Suspected Giant Cell Arteritis Research Articles

The Diagnostic Performance of an Extended Ultrasound Protocol in Patients With Clinically Suspected Giant Cell Arteritis.

ObjectiveTo evaluate the diagnostic performance of an extended ultrasound protocol in patients referred under the suspicion of giant cell arteritis (GCA).MethodsConsecutive patients with suspected GCA were examined with an extended color duplex ultrasound (CDU) protocol during a period of 2 years. The extended CDU protocol included temporal, axillary, subclavian, brachiocephalic, and carotid arteries. The reference was clinically diagnosed GCA, confirmed after ≥6-month follow-up. Hypo- or medium-echogenic, circumferential, homogenous wall thickening, and/or a positive compression sign in temporal arteries, were regarded as typical signs of arteritis.ResultsOf the eligible 201 patients, 83 (41%) received a clinical GCA diagnosis at follow-up ≥6 months post CDU examination. Among these cases, 48 (58%) demonstrated inflammation solely in temporal arteries, 8 (10%) showed abnormalities restricted to extra-cranial vessels, and 23 (28%) patients displayed inflammatory changes in both temporal and extra-cranial arteries. Color duplex ultrasound of temporal arteries yielded a diagnostic sensitivity and specificity [95% confidence intervals (CI)] of 86% (76–92%) and 99% (95–99%), respectively. By adding axillary artery examination, the sensitivity increased to 92% (83–97%) while the specificity remained unchanged. Further, inclusion of subclavian artery marginally increased the sensitivity by 1%. Finally, by also including brachiocephalic and common carotid arteries resulted in a sensitivity of 95% (88–99%) and a specificity of 98% (94–99%).ConclusionsColor duplex ultrasound examination demonstrated a high accuracy in diagnosing patients both with cranial and extra-cranial GCA. Further examination of brachiocephalic and common carotid arteries can increase the sensitivity without affecting the specificity when temporal and axillary findings are indecisive. Finally, the extended CDU protocol allows measurement of the general burden of inflammation, which could be relevant for future monitoring purposes.

Should Ultrasonographic Giant-Cell Arteritis Signs be Detected in Patients with Polymyalgia Rheumatica?

Assessing the presence of ultrasonographic findings of Giant-Cell Arteritis in Polymyalgia Rheumatica patients using Ultrasonography on the temporal artery. The study contributes to the literature evaluating the unclear relationship between Polymyalgia Rheumatica and Giant-Cell Arteritis. It raises awareness that Ultrasonography can be used instead of biopsy in patients with suspected Giant-Cell Arteritis. Twenty patients were newly diagnosed with Polymyalgia Rheumatica, and 20 participants as a control group were included in the study. While the Polymyalgia Rheumatica group was evaluated at baseline and sixth month, the control group was evaluated only at baseline. Laboratory, clinical and ultrasonographic findings of all participants were assessed. Gray-scale Ultrasonography and colored Doppler Ultrasonography were used to present halo and compression, occlusion, and stenosis in addition to intima-media complex thickness in bilateral temporal arteries and frontal-parietal branches by an experienced radiologist blinded to the subject. No significant difference was found between Polymyalgia Rheumatica and control groups based on demographic features, clinical and ultrasonographic results at baseline and sixth month. Erythrocyte sedimentation rate of Polymyalgia Rheumatica at baseline was statistically higher than the control group. Erythrocyte sedimentation rate values have declined significantly in Polymyalgia Rheumatica patients, but no significant changes were found for clinical or ultrasonographic features during the sixth month. Ultrasonographic findings of Giant-Cell Arteritis are not present in newly diagnosed and six months followed up Polymyalgia Rheumatica patients. Further studies are needed.

Should Ultrasonographic Giant-Cell Arteritis Signs be Detected in Patients with Polymyalgia Rheumatica?

