Progressive and Fatal Brainstem Stroke in Systemic Giant Cell Arteritis

A 74-year-old woman presented with acute worsening of a 6-month long history of vertigo and postural instability with MRI evidence of cerebellar and brainstem acute infarcts. Extensive neurovascular assessment revealed a severe vascular damage with multiple stenoses and occlusions along the vertebrobasilar axis (Figure 1). Duplex ultrasonography showed hypoechoic halo sign along facial artery, whereas PET-CT highlighted increased fluorine-18-fluorodeoxyglucose uptake along vertebral and other larger arteries, thus allowing a diagnosis of giant cell arteritis (Figure 2).^1,2 Despite prompt treatment with high-dose steroids and tocilizumab, which probably made uninformative a subsequent temporal artery biopsy (Figure 2), patient died of reported disability after strokes.

Figure 1. Diffusion-Weighted Imaging (DWI), Magnetic Resonance Angiography (MRA), and Digital Subtraction Angiography (DSA).

DWI shows cerebellar infarctions (A). Time-of-flight MRA shows neither left vertebral nor basilar arteries (B). Contrast-enhanced MRA shows occlusion long extracranial VAs, regular intracranial VAs, and BA (C). DSA shows collateral between right external carotid and VA (D.a–E.c). BA = basilar artery; VA = vertebral artery.

Figure 2. Duplex Sonography, Superficial Temporal Artery Biopsy (STAb), Fluorine-18-Fluorodeoxyglucose ([18F]-FDG) PET-CT.

Facial artery duplex sonography shows hypoechoic halo (A.a), disappeared after therapy (A.b). STAb after 11-day-therapy shows intimal thickening and elastic lamina fragmentation (B.a, B.b). PET-CT shows [18F]-FDG uptake in vertebral artery, subclavian artery, iliac artery, and thoracic aorta (C–F).

Appendix. Authors

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