Giant cell arteritis of the middle cerebral artery

An elderly Japanese woman in her 80s had left hemiparesis and hemiparesthesia, which were accompanied by a newly developed temporal headache that had lasted for 2 weeks. Since these symptoms were not severe, she was not admitted to a hospital for care. She has a history of well-controlled hypertension and bronchial asthma. MRI revealed a subacute right cerebral infarction with multiple severe stenosis of the bilateral middle cerebral arteries (MCAs) (figure 1A), even though they were intact when the MRI was performed, which is, by chance, due to the detailed examination for the numbness of the extremities and dizziness 3 years before (figure 1B). Simultaneously, prolonged erythrocyte sedimentation rate (ESR) elevation (131 mm/hour) also coexisted. Serum myeloperoxidase and proteinase 3 antineutrophil cytoplasmic antibody were both negative and no other vascular complication as well as malignant tumour or signs of infectious diseases was shown by whole body contrast enhanced CT, however, the biopsy of the superficial temporal artery revealed inflammatory cell infiltration into the tunica media and thickening of the tunica intima (figure 2), which were consistent with giant cell arteritis (GCA). According to the American College of Rheumatology 1990 criteria for the classification of GCA,1 the diagnosis of GCA and intracranial GCA (IC-GCA) was made and the patient was administered 25 mg per day of oral prednisolone (0.5 mg/kg/day) in addition to antiplatelet therapy. After the initiation of prednisolone, the ESR promptly improved to 20 mm/hour, and the follow-up MRI exhibited an improvement in the MCA stenosis (figure 3) without any recurrence of infraction up to 3 months later.