Systemic giant cell arteritis and cerebellar infarction

Adult and childhood vasculitis

Vasculitis refers to heterogeneous clinicopathologic disorders that share the histopathology of inflammation of blood vessels. Unrecognized and therefore untreated, vasculitis of the nervous system leads to pervasive injury and disability, making this a disorder of paramount importance to all clinicians. There has been remarkable progress in the pathogenesis, diagnosis, and treatment of primary CNS and PNS vasculitides, predicated on achievement in primary systemic forms. Primary neurological vasculitides can be diagnosed with assurance after intensive evaluation that incudes tissue confirmation whenever possible. Clinicians must choose from among the available immune modulating, suppressive, and targeted immunotherapies to induce and maintain remission status and prevent relapse, unfortunately without the benefit of RCTs, and tempered by the recognition of anticipated medication side effects. It may be said that efforts to define a disease are attempts to understand the very concept of the disease. This has been especially evident in systemic and neurological disorders associated with vasculitis. For the past 100 years, since the first description of granulomatous angiitis of the brain, the CNS vasculitides have captured the attention of generations of clinical investigators around the globe to reach a better understanding of vasculitides involving the central and peripheral nervous system. Since that time it has become increasingly evident that this will necessitate an international collaborative effort.

Giant cell arteritis-related stroke in a large inception cohort: A comparative study

OBJECTIVE

Stroke caused by giant cell arteritis (GCA) is a rare but devastating condition and early recognition is of critical importance. The features of GCA-related stroke were compared with those of GCA without stroke and atherosclerosis-related or embolic stroke with the aim of more readily diagnosing GCA.

METHODS

The study group consisted of 19 patients who experienced GCA-related strokes within an inception cohort (1982-2021) of GCA from the internal medicine department, and the control groups each consisted of 541 GCA patients without a stroke and 40 consecutive patients > 50 years of age with usual first ever stroke from the neurology department of a French university hospital. Clinical, laboratory, and imaging findings associated with GCA related-stroke were determined using logistic regression analyses. Early survival curves were estimated using the Kaplan-Meier method and compared using the log rank test.

RESULTS

Amongst 560 patients included in the inception cohort, 19 (3.4%) developed GCA-related stroke. GCA-related stroke patients had more comorbid conditions (p = 0.03) and aortitis on imaging (p = 0.02), but less headache (p < 0.01) and scalp tenderness (p = 0.01). Multivariate logistic regression analysis showed that absence of involvement of the anterior circulation (OR = 0.1 - CI: 0.01-0.5), external carotid ultrasound (ECU) abnormalities (OR = 8.1 - CI: 1.3-73.9), and C-reactive protein (CRP) levels > 3 mg/dL (OR = 15.4 - CI: 1.9-197.1) were independently associated with GCA-related stroke. Early survival of GCA-related stroke patients was significantly decreased compared with control stroke patients (p = 0.02) and GCA patients without stroke (p < 0.001).

CONCLUSIONS

The location of stroke and assessment of ECU results and CRP level could help improve the prognosis of GCA-related stroke by bringing this condition to the clinician's attention more quickly, thus shortening diagnostic delay.

Giant cell arteritis with simultaneous onset of multiple intracranial vascular occlusions: A case report

Background:

Giant cell arteritis (GCA) causes severe stenosis or occlusion of the arteries but rarely affects the intracranial arteries. We report a rare case of GCA along with autopsy results.

Case Description:

A 69-year-old man developed gait disturbance due to vertebral artery (VA) occlusion. As is common in atherothrombotic stroke, dual antiplatelet therapy was administered. The patient’s symptoms improved temporarily. However, his symptoms relapsed and his consciousness was acutely disturbed. Digital subtraction angiography revealed an appearance of stenosis of the internal carotid artery (ICA) C2 portion on the right side and decreased retrograde basilar artery (BA) blood flow through the right posterior communicating artery. Balloon angioplasty was performed, and BA blood flow increased. GCA was suspected, and a definitive diagnosis was made based on temporal artery biopsy findings. Steroid therapy was initiated but failed to control disease progression, and the patient died. The autopsy findings revealed GCA in the bilateral ICAs and VAs, and no signs of GCA were found in other intracranial arteries, despite occlusion on magnetic resonance angiography.

