Presentation
3-week history of intermittent episodes of vertigo, bilateral blurry vision and ataxia, later re-presenting with headaches, scalp tenderness and jaw pain. She had a background of type 2 diabetes, hypertension and dyslipidemia.
Patient Data
Multifocal severe stenoses involving both vertebral arteries, predominantly through extracranial segments. There is luminal narrowing bilaterally and wall thickening
MRI shows multiple small bilateral cerebellar infarcts. They appear as hyperintensities on DWI and FLAIR, while on the ADC images there is corresponding low signal, suggestive of infarcts.
MRA also shows significant stenosis of the basilar artery over 1.2cm distance and thickening of vertebral artery walls bilaterally.
Case Discussion
Significant basilar artery stenosis and thickening of the vertebral arteries were seen on MRA, and diffusely narrowed vertebral arteries bilaterally were seen on CT angiogram of the head and neck. In this patient with significant vascular risk factors including diabetes, hypertension and dyslipidemia, atherosclerotic disease affecting the vertebrobasilar system was initially thought to be the underlying cause of stroke.
Following representation with headache, scalp tenderness and jaw pain, the patient was found to have raised CRP and ESR levels and proceeded to have a temporal artery biopsy confirming a diagnosis of GCA (Giant Cell Arteritis).
Intracranial vasculitis of the vertebrobasilar system is a less common cause of posterior circulation stroke, with other common known causes being embolism, atherosclerotic disease and dissection. GCA is the most common form of vasculitis in the older population, with a mean age of onset >65y and more frequently affecting females compared to males1.
In addition to histological and laboratory markers suggestive of vasculitis, high resolution MRI (T1-weighted contrast enhanced images) may show vascular changes such as mural thickening and luminal narrowing to support the diagnosis. Ultrasound imaging also has a role in identifying mural thickening of the superficial temporal arteries or extracranial arteries, identified as a "halo" sign2.
Given the overlap in imaging characteristics in vasculitis and atherosclerotic disease, this was not able to be distinguished purely on the basis of imaging in our case.
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