Presentation
Increasing headache, postural dizziness and neck pain, with known severe, progressive Takayasu arteritis, currently managed on baricitinib, methotrexate and tacrolimus, previously complicated by left middle cerebral artery stroke and numerous prior stenting/angioplasties.
Patient Data
CT Angio COW: Vessel wall thickening of aortic arch, brachiocephalic trunk and bilateral common carotid and subclavian arteries. Bilateral stenoses of common carotid arteries and brachiocephalic.
CT Brain: No established infarct or intracranial hemorrhage demonstrated, but there is a distal left M1/prox M2 embolism with ischemic penumbra in left MCA territory.
Pre-angioplasty: stenoses of the left subclavian, left common carotid artery and left internal carotid artery. Post-angioplasty: improved blood flow through previously stenosed arteries
Case Discussion
This patient has severe Takayasu arteritis disease activity that has been difficult to control and she is currently on baricitinib, methotrexate and tacrolimus, having previously failed multiple other immunosuppressive agents. She has had multiple stent insertions for her left subclavian and left common carotid, and a bypass graft from her left subclavian to her right internal carotid. Given her refractory disease and recurrent in-stent stenoses, which correlate with her developing periodic cerebral hypoperfusion symptoms, this patient has had repeat angioplasties and these repeat angioplasties will likely form a significant part of her management moving forward.
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