Conclusion:

GCA of the intracranial blood vessels is rare and might be more likely to occur in the ICAs and VAs than in other intracranial blood vessels. GCA of the intracranial blood vessels has a poor prognosis, and as such, if rapid changes are observed in the ICAs or VAs, GCA should be considered a part of the differential diagnosis and immediate treatment should be administered.

Cerebral Infarction Due to Giant Cell Arteritis

The objective of this report was to explore the clinical features of patients with cerebral infarction due to giant cell (temporal) arteritis (GCA) and its characteristic changes in pathology, and on computed tomography (CT) and magnetic resonance imaging (MRI). Three cases of cerebral infarction due to GCA, treated during the past 2 years, were analyzed. Their clinical manifestations were observed carefully, their temporal artery biopsies were performed, their immunohistochemistries were done, and CT as well as MRI were used. The results showed that all the patients had new-onset headache and temporal artery abnormality when the disease began, and there was tremor on the right limbs of 1 patient; temporal artery biopsies revealed evidence of inflammatory cell infiltration in the arterial wall, mainly including T-lymphocytes and macrophages; small cerebral infarction foci were found on CT and MRI; and the responses to corticosteroid therapies were good. The results suggest that it is important to recognize the clinical features of cerebral infarction due to GCA, including the changes of pathology and on CT and MRI. In some cases, special attention is paid to differentiating between atherosclerotic infarction and infections to avoid misdiagnosis.

Severe Intracranial Involvement in Giant Cell Arteritis: 5 Cases and Literature Review

Objective.

Involvement of intracranial arteries in giant cell arteritis (GCA) is rare. We describe the neurologic complications of intracranial GCA (IC GCA) and available treatment options.

Methods.

We describe 5 IC GCA cases from 3 Canadian vasculitis centers and review the literature. We searched English-language publications reporting similar patients meeting American College of Rheumatology (ACR) criteria for GCA and having intracranial artery involvement diagnosed by autopsy, magnetic resonance angiography, computed tomography angiography, or conventional angiography.

Results.

All 5 cases of IC GCA met ACR criteria for GCA; 4 cases had a temporal artery biopsy that was consistent with GCA. All cases experienced cerebrovascular accident(s). Arteritis involved the following vessels: intracranial internal carotid (n = 1), vertebrobasilar arteries (n = 1), or both (n = 3). All cases received aspirin and oral prednisone (preceded by intravenous methylprednisone in 3 cases), combined with an immunosuppressant in 4 cases. All patients survived; 2 had complete neurological recovery, 3 had residual neurologic sequelae. The literature review included 42 cases from 28 publications. The clinical features of the reported cases were similar to those of our 5 cases. However, mortality was 100% in untreated cases (n = 2), 58% in those treated with corticosteroid alone (n = 31), and 40% in those treated with corticosteroid and an immunosuppressant (n = 10).

Conclusion.

IC GCA appears to be associated with neurologic complications and mortality. In some cases corticosteroid alone was not sufficient to prevent neurologic complications. The role of additional immunosuppressive agents needs further investigation.

3T MRI reveals extra- and intracranial involvement in giant cell arteritis

BACKGROUND AND PURPOSE

The frequency and amount of intracranial, intradural inflammatory vessel wall enhancement in giant cell arteritis remain unclear. The purpose of this work was to prospectively assess the intracranial extent of vasculitic changes in patients with giant cell arteritis using a dedicated MR imaging protocol optimized for assessment of mural changes of intracranial arteries.

MATERIALS AND METHODS

Twenty-eight patients with suspected giant cell arteritis underwent 3T MR imaging. Imaging included a fat-saturated T1WI pre- and postcontrast application optimized for assessment of intradural vessel wall enhancement and high-resolution fat-saturated T1WI to evaluate superficial extracranial vessels. Temporal artery biopsies were available in 11 cases. Vessel wall enhancement of intradural and extracranial vessels was evaluated by 2 observers independently.

