131 Acute stroke in ANCA associated vasculitis

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Background: Ischemic stroke is recognised in large vessel vasculitis, but is unusual in ANCA associated vascuiltis, often occurring with augmented cardiovascular risk factors and uncontrolled vascular inflammation. We describe three cases of ANCA associated vascuilitis presenting as acute stroke. Methods: Case 1: A 37 year old male with sudden onset dysarthria and sleep disturbance with no focal sensory or limb weakness. He had undiagnosed sinusitis and nose bleeds for 2 years. MRI demonstrated bilateral basal ganglia infarction. ANCA-PR3 testing was positive and a diagnosis of GPA made. The patient was treated with IV methylprednisolone, cyclophosphamide (EUVAS protocol) and then maintained on azathioprine. He made an excellent recovery but relapsed after 1 year with sinusitis and digital infarcts following which there was a recurrence of dysarthria and MRI demonstrated an acute basal ganglia stroke. He was treated with methylprednisolone, rituximab and maintained on methotrexate, resulting in resolution of vasculitis and full stroke recovery. At 6 years’ follow-up he remains in remission with no stroke recurrence. Case 2: An 82-year-old male with right sided weakness and right facial droop. He had a history of fever, weight loss, night sweats and impaired hearing. There was bilateral episcleritis and retinal vasculitis. MRI showed an acute ischaemic infarct in the left putamen extending to the corona radiata. ANCA-MPO testing was positive. He was treated with clopidogrel, prednisolone 60mg OD and methotrexate 20mg per week. He made an excellent recovery and after 4 years’ follow-up is ANCA negative and in remission. Case 3: A 71-year-old female with left sided weakness, left facial droop with numb hands and feet. Urine protein-creatinine ratio was raised at 139mg/mmol and eGFR 44. MRI showed an acute infarct in the posterior limb of the right internal capsule. pANCA (MPO 57) was positive and the patient treated with IV methylprednisolone, cyclophosphamide (EUVAS) and maintained on azathioprine. Urine PCR normalised and she made an excellent recovery with rehabilitation. Results: Stroke is an unusual presentation of ANCA-associated vasculitis which may affect deep non-conventional vascular territories. Conclusion: Systemic disease activity may correlate with the risk of stroke, whilst prompt immunosuppression and maintenance of remission will prevent stroke recurrence and improve outcomes. Glomerulonephritis Peripheral neuropathy Pulmonary granuloma CRP 49, ESR 107, Aspirin then clopidogrel IV methylpred Prednisolone Cyclo/ EUVAS Azathioprine IV methylprednisolone Rituximab (on relapse) Methotrexate Aspirin then clopidgrel Prednisolone 60mg OD Methotrexate Aspirin then clopidogrel IV Methylpred Cyclo/EUVAS Azathioprine Full recovery 5 year remission with Aza Disclosures: H.K. Hashim: None. A.W. Porter: None. R. Bathula: None. S. Hamdulay: None.

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