Ischemic Stroke as the First Manifestation of Takayasu Arteritis: A Case Report

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Especially in young stroke patients doctors should not slavishly follow algorythms and protocols. Examine the patient more fully. Feel pulses. takayasus was called "pulseless disease:. Likely the radial pulses would have benn abnormal and bruits were likely present over multiple neck  and supraclavicular sites. The message should be to do a more thorough exam and feel pulses. The same message for aortic dissection which often affects arm and femoral pulses.

Author Response

Comment: “Especially in young stroke patients doctors should not slavishly follow algorithms and protocols. Examine the patient more fully. Feel pulses. Takayasu’s was called ‘pulseless disease’. Likely the radial pulses would have been abnormal and bruits were likely present over multiple neck and supraclavicular sites. The message should be to do a more thorough exam and feel pulses.”

Response: We fully agree with this important observation and thank the Reviewer for highlighting this critical clinical message. During the initial acute stroke assessment, a detailed vascular physical examination was not performed, as standardized stroke protocols prioritize rapid neuroimaging and time-to-treatment. However, during rheumatological evaluation later during the same hospitalization, a diminished right radial pulse was documented, along with significant inter-arm blood pressure asymmetry (117/91 mmHg in the right arm vs. 139/100 mmHg in the left arm; home measurements showed a systolic difference exceeding 50 mmHg).

We have made the following revisions: - Added the pulse and blood pressure findings to the Case Presentation section (rheumatology consult paragraph). - Added a new paragraph in the Discussion addressing the historical term “pulseless disease” and emphasizing the importance of a thorough vascular physical examination — including palpation of peripheral pulses and auscultation for bruits — in young stroke patients, even in the acute setting. - Extended this message to other large-vessel pathologies presenting as acute stroke, such as aortic dissection, as suggested by the Reviewer. - Updated the Conclusions to reflect this important clinical lesson.

Reviewer 2 Report

Comments and Suggestions for Authors

I commend the authors for submitting this interesting manuscript of TA presenting as an acute ischemic stroke, treated with mechanical thrombectomy.

This patient had rheumatoid arthritis which could lead to rheumatoid vasculitis and at the same time patient has Lymes disease that can also present with Vasculitis. Could what criteria was used to justify the diagnosis of TA over or other confounders?   Authors performed mechanical Thrombectomy And balloon angioplasty as common Carotid artery was completely occluded. The text doesn’t mention clearly the sequence of procedures.    Follow up sections need to be rewritten as it doesn’t provide enough information regarding subsequent stroke and redo endovascular intervention. What was the patient status after another event?   The discussion section mentions that this case is notable for the successful use of mechanical thrombectomy in acute treatment of stroke associated with Takayasu arteritis without short or long-term complications, finding rarely documented in the literature however, this patient presented with recurrent stroke after mechanical thrombectomy which is a complication, so needs to be paraphrased.   Authors mentioned that combining intravenous thrombolysis and mechanical thrombectomy, may result in substantial neurological recovery, even in the presence of large vessel occlusion. I believe this should be paraphrased as this patient developed another cerebrovascular event After the procedure. Comments on the Quality of English Language

The English could be improved to more clearly express the research.

Author Response

Comment 1: “This patient had rheumatoid arthritis which could lead to rheumatoid vasculitis and at the same time patient has Lyme’s disease that can also present with vasculitis. What criteria was used to justify the diagnosis of TA over other confounders?”

Response: We thank the Reviewer for this important question regarding the differential diagnosis. We have added a dedicated paragraph in the Discussion addressing this issue. In summary:

• Rheumatoid vasculitis predominantly affects small- and medium-sized vessels (e.g., vasa nervorum, cutaneous arterioles) and is not typically associated with large-vessel involvement.
• Although neuroborreliosis may rarely cause cerebral vasculitis, it primarily involves small- and medium-sized intracranial vessels.
• The pattern observed in our patient — inflammatory wall changes of the aortic arch branches including the brachiocephalic trunk, bilateral subclavian arteries, and common carotid artery — is characteristic of large-vessel vasculitis and inconsistent with either rheumatoid or Lyme-associated vasculopathy.
• Furthermore, clinical findings including a diminished right radial pulse and inter-arm blood pressure asymmetry exceeding 50 mmHg fulfilled the ACR criterion of a blood pressure difference >10 mmHg between the arms.
• The diagnosis was confirmed by a rheumatologist, and the patient responded to immunosuppressive therapy.