RESULTS

Twenty patients had giant cell arteritis; 9 cases were biopsy-proved. Clear vessel wall enhancement of superficial extracranial and intradural internal carotid arteries was detected in 16 and 10 patients, respectively. Slight vessel wall enhancement of the vertebral arteries was seen. Of 9 patients with giant cell arteritis with vessel occlusion or stenosis, 2 presented with cerebral ischemic infarcts. Vessel occlusion or stenosis site coincided with the location of vessel wall enhancement of the vertebral arteries in 4 patients and of the intradural ICA in 1 patient.

CONCLUSIONS

Vessel wall enhancement of intradural arteries, mainly the ICA, can be regularly found in patients with giant cell arteritis. Mural inflammatory changes of the intradural ICA detected on MR imaging may identify a subgroup of patients with giant cell arteritis and should be further evaluated in clinical studies.

Giant cell arteritis causing symmetric bilateral posterior circulation infarcts

An 82-year-old woman presented with bilateral, symmetric posterior circulation infarctions secondary to giant cell arteritis (GCA). Her atypical clinical presentation included a lack of headache and fever, but she exhibited signs of systemic illness including generalized weakness, cachexia, apathy, and anemia. Laboratory testing revealed a markedly elevated erythrocyte sedimentation rate, but only a borderline elevated C-reactive protein. Head and neck vascular imaging demonstrated a pattern of vertebral arterial narrowing consistent with GCA-a diagnosis confirmed by temporal artery biopsy. Her unusual symptomatic, laboratory, and imaging presentation highlights the importance of considering GCA in the differential diagnosis of unusual bilateral stroke syndromes, where early treatment decreases morbid outcomes.

[Cerebellar infarction]

Cerebellar infarction can be difficult to diagnose because the clinical picture is often dominated by fairly non-specific symptoms, which are more indicative of a benign condition. When cerebellar infarction affects the brainstem, the semiology is richer, and pure cerebellar signs are rendered less important. A perfect knowledge of the organisation of the cerebellar artery territories is required, regardless of the infarct topography. This knowledge is essential for making an accurate diagnosis, understanding the mechanisms and organising a treatment plan. Clinical algorithms for the treatment of dizziness, headaches and vomiting would improve the selection of candidates for brain imaging. Thus, the early identification of patients with a high risk of subsequent deterioration would lead to a better prognosis in cases of cerebellar artery territory infarction.

A 24-year-old male with headaches

A 24-year-old man presented with a ten-day history of severe headache leading to collapse. CT studies showed filling defects involving the anterior, middle and posterior cerebral arteries and evidence of ischemia and infarction. Post-mortem examination revealed multiple cerebral infarcts secondary to an arteritic process composed of multi-nucleated giant cells, lymphocytes and histiocytes in both middle and anterior cerebral arteries and one posterior cerebral artery. Both carotid siphons and one renal artery segment were also involved. Extensive workup and stains for systemic and infectious causes were negative, leading to a diagnosis of atypical giant cell arteritis (GCA). Disseminated GCA involving extracranial arteries and the anterior, middle and posterior cerebral arteries leading to cerebral infarction has not been previously reported. We report this atypical case of disseminated GCA in a young patient with clinical features distinct from classic GCA (temporal arteritis) and discuss the differential diagnosis.

Systemic, secondary and infectious causes for cerebral vasculitis: clinical experience with 16 new European cases

Cerebral vasculitis represents a rare form of vascular inflammatory involvement caused by heterogeneous conditions. In this study, the wide spectrum of cerebral vasculitis despite primary angiitis of the CNS is analyzed. Our cohort included 16 white patients with cerebral vasculitis treated in a single German institution between 2003 and 2008. Clinical and diagnostic features were obtained by retrospective chart review; follow-up information and outcome were obtained prospectively. The spectrum of conditions responsible for cerebral vasculitis included seven patients with Behçet syndrome and one case each of giant cell arteritis, Wegener's granulomatosis and Churg-Strauss syndrome, respectively. Vasculitis secondary to systemic diseases included two patients with systemic lupus erythematodes, one with sarcoidosis and one with ANA-positive systemic vasculitis. Two patients suffered from infectious angiitis caused by borreliosis and syphilis. The mean age at onset of cerebral symptoms was 41.38 years. The most frequent clinical symptoms were headache, gait disturbances and unilateral numbness. None of the patients with Behçet syndrome experienced any ischemic event, which was a significant difference compared with the other patients (P = 0.011). Gadolinium-enhancing lesions were significantly more frequent in Behçet syndrome compared to the other types of vasculitis (P = 0.041). There was no significant difference between vasculitis patients with or without Behçet syndrome regarding outcome parameters. The differential diagnosis of conditions responsible for cerebral vasculitis includes a wide spectrum of diseases. Clinical features and the course of cerebral vasculitis are highly variable. The enigma of cerebral vasculitis will only be solved by implementing large, prospective, multicenter databases.

