1402 - Staring spells: A case of primary angiitis of the central nervous system (PACNS)

Friday, February 20, 2026

5:00 PM - 6:30 PM AST

Presenting Author(s)

NC

Natalie D. Curley, DO

Resident Physician
UPMC
Pittsburgh, Pennsylvania, United States

Co-Author(s)

KB

Krish T. Bharat, MD

Resident Physician
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania, United States
BC

Bryan Chadwick, MD

Resident physician (until June 2025), Attending physician (beginning July 2025)
UPMC (until June 2025), Novant New Hanover Rehabilitation Hospital (beginning July 2025)
Wilmington, North Carolina, United States

Corresponding Author(s)

DT

Debbie Tan, MD

Assistant Professor
UPMC Rehabilitation Institute
Pittsburgh, Pennsylvania, United States

Submitter(s)

NC

Natalie D. Curley, DO

UPMC
Pittsburgh, Pennsylvania, United States

Case Diagnosis:
Primary angiitis of the central nervous system (PACNS)

Case Description: A 47-year-old male with obstructive sleep apnea presented and found to have multifocal stroke. Electrocardiogram and echocardiogram were unrevealing for embolic source. He transferred to inpatient rehab, where he had intermittent staring spells concerning for seizures. MRI brain demonstrated no new pathology. Despite increasing antiepileptics, staring spells continued. Electroencephalogram (EEG) demonstrated generalized slowing. He was transferred to neurology service for further workup. Repeat MRI brain revealed new left basal ganglia infarct; no epileptiform discharges noted on continuous EEG; cerebrospinal fluid (CSF) analysis demonstrated mild elevations in protein and white blood cells. Autoimmune, infectious, and hypercoagulable panels were negative besides low antithrombin III. Digital subtraction angiography demonstrated multiple areas of narrowing involving bilateral anterior, middle, and posterior cerebral arteries. Brain biopsy showed reactive changes without definitive evidence of vasculitis. PACNS deemed most likely diagnosis, prompting initiation of steroids and cyclophosphamide with clinical improvement. He later transitioned to mycophenolate mofetil and rituximab.

Discussions: Determining stroke etiology is important in guiding stroke prevention, and guidelines for evaluation have been established. Important considerations for multifocal stroke include cardioembolism, thrombophilia, hypertension, cerebroatherosclerosis, and vasculitis. In a relatively young, healthy patient with no clear etiology, vasculitis work up is warranted especially with ongoing staring spells that do not correlate to seizure activity. Because of the skipped and segmental pattern of vasculitis, negative brain biopsy findings are not uncommon. Diagnosis is still likely with suggestive angiographic findings, abnormal MRI, and CSF profile consistent with PACNS (modest elevations in white blood cell count and protein) as demonstrated in this case.

Conclusions: Intermittent episodes of altered mental status in the setting of prior multifocal stroke with no other identified etiology may represent ongoing ischemic events secondary to vasculitis.