Endovascular Therapy for Intracranial Giant Cell Arteritis : Systematic Review, Technical Considerations and the Effect of Intra-arterial Calcium Channel Blockers

Clinical Reasoning: A 70-Year-Old Man With Systemic Illness Related Strokes Refractory to Medical Treatment Managed With Intracranial Stent

We present the case of a 70-year-old man with a history of embolic stroke, atrial fibrillation, deep vein thrombosis, and polymyalgia rheumatica who presented as a stroke code with transient right-sided focal neurologic deficits (motor and sensory), mild alteration in consciousness, and mild aphasia. His cerebrovascular imaging revealed new multifocal intracranial stenoses. Despite best medical management, this patient continued to have recurrent symptomatic cerebrovascular events. This case illustrates the evaluation approach and key differential diagnoses to consider in patients with stroke-like symptoms that fail to respond to best stroke medical management. Readers will be taught the importance of considering unusual stroke mechanisms in their initial evaluation of stroke codes and the intricate subtleties in medical and interventional management decisions.

Risk Factors and Pharmacological Interventions Impacting Cerebrovascular Ischemic Events in Giant Cell Arteritis: A Narrative Review

INTRODUCTION

Giant cell arteritis (GCA) is a common vasculitis predominantly affecting larger vessels, especially in individuals aged 70-79. Cerebrovascular ischemic events (CIE), such as stroke and transient ischemic attacks, are serious but rare complications of GCA, with a pooled prevalence of 4%. Some studies found that within 2 weeks of GCA diagnosis, 74% and 34% of patients experience transient or severe ischemic events, respectively.

AIMS

Our study aims to help physicians better manage GCA patients to reduce GCA-related CIE by indicating important risk factors and pharmacological intervention to prevent GCA-related CIE, particularly in the first few days of diagnosis when the risk of CIE is highest.

METHODS

A comprehensive literature search was conducted using Pubmed, Google Scholar, Scopus, and other relevant medical databases. As this study was a narrative review, the literature search was done in a nonsystematic manner. Studies published from 2000 to 2024 were reviewed in a nonsystematic manner for information on incidence, pathology, risk factors, pharmacological intervention, and management of GCA-related CIE.

RESULTS

Findings indicate that age, male gender, hypertension, and smoking significantly increase the risk of GCA-related CIE, while factors such as anemia, higher body mass index (BMI), and elevated inflammatory markers (C-reactive protein [CRP] and erythrocyte sedimentation rate [ESR]) appear to have protective effects. Symptoms of ischemia in the ophthalmic artery were identified as the strongest predictors of CIE. Pharmacological treatments, including glucocorticoids and tocilizumab, are instrumental in managing and potentially preventing CIE in GCA patients, with adjunctive therapies such as aspirin and antiplatelet agents also showing promise.

CONCLUSION

GCA-related CIE such as stroke can be very debilitating and deadly conditions, particularly when GCA is initially diagnosed. However, with early diagnosis and proper management of risk factors, GCA-related CIE can be prevented and its severity can be reduced. Ischemia in the ophthalmic artery is found to strongly predict GCA-related CIE while aspirin and antiplatelet agent during the first 3 months may prevent GCA-related CIE. Risk factors such as BMI and smoking may help in stratifying the risk of GCA-related CIE. This review underscores the importance of further studies with detailed, well-designed approaches to risk factor analysis to strengthen these associations. Identifying these risk factors is crucial for reducing morbidity and mortality, equipping physicians to better assess and mitigate the risk of CIE in GCA patients.

Emergency Revascularization for Acute Vertebral Artery Occlusion Accompanied by Systemic Lupus Erythematosus: A Case Report

The efficacy of mechanical thrombectomy (MT) for acute ischemic stroke has been established, but there are few reports on the effectiveness of MT for stroke patients with collagen disease. We report the case of a systemic lupus erythematosus (SLE) patient with cerebral infarction who underwent MT. A 48-year-old woman had been diagnosed with SLE for 30 years. She visited our hospital because of dizziness from the day before, but when she arrived at the hospital parking lot, she developed vomiting and impaired consciousness. An MRI revealed increased cerebellar hemisphere infarction and magnetic resonance angiography (MRA) did not visualize the right vertebral artery or basilar artery. Urgent cerebral angiography was performed, and angiography of the right vertebral artery revealed occlusion of the V4 segment of the vertebral artery. In addition to these angiographic findings, the patient also had impaired consciousness and was judged to be in need of emergency revascularization treatment. We performed an MT using a stent retriever. Immediately after the angiography examination, reperfusion to the basilar artery and severe stenosis of the right vertebral artery were noted. Therefore, percutaneous transluminal angioplasty (PTA) and stent placement for vertebral artery stenosis were done. This procedure successfully maintained the patency of the vertebral artery and blood flow to the basilar artery. Her consciousness improved; she only had mild nausea and no remarkable neurological findings.