Assessing the presence of ultrasonographic findings of Giant-Cell Arteritis in Polymyalgia Rheumatica patients using Ultrasonography on the temporal artery. The study contributes to the literature evaluating the unclear relationship between Polymyalgia Rheumatica and Giant-Cell Arteritis. It raises awareness that Ultrasonography can be used instead of biopsy in patients with suspected Giant-Cell Arteritis. Twenty patients were newly diagnosed with Polymyalgia Rheumatica, and 20 participants as a control group were included in the study. While the Polymyalgia Rheumatica group was evaluated at baseline and sixth month, the control group was evaluated only at baseline. Laboratory, clinical and ultrasonographic findings of all participants were assessed. Gray-scale Ultrasonography and colored Doppler Ultrasonography were used to present halo and compression, occlusion, and stenosis in addition to intima-media complex thickness in bilateral temporal arteries and frontal-parietal branches by an experienced radiologist blinded to the subject. No significant difference was found between Polymyalgia Rheumatica and control groups based on demographic features, clinical and ultrasonographic results at baseline and sixth month. Erythrocyte sedimentation rate of Polymyalgia Rheumatica at baseline was statistically higher than the control group. Erythrocyte sedimentation rate values have declined significantly in Polymyalgia Rheumatica patients, but no significant changes were found for clinical or ultrasonographic features during the sixth month. Ultrasonographic findings of Giant-Cell Arteritis are not present in newly diagnosed and six months followed up Polymyalgia Rheumatica patients. Further studies are needed.

A Predictive Model for Temporal Artery Biopsy in the Setting of Suspected Giant Cell Arteritis: A Validation Study.

A previously published predictive model based on threshold parameters for erythrocyte sedimentation rate, c-reactive protein, and platelet count demonstrated that 40% of patients who underwent biopsy may not have required it. The current study was performed to evaluate the model's performance on an independent data set. This is a retrospective consecutive series of patients undergoing temporal artery biopsy (TAB) in a single health region in Canada. The model was applied to a multicenter cohort of patients undergoing TAB by a variety of surgical services. A centralized pathological database serving multiple institutions and surgical services was used to identify patients undergoing TAB. Over a 7-year period, patients undergoing TAB were identified via a central pathological database. Those who had concurrent illnesses which would likely affect erythrocyte sedimentation rate, c-reactive protein, and platelet count, patients on steroids for >2 weeks by the time of biopsy, and those with missing serum markers were excluded. The previously developed model was applied to the 222 patients enrolled. The model correctly identified 29% of patients with a pretest probability of 0% for a positive biopsy and 9% with a pretest probability of 100%, suggesting that in total, 38% of patients could have avoided TAB. The results of this independent data set support the previously published predictive formula. Utilizing a simple, clinically applicable predictive model of the pretest probabilities, approximately 38% of TAB currently being performed may be avoided. The results suggest that evaluation with a prospective multicentre study would be appropriate.

Halo score (temporal artery, its branches and axillary artery) as a diagnostic, prognostic and disease monitoring tool for Giant Cell Arteritis (GCA)

BackgroundGiant cell arteritis (GCA) is a common large vessel vasculitis of the elderly, often associated with sight loss. Glucocorticoids (GC remain the mainstay of treatment, although biologic treatments have been approved. Biomarkers predicting disease severity, relapse rates and damage are lacking in GCA.EULAR recommends ultrasound (US) as the first investigation for suspected GCA. The cardinal US finding, a non-compressible halo, is currently categorised as either negative or positive. However, the extent and severity of this finding may vary.In this study, we hypothesise whether the extent and severity of the halo sign [calculated as a single composite Halo score (HS)] of temporal and axillary arteries may be of diagnostic, prognostic and monitoring importance; whether baseline HS is linked to disease outcomes, relapses and damage; whether HS can stratify GCA patients for individual treatment needs; whether HS can function as an objective monitoring tool during follow up.MethodsThis is a prospective, observational study. Suspected GCA Participants will be selected from the GCA FTC at the participating centres in the UK. Informed consent will be obtained, and patients managed as part of standard care. Patients with GCA will have HS (temporal and axillary arteries) measured at baseline and months 1,3,6 and 12 long with routine clinical assessments, blood sampling and patient-reported outcomes (EQ5D). Non-GCA patients will be discharged back to the referral team and will have a telephone interview in 6 months.We aim to recruit 272 suspected GCA referrals which should yield 68 patients (25% of referrals) with confirmed GCA. The recruitment will be completed in 1 year with an estimated total study period of 24 months.DiscussionThe identification of prognostic factors in GCA is both timely and needed. A prognostic marker, such as the HS, could help to stratify GCA patients for an appropriate treatment regimen. Tocilizumab, an IL-6R blocking agent, switches off the acute phase response (C-Reactive Protein), making it difficult to measure the disease activity. Therefore, an independent HS, and changes in that score during treatment and follow-up, maybe a more objective measure of response compare to patient-reported symptoms and clinical assessment alone.

