C Cantu

Carl-Albrecht Haensch

Dirk-Armin Röhlen

EY Kissin

K de Leeuw

M Hara

M Takahashi

M Webb

Stefan Isenmann

WP Arend

Y Kobayashi

Journal of Medical Case Reports

English

PubMed

Crossref

F-18-fluorodeoxyglucose positron emission tomography-computed tomography for the diagnosis of Takayasu's arteritis in stroke: a case report

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BioMed CentralJournal of Medical Case Reports
ssOpen AcceCase report
F-18-fluorodeoxyglucose positron emission tomography-computed 
tomography for the diagnosis of Takayasu's arteritis in stroke: a 
case report
Carl-Albrecht Haensch*1, Dirk-Armin Röhlen2 and Stefan Isenmann1
Address: 1Department of Neurology, HELIOS-Klinikum Wuppertal and University of Witten/Herdecke, Heusnerstraße 40, D-42283 Wuppertal, 
Germany and 2Radprax Wuppertal, Bergstraße 7-9, D-42105 Wuppertal, Germany
Email: Carl-Albrecht Haensch* - carl-albrecht.haensch@helios-kliniken.de; Dirk-Armin Röhlen - info@radprax.de; 
Stefan Isenmann - stefan.isenmann@helios-kliniken.de
* Corresponding author    
Abstract
Introduction: Diagnosis of Takayasu's arteritis as the cause of stroke is often delayed because of
non-specific clinical presentation. F-18-fluorodeoxyglucose positron emission tomography-
computed tomography may help to accurately diagnose and monitor Takayasu's arteritis in stroke
patients.
Case presentation: We report the case of a left middle cerebral artery stroke in a 39-year-old
man. Laboratory data were consistent with an inflammatory reaction. While abdominal contrast-
enhanced computed tomography showed an aneurysm of the infrarenal aorta, only F-18-
fluorodeoxyglucose positron emission tomography-computed tomography revealed pathology
(that is, intense F-18-fluorodeoxyglucose accumulation) in the carotid arteries, ascending aorta and
the abdominal aorta cranial to the aneurysm. After treatment with high-dose prednisone followed
by cyclophosphamide, the signs of systemic inflammation decreased and F-18-fluorodeoxyglucose
uptake was reduced as compared with the initial scan.
Conclusion: F-18-fluorodeoxyglucose positron emission tomography-computed tomography
showed inflammatory activity in the aorta and carotid arteries, suggestive of Takayasu's arteritis in
a young stroke patient, and follow-up under immunosuppressive therapy indicated reduced F-18-
fluorodeoxyglucose uptake. F-18-fluorodeoxyglucose positron emission tomography-computed
tomography appears to be useful in detecting and quantifying the extent of vascular wall activity in
systemic large-vessel vasculitis.
Introduction
Takayasu's arteritis (TA) is a rare, chronic panarteritis
localized to the aortic arch or its branches, the ascending
thoracic aorta, the abdominal aorta, or the entire aorta.
TA, also known as 'pulseless disease', is more common in
women than in men. More than half of patients may
develop diverse neurological manifestations, such as
headache, visual disturbances, seizures, transient ischemic
attack, cerebral infarction, intracerebral hemorrhage, and
orthostatic syncopal attacks [1]. Typically, early symp-
toms of systemic inflammatory disease are followed by
inflammation of the aorta and its branches. TA has two
Published: 24 July 2008
Journal of Medical Case Reports 2008, 2:239 doi:10.1186/1752-1947-2-239
Received: 28 August 2007
Accepted: 24 July 2008
This article is available from: http://www.jmedicalcasereports.com/content/2/1/239
© 2008 Haensch et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 5
(page number not for citation purposes)
Journal of Medical Case Reports 2008, 2:239 http://www.jmedicalcasereports.com/content/2/1/239distinctive phases: a prepulseless (inflammatory or sys-
temic) phase and a pulseless phase. Clinical disease pre-
ceding the pulseless phase of TA will not fulfill the
diagnostic criteria of the American College of Rheumatol-
ogists for TA, which are based on advanced disease [2]. As
histological diagnosis is usually impractical, angiography,
and, more recently, contrast enhanced computed tomog-
raphy (CT) and magnetic resonance imaging (MRI) have
gained a role in the diagnosis. Laboratory abnormalities
may include anemia, leukocytosis, increased erythrocyte
sedimentation rate (ESR), elevated C-reactive protein
(CRP), and hypergammaglobulinemia. We suggest that
abnormal F-18-fluorodeoxyglucose (18F-FDG) accumula-
tion may be useful in diagnosing the early-phase of TA.
Case presentation
A 39-year-old right-handed man had sudden onset of
unsteady gait, right-sided hemihypesthesia and failure of
speech. His medical history was significant for arterial
hypertension for the past 2 years and a past history of
smoking. ESR had been noted to be elevated (55 mm/
hour) for the past 18 months, without any known reason.
His initial examination was remarkable for dysarthria, dis-
crete right hemiplegia and gait ataxia. The National Insti-
tutes of Health Stroke Scale score was 3. Also, marked
hypertension (170/90 mmHg) was present on both sides
without a blood pressure difference. Radial pulses were
not diminished. Pulse was 85 beats per minute.
The head CT showed a demarcated infarction in the left
middle cerebral artery territory. A subsequent MRI scan
also revealed a subacute left-sided pontine infarction.
Magnetic resonance angiography demonstrated no abnor-
malities of the cerebral vessels (Figure 1B). While transcra-
nial and extracranial ultrasound was normal, abdominal
CT showed an aneurysm of the infrarenal aorta with a
diameter of 4.8 cm and a marginal thrombus (Figure 1C
and 1D). CT angiography of the coronary arteries was nor-
mal. Transthoracic and transesophageal echocardiogra-
phy and hypercoagulability state (proteins C and S, factor
V Leiden mutation, homocysteine level, and lupus antico-
agulant) were unremarkable. Laboratory studies revealed
increases in ESR (46 mm/hour), CRP (47 mg/l), C3-com-
plement levels (194 mg/dl) and hypergammaglobuline-
mia (1.11 g/dl). MPO/P-ANCA, C-ANCA and rheumatoid
factors were negative. Cerebrospinal fluid protein level
(94 mg/dl) was increased without intrathecal synthesis of
immunoglobulins. For suspected arteritis and to detect
systemic inflammatory disease, whole body scans in one
session on a dual modality positron emission tomogra-
phy (PET)-computed tomography system were performed
60 minutes after intravenous administration of 243MBq
18F-FDG. PET and CT images were reconstructed in coro-
nal, sagittal, and transverse planes (Figures 1A and 2).
The inflammatory vascular lesion was evaluated using the
standardized uptake value (SUV) of 18F-FDG accumula-
tion as an index. F-18-fluorodeoxyglucose positron emis-
sion tomography-computed tomography (18F-FDG PET-
CT) revealed intense 18F-FDG accumulation in the
carotid arteries (maximal SUV = 3.55), ascending aorta
(SUV = 4.52), and the abdominal aorta cranial to the
aneurysm (maximal SUV = 4.65). No 18F-FDG accumula-
tion was observed in other sites. The patient was given
intravenous high-dose bolus prednisone followed by
pulse cyclophosphamide, which resulted in a favorable
clinical course and normalization of the ESR (4 mm/
hour).
In a follow-up 18F-FDG PET-CT study after 2 months the
patient revealed reduced wall enhancement in the aorta
(maximal SUV = 2.93) and in the left carotid artery (max-
imal SUV = 2.47) under immunosuppressive therapy.
Unchanged increased glucose utilization was found in the
right carotid artery (maximal SUV = 3.6). MRI and mag-
netic resonance angiography showed no abnormalities
besides the infrarenal aneurysm at this time (Figure 3).
FDG PET-CT, MR-angiography and CT in a patient with TA and strokeigure 1
FDG PET-CT, MR-angiography and CT in a patient 
with TA and stroke. (A) F-18-fluorodeoxyglucose posi-
tron emission tomography-computed tomography showing 
fluorodeoxyglucose accumulation in the carotid arteries, 
ascending aorta, and the abdominal aorta cranial to the aneu-
rysm (arrows with corresponding maximal standardized 
uptake values). (B) Magnetic resonance angiography of the 
cerebral vessels. (C), (D) Infrarenal aortic aneurysm (13 cm 
× 4.8 cm) with mural thrombus (arrows). (E) Computed 
tomography and fluorodeoxyglucose positron emission tom-
ography revealing middle cerebral artery stroke (arrows).