Comment 2: “Authors performed mechanical thrombectomy and balloon angioplasty as common carotid artery was completely occluded. The text doesn’t mention clearly the sequence of procedures.”

Response: We have revised the Therapeutic Intervention section to clearly describe the procedural sequence. Via right femoral artery access, mechanical thrombectomy of the right MCA was performed first using a thromboaspiration technique, achieving complete recanalization (mTICI grade 3). During the same endovascular session, balloon angioplasty of the right common carotid artery and right subclavian artery was then performed. Door-to-groin time (200 minutes) has been added to the text.

Comment 3: “Follow-up sections need to be rewritten as it doesn’t provide enough information regarding subsequent stroke and redo endovascular intervention. What was the patient status after another event?”

Response: We have substantially expanded the Follow-up section with detailed clinical data from the recurrent event: - NIHSS score of 12 on admission, with left upper extremity plegia, severe left lower extremity paresis, and left-sided hemihypoesthesia. - CT findings: subacute ischemic changes in the deep structures of the right cerebral hemisphere. - CTA findings: persistent occlusion of the right MCA and CCA, patent right ICA with possible segmental wall thickening and 60–70% stenosis. - Intravenous thrombolysis was contraindicated (recent thrombolysis, ongoing DAPT and therapeutic-dose enoxaparin), and the patient was not deemed a candidate for mechanical thrombectomy following conventional angiography. - Notably, her neurological status improved rapidly, with only trace left-sided paresis documented two days after the event.

Comment 4: “The discussion section mentions that this case is notable for the successful use of mechanical thrombectomy without short or long-term complications; however, this patient presented with recurrent stroke after mechanical thrombectomy which is a complication.”

Response: We agree that the original wording was misleading. The Discussion has been revised to state that the initial MT was technically successful with no procedural complications and substantial immediate neurological recovery, while explicitly acknowledging that the recurrent cerebrovascular event highlights that successful acute reperfusion does not eliminate the long-term risk of recurrence in the setting of ongoing vascular inflammation. We have reframed the message to emphasize that early and sustained immunosuppressive therapy is essential to complement acute endovascular strategies.

Comment 5: “Authors mentioned that combining intravenous thrombolysis and mechanical thrombectomy may result in substantial neurological recovery, even in the presence of large vessel occlusion. I believe this should be paraphrased as this patient developed another cerebrovascular event after the procedure.”

Response: We agree and have revised the Conclusions accordingly. The revised text now states that early reperfusion therapy “may achieve immediate neurological improvement even in the presence of large-vessel occlusion; however, the risk of recurrence remains substantial without adequate immunosuppressive control of the underlying vasculitis.”

Comment 6 (Quality of English Language): “The English could be improved to more clearly express the research.”

Response: The manuscript has been thoroughly revised for English language clarity, grammar, and medical terminology throughout the text and figure legends.

Reviewer 3 Report

Comments and Suggestions for Authors

This is an interesting and clinically relevant case report that is, in my opinion, worth publication. The manuscript addresses an important and rare cause of ischemic stroke in young adults and provides a clear description of diagnostic work-up and therapeutic management. However, several minor revisions are required, mainly related to the presentation of imaging data and clarification of selected clinical aspects.
– The figures are currently distributed throughout the manuscript in a strictly chronological manner; however, from a didactic and comparative perspective, it would be preferable to group all key imaging figures on a single page (or adjacent pages) to facilitate direct comparison between acute stroke imaging and follow-up findings.
– The CT images (in particular Figures 1 and 4) are small and of limited visual clarity; these images should be enlarged and re-uploaded with higher resolution to allow proper assessment of the reported findings.
– All imaging figures should be systematically annotated with arrows indicating the exact abnormalities discussed in the text; all marked findings should be clearly labeled and described in the figure legends to improve clarity for the reader.
– The manuscript does not sufficiently explain why a patient with an acute ischemic stroke experienced a relatively long delay before mechanical thrombectomy; this important clinical aspect should be addressed and briefly discussed.
– Consider adding a schematic timeline figure summarizing diagnostic procedures (above the axis) and therapeutic interventions (below the axis), which would substantially enhance the readability and educational value of the case report.
– A careful re-evaluation of the description of acute and secondary stroke therapy is recommended to exclude potential inconsistencies and to ensure full alignment between the text, figures, and reported clinical decisions.
These issues are minor in nature and do not affect the overall scientific message of the manuscript; nevertheless, addressing them would significantly improve its clarity and visual quality.

