Temporal arteritis/GCA

 

Written by: Pat Monahan MD. Edited by: Jeff Greco MD

Overview:

Giant cell arteritis is a systemic vasculitis commonly involving medium sized arteries in the carotid circulation. When it affects the temporal artery it is known as temporal arteritis. Symptoms

  • Headache, temporal

  • Jaw pain/claudication

  • Vision loss on the affected side

  • Fever and fatigue.

Epidemiology

  • Affects 1% of population

  • Most commonly women between 50-70y

  • Associated with polymyalgia rheumatica

Clinical features [1]

 
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Diagnosis [2]

3 or more criteria 93% sensitive and 91% specific

  • Age ≥ 50 years old

  • New onset of headache

  • Temporal artery tenderness or DECREASED temporal pulse (not related to carotid disease)

  • ESR ≥ 50 mm/hr

  • Artery biopsy with necrotizing arteritis or a granulomatous process with multinucleated giant cells

Ultrasound

Temporal arteritis is a vision threatening illness that requires prompt diagnosis and treatment. Temporal artery biopsy is difficult/impossible to obtain in the emergency room setting. Ultrasound can provide an additional data point supporting the diagnosis before treating with high dose methylprednisolone (1000mg daily for 3 days) which requires a steroid taper and exposes patients to side effects of high dose steroid use.

 

US findings

  • Stenosis

  • Occlusions

  • Non-compressible

  • Halo sign

    • Inflammatory infiltrate and edema of tunica media

    • Appears as hypoechoic, thickened vessel wall, that is non-compressible

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Before Treatment After Treatment

Before Treatment After Treatment


Normal temporal artery (a, b) vs temporal arteritis (c, d) [4]

Normal temporal artery (a, b) vs temporal arteritis (c, d) [4]

- Sensitivity of temporal artery duplex ultrasound was 87% with regard to clinical diagnosis, and specificity was 96% in one of the meta-analyses [5]- Bilateral halo sign increases specificity.- Can also have findings in axillary artery.

- Sensitivity of temporal artery duplex ultrasound was 87% with regard to clinical diagnosis, and specificity was 96% in one of the meta-analyses [5]

- Bilateral halo sign increases specificity.

- Can also have findings in axillary artery.

Results indicated that though normal IMC (intima-media complex) has diameters of about 0.2 and 0.6 mm in temporal and axillary arteries, respectively, vasculitic wall swelling most commonly results in diameters of 0.5–0.8 mm in temporal arteries an…

Results indicated that though normal IMC (intima-media complex) has diameters of about 0.2 and 0.6 mm in temporal and axillary arteries, respectively, vasculitic wall swelling most commonly results in diameters of 0.5–0.8 mm in temporal arteries and 1.5–2 mm in axillary arteries

References

1. Smetana GW, et al. Does this patient have temporal arteritis? JAMA. 2002;287:92-101

2. Hunder GG. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum. 1990; 33(8):1122-8

3. Ching J, Smith SM, Dasgupta B, Damato EM. The role of vascular ultrasound in managing giant cell arteritis in ophthalmology. Surv Ophthalmol. 2020 Mar-Apr;65(2):218-226. doi: 10.1016/j.survophthal.2019.11.004. Epub 2019 Nov 24. PMID: 31775013.

4. Schmidt WA. Role of ultrasound in the understanding and management of vasculitis. Therapeutic advances in musculoskeletal disease. 6 (2): 39-47. doi:10.1177/1759720X13512256 - Pubmed

5. Karassa, F., Matsagas, M., Schmidt, W., Ioannidis, J. (2005) Meta-analysis: test performance of ultrasonography for giant-cell arteritis. Ann Intern Med 142: 359–369.

 
 
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