Stroke and multi-infarct dementia as presenting symptoms of giant cell arteritis: report of 7 cases and review of the literature

Cerebrovascular accidents (CVAs) and multi-infarct dementia have rarely been reported as presenting symptoms of giant cell arteritis (GCA), although 3%-4% of patients with GCA may present with CVAs during the course of the disease. We describe 7 patients with biopsy-proven GCA who presented with stroke or multi-infarct dementia. Most of them had other symptoms of GCA when the disease began that were misdiagnosed or not noticed. The internal carotid arteries were involved in 4 patients and the vertebrobasilar arteries in 3, with bilateral vertebral artery occlusion in 1. Small cerebral infarction foci on cranial computed tomography (CT) scan and magnetic resonance imaging (MRI) were found in 5 cases, and cerebellar infarction, in 2. MR angiography showed intracranial arteritis in 4 cases. Treatment with glucocorticoids and adjunctive antiplatelet or anticoagulant therapy was given in all cases, with neurologic improvement in 5. Two patients died. Necropsy demonstrated generalized GCA involving the medium and small cerebral vessels in 1 case. Central nervous system involvement is a rare complication in GCA but is important to recognize, as it can be reversible if diagnosed and treated promptly. Suspicion should arise in elderly patients suffering from strokes with a quickly progressing stepwise course and associated headache, fever, or inflammatory syndrome. In these cases, temporal artery biopsy should be performed without delay. Early diagnosis of GCA and immediate initiation of corticosteroid treatment may prevent progressive deterioration and death. Additional antiplatelet or anticoagulant therapy should be evaluated according to the individual risk and benefit to the patient under care.

Integrated head-thoracic vascular MRI at 3 T: Assessment of cranial, cervical and thoracic involvement of giant cell arteritis

Recently, high-resolution contrast-enhanced MRI has proven to be feasible for noninvasive diagnosis of giant cell arteritis in the cranium. In such examinations, thickening of the vessel wall and/or increased contrast enhancement demonstrate mural inflammation. Typically, the superficial cranial arteries with predominance of the superficial temporal artery are affected by the disease. However, giant cell arteritis can also involve other parts of the vascular system and an examination with extended coverage, including head, neck, and thorax would be advantageous. In this study, a novel approach for integrated head-thoracic vascular MRI at 3 T is presented. Combining first-pass imaging of a single-dose contrast agent with post-contrast imaging permits the assessment of both thoracic aortic geometry and wall, in addition to high-resolution head imaging needed for the analysis of the small superficial cranial arteries. Results from a patient feasibility study are presented and confirm that the protocol can successfully be completed in less than 40 min.

Vertebrobasiläre Ischämie als Komplikation der Arteriitis temporalis

BACKGROUND

Cerebral symptoms in temporal arteritis (TA) may occur if large arteries are affected. To avoid progression of the disease, the immediate administration of adequate doses of steroids is mandatory.

PURPOSE

The prevalence and severity of vertebrobasilar ischemia (VBI) and its relation to structural abnormalities of the vertebral arteries were studied.

METHODS

Clinical and ultrasound data were analyzed in a hospital-based group of 91 patients who received the diagnosis of TA following standard criteria.

RESULTS

In contrast to the occurrence of neuro-ophthalmological complications (27.5%), the rate of VBI was low (4.4%). TIA occurred in three cases and mild stroke in one. Ultrasound demonstrated severe occlusive disease of the extradural parts of the vertebrobasilar arteries consisting of hypoechogenic, concentric, mural thickening. The same was found in the superficial temporal arteries.

