LAUSR

A 72-year-old right-handed woman with a history of hypertension was brought to a local Emergency Department by her son ≈6 hours after she fell at home. The day before Emergency Department arrival she had recurrent episodes of vertigo with nausea and vomiting associated with mild gait instability. She went to bed the night before presentation feeling unwell and reported that when she woke up in the morning she fell onto her right side. Upon further questioning, she reported that for the past 2 to 3 weeks, she had been having dull, throbbing, intermittent bitemporal headaches with occasional radiations of pain to her right ear. Over the same time period, chewing had become uncomfortable. She denied any additional neurological, ophthalmological, or constitutional symptoms. On physical examination, she was afebrile and in normal sinus rhythm with an initial blood pressure of 140/62. Her general exam was unremarkable. On neurological examination, she was noted to have direction changing nystagmus with horizontal gaze, flattening of her right nasolabial fold, and mild dysarthria with normal facial sensation to light touch and temperature. Additionally, she had decreased sensation to temperature on her left arm and left leg, dysmetria in her right arm and right leg, and truncal ataxia. She was unable to ambulate without assistance due to gait instability. She was treated for presumed posterior circulation infarct and received aspirin in the Emergency Department after an unrevealing computed tomography scan of the head. A few hours after Emergency Department arrival, magnetic resonance imaging of the brain showed an acute right lateral medullary infarct (Figure 1A). After the magnetic resonance imaging, she complained of new-onset oscillopsia as well as worsening dysarthria. Due to clinical worsening, she was transferred to our tertiary referral center. Upon arrival at our center, her clinical exam stabilized. Urgent computed tomography angiogram demonstrated multifocal stenoses involving both vertebral arteries throughout their course with near occlusion of the fourth segment of the right vertebral artery (Figure 1B through 1D). The basilar artery was patent. There was no new evidence of cerebral infarction on repeat magnetic resonance imaging of the brain. Initial laboratory testing including complete blood counts and basic metabolic testing were unremarkable aside from thrombocytosis to 450 000/μL. Her erythrocyte sedimentation rate was mildly elevated at 37 mm/h as was her CRP (C-reactive protein) at 1.7 mg/dL. Our patient’s age, presenting symptoms of headache and jaw claudication, as well as her imaging findings were highly suggestive of an inflammatory vasculitic process. Therefore, high-dose methylprednisolone was initiated a few hours after her arrival at our center and aspirin was continued. On day 3 of her hospitalization, a right temporal artery biopsy was performed. Pathological examination of her temporal artery showed lymphohistiocytic inflammation, giant cells, and intimal hyperplasia all consistent with giant cell arteritis (GCA; Figure 2). By hospital day 4, she had complete resolution of her headache symptoms but had persistent right-sided dysmetria and mild dysarthria. At the time of hospital discharge, her headaches had completely resolved though her gait remained unstable requiring acute rehabilitation. At 6-month follow-up, our patient reported feeling well overall and was able to ambulate with a cane.