Takayasu arteritis is a large vessel vasculitis that affects most commonly young to middle aged Asian women. It typically presents as a systematic illness with symptoms such as fever, malaise, pulselessness, renal artery stenosis, and extremity claudication. While stroke is well documented in Takayasu arteritis, it is rarely the presenting feature. 

A 42 year old Indian woman presented to the ED with transient LOC associated with episodes of vertigo and instability on her feet. She had been experiencing episodes of vertigo over the previous 3 years although episodes had increased in severity in the month prior to presentation. A code stroke was initiated on arrival and NIHSS was 2 for left sided dysmetria. She also had a primary position nystagmus.  CT Angiogram showed proximal occlusion of her bilateral vertebral arteries with reconstitution distally and multifocal stenosis of the left carotid and bilateral subclavian arteries, concerning for vasculitis. MRI showed patchy infarctions in the left cerebellum. She was started on dual antiplatelet therapy and underwent digital subtraction angiography (DSA) as a part of her workup.

DSA revealed findings consistent with vasculitis in the great vessels.  Additional workup showed bilateral renal artery stenosis, ESR at 17, CRP elevated at 6.2. ANA and serologic studies are still pending. She did not have any additional risk factors such as uncontrolled hypertension, diabetes, or hyperlipidemia. Presentations including her clinical picture, imaging findings and lab workup were consistent for Takayasu Arteritis. 

It is well documented that stroke is a common complication in 10-20% of Takayasu Arteritis. However, it is extremely rare for it to be the initial presentation in an otherwise healthy young female. A high degree of suspicion is needed so as not to delay therapy and seek rheumatological consultation for long term monitoring.