Florid Arteritis Confined to a Single Branch of the Superficial Temporal Artery

Abstract

for the integrity of the data and the accuracy of the data analysis. Financial Disclosure: None reported. Funding/Support: This work was supported by Eye Tu- mor Research Foundation, Philadelphia, Pennsylvania (Drs J. A. Shields and C. L. Shields). Role of the Sponsor: The sponsor had no role in the de- sign and conduct of the study; in the collection, analy- sis, and interpretation of the data; or in the preparation, review, or approval of the manuscript. 1. Zimmerman LE, Garron LK. Melanocytoma of the optic disc. Int Ophthalmol Clin. 1962;2:431-440. 2. Apple DJ, Craythorn JM, Reidy JJ, Steinmetz RL, Brady SE, Bohart WA. Ma- lignant transformation of an optic nerve melanocytoma. Can J Ophthalmol. 3. Shields JA, Shields CL, Eagle RC Jr, Lieb WE, Stern S. Malignant melanoma associated with melanocytoma of the optic disc. Ophthalmology. 1990;97 4. Meyer D, Ge J, Blinder KJ, Sinard J, Xu S. Malignant transformation of an op- tic disk melanocytoma. Am J Ophthalmol. 1999;127(6):710-714. 5. Shields JA, Demirci H, Mashayekhi A, Shields CL. Melanocytoma of optic disc in 115 cases: the 2004 Samuel Johnson Memorial Lecture, part 1. Ophthalmology. 6. Shields JA, Demirci H, Mashayekhi A, Eagle RC Jr, Shields CL. Melanocy- toma of the optic disk: a review. Surv Ophthalmol. 2006;51(2):93-104. 7. Horgan N, Shields CL, Swanson L, et al. Altered chromosome expression of uveal melanoma in the setting of melanocytosis. Acta Ophthalmol. 2009;87 branches of the superficial temporal artery. In fact, sur- geons usually fail to specify which branch was biopsied when they submit specimens, and no histological data exist regarding which branch is more likely to demon- strate arteritis. Recently, it was suggested that the parietal branch, rather than the frontal branch, should be biopsied in pa- tients with suspected temporal arteritis. 3 This approach eliminates the remote risk of facial nerve injury and usu- ally hides the scar behind the hairline. However, this rec- ommendation was predicated on the assumption that the prevalence of arteritis is equal in the parietal and frontal branches. We now show that selective involvement of a single vessel branch can occur in temporal arteritis. Magnetic resonance imaging has been used to com- pare the involvement of the parietal vs frontal branch in temporal arteritis. In 21 patients with suspected giant cell arteritis, involvement was rated by noting the amount of mural thickening and gadolinium enhancement of the vessel and perivascular tissue. 4 On the left side, abnor- malities were present in 14 patients in the frontal branch and in 6 patients in the parietal branch. On the right side, A Florid Arteritis Confined to a Single Branch of the Superficial Temporal Artery B iopsy of the superficial temporal artery provides vital confirmation of the diagnosis of giant cell arteritis. The vessel splits into 2 main branches: frontal and parietal. It is unknown which branch is most likely to yield a positive biopsy finding or, indeed, whether arteritis is ever confined to a single branch. Report of a Case. A 69-year-old woman had a 5-week history of neck stiffness and malaise. The erythrocyte sedi- mentation rate was 55 mm/h. A 30-mm segment of the parietal branch of the left superficial temporal artery was harvested. It was processed with hematoxylin-eosin stain and an elastic Van Gieson stain. A total of 108 sections were examined at 36 different levels. None showed evi- dence of arteritis ( Figure 1 ). Two days later, a 30-mm section of the frontal branch of the left superficial tem- poral artery was biopsied. Every section showed exten- sive granulomatous inflammation ( Figure 2 ). The pa- tient was treated with prednisone and her symptoms resolved. Comment. It is crucial to obtain a biopsy specimen of adequate length to avoid the problem of “skip areas” in the superficial temporal artery. It is also important to ex- amine the specimen thoroughly by reviewing sections cut at many levels because inflammation can be confined to just a few portions of the artery. Otherwise, there is risk of a false-negative biopsy result. 1,2 We describe an ex- treme example of a skip area: a parietal branch com- pletely free of inflammation in a patient with extensive arteritis of the frontal branch. To our knowledge, no prior report has compared pathological findings in the 2 B Figure 1. Patient showing biopsy sites from the parietal and frontal branches of the left superficial temporal artery (A), and representative sections, spaced evenly from 9 different levels of the parietal branch of the left superficial temporal artery, showing no evidence of arteritis (hematoxylin-eosin, original magnification ⫻12) (B). ARCH OPHTHALMOL / VOL 130 (NO. 10), OCT 2012 WWW.ARCHOPHTHALMOL.COM ©2012 American Medical Association. All rights reserved. Downloaded From: http://archopht.jamanetwork.com/ by a UCSF LIBRARY User on 08/10/2015