Recurrent Stroke in Giant Cell Arteritis Despite Immunotherapy

Area of Science:

• Neurology
• Rheumatology
• Vascular Medicine

Background:

• Giant cell arteritis (GCA) is a systemic vasculitis primarily affecting medium and large arteries.
• Cerebrovascular complications, though rare, represent a significant cause of morbidity and mortality in GCA patients.

Observation:

• A 59-year-old male with GCA presented with lower extremity vasculitis, followed by multiple strokes despite corticosteroid therapy.
• Angiography revealed stenosis at the dural entry points of bilateral carotid and vertebral arteries.
• Disease progression and additional strokes occurred even after initiating cyclophosphamide and later switching to tocilizumab.

Findings:

• GCA can manifest with cerebrovascular events, particularly affecting vessels at the dura mater's entry point.
• Corticosteroids alone may be insufficient to prevent stroke progression in some GCA cases.
• Aggressive immunosuppressive therapy escalation is necessary, but outcomes remain poor in severe cases.

Implications:

• This case underscores the importance of recognizing and promptly treating cerebrovascular complications in GCA.
• Early escalation of immunosuppressive therapy may be critical for improving outcomes.
• The predilection for dural entry vessels highlights a specific vulnerability in GCA-related stroke.