CONCLUSIONS

In elderly patients presenting with VBI, TA affecting the vertebral arteries should be considered. In experienced hands, ultrasonography allows the atraumatic preliminary diagnosis of TA.

Bilateral vertebral artery occlusion resulting from giant cell arteritis: report of 3 cases and review of the literature

Giant cell arteritis (GCA) is known to affect the extracranial part of the vertebral arteries. Bilateral vertebral artery occlusion (BVAO) is a rare but serious neurologic condition. We report 3 patients with autopsy-proven (2 patients) or clinically diagnosed (1 patient) GCA causing BVAO. A review of the literature concerning BVAO revealed 5 other cases of BVAO resulting from GCA and 110 cases with underlying arteriosclerotic disease. Our 3 patients (mean age, 66 yr; range, 60-78 yr) with BVAO resulting from GCA all had initial severe headache followed by the onset of stepwise progressive, partly side-alternating neurologic deficits due to bilateral infarctions in the vertebrobasilar circulation territory. This course, more accelerated in BVAO due to GCA than in BVAO of arteriosclerotic origin, seems to be a typical, if not particular, clinical syndrome. BVAO was the first clinical manifestation of GCA in 1 of our patients and in 1 published case. From a clinical view, BVAO resulting from GCA differs from BVAO of arteriosclerotic origin by the much higher mortality rate (75% versus 19%, respectively), the presence of headache (100% versus 22%), fever (50% versus 0%), and elevated erythrocyte sedimentation rate (ESR in all GCA cases >45 mm/h; no data in the arteriosclerotic patient group), but not by the neurologic signs themselves. Therapy of BVAO resulting from GCA is purely empiric. In view of the serious prognosis, we propose treatment with intravenous high-dose glucocorticoids and additional immunosuppression with cyclophosphamide; the use of anticoagulation depends on the individual patient's estimated risk-benefit profile. Although BVAO due to GCA is rare, physicians and especially rheumatologists or neurologists should be aware of this entity because of its high mortality in patients without immediate introduction of a high-dose immunosuppressive therapy. Suspicion of GCA should arise in a patient aged over 50 years with no other vascular risk factors suffering from bilateral symptoms of ischemia in the vertebrobasilar territory, with a quickly progressing stepwise course and with headache, fever, or history of myalgia. ESR and temporal artery biopsy should be performed without delay. Early diagnosis of GCA is necessary for immediate initiation of intensive antiinflammatory and immunosuppressive treatment, without which progressive deterioration and systemic involvement are likely to be fatal.

Infrequent causes of stroke

Infrequent causes of stroke are likely to be encountered by emergency physicians. Infrequent causes of stroke can be recalled using the ABC-IT mnemonic. Of the many infrequent causes, the five conditions more likely to be encountered are sickle cell anemia, migrainous stroke, antiphospholipid antibody syndrome, arterial dissection, and cocaine-related stroke. Consideration of the use of thrombolytic therapy in a patient with stroke from any cause lies at the forefront of treatment strategy in the emergency department.

Giant cell (temporal) arteritis involving both external and internal carotid arteries

A 76-year-old woman with giant cell (temporal) arteritis was described; she presented with a one year history of headache and tinnitus. Histopathological findings from a superficial temporal artery showed arteritis with granulomatous changes. Bilateral carotid arteriograms demonstrated the stenoses of both internal carotid arteries as well as the narrowing of the superficial temporal arteries. Although we dermatologists rarely encounter the disease in daily clinical practice, it is of clinical importance to perform cerebral angiography in patients suspected of temporal arteritis.

Association between strong inflammatory response and low risk of developing visual loss and other cranial ischemic complications in giant cell (temporal) arteritis

OBJECTIVE

To identify clinical and biochemical parameters that have good predictive value for identifying giant cell (temporal) arteritis (GCA) patients who are at high or low risk of developing cranial ischemic events.

METHODS

In this multicenter study, records of patients at 3 university hospitals in Barcelona were reviewed retrospectively. Two hundred consecutive patients with biopsy-proven GCA were studied.

