İnme (stroke) geçiren takayasu arteriti hastalarının klinik değerlendirilmesi
Takayasu arteritis patients with stroke clinical evaluation
Yazar: HÜLYA ODABAŞI BÜKÜN
Danışman: PROF. DR. EMİRE SEYAHİ
İstanbul Üniversitesi-Cerrahpaşa / Cerrahpaşa Tıp Fakültesi / İç Hastalıkları Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2020
Konu: İç Hastalıkları = Internal diseases
Dizin: Arterit = Arteritis ; Serebrovasküler bozukluklar = Cerebrovascular disorders ; Serebrovasküler dolaşım = Cerebrovascular circulation ; Takayasu arteriti = Takayasu arteritis ; Vaskülit = Vasculitis ; İnme = Stroke

Özet:
1.Giriş-Amaç: Takayasu arteriti (TA) aorta ve dallarını etkileyen kronik granülomatöz büyük damar vaskülitidir. Biz romatoloji polikliniği tarafından izlenen tüm TA kohortu içindeki inme sıklığını, hastaların demografik, klinik ve nöro-radyolojik özelliklerini karşılaştırmayı amaçladık. 
2.Metod: İ.Ü.-C Cerrahpaşa Tıp Fakültesi, Romatoloji Bilim Dalı veri tabanında inme öyküsü olan 35 TA hastası (27K/8E) ile inme öyküsü bulunmayan 50 TA hastası (47K/3E) çalışmaya alındı. Hastaların demografik-klinik verileri, tedavileri incelendi ve nörolojik muayeneleri yapıldı. İnme geçirenlerin  kraniyal radyolojik görüntülemeleri değerlendirildi.
3.Bulgular: İnme geçiren hastalar daha az kadından oluşuyordu, biraz daha yaşlı ve daha erken tanı almışlardı. 35 hastadan 14'ü (%40) inme ile tanı almıştı. 5' i carotis cerrahisi sonrası olmak üzere 21 hasta tanı sonrasında inme geçirmişti. Bu 21 hastanın 18'i immünsüpresif tedavi altında idi. 32 hastada iskemik, 3 hastada hemorajik özellikteydi. İnme geçiren hastalarda İCA tutulumu daha sık ve enfarkt alanı en çok anterior bölgede (%82.8) ve sol tarafta (%60.0) yerleşmişti. İnme öyküsü olan grupta, olmayanlara göre EDSS skoru, Barthel indeksi, Modifiye Rankin skoru anlamlı olarak daha yüksekti. 
4.Sonuçlar: İnmelerin daha çok iskemik özellikte olması, beynin anterior – sol alanının tutulması, özellikle İCA tutulumu ile belirgin şekilde ilişkili olması, intra-kranyal vaskülitin nadir olması, bir kısmının TA ile aynı anda ortaya çıkması veya karotis cerrahisi sonrasında gelişmesi literatür ile uyumlu bulunmuştur. TA tanısı sonrası inme geçiren 21 hastanın 18'inin immünsüpresif, 11'inin de anti-agregan tedavi altında olması, mevcut tedavilerin TA için yeterli olmadığını düşündürmüştür. Ölümcüllük %11,4 (4/35) saptanmıştır, ağır nörolojik hasar, nüks ve epileptik ataklar nadiren gözlenmiştir. 

Anahtar sözcükler: Takayasu arteriti ve inme, TA'lı hastalarda serebrovasküler olaylar

Abstract:
1.Introduction- Objectives: Takayasu arteritis (TA) is a chronic granulomatous large-vessel vasculitis which affects the aorta and its major branches. Although stroke is an important cause of morbidity and mortality in TA, information about its pathogenesis, frequency, clinical outcome, radiological features, follow-up and treatment are scarce. In this study we aimed to assess the frequency of those patients having stroke and to compare the demographic and clinical characteristics of the patients with and without stroke. Also, we evaluated neurological symptoms, radiological imaging, outcome and damage among patients with and without stroke using EDSS, modified Rankin and Barthel scales. 
2.Method: Thirty-five patients (27 F/8M) who had a history of stroke were included as the study group. Also 50 (47F/3M) consecutive TA patients who did not have any stroke or TIA history were studied as the control group. All patients were followed at the rheumatology outpatient clinic at I.U.-C, Cerrahpaşa Medical Faculty, Istanbul. The demographic and clinical data, comorbidities, and their treatments were examined. A neurological examination was done to all patients. The radiological imaging studies obtained in the previous 6 months were evaluated. 
3.Results: There were in total 35 (F:27 M:8) patients with stroke, of whom 14 were diagnosed after stroke while 18 had a stroke after having been diagnosed with TA. Those with stroke were significantly older (38.5±10.7 vs 35.7±11.6) with a smaller F/M ratio. A total of 14 patients (%40) had presented with stroke, while the remaining 21 had developed stroke during the follow-up. Of these 21 patients, 18 were using immunsuppressives and 11 were using asprin. Of the 35 patients who had stroke, 4 had died, therefore, we could be able to evaluate the remaining 31. At final examination which was done a mean of 12.2±7.9 years after the stroke, visual and speech disturbances and facial paralysis were found to be significantly more common among stroke patients. The majority (32/35) had an ischemic stroke, while 3 patients had hemorrhagic stroke. Imaging studies showed that stroke patients were significantly more likely to have ICA involvement, additionally, infarct area was more likely to be found in the anterior region (82.8%) and especially on the left side (60.0%).  Those with stroke were found to have significantly higher scores on the EDSS, Barthel index, modified Rankin. The infarct area tended to be localized mostly in the anterior region with 82.8% (n= 29) with left-side involvement 60.0% (n= 21). There was no sign of neurodegenerative diseases in the imaging. 
4.Discussion: Our study was in line with the literature. We observed that the strokes were mostly ischemic and the anterior blood supply area of the brain was mostly affected. There was significant association with ICA involvement. Intracranial vasculitis was rare. Five patients had developed stroke after carotid surgery. Our study indicates that infarct areas are mostly clustered on the left side. The fact that 18 of 21 patients who had developed stroke after TA diagnosis were under immunsuppressive agents and 11 under asprin treatment implied that the current treatment for TA may not be effective. On the other hand, we also observed that patients who had stroke were using more biological DMARDs and anti-lipidemic drugs. Mortality ratio was determined as %11.4 (4/35). Severe neurological damage, relapse and epileptic attacks were rare in our study. Since conventional angiography was not routinely done, CNS vasculitis could not be eliminated and thus was considered as a limitation of the study. However, we have not observed MS-like or Behcet's-like lesions in the imaging. Stroke is a significant cause of morbidity and mortality in TA and should be evaluated vigorously. 

Key words: Takayasu arteritis and stroke, cerebro-vascular accident with TA patients, ischemic stroke.