Intracranial Atherosclerosis PDF Download

Background and Aims: Cerebral vasculitis is rare and can present as stroke in multiple vascular territories. Workup excluding vasculitis mimics and secondary causes is important to provide appropriate treatment.Results: We present a 41-year-old male with history of medication non-compliance, diabetes, hyperlipidemia, hypertension, headaches, and right middle cerebral artery (MCA) ischemic stroke, who developed intermittent episodes of hemisensory loss and a left homonymous heminanopsia. MRI confirmed an acute left occipital stroke and the prior right middle cerebral artery stroke, and CT angiography showed focal narrowing in the right posterior cerebral artery (PCA) and MCAu2019s bilaterally, initially concerning for possible secondary vasculitis. His extensive work-up was significant for triglycerides of 458mg/dL, A1c of 11.7 % (consistent with history of medication non-compliance), 1:80 ANA , cerebral spinal fluid (CSF) protein of 917 mg/dL without a pleocytosis, ESR of 10, and otherwise negative infectious, rheumatologic, and hypercoagulability labs. Direct angiography confirmed diffuse intracranial stenosis most prominent in the right PCA and two dural arteriovenous fistulas in the left temporal lobe. Abrupt cessation of CSF flow on 2 LP attempts and elevated CSF protein prompted acquisition of MRI of his spine, which showed diffuse epidural lipomatosis, ligamentum flavum thickening, and prominent lumbar disc protrusion causing canal stenosis, leading to a diagnosis of pseudo-Froinu2019s syndrome. Conclusions: This is a case of a young patient presenting with multiple strokes and imaging findings concerning for vasculitis, with work up ultimately more consistent with intracranial atherosclerosis from medication non-compliance and poor risk factor control, illustrating the broad differential for cerebral vasculopathies.