Author Response

Comment 1: “The figures are currently distributed throughout the manuscript in a strictly chronological manner; it would be preferable to group all key imaging figures on a single page or adjacent pages.”

Response: All figures have been redesigned as composite panels (Figure 1: three CTA panels; Figure 2: three MRI panels; Figure 3: two DSA panels) to facilitate direct comparison. We will follow the journal’s formatting guidelines regarding figure placement.

Comment 2: “The CT images (in particular Figures 1 and 4) are small and of limited visual clarity; these images should be enlarged and re-uploaded with higher resolution.”

Response: All imaging figures have been replaced with higher-resolution images exported directly from the PACS system, cropped to remove unnecessary black borders, and saved in TIFF format at 600 dpi as recommended by MDPI guidelines.

Comment 3: “All imaging figures should be systematically annotated with arrows indicating the exact abnormalities discussed in the text.”

Response: All figures now include red arrows indicating the key findings, with corresponding descriptions in the figure legends.

Comment 4: “The manuscript does not sufficiently explain why a patient with an acute ischemic stroke experienced a relatively long delay before mechanical thrombectomy.”

Response: We thank the Reviewer for raising this important point. The prolonged time-to-treatment resulted from two factors. First, the patient presented with a wake-up stroke (symptom onset unknown), which required qualification under the WAKE-UP protocol. This protocol mandates MRI confirmation of DWI–FLAIR mismatch to establish eligibility for intravenous thrombolysis, adding to the door-to-needle interval (101 minutes). Second, the nearest comprehensive stroke center with endovascular capabilities was located approximately 100 km from the patient’s place of residence, resulting in a prolonged prehospital transport time that contributed to the door-to-groin interval of 200 minutes. These time intervals and circumstances have been added to the Therapeutic Intervention section of the revised manuscript. We believe that this real-world scenario, reflecting the challenges of limited geographic access to thrombectomy-capable centers, adds to the clinical relevance of the case.

Comment 5: “Consider adding a schematic timeline figure summarizing diagnostic procedures and therapeutic interventions.”

Response: We have added Figure 5, a schematic clinical timeline with diagnostic procedures displayed above the axis and therapeutic interventions below, covering the entire clinical course from initial admission through the recurrent cerebrovascular event. This figure includes key time points, NIHSS scores, imaging findings, and treatment decisions.

Comment 6: “A careful re-evaluation of the description of acute and secondary stroke therapy is recommended to exclude potential inconsistencies.”

Response: We have carefully reviewed the entire manuscript for consistency between the text, figures, and reported clinical decisions. Key revisions include: clarification of the procedural sequence (MT followed by angioplasty), addition of procedural timing data, expanded description of the recurrent stroke with detailed clinical and imaging findings, and revision of the Discussion and Conclusions to accurately reflect both the initial treatment success and the subsequent recurrent event.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Thanks for addressing the concerns and making revisions.

Comments on the Quality of English Language

The English could be improved to more clearly express the research.

Author Response

"The English could be improved to more clearly express the research".
The manuscript has been thoroughly revised for English language clarity and medical terminology. All changes were implemented in Round 1 and accepted by the Editorial Office in the current version. No specific language issues were identified by the Reviewer in Round 2.

Reviewer 3 Report

Comments and Suggestions for Authors

The authors have addressed the reviewers’ comments and introduced the requested corrections. In the present form, the manuscript has clearly improved and, in my opinion, it can be considered for publication.

One minor technical issue remains. In Figure 3, the red arrows appear to have slightly shifted from their intended positions. It would be advisable to reposition them precisely over the relevant structures. To avoid similar misalignment during the final layout process, the arrows could be merged directly with the image before inserting the complete figure into the manuscript.

Author Response

Comments: "The authors have addressed the reviewers’ comments and introduced the requested corrections. In the present form, the manuscript has clearly improved and, in my opinion, it can be considered for publication.

One minor technical issue remains. In Figure 3, the red arrows appear to have slightly shifted from their intended positions. It would be advisable to reposition them precisely over the relevant structures. To avoid similar misalignment during the final layout process, the arrows could be merged directly with the image before inserting the complete figure into the manuscript".

Response: We thank the Reviewer for the positive assessment. The arrows in Figure 3 have been repositioned and merged directly into the image file to prevent misalignment during the layout process."