TAKAYASU ARTERITIS WITH ACUTE LIMB ISCHEMIC AND

SUSPECT HAEMORRHAGIC STROKE : A CASE REPORT

Putri Anggraeni, IdarMappangara, AndiAliefUtama

Department of Cardiology and Vascular Medicine, Faculty of Medicine Hasanuddin University,

Wahidin Sudirohusodo Hospital Makassar

Introduction :
Takayasu’s arteritis, or “pulseless” disease is a rare,idiopathic, chronic granulomatous vasculitis that affects aorta and its major
branches. Clinical presentation is nonspecific at the beginning and furthermore the ischemic disease’s stage depends on the territories
affected. In this case we describe a 52-year-old man who presented with acute limb ischemic, congestive heart failure, and severe
aortic regurgitation. Multiple vascular abnormalities of aorta and its branches, severely reduced left ventricular function were present
at the time of diagnosis. He was later diagnosed as having Takayasu’s disease.

Case Description :
A 52-year-old man was hospitalized in our institution with shortness of breath and
diagnosed as congestive heart failure. The patient reported sudden onset and bluish
discoloration of his right leg on 5th day. The Glasgow Coma Scale was 15 (E4, V6,
M5), BP157/47mmHg in right arm and 141/48 mmHg in left arm, HR 95 bpm, body
temperature 36.7°C, RR 28tpm, and oxygen saturation 96%. A significant clinical
finding included a diminished right radial pulse compared to the left, temporal artery
pulsation was normal. Chest auscultation revealed a diastolic murmur grade 2/4
throughout the precordium. There was bruitover abdominal artery. At the right inferior
extremity especially distal of popliteal artery were pale, cold, pulseless, and fig. 2 Chest X-ray
paraesthesia (figure 1).So we performed serial exam such as Chest X-Ray shows fig. 1 Acute Limb Ischemic at
cardiomegaly, dilatation, and elongation aortae (figure 2). A computed tomography Right Leg
arteriogram shows aneurysm, multiple stenosis and dilatations of the aortic arch,
ascending and descending aorta with features of arteritis in the wall. Most of the main
branches of aorta appeared irregularly shaped (figure 3). A transthoracic
echocardiography revealed a severe grade aortic regurgitation and left ventricular
enlargement with a severe impairment of systolic function with ejection fraction of
40%, a large ascending aorta and a thickened aortic wall.Important findings
obtained on Echo Vascular Doppler exams obvious high-grade stenosis at the both of
femoral artery until distal be accompanied by thrombus with significant total occlusion
at right popliteal artery (figure 4). We administered maintenance dose of heparin (18
U/kgBW/h) after initial injection of 80 U/kgBW/h) and 2 mg warfarin. Within three
days, the symptoms rapidly deteriorated so we decided to amputate above knee as
high as distal femoral. Actually posibility of TA had been suspected, so we performed fig. 3 Dilatation, stenosis, and aneurysm aorta
and its branches
laboratory examination and the results show increase of erythrocyte sedimentation
rate (ESR) and C-reactive protein (CRP) at 106 mm/h and 30 mg/L, respectively. fig. 4 Echo vascular Doppler
Those we pretty sure that this patient got Takayashu Arteritis. But before Right Transversal Popliteal
administration immunosuppressant agent, patient got decrease of counsciousness and Artery
right-sided hemiparesis. The patient was died one day later with possibility of stroke
attack.

Discussion :
Takayasu’s arteritis is a systemic inflammatory disease of unknown etiology. It is a panarteritis mediated by T lymphocyte, monocyte and
macrophage that infiltrate arterial wall, leading to marked intimal myofibroblast proliferation and fibrosis of the media and adventitia.
From the ACR proposed classification criteria for diagnosis of TA this patients fulfilled 4 out of 6 criteria of TA: claudication of extremities,
blood pressure difference >10 mmHg, bruit over abdominal aorta, arteriogram with stenosis, occlusion, and aneurysm of thoracic aorta
untill popliteal artery. The presence of 3 or more of these 6 criteria demonstrated a sensitivity of 90.5% and a specificity of 97.8% in
diagnosis of TA. Some patients develop cardiac abnormalities like aortic regurgitation and congestive heart failure. A similar situation is
faced with the assessment of laboratory markers such as ESR and several other acute phase reactants.Surgical interventionwas needed
topatients with acute limb ischemic to improve his quality of life. Decrease of counsciousness is one of complication of Takayasu Arteritis
promote by cerebral ischemic or haemorragic attacks even thoughts it is a rare complications of TA, they can give rise to devastating
neurological symptoms and be a major cause of morbid events and premature death. In recent study1, four out of sixteen patients with
SAH due to ruptured intracranial aneurysm had occlusive cerebrovasculardisease. Neurologic deficit in this patient probably due to
ruptured intracranial aneurysm, but patient died before had CT Scan could be performed.

Conclusions :
The exact etiology of TA is unknown. It should be highlighted that the correct diagnosis of TA is seldom made in the early phase.
Clinicians should consider that TA might be causally associated with acute limb ischemic.

References
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2. Ahmed Abdel Hady El Danaf, 2016. Fat Re-Grafting in Facial Asymmetry: A 2-Case Report
3. George Dimitrouliset. all, 2011. Macroscopic and Histologic Analysis of Abdominal Dermis-Fat Grafts Retrieved From Human Temporomandibular Joints