Title: Giant cell arteritis with rare manifestations of stroke and internal carotid artery dissection: A case study

Abstract

Giant cell arteritis (GCA) is the most prevalent systemic arthritis that influences medium-sized and larger extramural arteries, usually in the fifth decade of life. A 51-year- old man was presented with sudden onset of right-side blurred vision, frozen movements, and ptosis in the right eye and left side paresis. The right pupil was not responding to light, and the right eye's visual acuity was no light perception. Examination of ocular movements affirms a complete right ophthalmoplegia. Evaluation of the left eye was unremarkable. Spiral brain computed tomography (CT) scan and brain magnetic resonance imaging (MRI) showed multifocal diffusion restricting lesions involving all lobes of the right hemisphere (Figure 1) and some involvements in the maxillary sinus that spread to the cavernous sinus. Brain magnetic resonance angiography(MRA) demonstrated significant stenosis with a large clot in the right internal carotid artery (ICA) that spreads to the sinus cavernous. After this report, we promote a CT angiography that shows internal carotidartery dissection. Also, due to the history of ipsilateral frontotemporal headache and the high ESR level, we started pulse of Methylprednisolone 1 gram daily in suspicion of GCA, and temporal artery biopsy was done after 1 week, which was positive for GCA in pathology findings. After 10 days of undergoing corticosteroid therapy, inflammatory markers were reduced (ESR:40).Besides improving headaches, there was no significant change in ptosis and ocular movements, visual acuity, and reduction of left limb's force. Diagnosis of GCA is critical because delay can cause irreversible loss of vision in patients. Also, it can be challenging for those without the classic symptoms, such as headaches. The diagnosis of GCA with first manifestations of stroke and carotid dissection may be neglected as an underlying cause.