A Multidisciplinary Approach to Silent Ischaemic Strokes Unveiling Primary CNS Vasculitis: Exploring Beyond the Apparent

Diagnosing first-episode strokes due to central nervous system (CNS) vasculitis is challenging, particularly when systemic vasculitis features are absent. We present the case of a 42-year-old female patient with hypertension, type 2 diabetes mellitus, and a psychiatric history, who presented with confusion and sleep disturbances. Initial CT brain revealed multiple hypodense foci suggestive of vascular insult, and MRI demonstrated multiple ischaemic infarcts in the right middle cerebral artery (MCA) territory, with features raising suspicion for medium-vessel vasculitis. Despite dual antiplatelet therapy (DAPT), she experienced further silent infarcts in the left MCA territory. A multidisciplinary evaluation, including stroke, neuroradiology, and rheumatology specialists, led to a diagnosis of CNS vasculitis based on neuroimaging findings, elevated cerebrospinal fluid (CSF) protein, negative autoimmune screen, and normal complement levels. She received intravenous methylprednisolone followed by oral prednisolone and methotrexate. Primary CNS vasculitis (PCNSV) should be considered in young patients with unexplained recurrent or silent ischaemic strokes, and a multidisciplinary approach is essential for timely diagnosis and management.