Teaching NeuroImages Neurology Resident and Fellow Section A 72 year old woman with ischemic strokes in multiple arterial distributions Teaching NeuroImages Neurology Resident and Fellow Section © 2017 American Academy of Neurology

Case presentation A 72-year old female patient with a history of hypertension, diabetes mellitus and smoking is admitted for a 3-day history of dizziness, right upper and lower arm weakness and progressive somnolence. She reports a moderate to severe headache and generalized fatigue over the last 3-4 weeks Neurological examination: somnolent but easily aroused by voice with mild right hemiparesis with facial involvement, mild expressive aphasia and dysarthria and left homonymous hemianopia. NIHSS-score: 6 points Erythrocyte sedimentation rate (ESR) elevated at 98mm/h Brain MRI: acute ischemic lesions in multiple arterial distributions in the anterior and posterior circulation. Kargiotis et al © 2017 American Academy of Neurology

A C F G D B H E Kargiotis et al Right Intracranial Internal Carotid Artery & STA F Left Intracranial Vertebral Artery G D Left Intracranial Internal Carotid Artery & STA B Figure Legend Brain diffusion-weighted-imaging showing acute ischemic strokes in multiple arterial territories (Panel-A). Duplex-sonography of the right superficial temporal artery disclosing hypoechoic halo (Panel-B/arrows indicate arterial wall). Brain digital-subtraction-angiography showing severe intracranial stenoses of internal-carotid (Panel-C&D) and vertebral (Panel-E&F) arteries. Right superficial temporal artery is also affected (Panel-C/arrowheads) compared to normal left superficial temporal artery (Panel-D/arrowheads). Superficial temporal artery biopsy showing CD3+/inflammatory cells and elastic-lamina fragmentation (Panel-G&H). H E Right Intracranial Vertebral Artery Kargiotis et al © 2017 American Academy of Neurology

GIANT CELL ARTERITIS PRESENTING WITH ACUTE ISCHEMIC STROKES DUE TO DIFFUSE INTRACRANIAL STENOSES Acute ischemic strokes (AIS) in multiple arterial distributions are usually associated with cardioembolism. Other causes include mobile aortic plaques, stroke attributed to cancer related coagulopathy, moyamoya disease, diffuse atherosclerotic intracranial stenoses, and primary /systemic arteritis. Increased ESR and diffuse intracranial arterial stenoses may raise suspicion for an underlying inflammatory arteritis. Involvement of the temporal artery on duplex sonography and DSA point towards giant-cell arteritis (GCA), which is confirmed with biopsy of the superficial temporal artery. Intracranial arteries are uncommonly involved in GCA (≤4%). The presentation of GCA with AIS in different arterial distributions due to simultaneous involvement of multiple intracranial arteries may simulate cardioembolism and can be overlooked in AIS diagnostic work-up.. References Salvarani C, Giannini C, Miller DV, Hunder G. Giant cell arteritis: Involvement of intracranial arteries. Arthritis Rheum. 2006;55:985-989. Alsolaimani RS, Bhavsar SV, Khalidi NA, et al. Severe Intracranial Involvement in Giant Cell Arteritis: 5 Cases and Literature Review. J Rheumatol. 2016;43:648-656. Kargiotis et al © 2017 American Academy of Neurology