Takayasu arteritis (TA) is a rare large-vessel granulomatous vasculitis predominantly affecting young women. We report the case of a male patient in his early 20s presenting with a three-month history of pyrexia of unknown origin (PUO), significant weight loss, a left carotid bruit and massive splenomegaly, culminating in a diagnosis of Type V TA. The presentation was atypical in several respects: prolonged high-grade fever, marked splenomegaly and male sex are all uncommon in TA.CT angiography demonstrated concentric mural thickening with stenotic involvement of the aorta and its major branches. In conjunction with markedly elevated inflammatory markers, a diagnosis of Type V TA was established. The patient became apyrexial with resolution of constitutional symptoms following initiation of immunosuppressive therapy. This case highlights the imperative to consider TA in atypical clinical contexts, including male sex, PUO and massive splenomegaly. It underscores the value of systematic vascular evaluation in unexplained chronic pyrexia.

Riesman's sign or Snellen-Riesman's sign is a clinical sign characterized by bruit heard over the closed eye with a stethoscope in Graves' ophthalmopathy (thyroid eye disease or Graves' orbitopathy or thyroid-associated orbitopathy) in thyrotoxicosis. The bruit is audible during systole. 

Background and Clinical Significance: Carotid-cavernous fistulas (CCFs) are pathological communications between the carotid artery and the cavernous sinus, most commonly traumatic when direct and high-flow (Barrow type A). Bilateral traumatic CCFs are rare, occurring in approximately 1-2% of cases. Case Presentation: We report a 45-year-old male with polytrauma after a road traffic accident who presented with right-sided chemosis, pulsatile exophthalmos, and ocular bruit. Digital subtraction angiography revealed bilateral direct CCFs. The right fistula was treated with transarterial coil embolization combined with flow-diverter stent placement in the intracavernous internal carotid artery. Subsequent imaging demonstrated left-hemispheric ischemia while the contralateral high-flow CCF remained untreated; the underlying mechanism was considered potentially hemodynamic or thromboembolic. The left fistula was managed using the same technique. Final angiography confirmed complete bilateral occlusion. Despite transient postoperative epistaxis, the patient showed neurological improvement. Conclusions: This case highlights the effectiveness of combined flow diversion and coiling in managing rare bilateral traumatic CCFs.

Vascular Ehlers-Danlos syndrome, also known as Ehlers-Danlos syndrome type IV, is a rare inherited connective tissue disorder caused by autosomal-dominant pathogenic variants in the COL3A1 gene. Defective type III collagen results in marked fragility of arteries and hollow organs, predisposing affected individuals to spontaneous aneurysms, dissections, and rupture. We report the case of a 35-year-old Bangladeshi woman who presented with a gradually enlarging right-sided pulsatile neck mass accompanied by intermittent headache. Physical examination revealed a soft pulsatile cervical swelling with an audible bruit, thin skin, and joint hypermobility. Doppler ultrasonography followed by computed tomography angiography (CTA) demonstrated a large saccular aneurysm of the right internal carotid artery with additional aneurysmal involvement of the common hepatic and splenic arteries. Based on the characteristic clinical findings and multimodality imaging, a clinical diagnosis of vascular Ehlers-Danlos syndrome was established despite the unavailability of genetic testing. The patient was managed conservatively and referred to a tertiary vascular center for specialist evaluation. This case highlights the value of a systematic, noninvasive imaging approach for the clinical diagnosis of vascular Ehlers-Danlos syndrome in a resource-limited setting. The educational contribution of this report is limited to the diagnostic phase, as long-term follow-up data were unavailable.

Takayasu arteritis is a rare large-vessel vasculitis that often presents with asymmetric or absent pulses, vascular bruits, intermittent claudication, and cerebrovascular symptoms in over 50% of cases. Surgical intervention becomes essential in patients with severe, refractory disease. We report the case of a 30-year-old female presenting with upper limb claudication and decreased visual acuity in the right eye. Physical examination revealed bilateral carotid and subclavian bruits, significant blood pressure discrepancy between upper and lower limbs, and episodes of limb shaking. Vascular imaging demonstrated extensive involvement of the brachiocephalic trunk, common carotid, and vertebral arteries, with marked arterial wall thickening and gadolinium enhancement. Despite high-dose corticosteroids and tocilizumab therapy, the patient showed a poor clinical response. A successful aortobicarotid bypass was performed. This case underscores the importance of surgical revascularization in medically refractory Takayasu arteritis, offering symptom relief and improved quality of life.

Anatomic malformation as seen in subclavian steal syndrome leads to an alteration in the body's autonomic regulatory pattern, influencing varying physical manifestations. The autonomic nervous system provides situational regulatory feedback to the body, maintaining the body's desired point of homeostasis. We report the case of a 68-year-old male who initially came in with X-rays indicating retrolisthesis and calcifications in his carotids. A left-sided carotid bruit was also noted, as well as right-sided upper extremity weakness. Continued imaging studies indicated structural changes to his cervical regions and continued calcifications in the remainder of his arterial supply branching off of his carotid arteries. The patient's denial of surgical intervention led to treatments focused on symptomatic control until more conclusive data could be collected and interpreted.

Careful palpation and auscultation of carotid arteries, and palpation of superficial temporal arteries, provides vital information in evaluating both completed and threatened stroke, and sharpens risk assessment of asymptomatic persons with risk factors. Several measures allow firmer distinction of carotid bruits from transmitted cardiac murmurs, subclavian bruits, venous hums, and fistular bruits. The maneuvers described are complementary, to rather than, in conflict with technologic advances to assess these vessels, and can be applied anywhere that a stethoscope is in the hand of an informed and practiced examiner.

