Giant cell arteritis causing multifocal ischaemic stroke with normal erythrocyte sedimentation rate: a case report

Published Date: 17th January 2023

Publication Authors: Kaul A, Seed A, Cooney L

 

Introduction
Giant cell arteritis (GCA), a medium-to-large-vessel vasculitis affecting the over-50s, is a rare cause of ischaemic stroke, favouring the vertebrobasilar circulation. Erythrocyte sedimentation rate (ESR) is often used to help exclude the diagnosis but this is not always reliable. We discuss a case of ischaemic stroke due to GCA with normal ESR.

Method(s)
A 64-year-old male presented with acute unilateral sensorimotor symptoms and confusion, preceded by subacute constitutional symptoms with painful neck and shoulders. Examination revealed dysarthria with left-sided hemiparesis and numbness with left inferior homonymous quadrantanopia. Temporal arteries were thickened with reduced rightsided pulsatility. C-reactive protein was mildly elevated (41). ESR was 37mm/hr, below the American College of Rheumatology (ACR)'s 50mm/ hr cut-off. Regardless, there was high suspicion for GCA so oral prednisolone and aspirin were given, pending further investigations.

Result(s)
There were GCA features on temporal artery ultrasound and acute infarcts in multiple cerebrovascular territories on MRI. CT angiography demonstrated bilateral vertebral artery occlusion. Pulsed intravenous methylprednisolone was given for 3 days before resuming prednisolone. We prescribed atorvastatin to limit carotid atherosclerosis and targeted systolic blood pressure at 140-150mmHg to balance cardiovascular risk and vertebrobasilar perfusion. Rehabilitation was provided in an Acute Stroke Unit.

Conclusion(s)
Inflammatory biomarkers are commonly used when considering GCA but ACR criteria do not mandate elevated ESR for diagnosis. Indeed, GCA presenting with stroke frequently has only modestly-raised inflammatory markers. This may be due to aggressive disease manifesting before ESR has risen. In current practice, GCA can be diagnosed purely on clinical and radiological findings.
 

Kaul, A; Seed, A; Cooney, L. (2023). Giant cell arteritis causing multifocal ischaemic stroke with normal erythrocyte sedimentation rate: a case report. International Journal of Stroke. 18(Suppl 1), p.64. [Online]. Available at: https://journals.sagepub.com/toc/wsoa/18/1_suppl [Accessed 11 April 2023].

 

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