Stroke Note Published online: March 28, 2012 Cerebrovasc Dis 2012;33:408–409 DOI: 10.1159/000336243 Takayasu Arteritis Presenting with Internal Carotid Artery Dissection R. Geraldesa , P. Batistaa , L.M. Pedrob, A. Fernandesc, T.P. Meloa a Stroke Unit, Department of Neurosciences (Neurology), Background In Takayasu arteritis (TA), vessel wall thickening and stenosis are the most common findings, whereas aneurysmal dilatations occur less frequently [1, 2] and arterial dissection is rare. Cerebral ischemia may occur in up to 16% of the patients with TA [3] and can be due to several mechanisms such as subclavian steal in the arm, vessel stenosis/occlusion and embolism from the aorta or the heart [4]. Case Report A 35-year-old woman presented with a left temporal headache while lifting weight followed by dysphasia and right hemiparesis. Observation disclosed dysphasia, right brachiofacial hemiparesis, weak arterial lower limb pulses and normotension in both arms. Brain MRI revealed left middle cerebral (posterior branch) artery acute ischemia. Cervical vessel ultrasonography and digital subtraction angiography (DSA; fig. 1a–c) showed a left internal carotid artery (ICA) dissection with no other abnormalities. Six months later, the patient had a slight anomia and hemiparesis but complained of transient lower limb claudication. DSA (fig. 1d) and angio-MRI disclosed normal aorta and bilateral external iliac artery occlusion with compensatory circulation and presence of flow at the origin of the femoral arteries, without surgical indication. Initial anticoagulation was substituted by aspirin. A 2-year follow-up cervical vessel ultrasonography showed a concentric segmental right common carotid artery (CCA) 90% stenosis (fig. 1e) and persistent left ICA occlusion. At this point, there were no new symptoms but there was a decrease in the right brachial artery pulse and a blood pressure difference between the arms of 30 mm Hg. Steroids were started but DSA showed persistence of right CCA stenosis (fig. 1f), left ICA occlusion and a new right subclavian artery segmental stenosis (fig. 1g). Prosthetic replacement of the right CCA was performed. Histology of the removed vessel segment showed a panarteritis (fig. 1h–l). Fluorodeoxyglucose PET scan was normal. Cell blood count, erythrocyte sedimentation rate, C-reactive protein, biochemistry, antinuclear, anti-double-stranded DNA and antiphospholipid antibodies, HIV, hepatitis B and C, and Venereal Disease Research Laboratory serology were normal at presentation and in all follow-up © 2012 S. Karger AG, Basel 1015–9770/12/0334–0408$38.00/0 Fax +41 61 306 12 34 E-Mail karger@karger.ch www.karger.com Accessible online at: www.karger.com/ced Discussion Our patient fulfills all the American College of Rheumatology criteria for TA [5], and vessel vasculitis was histologically proven. Arterial dissection in TA is rare [2, 6], with few reports of aortic dissection [7] and only one report of ICA dissection [8]. In our patient, at the moment of ICA dissection, all the other aortic archs and their branches were angiographically normal and the laboratory tests unremarkable. Extension of arteritis in TA seems to occur in a symmetric way to the paired vascular beds and contiguously in the aortic arch, brachiocephalic trunk and the aorta [1]. Iliac occlusion is an uncommon complication of TA [2, 3]. Our case, with initial ICA and external iliac artery involvement, is atypical but clearly evolved to a typical TA. Large-vessel vasculitis is not in the differentials of ICA dissection [9]; however, ICA dissection can be the first manifestation of TA and is another possible mechanism of cerebrovascular ischemia in TA. References 1 Arnaud L, Haroche J, Toledano D, Cacoub P, Mathian A, CostedoatChalumeau N, et al: Cluster analysis of arterial involvement in Takayasu arteritis reveals symmetric extension of the lesions in paired arterial beds. Arthritis Rheum 2011;63:1136–1140. 