Recurrent ischemic strokes with normal inflammatory markers: when tests mislead

Giant cell arteritis (GCA) is an uncommon cause of ischemic stroke, and diagnosis may be particularly challenging when inflammatory markers remain normal. We describe a 67-year-old woman with recurrent ischemic strokes preceded by new-onset headache. Neuroimaging showed bilateral severe stenosis of the distal intracranial internal carotid arteries, while temporal artery ultrasound and biopsy confirmed GCA. Recurrent cerebrovascular events occurred despite glucocorticoids and tocilizumab, requiring rescue therapy with cyclophosphamide, which achieved disease stabilization. This case illustrates an aggressive intracranial phenotype of GCA in which diagnosis and treatment decisions relied on clinical and imaging findings rather than inflammatory markers alone.