A man in his 60s with multiple vascular comorbidities presented with sudden, painless vision loss in one eye. Although he had a high risk for atherosclerotic events, initial evaluation for stroke was negative for acute ischemia, but found to have markedly elevated inflammatory markers. Accordingly, giant cell arteritis was investigated and Ophthalmologic findings and fulfillment of the 2022 American College of Rheumatology/European Alliance of Associations for Rheumatology classification criteria supported the diagnosis of giant cell arteritis, despite a negative temporal artery biopsy. Management included high-dose glucocorticoids and delayed tocilizumab initiation due to the need for multiple vascular surgeries. Vision loss was irreversible, but systemic symptoms resolved and vascular interventions were successful. This case highlights the diagnostic and management complexities of biopsy-negative giant cell arteritis in patients with severe atherosclerotic vascular disease, emphasizing the importance of clinical judgment and established classification criteria when imaging and biopsy results are inconclusive.

Pulsatile blood flow in a subject-specific human aortic arch and its major branches is studied computationally for a peak Reynolds number of 1553 and a Womersley number of 22.74. The aortic geometry is constructed from the CT-scan images of a subject. The aorta has out-of-plane curvature and significant area variation along the flow direction. A physiologically representative pulsatile velocity waveform is applied as boundary condition at the inlet of the aorta. The primary velocity profiles are skewed towards the inner wall of the ascending aorta during the entire cardiac cycle. In the decelerating phase, reverse flow is noted along the inner wall and the magnitude of maximum velocity is about 50 % of the peak flow condition. Flow separation is observed in the inner wall of the ascending aorta during the decelerating and reverse flow phases of the cardiac cycle. In the accelerating phase, however, flow separation does not occur. The major observation of the present work is the existence of complex and asymmetrical vortical flow structures which are not observed either in simple curved pipes or in idealized aortic arch computational studies. The relative strength of the secondary flow with respect to the primary flow is quantified by means of Relative Secondary Kinetic Energy whose highest value is evaluated to be 1.202 occurring near the entrance of the right carotid artery during the maximum reverse flow condition. High values of wall shear stress is observed at distal of the left and right subclavian arteries, the bifurcation of brachiocephalic artery between right subclavian artery and right carotid artery, and proximal inner wall of descending aorta during the cardiac cycle. The wall shear stress at the bifurcations of the branches are low and oscillatory and generally correlates with the preferential sites for atherosclerosis. The flow structures on the aorta wall are explicitly highlighted by the limiting streamlines. The application of limiting streamlines to clearly elucidate the complex on-wall flow structures is one of the key contributions of the present study. During the decelerating and reverse flow phases several critical points are observed on the aortic wall. These complex flow structures vanish during the accelerating phase. The observations made in the present study will be helpful in creating accurate and clinically useful computational models.