SHM Converge Scientific Abstract ePoster Gallery-Stroke as the Initial Presentation of Advanced Takayasu Arteritis

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This case describes a 55-year-old man with unknown past medical history who presented with acute neurologic deficits, including left facial droop, left hemiplegia, and dysarthria. CT head showed a right MCA stroke, and thrombolysis was not given because he was outside the treatment window. After transfer to acute rehabilitation, he developed recurrent orthostatic hypotension that did not improve with midodrine. Adrenal insufficiency was excluded, but exam revealed a 40 mmHg systolic blood pressure difference between his upper and lower extremities. Although inflammatory markers were normal, whole-body CT angiography demonstrated severe stenosis of the great vessels arising from the aortic arch, leading to a diagnosis of Takayasu arteritis.<br /><br />He was started on monthly tocilizumab infusions, and follow-up imaging showed no progression of disease. He was then discharged to a subacute rehabilitation facility.<br /><br />Takayasu arteritis is a granulomatous large-vessel vasculitis that affects the aorta and its major branches. It usually occurs in young women, but this case highlights that it can also present in middle-aged men. Neurologic ischemic events such as stroke occur in up to 13% of patients. The diagnosis may be difficult because systemic inflammatory markers can be normal, especially when stroke is the presenting feature. Careful vascular examination, including blood pressure measurements in all four extremities, can provide key clues. In this patient, the lower-extremity hypotension relative to the upper extremities prompted further vascular imaging and ultimately revealed the underlying arterial disease.<br /><br />Key takeaway: Takayasu arteritis should be considered in patients with stroke and unexplained blood pressure differences between limbs, even when inflammatory markers are normal.

Asset Subtitle

Harleen K. Sidhu

Meta Tag

Author List Alexander Conant, Hannah Hugo, Harleen K. Sidhu

Category Clinical Vignettes

Concept Takayasu Arteritis

Concept Ischemic Stroke

Concept Large-Vessel Vasculitis

Concept CT Angiography

Concept Blood Pressure Discrepancy

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

Takayasu arteritis

right MCA stroke

orthostatic hypotension

great vessel stenosis

aortic arch

large-vessel vasculitis

blood pressure difference

tocilizumab

neurologic deficits

stroke rehabilitation

Takayasu Arteritis

Ischemic Stroke

Large-Vessel Vasculitis

CT Angiography

Blood Pressure Discrepancy