Giant Cell Arteritis Presenting as Multiple Ischaemic Strokes: A Successful case of Endovascular Treatment

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.

LEARNING POINTS

Giant cell arteritis may manifest with aggressive and symptomatic intracranial arterial stenoses.Endovascular treatment is an effective intervention to prevent ischaemic complications in intracranial giant cell arteritis.

European Stroke Organisation (ESO) guidelines on Primary Angiitis of the Central Nervous System (PACNS)

The European Stroke Organisation (ESO) guideline on Primary Angiitis of the Central Nervous System (PACNS), developed according to ESO standard operating procedures (SOP) and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, was elaborated to assist clinicians in the diagnostic and treatment pathway of patients with PACNS in their decision making. A working group involving vascular neurologists, neuroradiologists, rheumatologists, a neuropathologist and a methodologist identified 17 relevant clinical questions; these were addressed according to the patient/population, intervention, comparison and outcomes (PICO) framework and systematic literature reviews were performed. Notably, each PICO was addressed with respect to large vessel (LV)-PACNS and small vessel (SV)-PACNS. Data to answer many questions were scarce or lacking and the quality of evidence was very low overall, so, for some PICOs, the recommendations reflect the ongoing uncertainty. When the absence of sufficient evidence precluded recommendations, Expert Consensus Statements were formulated. In some cases, this applied to interventions in the diagnosis and treatment of PACNS which are embedded widely in clinical practice, for example patterns of cerebrospinal fluid (CSF) and Magnetic Resonance Imaging (MRI) abnormalities. CSF analysis for hyperproteinorrachia and pleocytosis does not have evidence supporting their use as diagnostic tools. The working group recommended that caution is employed in the interpretation of non-invasive vascular imaging due to lack of validation and the different sensitivities in comparison with digital subtraction angiography (DSA) and histopathological analyses. Moreover, there is not a neuroimaging pattern specific for PACNS and neurovascular issues are largely underreported in PACNS patients. The group's recommendations on induction and maintenance of treatment and for primary or secondary prevention of vascular events also reflect uncertainty due to lack of evidence. Being uncertain the role and practical usefulness of current diagnostic criteria and being not comparable the main treatment strategies, it is suggested to have a multidisciplinary team approach in an expert center during both work up and management of patients with suspected PACNS. Highlighting the limitations of the currently accepted diagnostic criteria, we hope to facilitate the design of multicenter, prospective clinical studies and trials. A standardization of neuroimaging techniques and reporting to improve the level of evidence underpinning interventions employed in the diagnosis and management of PACNS. We anticipate that this guideline, the first comprehensive European guideline on PACNS management using GRADE methodology, will assist clinicians to choose the most effective management strategy for PACNS.

Current developments in the diagnosis and treatment of giant cell arteritis

Giant cell arteritis is the most common vasculitis in adults above 50 years old. The disease is characterized by granulomatous inflammation of medium and large arteries, particularly the temporal artery, and is associated acutely with headache, claudication, and visual disturbances. Diagnosis of the disease is often complicated by its protean presentation and lack of consistently reliable testing. The utility of color doppler ultrasound at the point-of-care and FDG-PET in longitudinal evaluation remain under continued investigation. Novel techniques for risk assessment with Halo scoring and stratification through axillary vessel ultrasound are becoming commonplace. Moreover, the recent introduction of the biologic tocilizumab marks a paradigm shift toward using glucocorticoid-sparing strategies as the primary treatment modality. Notwithstanding these developments, patients continue to have substantial rates of relapse and biologic agents have their own side effect profile. Trials are underway to answer questions about optimal diagnostic modality, regiment choice, and duration.