2 Maffei S, Di Renzo M, Bova G, Auteri A, Pasqui AL: Takayasu’s arteritis: a review of the literature. Intern Emerg Med 2006;1:105–112. 3 Arnaud L, Haroche J, Limal N, Toledano D, Gambotti L, Costedoat Chalumeau N, et al: Takayasu arteritis in France. A single-center retrospective study of 82 cases comparing white, North African and black patients. Medicine 2010;89:1–17. 4 Kim HJ, Suh DC, Kim JK, Kim SJ, Lee JH, GC Choong, et al: Correlation of neurological manifestations of Takayasu’s arteritis with cerebral angiographic findings. Clin Imaging 2005;29:79–85. 5 Arend WP, Michel BA, Bloch DA, Hunder GC, Calabrese LH, Edworthy SM, et al: The American College of Rheumatology 1990 criteria for the classification of Takayasu arteritis. Arthritis Rheum 1990; 33: 1129–1134. 6 Vanoli M, Daina E, Salvarani C, et al: Takayasu’s arteritis: a study of 104 Italian patients. Arthritis Rheum 2005;53:100–107. 7 Khalife T, Alsac JM, Lambert M, Messas E, Duong Van Huyen JP, Bruneval P, et al: Diagnosis and surgical treatment of a Takayasu disease on an abdominal aortic dissection. Ann Vasc Surg 2011; 25: 556.e1–e5. 8 Casoa V, Paciaronia M, Parnettia L, Cardaiolia G, Biscarini L, Acciarini AE, et al: Stroke related to carotid artery dissection in a young patient with Takayasu arteritis, systemic lupus erythematosus and antiphospholipid antibody syndrome. Cerebrovasc Dis 2002; 13: 67–69. 9 Debette S, Leys D: Cervical-artery dissections: predisposing factors, diagnosis, and outcome. Lancet Neurol 2009;8:668–678. Ruth Geraldes, MD Department of Neurology, Hospital de Santa Maria Av. Prof. Egas Moniz, PT–1649-035 Lisboa (Portugal) Tel. +351 217 957 474 E-Mail ruth.geraldes @ netcabo.pt Downloaded from http://karger.com/ced/article-pdf/33/4/408/2350381/000336243.pdf by guest on 12 April 2024 Departments of b Vascular Surgery and c Pathology, Hospital de Santa Maria, Lisbon, Portugal evaluations. Transesophagic echocardiogram and electrocardiogram were unremarkable. After surgery, azathioprine was added, steroids were tapered to 5 mg and aspirin continued. At 2-year follow-up after CCA surgery, she has been clinically and imagiologically stable. Color version available online a c b d i f j g k l Fig. 1. ICA dissection in TA. Cervical ultrasonography at initial stroke investigation showed the typical signs of left ICA dissection with occlusion, without any wall thickening or inflammatory halo suggesting vasculitis at the left ICA (a, b) or the contralateral ICA (not shown). The first DSA showing a dissection of the left ICA (c) and the lower limb DSA showing an occlusion of the external iliac arteries with compensatory anastomosis to the femoral arteries (d). Two years after stroke, cervical ultrasonography showed a concentrically segmental stenosis of the right CCA (e), also depicted in DSA 1 month after high-dose steroids (f). DSA showed persistent left ICA occlusion and a new right subclavian artery segmental stenosis 3 cm from the vertebral artery orifice (g). Histological examination (hematoxylin-eosin staining) of the removed CCA segment showed a panarteritis: inflammatory cell infiltration, vessel wall thickening with fibrinoid proliferation and neovascularization (h), given in detail in a higher magnification (i) and with Verhoeff-Van Gieson staining ( j), showing elastic fiber disruption with a ‘moth-eaten’ appearance of the media. Immunohistochemistry with anti-CD20 (k) and anti-CD3 (l) antibodies showed B- and T-lymphocyte infiltration of the three vessel layers, respectively; no giant cells were observed. Stroke Note Cerebrovasc Dis 2012;33:408–409 409 Downloaded from http://karger.com/ced/article-pdf/33/4/408/2350381/000336243.pdf by guest on 12 April 2024 h e