Beyond Atherosclerosis: Takayasu Arteritis Presenting as Ischemic Stroke in a Young Patient With Significant Traditional Vascular Risk Factors.

A 46-year-old lady, with insulin-dependent type 2 diabetes, ischaemic heart disease, hypertension, high cholesterol, and being a current smoker, presented with acute left-sided weakness involving her upper and lower limbs. She was admitted with a clinical diagnosis of right lacunar ischemic stroke. Initial CT brain revealed an old right basal ganglia infarct, and CT carotid angiography revealed irregularities in the right middle cerebral artery with no occlusion, subtle mural thickening, and periarterial changes surrounding the origin of the great vessels arising from the aortic arch, features suggestive of vasculitis. Subsequent MRI brain demonstrated multiple infarcts in the high right frontoparietal and occipital regions, while CT aorta with contrast revealed mural thickening in the aortic arch involving the proximal aspect of the great vessels and stenosis of the proximal left subclavian artery, including the vertebral artery origin. Evidence of atheroma in the right coronary artery and iliac vessels was also noted. Dual antiplatelet therapy (DAPT) was initiated, but given the characteristic vascular imaging features of a thickened aortic wall and its branches, the diagnosis of Takayasu arteritis (TA) was made following rheumatology consultation. Unfortunately, she did experience a further ischaemic stroke on the same admission, but recovered well following immunosuppression. Treatment with steroids was initiated, and following a subsequent review in a specialist UK vasculitis centre, she was commenced on methotrexate, following which she has not had any further recurrent events. This case highlights the challenges of diagnosing TA in stroke patients with multiple comorbidities with traditional vascular risk factors and the need for a low threshold of suspicion in those with atypical imaging, particularly angiographic findings, especially if they are relatively young. A timely diagnosis of arteritis could help facilitate targeted management to reduce future risks and recurrent vascular episodes.