A BPage 2 of 5
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Journal of Medical Case Reports 2008, 2:239 http://www.jmedicalcasereports.com/content/2/1/239Discussion
Vasculitis is reported to be responsible for 3% to 5% of
strokes that occur in people under 50 years old. TA typi-
cally occurs in patients younger than 50 years old. Central
nervous system involvement is seen in up to one-third of
cases and is secondary to carotid artery stenosis, cerebral
hypoperfusion, and subclavian steal syndrome. We have
described the case of a young man in whom stroke was the
initial presentation of TA. From a clinical point of view,
aortitis most often presents as a vague syndrome of
malaise, fever, and weight loss, while blood tests indicate
an inflammatory reaction.
18F-FDG PET-CT is an imaging technique that can be used
to assess regional differences in glucose metabolism.
Inflammatory cells take up increased amounts of glucose,
and therefore FDG accumulation on PET-CT scanning has
been reported in patients with TA [3-6]. In contrast to
other imaging modalities in TA, FDG PET-CT measures
inflammation through the metabolic activity in the arte-
rial wall [7]. The cutoff point of maximal SUV for the diag-
nosis of vascular inflammation was estimated to be 1.3
with a sensitivity for TA of 90.9% and a specificity of
88.8% [8].
Conclusion
To the best of the authors' knowledge, FDG PET-CT find-
ings have not previously been reported in patients with TA
and stroke. Coregistration of 18F-FDG PET and CT
showed the anatomical distribution of the inflammation
in the walls of the aorta and carotid arteries. This method
offers the advantages of early detection of disease activity
and the global assessment of the arterial system in a single
examination.
F-18-fluorodeoxyglucose positron emission tomography-computed tomography maximum intensity projection imagesigure 2
F-18-fluorodeoxyglucose positron emission tomography-computed tomography maximum intensity projec-
tion images.Page 3 of 5
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Journal of Medical Case Reports 2008, 2:239 http://www.jmedicalcasereports.com/content/2/1/239Abbreviations
18F-FDG: F-18-fluorodeoxyglucose; CRP: C-reactive pro-
tein; CT: computed tomography; ESR: erythrocyte sedi-
mentation rate; MRI: magnetic resonance imaging; PET:
positron emission tomography; SUV: standardized uptake
value; TA: Takayasu's arteritis.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
C–AH and SI contributed to the care of the patient, as well
as to writing and reviewing the manuscript. D–AR per-
formed the F-18-fluorodeoxyglucose positron emission
tomography-computed tomography. All authors read and
approved the final manuscript.
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
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F-18-fluorodeoxyglucose positron emission tomography-computed tomography for the diagnosis of Takayasu's arteritis in stroke: a case report

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