of presentations of giant cell arteritis, physicians need to be equally familiar with both typical and atypical presentations.• The presenting manifestation of giant cell arteritis may be stroke. Giant cell arteritis should be considered as a cause of stroke in patients with "red flags."• Concentric, long-segment, increased thickening of the arterial wall, particularly extracranially, on computed tomography angiography may indicate giant cell arteritis. See related practice article by B...

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Section: Investigationssupporting

confidence: 55%

Section: Discussionmentioning

confidence: 94%

An atypical presentation of giant cell arteritis

Zwicker¹,

Atkins²,

Lum³

et al. 2011

Canadian Medical Association Journal

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“…Small cerebral vessel involvement has been found on autopsy, 9 and lacunar infarctions have been reported on brain MRI. 10 Approximately 0.15 % of first-ever ischemic strokes are blamed on GCA. 10 In a series of 287 biopsy-proven cases of GCA, stroke developed in 7 (close to 3%), 1 of which in the carotid territory distribution.…”

Section: Discussionmentioning

confidence: 99%

Selective Infarction of the Anterior Genu Fornices Associated with Giant Cell Arteritis

Murr

Thaisetthawatkul

Helvey

et al. 2012

Journal of Stroke and Cerebrovascular Diseases

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“…It is reportedly the cause of fi rst-ever stroke in only 0.11% of patients. 4 In our patient, diagnosis was delayed by the sepsis-like and the subacute stroke-like features. The clinical features in the same distribution supported an ICA pathology as opposed to a cardioembolic source, which usually affects different territories.…”

Section: Discussionmentioning

confidence: 61%

A stroke of bad luck

2014

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Lesson of the month 2: A stroke of bad luckGiant cell arteritis is a common cause of headache in patients aged more than 50 years. It is an easy diagnosis to make if classical features, ie temporal headache, jaw claudication, visual symptoms, systemic symptoms of fever or weight loss with high erythrocyte sedimentation rate and anemia, are present. However, it may present atypically and stroke can be the presenting feature. A high index of suspicion is needed in atypical presentations such as stroke. Once a diagnosis is suspected it is imperative to start high dose steroids to prevent visual and neurological complications. KEYWORDS: Giant cell arteritis, stroke, vasculitis, steroids, aspirin Case presentationA 62-year-old woman who was previously fi t and well was admitted with a 6-week history of headaches and feeling generally unwell. In the last 8 months she was investigated for unexplained iron defi ciency anaemia. Her coeliac serology and upper and lower gastrointestinal endoscopy were normal. Her past medical history included polio of the right leg and agoraphobia. Her only known vascular risk factors included a 30-packs-per-year smoking history. She was not on any medications.Over the last 3-4 weeks she had noticed diffi culty with coordination of her right hand. Three days prior to admission, she developed fever, slurring of speech and increasing weakness of the right hand. On admission she was pyrexial at 38.0°C, blood pressure 130/80 in sinus rhythm and a Glasgow coma score (GCS) of 15; no rash or meningeal signs were noted. However she had right upper and lower limb weakness (4/5) with upper motor neuron facial palsy. Her cardiovascular examination revealed no obvious murmurs.

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Giant Cell Arteritis as a Cause of First-Ever Stroke

Cited by 52 publications

References 34 publications

An atypical presentation of giant cell arteritis

An atypical presentation of giant cell arteritis

Selective Infarction of the Anterior Genu Fornices Associated with Giant Cell Arteritis

A stroke of bad luck

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