Median arcuate ligament syndrome (MALS) is an uncommon vascular condition caused by external compression of the celiac artery by the median arcuate ligament. Although it predominantly affects young women, late-onset presentations in older men have been reported and may reflect a different underlying mechanism. We present a 62-year-old man with dyslipidemia and a 20-pack-year smoking history who came to the emergency department with chronic postprandial epigastric pain. Physical examination was unremarkable. There was no abdominal bruit and no tenderness to palpation. Routine blood work showed a mildly elevated prothrombin time (14.4 seconds; international normalized ratio (INR): 1.30), an intermediate Fibrosis-4 (FIB-4) score of 2.39, and an elevated mean platelet volume (MPV) (10.5 fL). Contrast-enhanced CT of the abdomen and pelvis at Bayonne Medical Center demonstrated moderate to severe stenosis of the celiac axis origin related to acute angulation, with post-stenotic dilatation, and findings correlating with median arcuate ligament syndrome per the final radiology report. No other cause of his symptoms was identified. He was transferred to a tertiary care facility and underwent a minimally invasive median arcuate ligament decompression without complications. This case raises awareness of MALS as a diagnosis that should be considered in older male patients with cardiovascular risk factors and unexplained postprandial pain. The severity of stenosis in this case, beyond what is typically seen in young women with classic MALS, suggests that intrinsic atherosclerotic disease may compound extrinsic ligamentous compression in older patients.

Carotid body paraganglioma is a rare hypervascular neuroendocrine tumor of the head and neck, and presentation in a 20-year-old woman is uncommon. We report a young woman with a painless left lateral neck mass present for more than 5 years, with more noticeable enlargement during the preceding year. On admission, a firm, mobile, non-tender mass was palpated along the anterior border of the left sternocleidomastoid muscle, without an audible bruit. Initial and targeted ultrasonography demonstrated a hypervascular lesion centered at the left carotid bifurcation. Preoperative contrast-enhanced computed tomography angiography (CTA) demonstrated a hypervascular mass centered at the left carotid bifurcation with widening of the bifurcation and separation of the internal and external carotid arteries; magnetic resonance imaging (MRI) showed a heterogeneously enhancing carotid-space mass with internal flow-void foci; and digital subtraction angiography (DSA) confirmed marked tumor blush, collectively supporting the diagnosis of carotid body paraganglioma. Surgical excision was performed under general anesthesia. Intraoperatively, the tumor crossed the carotid bifurcation, wrapped around the internal and external carotid arteries, and was extremely vascular; however, grossly complete, vessel-preserving excision was achieved with preservation of the carotid arteries, hypoglossal nerve, and vagus nerve. Histopathology confirmed carotid body paraganglioma with an organoid/nested architecture within a rich vascular stroma and immunohistochemistry showing synaptophysin (Syn)(+), chromogranin A (CgA)(+), S-100(+), and a Ki-67 labeling index of approximately 5%; the original pathology report did not specify a formal microscopic margin status. Balloon occlusion testing, biochemical catecholamine work-up, functional imaging, and genetic testing were not documented in the available record. The postoperative course was uneventful. Ultrasonographic follow-up on July 26, 2018 showed no definite recurrent lesion or obvious vascular abnormality, and long-term clinical follow-up by telephone revealed no recurrence-related symptoms, although no further imaging surveillance was available, and asymptomatic radiologic recurrence cannot be fully excluded. This case highlights the value of multimodal imaging in diagnosis and operative planning and shows that grossly complete, vessel-preserving excision can be associated with favorable short-term imaging and long-term symptom-based follow-up findings in a young patient.

We report a 50-year-old male who sustained a right abdominal stab wound 20 years ago requiring laparotomy and extensive repair, now presenting with worsening dyspnea on exertion and palpitations. Physical examination was remarkable for jugular venous distention, bilateral lower extremity edema, and a right abdominal pulsatile mass with audible bruit. Transthoracic echocardiogram revealed a left ventricular ejection fraction (LVEF) of 30%-35% and a severely dilated inferior vena cava (IVC) with turbulent flow. Computed tomography venography of the abdomen revealed a fistula between the IVC and right renal artery, with aneurysm of the IVC measuring 8 cm. Cardiac catheterization confirmed a high cardiac output of 12 l/min. The patient underwent endovascular repair of the fistula with the use of an Amplatzer septal occluder, and subsequent improvement in symptoms and LVEF. This case highlights a unique etiology of high output heart failure, treated successfully by novel endovascular means.

Takayasu arteritis (TA) is a rare chronic granulomatous large-vessel vasculitis predominantly affecting the aorta and its major branches, leading to stenosis, occlusion, or aneurysm formation. It typically presents in young women, though atypical cases can occur in older adults. Diagnosis is often delayed owing to nonspecific symptoms and a lack of reliable biomarkers. We report a case of a 57-year-old woman who presented with recurrent syncope, dizziness, and chest tightness. Physical examination revealed a significant blood pressure discrepancy between arms and carotid bruits. Although erythrocyte sedimentation rate (ESR) was normal, other inflammatory markers were elevated. Angiography and computed tomography angiography demonstrated multi-vessel involvement, including subtotal occlusion of the right subclavian artery, complete occlusion of the left subclavian artery, and stenosis of the right vertebral artery and abdominal aorta. The patient met the 2022 American College of Rheumatology classification criteria for TA. Treatment with glucocorticoids and cyclophosphamide resulted in symptomatic improvement, with no recurrence during a six-month follow-up. This case underscores that syncope can be a rare initial manifestation of TA, and normal ESR does not exclude active disease. Thorough clinical evaluation and vascular imaging are essential for timely diagnosis and management to prevent serious complications.