Paper Title
Takayasu Arteritis Presenting as Malignant Large-Vessel Stroke in a Young Female With Recurrent Pregnancy Loss: A Peculiar Diagnostic Mimic

Abstract
Introduction: Takayasu arteritis (TA) is a chronic granulomatous large-vessel vasculitis involving the aorta and its major branches, predominantly affecting young females. As per recent EULAR/ACR updates (2023–2025), early diagnosis relies on vascular imaging and prompt initiation of immunosuppressive therapy. Common clinical presentations include constitutional symptoms (~50–70%), limb claudication (~30–50%), diminished or absent pulses (~60–90%), vascular bruits (~40–80%), and hypertension (~30–40%). Neurological involvement occurs in 10–20% of patients, while stroke is reported in only ~8–10%, and is rarely the initial manifestation. Case Presentation: A 33-year-old non-smoker female (Reena) was referred from a peripheral dispensary with sudden onset right-sided upper and lower limb weakness, slurring of speech, and altered sensorium. The time from symptom onset exceeded 4 hours, precluding thrombolysis, and she was initially evaluated as a young cerebrovascular accident (CVA). She had a history of two spontaneous abortions, raising suspicion of antiphospholipid syndrome; however, antiphospholipid antibody and thrombophilia workup were negative. On examination, she had dense right hemiparesis with altered consciousness. Vascular examination revealed feeble upper limb pulses, significant inter-arm blood pressure discrepancy, and audible carotid and subclavian bruits. Laboratory evaluation showed elevated ESR and CRP, suggestive of active inflammation. Neuroimaging Findings: MRI brain revealed a large acute–subacute left MCA territory infarct, mild midline shift (~2 mm), cortical laminar necrosis, and early Wallerian degeneration. MRA showed severe attenuation of left MCA (M2–M3) with paucity of distal branches, along with ~40–50% narrowing of the right ICA and distal A1 segment of the right ACA. MR venography demonstrated absent flow in the left transverse and sigmoid sinuses. CT neck angiography revealed near-total occlusion of bilateral common carotid arteries with long-segment narrowing and ~70% stenosis of the left CCA. CT aortogram showed diffuse concentric mural thickening of the aorta and major branches with significant subclavian and carotid stenosis, consistent with large-vessel vasculitis. Management and Outcome: The patient was initially started on antiplatelet therapy and statins. Following confirmation of arteritis, high-dose pulse corticosteroid therapy was initiated as per EULAR recommendations, with plans for steroid-sparing immunosuppression. She showed significant clinical improvement, with recovery of sensorium and improvement to motor power 2/5 in both upper and lower limbs at discharge. Discussion: This case is particularly notable due to: 1. Stroke as the initial manifestation of TA (~8–10%) 2. Extensive multilevel large-vessel involvement mimicking thromboembolic or atherosclerotic stroke 3. History of recurrent pregnancy loss creating a diagnostic dilemma with hypercoagulable states 4. Imaging evidence of concentric mural thickening with non-calcified lesions, favouring vasculitis This highlights the importance of detailed vascular examination and early large-vessel imaging in young stroke patients without conventional risk factors. Conclusion: Takayasu arteritis should be considered in young females presenting with large-vessel stroke, especially in the presence of pulse deficits and vascular bruits. Early recognition, comprehensive vascular imaging, and timely immunosuppressive therapy are crucial to improve outcomes and prevent disease progression. Keywords - Takayasu Arteritis, Young Stroke, Large-Vessel Vasculitis, Recurrent Pregnancy Loss, MCA Infarct