Atypical Case of Takayasu Aortitis Presenting as Embolic Stroke With Concomitant Massive Thoracic Artery Aneurysm

We describe the case of a 44-year-old female with a history significant for only hypertension who presented to the emergency department with symptoms of aphasia and difficulty concentrating, persisting for six hours. Work-up revealed evidence of a multifocal infarct suggestive of embolic etiology, along with evidence of a large 6.0 × 6.0 ascending thoracic artery and simultaneous aneurysm of the transverse arch. The patient subsequently underwent open surgical repair with placement of a Dacron graft, which she tolerated well without complications. Surgical pathology was positive for granulomatous inflammation suggestive of autoimmune or infectious etiology, and the patient was readmitted post-surgical discharge for an extensive work-up, which was found to be negative. A new diagnosis of Takayasu arteritis (TA) was made. During her subsequent hospitalization, she developed an episode of unstable atrial fibrillation with rapid ventricular response and acute hypotension requiring medical ICU observation. She was started on high-dose steroids, trimethoprim-sulfamethoxazole prophylaxis, and amiodarone with a positive clinical response. She underwent a cardiac MRI to evaluate for evidence of myocardial infiltration, which was determined to be normal. The development of atrial fibrillation was considered a postoperative complication, and amiodarone was discontinued at eight weeks. The patient received a gradual steroid taper with initiation of daily low-dose prednisone and methotrexate and made a full recovery.