Giant cell arteritis presenting as a stroke in the internal carotid artery territory: a case-based review

Conticini, Edoardo; Falsetti, Paolo; Bardelli, Marco; Cantarini, Luca; Frediani, Bruno

doi:10.5114/reum.2021.105414

Cited by 2 publications

(2 citation statements)

References 31 publications

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“…The late outcome of stenosis has never been systematically followed up, and uncertainties exist about rates of outcome. Stenosis or occlusion may persist after treatment initiation ( 132 , 166 , 167 , 215 – 217 ) or variably regress, from partial change ( 30 , 46 , 168 , 218 ), to complete re-permeabilization ( 173 , 194 , 219 – 223 ). However, stenosis sometimes appears or worsens after steroid and/or TCZ initiation ( 44 , 86 , 137 , 166 , 200 ).…”

Section: Resultsmentioning

confidence: 99%

“…Series and reviews of intracranial GCA focused on the main clinical and predictive features of intracranial lesions (4,5,17,(23)(24)(25)(26)(27)(28)(29)(30), but none of them examined stroke mechanisms in detail, and most data about GCA-related stroke derive from unrelated or heterogeneous case reports that were never systematically examined. Pathological examination of arteries involved in GCA reveals an extended range of transmural inflammation, with granuloma reducing the inner caliber of the artery.…”

Section: Introductionmentioning

confidence: 99%

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Giant-cell arteritis related strokes: scoping review of mechanisms and rethinking treatment strategy?

Bonnan,

Debeugny

2023

Front. Neurol.

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Stroke is a rare and severe complication of giant cell arteritis (GCA). Although early diagnosis and treatment initiation are essential, the mechanism of stroke is often related to vasculitis complicated by arterial stenosis and occlusion. Its recurrence is often attributed to early steroid resistance or late GCA relapse, so immunosuppressive treatment is often reinforced. However, many questions concerning the mechanisms of stroke remain elusive, and no review to date has examined the whole data set concerning GCA-related stroke. We therefore undertook this scoping review. GCA-related stroke does not necessarily display general signs and inflammatory parameters are sometimes normal, so clinicians should observe caution. Ischemic lesions often show patterns predating watershed areas and are associated with stenosis or thrombosis of the respective arteries, which are often bilateral. Lesions predominate in the siphon in the internal carotid arteries, whereas all the vertebral arteries may be involved with a predominance in the V3-V4 segments. Ultrasonography of the cervical arteries may reveal edema of the intima (halo sign), which is highly sensitive and specific of GCA, and precedes stenosis. The brain arteries are spared although very proximal arteritis may rarely occur, if the patient has microstructural anatomical variants. Temporal artery biopsy reveals the combination of mechanisms leading to slit-like stenosis, which involves granulomatous inflammation and intimal hyperplasia. The lumen is sometimes occluded by thrombi (<15%), suggesting that embolic lesions may also occur, although imaging studies have not provided strong evidence for this. Moreover, persistence of intimal hyperplasia might explain persisting arterial stenosis, which may account for delayed stroke occurring in watershed areas. Other possible mechanisms of stroke are also discussed. Overall, GCA-related stroke mainly involves hemodynamic mechanisms. Besides early diagnosis and treatment initiation, future studies could seek to establish specific preventive or curative treatments using angioplasty or targeting intimal proliferation.

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Section: Resultsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Giant-cell arteritis related strokes: scoping review of mechanisms and rethinking treatment strategy?

Bonnan,

Debeugny

2023

Front. Neurol.

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A severe cerebral infarction associated with giant cell arteritis, which developed during tocilizumab therapy and was successfully treated with intravenous cyclophosphamide

Suzuki

Akiyama

Ishigaki

et al. 2023

Modern Rheumatology Case Reports

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Giant cell arteritis (GCA) is a large vessel vasculitis that primarily involves aorta and its major branches. Cerebral infarction is a serious complication that can occur secondary to GCA in up to 3% of patients with a mortality rate of over 50%. Due to the rarity of this severe complication, no therapeutic strategies are currently available. Furthermore, despite the recent progress in molecular-targeted therapy for GCA, it remains unknown whether tocilizumab is effective for severe ischemic complications such as cerebral infarction. Accumulation of individual cases in which this fatal complication could be treated is apparently required to build a better management of the disease. We present our case of GCA that developed severe cerebral infarction during high dose glucocorticoid and tocilizumab therapy and its symptoms and image findings were improved by switching to intravenous cyclophosphamide. Our case suggests that an intensive immunosuppressive therapy including cyclophosphamide may be necessary to stabilize this fatal complication of GCA.

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Giant cell arteritis presenting as a stroke in the internal carotid artery territory: a case-based review

Cited by 2 publications

References 31 publications

Giant-cell arteritis related strokes: scoping review of mechanisms and rethinking treatment strategy?

Giant-cell arteritis related strokes: scoping review of mechanisms and rethinking treatment strategy?

A severe cerebral infarction associated with giant cell arteritis, which developed during tocilizumab therapy and was successfully treated with intravenous cyclophosphamide

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