Objective:

We report a patient with multifocal posterior circulation infarcts secondary to intracranial giant cell arteritis (GCA) mimicking bilateral vertebral artery dissections. 

Background:

GCA is a large and medium vessel inflammatory vasculopathy with a tendency to involve the aorta, external carotid arteries, and ophthalmic arteries. GCA is the most common inflammatory vasculopathy among patients older than 50. Inflammatory vasculopathies are an uncommon cause of stroke, and among patients with GCA, cerebral infarcts are a rare presentation.  

Design/Methods:

Case report 

Results:

A 67-year-old woman with 2 months of headache without jaw claudication presented with several days of vertigo and lethargy. MRI brain revealed acute ischemic strokes within the brainstem and bilateral cerebellum. Noninvasive vascular imaging demonstrated multifocal narrowing of the bilateral V2-V4 vertebral arteries suggestive of occlusive dissections. She was initiated on therapeutic anticoagulation for secondary stroke prevention. The patient returned one month later with acute worsening vertigo and left hemiparesis. There was mild thrombocytosis to 387 (reference range 157-371), sedimentation rate was high at 27 mm/h (reference range 2-22), and CRP was normal. She was found to have additional bilateral posterior circulation ischemic strokes on MRI. Repeat MR angiogram of the head and neck revealed new stenoses of the basilar artery and bilateral supraclinoid internal carotid arteries, with vessel wall MR showing vessel wall enhancement of the basilar, bilateral vertebral, bilateral internal carotid, and right superficial temporal arteries. Subsequent superficial temporal artery biopsy confirmed GCA. She received 5 days of intravenous methylprednisolone followed by an oral prednisone taper, tocilizumab, and eventually cyclophosphamide.   

Conclusions:

Large vessel vasculitis can mimic craniocervical artery dissection. A high clinical suspicion is required for this diagnosis. MR vessel wall imaging may aid in the diagnosis, but confirmation with temporal artery biopsy is required.