So under Takayasu—a young, Asian lady
walking through the door.
You each try checking for
her pulses. Radial—nothing.
It’s known as pulseless disease. So what’s
going on here with this large vessel issue?
There’s going to be granulomatous
95% of the time, the blood vessels that
are being affected, the large ones,
are going to be the branches
of the arch of aorta.
So you’re going to be focusing upon
asymmetric blood pressure,
Diagnostically, what are you going to do?
Well, in many of these issues
with the blood vessels, you’re going to find
an elevated erythrocyte sedimentation rate.
So that doesn’t tell you much apart
from the fact that—okay, maybe
your patient has vasculitides.
On MRI/MRA, what are we looking for?
On angiography or our imaging study?
It’s those blood vessels coming of
the—you’re going to focus upon
the branches of the arch of aorta.
So now, as I’ve told you,
the patient—a young, Asian,
less than 40 lady, doesn’t
have pulses in the carotids
and may not have pulses in the radial
because of issues of vasculitis
in maybe left subclavian,
maybe of the carotid.
Management: High-dose steroids,
but even that could be
unaffected or ineffective
therefore, you might be thinking
about repeat, repeat, repeat
coronary artery bypass grafting or CABG’s.
Going on to our next major
large vessel disease.
Here we have giant-cell arteritis
AKA temporal arteritis.
There’s this patient walking through
the door. She’s complaining of pain,
maybe in the temporal region
and maybe in the jaw area.
In addition, there might also be
involvement of neck and shoulder issues
or maybe hip. In other words,
there is an association with
connective tissue disease
and a high percentage, 50%,
usually going to be an elderly lady,
maybe about 67 or so—it doesn’t
always have to be but could be
and what you’re worried about with
temporal arteritis or giant-cell arteritis is
a particular branch off the temporal
artery known as the ophthalmic branch.
And if not careful, that ophthalmic
branch with severe vasculitis,
will then undergo or may lead
into blindness, permanently,
in that patient.
What do you do for diagnosis?
You’re going to do a biopsy,
and in that biopsy, you’re then
going to find a granuloma.
You find granulomatous changes and
giant cell and mononuclear
infiltration of the vessel wall.
That must be understood.
Yeah, you also find a high ESR. I told you
the elevated ESR is nonspecific.
You must immediately begin
the patient on corticosteroids,
because if you don’t—please
focus on the fact
that the ophthalmic branch will
undergo severe vasculitis,
and the end organ here
would be the eyes and,
therefore, resulting in permanent
blindness. Giant-cell arteritis.
Let me show you a picture here.
On the left,
are the branches of the aorta.
Now those arrows are pointing to
areas of the blood vessel
in which there’s no perfusion.
If you take a look at the arch,
there is blood passing through there
and the areas that are less opaque
and more lucent, in other words,
the areas that look more black
are the areas in which no
blood is passing through.
So off the arch, let’s say
that it’s the carotid,
well if there’s no blood passing
through the carotid
then the patient—or you,
the sign, is no pulse.
Welcome to Takayasu.
On the left, narrowing.
Treatment, please? Corticosteroids.
If that doesn’t work,
maybe perhaps you need to
do some bypass surgeries.
The picture on the right is the
forehead of your patient.
In this elderly lady, take a look
at the hair here—greyish,
things like that you want to observe,
and specifically, you’re looking at
branches of the temporal artery
that has been affected
in giant-cell arteritis or temporal
arteritis undergoing inflammation.
Remind me again. If left untreated,
not given steroids, what may then happen?
Correct. Permanent blindness;
and the picture on the right
depicting giant-cell arteritis.