E-060 Endovascular treatment for intracranial giant cell arteritis with angioplasty, stenting, and intra-arterial calcium channel blockers

Background Giant cell arteritis (GCA) is a systemic vasculitis that causes ischemic stroke in 2-7% of patients, typically due to extracranial vessel inflammation. However, in rare instances, GCA can present with fulminant intracranial stenoses which are refractory to medical therapy. In these cases, endovascular treatment (EVT) is a possible rescue strategy to prevent life-threatening ischemic complications, but the safety and efficacy of EVT in this setting are not well-described. Methods A systematic literature review was performed according to PRISMA-IPD guidelines to identify case reports and series with individual patient-level data describing EVT for intracranial GCA. The clinical course, therapeutic considerations, and technique of seven endovascular treatments in a single patient from the authors’ experience are presented. Results Nine reports comprising 19 treatments (percutaneous transluminal angioplasty, PTA, with or without stenting) in 14 patients (mean age 69.6 ± 6.3 years, 63.4% women) were identified in the literature. 66.7% of patients had >1 pre-existing cardiovascular risk factor. All patients had infarction on MRI while on corticosteroids and 50% progressed despite adjuvant immunosuppressive agents. Treatment was PTA alone in 78.9% of cases and PTA + stenting in 21.1%. Repeat treatments were necessary for 28.6% of patients (100% PTA-only). Non-flow limiting dissection was reported in 10.5% of treatments. The technical details of a single patient with aggressive, FDG-PET avid intracranial GCA who was treated with multiple EVT are discussed. Adequate restoration of cerebral blood flow was achieved in 100% of interventions and complications included one non-flow limiting dissection (12.5%) and two small, delayed, reperfusion hemorrhages (25%). The authors also report the novel use of intra-arterial calcium-channel blocker infusion (verapamil) as an adjuvant to PTA and as monotherapy, which resulted in immediate improvement in cerebral blood flow (figure 1). Conclusions Endovascular treatment, including PTA (with or without stenting) and CCB infusion, may be effective in medically-refractory GCA with intracranial arterial stenosis but complication rates are considerable. The efficacy of CCB monotherapy implicates vascular smooth muscle dysfunction in the pathogenesis of intracranial GCA. Calcium-channel blocker infusion as monotherapy for intracranial giant cell arteritis. Pre-treatment angiography (lateral right internal carotid artery projection) shows severe focal supraclinoid ICA stenosis (curved white arrow, 1A). Post-verapamil infusion (20mg, 15 min delay) angiogram (1B) shows significant improvement in lumen diameter. Four-dimensional digital subtraction angiography (not shown) confirmed normalization of time-to-peak in the petrous ICA from 4.5s to 1.0s after verapamil infusion. Disclosures M. Caton: None. I. Mark: None. A. Baker: None. K. Narsinh: None. V. Halbach: None. S. Hetts: None. D. Cooke: None. R. Higashida: None. C. Dowd: None. W. Smith: None. M. Amans: None.