SHM Converge Scientific Abstract ePoster Gallery-Giant Cell Arteritis and Essential Thrombocytosis: A Dual Threat for Ischemic Stroke

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This case describes a 63-year-old woman with hypertension and essential thrombocytosis who initially presented with transient left eye vision loss and was found to have a left parietal stroke, moderate left internal carotid artery stenosis, and diffuse intracranial atherosclerosis. She was discharged on dual antiplatelet therapy, but returned one week later with complete left eye vision loss and new right-sided hemiparesis, aphasia, hemianopia, and facial droop.<br /><br />Subsequent MRI showed hemorrhagic conversion of the prior infarct plus new infarctions in the left MCA and deep watershed regions, with worsening left ICA stenosis on MRA. Although her inflammatory markers were low, temporal artery biopsy confirmed giant cell arteritis (GCA). Additional evaluation revealed a JAK2 mutation, supporting essential thrombocytosis as an additional prothrombotic risk factor. The remainder of the hypercoagulable workup was negative.<br /><br />She was treated with IV methylprednisolone followed by a prednisone taper and aspirin monotherapy, but continued to have recurrent strokes and progressive neurologic deficits, including right-sided weakness and bilateral vision loss. Despite repeated pulse-dose steroids, imaging showed ongoing infarcts in the left ACA and MCA territories, suggesting steroid-refractory GCA.<br /><br />Because of continued cerebrovascular events despite corticosteroids, tocilizumab, an IL-6 receptor antagonist, was started with steroid tapering. After initiation of tocilizumab, further stroke recurrence stopped.<br /><br />Key takeaways: GCA can cause stroke in older adults, including atypical anterior circulation infarcts. Diagnosis may be difficult when vascular risk factors and thrombocytosis coexist. In steroid-refractory GCA, treatment escalation such as tocilizumab should be considered.

Asset Subtitle

Harleen K. Sidhu

Meta Tag

Author List Harleen K. Sidhu, Umaima Dhamrah

Category Clinical Vignettes

Concept Giant Cell Arteritis

Concept Ischemic Stroke

Concept Essential Thrombocytosis

Concept Temporal Artery Biopsy

Concept Steroid-Refractory Giant Cell Arteritis

Distinguished Non-Finalist

Presenter Organization Department of Medicine, NYC Health + Hospitals/Elmhurst, Icahn School of Medicine at Mount Sinai

Presenting Author Harleen K. Sidhu

Track Adult

Keywords

giant cell arteritis

stroke

tocilizumab

essential thrombocytosis

JAK2 mutation

carotid stenosis

intracranial atherosclerosis

hemorrhagic conversion

cerebrovascular infarction

steroid-refractory

Giant Cell Arteritis

Ischemic Stroke

Essential Thrombocytosis

Temporal Artery Biopsy

Steroid-Refractory Giant Cell Arteritis