An Unusual Case of Stroke as the Initial Manifestation of Early Takayasu Arteritis with Normal Erythrocyte Sedimentation Rate (ESR): Diagnosis and Treatment

Patient: Female, 37-year-old Final Diagnosis: Ischaemic stroke secondary to Takayasu arteritis Symptoms: Altered mental status • limbs claudication Medication: — Clinical Procedure: — Specialty: Neurology OBJECTIVE: Rare coexistence of disease or pathology BACKGROUND: Takayasu arteritis is a rare systemic inflammatory vasculitis of granulomatous nature. The etiology of Takayasu arteritis is still unknown and it affects the aorta and its main branches. Takayasu arteritis is more common in Asians and women of childbearing age. However, ischemic stroke as the initial manifestation of Takayasu arteritis is uncommon. We report a young, stroke patient in early Takayasu Arteritis with normal ESR who improved with immunosuppressants. CASE REPORT: A previously healthy young patient was admitted to hospital due to lethargy, limbs claudication, and altered mental status. The patient was also febrile, hypertensive, and her physical examination revealed carotid artery tenderness and a loud carotid bruit suggestive of carotid stenosis or an active inflammatory process. Her erythrocyte sedimentation rate was normal. Magnetic resonance imaging of the brain showed acute ischemic stroke and a computed tomography angiogram showed typical angiographic features, so the diagnosis of Takayasu arteritis with acute ischemic stroke was made. The patient’s condition improved with corticosteroid therapy without residual neurological deficits. CONCLUSIONS: In conclusion, stroke may rarely be the first symptom of Takayasu arteritis, and the ESR value may be normal even in early, active disease. A normal ESR value should not lead to false reassurance. A thorough clinical examination and angiographic features remain the criterion standard for the diagnosis of Takayasu arteritis. The mainstay of treatment for Takayasu arteritis consists of glucocorticoids and immunosuppressants. Further studies are needed to demonstrate the therapeutic benefit of antithrombotic and vascular intervention in this clinical entity.