RESULTS

Thirty-two patients developed irreversible cranial ischemic complications. The duration of clinical symptoms before diagnosis was similar in patients with and those without ischemic events. Patients with ischemic complications less frequently had fever (18.8% versus 56.9%) and weight loss (21.9% versus 62%) and more frequently had amaurosis fugax (32.3% versus 6%) and transient diplopia (15.6% versus 3.6%). Patients with ischemic events had lower erythrocyte sedimentation rates (ESR) (82.7 mm/hour versus 104.4 mm/hour) and higher concentrations of hemoglobin (12.2 gm/dl versus 10.9 gm/dl) and albumin (37.4 gm/liter versus 32.7 gm/liter). Clinical inflammatory status and biologic inflammatory status were defined empirically (clinical: fever and weight loss; biologic: ESR > or =85 mm/hour and hemoglobin < 11.0 gm/dl). Patients not showing a clinical and biologic inflammatory response were at high risk of developing ischemic events (odds ratio [OR] 5, 95% confidence interval [95% CI] 2.05-12.2). The risk was greatly reduced among patients with either a clinical (OR 0.177, 95% CI 0.052-0.605) or a biologic (OR 0.226, 95% CI 0.076-0.675) inflammatory reaction. No patient with both a clinical and a biologic response developed ischemic events.

CONCLUSION

The presence of a strong acute-phase response defines a subgroup of patients at very low risk of developing cranial ischemic complications. Our findings provide a rationale for testing less aggressive treatment schedules in these individuals. Conversely, a low inflammatory response and the presence of transient cranial ischemic events provide a high risk of developing irreversible ischemic complications and require a prompt therapeutic intervention.

Vasculitis and the nervous system. Historical perspective and overview

This article is an introduction to the historical background, clinical and laboratory diagnosis, pathogenesis, and treatment of vasculitis involving the peripheral and central nervous system. It also provides a background for the articles that follow.

Radiographic features of central nervous system vasculitis

Central nervous system (CNS) vasculitis refers to primary and secondary disorders of the CNS vasculature. Most authorities agree that CNS vasculitis is a potentially serious disorder; therefore, prompt diagnosis and initiation of therapy are high priorities in treatment. Remarkable progress has been made in the diagnosis, evaluation, and treatment of this disorder. This article examines many aspects of the radiographic evaluation of CNS vasculitis.

Granulomatous angiitis of the nervous system

Granulomatous angiitis of the nervous system (GANS) refers to distinctive clinicopathologic disorders with the essential feature of granulomatous inflammation of cerebral and spinal vessels, accompanied by multinucleate giant cells and epithelioid cells. This article reviews and examines the clinical, laboratory, and neuropathologic findings of patients with granulomatous angiitis.

Stroke is an emergency

Stroke is an emergency. Ischemic stroke is similar to myocardial infarction in that the pathogenesis is loss of blood supply to the tissue, which can result in irreversible damage if blood flow is not restored quickly. Public education is needed to emphasize the warning signs of stroke. Patients should seek medical help immediately, using emergency transport systems. Therapy geared toward minimizing the damage from an acute stroke should be started without delay in the emergency room. This includes measures to protect brain tissue, support perfusion pressure, and minimize cerebral edema. Strategies for improving recovery should also begin immediately. All major medical centers need stroke teams and stroke units. Stroke prevention should be given high priority as a public health strategy. Risk factor management should be part of general health care and should begin in childhood, with emphasis on nutrition, exercise, weight control, and avoidance of tobacco. Health screening and early treatment of hypertension and hypercholesterolemia has decreased the incidence of stroke and heart disease, but these efforts need to be expanded to reach all segments of the population. Basic research has opened the door to new therapies aimed at re-establishing blood flow and limiting tissue damage. Clinical trials have already led to changes in stroke prevention, including studies of carotid endarterectomy and ticlopidine and warfarin therapy (for patients with atrial fibrillation). Trials in progress are testing the usefulness of ancrod, neuroprotective agents, antioxidant agents, anti-inflammatory agents, low-molecular-weight heparin, thrombolytic drugs, and angioplasty. Any delay starting therapy after an acute stroke will result in progressive, irreversible loss of brain tissue. Clinicians should remember that for a stroke patient, time is brain tissue.