Abstract TP475: A Case of Suspected Vertebral Giant Cell Arteritis Causing Cervico-medullary Ischemia

Abstract

Objective: To present a rare case of cervico-medullary ischemia suspected to be from giant cell arteritis (GCA). Background: In patients with GCA, vertebral artery involvement occurs in 3-4% of ischemic events and manifests by disturbances, cranial nerve palsies, cerebellar signs, weakness and altered consciousness (1,2). Design: Case Report. Results: A 79-year-old man presented with 2-week history of vertigo right-sided weakness, right-sided neck pain and occipital headaches with magnetic resonance imaging (MRI) brain and cervical spine without contrast showing right distal medulla and cervico-medullary junction infarct and magnetic resonance angiogram (MRA) neck showing bilaterally diminutive/atherosclerotic vertebral arteries with absence of flow in right vertebral C2 segment. Relevant tests showed an elevated white cell count of 14 K/mm 3 , C-reactive protein (CRP) of 171 mg/L, erythrocyte sedimentation rate (ESR) of 67 mm/hour, antinuclear antibodies (ANA) of 1: 1280 and unrevealing Reichlin profile, temporal artery ultrasound, carotid duplex, PET/CT and cerebrospinal fluid infectious workup. After initiation of Prednisolone 60 mg PO daily, patient reported improvement in pain and levels of inflammatory markers decreased. As patient was on Clopidogrel, temporal artery biopsy (TAB) was delayed and performed 14 days after initiation of steroids and showed no signs of inflammation. Patient is being planned for gradual steroid taper and monitoring of response. Conclusion: Vertebral GCA is a high fatality condition. A combination of persistently elevated inflammatory markers, unusual stroke location, bilateral vertebral artery disease with multiple areas of stenosis, improvement in weakness and pain after initiation of steroids were all highly suggestive of GCA vasculitic process. High index of suspicion is crucial as specific and curative treatment exists. In select cases where TAB is delayed, treatment should not be withheld.