Managing What You Cannot Measure: Anesthetic Implications of Takayasu’s Arteritis in Hypertensive Intracranial Hemorrhage

Abstract

Takayasu’s arteritis is a rare inflammatory vasculopathy affecting medium- and large-caliber arteries, often presenting as cerebrovascular incidents in young individuals, primarily due to uncontrolled hypertension. The following is the case of a young male with no known comorbidities who exhibited intracranial hemorrhage resulting from accelerated hypertension. The fundamental diagnosis of autoimmune arteritis concerning the aorta was determined during the perioperative phase. Emphasized are the challenges posed by uncommon etiologies of secondary hypertension in anesthetic and perioperative blood pressure management, especially in emergency situations, stressing the necessity of a heightened index of suspicion in young patients presenting with severe, refractory hypertension.

INTRODUCTION

Stroke in young adults is infrequent, resulting from various etiologies. In cases of hypertensive emergency accompanied by intracranial hemorrhage, a thorough assessment for secondary causes is imperative, although frequently limited in emergency perioperative contexts. We present a case of accelerated hypertension with intracranial hemorrhage in a young male, characterized by a significant upper–lower limb blood pressure discrepancy identified perioperatively, resulting in a postoperative diagnosis of Takayasu’s arteritis. These unusual presentations pose considerable perioperative challenges, especially in blood pressure monitoring and titration of antihypertensive therapy, potentially leading to persistent end-organ injury if not identified.

CASE REPORT

A 26-year-old man arrived at the emergency room with a history of right-sided hemiparesis, one episode of generalized tonic–clonic seizures, and decreased responsiveness for 12 h. His vital signs upon arrival were as follows: respiratory rate 28 cycles/min, SpO₂ of 97%, heart rate 83 beats/min, blood pressure 240/130 mmHg (noninvasive blood pressure measured in the upper limb), and Glasgow Coma Scale score E1V1M5. Respiratory acidosis with metabolic compensation was found through arterial blood gas analysis. A 12-lead ECG revealed a negative troponin I, left bundle branch block, left ventricular hypertrophy, strain pattern, and T-wave inversions in leads II, III, avF, and V5-V6.

Brain computed tomography showed signs of transtentorial herniation, a left ganglioscapular hemorrhage with intraventricular extension, and a 10 mm midline shift. After several labetalol boluses failed to result in a sufficient response, the patient was started on a labetalol infusion for blood pressure control and given antiepileptics, antifibrinolytics, and anti-edema measures. He was intubated in the emergency room with etomidate, fentanyl, midazolam, succinylcholine, and vecuronium, then moved to the operating room for an emergency decompressive hemicraniectomy.

Noninvasive upper limb blood pressure measured in the operating room complex was 190/100 mmHg while receiving a labetalol infusion (5 mg/mL at 5 mL/h). The pupils were bilaterally sluggishly reactive, and other vital parameters did not change. The patient was moved to the operating room and connected to standard monitors recommended by the American Society of Anesthesiologists after informed high-risk consent was obtained. Differential pulse volumes between the upper and lower limbs were recorded after a large-bore intravenous access was established. Compared to the noninvasive upper-limb measurements, invasive blood pressure monitoring using femoral arterial access showed noticeably lower pressures. Severe left ventricular hypertrophy with a normal outflow tract was discovered during a focused transthoracic echocardiographic examination done before incision to rule out left ventricular outflow obstruction [Figure 1].

Figure 1.

Intraoperative on-table screening transthoracic two-dimensional echocardiography showing severe concentric left ventricular hypertrophy

During the procedure, isoflurane, fentanyl, propofol, and labetalol were used to maintain blood pressure, which was titrated based on the upper-limb measurements. At more than 0.5 mL/kg/h, urine production was still sufficient. Upper-limb blood pressure trends during surgery were 180–160/120–100 mmHg, whereas lower-limb blood pressure ranged from 90 to 60/70–50 mmHg.

The diagnosis of Takayasu’s arteritis was confirmed postoperatively after a cardiology consultation. A CT aortogram showed several stenotic segments in the descending aorta with potential left renal artery stenosis [Figures 2 and 3].

Figure 2.

Computed tomography angiogram – contrast showing presence of stenosis along the length of the aorta

Figure 3.

Three-dimensional reconstruction of the same demonstrating multiple stenotic segments

After neurological improvement and stable serial CT brain imaging on postoperative day 10, the patient was extubated and moved to the intensive care unit for additional care. After an immunology consultation, steroid therapy was started after inflammatory markers such as C-reactive protein and antiphospholipid antibody profile were sent and found to be positive. Several antihypertensive medications, such as labetalol, cilnidipine, prazosin, nitroglycerin, metoprolol, isosorbide dinitrate, telmisartan, moxonidine, and amlodipine, were needed for the difficult postoperative blood pressure control monitored by radial arterial invasive blood pressure measurement.

DISCUSSION

To avoid end-organ damage and worsening of the pre-existing morbidity due to severe hypertension, management of undiagnosed accelerated hypertension linked to intracranial hemorrhage during the perioperative period is crucial. In emergency situations, this task becomes challenging, even more so when the presentation is ununsual due to rare underlying etiologies. A thorough clinical examination can greatly aid in reducing the range of possible diagnoses in these circumstances.[1,2]

The clinical picture in this case suggested aortic diseases, such as coarctation, dissection, and aneurysm, as well as potential cardiac pathologies like hypertrophic obstructive cardiomyopathy and aortic stenosis. These conditions were successfully ruled out with the help of advanced imaging modalities. Despite being rare, Takayasu’s arteritis is a crucial differential diagnosis for young patients exhibiting hypertensive urgencies. It has an autoimmune origin, is more prevalent in young Asian women, and favors the aorta and its main branches. There are two disease patterns described: aneurysmal and stenotic.[1,2,3]

The natural history of Takayasu’s arteritis is typically characterized by a waxing and waning course, with episodes of uncontrolled hypertension.[1,4] Systemic manifestations of relevance to the anesthesiologist include those resulting in vital organ ischemia, such as renal artery stenosis and pulmonary artery involvement.[1,5] From the above discussion, it is evident that markedly elevated blood pressures in young patients, particularly when refractory to treatment, may be secondary to rare conditions such as Takayasu’s arteritis. It poses unique intraoperative challenges, especially in the presence of end-organ damage.

This case report highlights the importance of maintaining a high index of suspicion for secondary causes of hypertension in young patients presenting with hypertensive emergencies and intracranial hemorrhage. Recognition of inter-limb blood pressure discrepancies can provide a crucial diagnostic clue and significantly influence perioperative management.[3,6,7,8,9] In the present patient, achieving adequate blood pressure control was inherently difficult and was further complicated by the need to balance cerebral perfusion in the setting of intracranial hemorrhage. Similar presentations of stroke and intracranial hemorrhage as initial manifestations of Takayasu’s arteritis have been reported in young patients.[6,7,8] Vigilant intraoperative assessment by the anesthesiology team led to the recognition of an atypical hemodynamic pattern, prompting targeted postoperative evaluation and facilitating the diagnosis of Takayasu’s arteritis. This report highlights such contribution in complex emergency settings, where early identification of unexpected findings can guide diagnostic decision-making and improve perioperative outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.