Impact of Temporal Artery Biopsy on Clinical Management of Suspected Giant Cell Arteritis

Temporal arteritis (TA) is a systemic inflammatory vasculitis of unclear etiology that affects medium-sized vessels. The gold standard for diagnosis has traditionally been histological, by temporal artery biopsy. Improved imaging modalities have been increasingly used to aid diagnosis and are recommended in the newest 2018 European (EULAR) guidelines.1 We hypothesize that a negative TA biopsy result does not change management in patients for whom TA is strongly suspected and that duplex ultrasound can be successfully used as a screening tool. This is a retrospective review of patients who underwent TA biopsy between May 1, 2012 and June 1, 2017. We reviewed patient's demographics, comorbidities, symptoms, histology, and treatment. We also present a small series of patients for whom ultrasound of the bilateral temporal arteries was performed. Radiology and pathology reports on these 7 patients were reviewed. A total of 264 patients underwent temporal artery biopsies over the study period. Histology was positive in 21 (8.0%) and negative in 243 (92%) patients. In 74 (41%) patients with negative biopsies on steroids preoperatively, steroids were continued despite negative biopsy result. In prospective series, 7 patients underwent duplex ultrasound evaluation before scheduling for biopsy. Biopsy followed ultrasound in 4 cases, and in all 4 cases, histology was congruent with ultrasound findings. The yield of temporal artery biopsy is low, and a negative biopsy alone often does not lead to termination of steroid therapy. Ultrasound may present a viable diagnostic tool to reduce the number of unnecessary temporal artery biopsies performed.

Diagnostic Algorithm for Suspected Giant Cell Arteritis: Response.

Diagnostic Algorithm for Suspected Giant Cell Arteritis: Response.

O09 Ultrasound Compared with Biopsy in the Diagnosis of Suspected Giant Cell Arteritis

O09 Ultrasound Compared with Biopsy in the Diagnosis of Suspected Giant Cell Arteritis

306. How Do General Practitioners Manage Suspected Giant Cell Arteritis

306. How Do General Practitioners Manage Suspected Giant Cell Arteritis

Is temporal artery biopsy (TAB) always necessary in suspected giant cell arteritis (GCA)?

s / International Journal of Surgery 12 (2014) S13eS117 S114 Department of Surgery, University of Queensland, Queensland, Australia; Imperial College NHS Healthcare Trust, London, UK; Department of Vascular Surgery, Norfolk and Norwich, Norfolk and Norwich, UK. Introduction: Aortic aneurysms represent a significant burden of disease worldwide. Whilst some risk factors for rupture are well established, such as hypertension, smoking and female gender, the impact of season and meteorological variables is less clear. We systematically reviewed the literature in order to conclusively determine whether these variables are associated with aortic aneurysm rupture. Methods: Reviewmethodswereaccording to thePreferredReporting Items for Systematic Reviews and Meta-Analysis guidelines. Data was extracted from all identified studies with regard to study design, geographical location, aortic lesion, sample size, and meteorological variables including season, atmospheric pressure, temperature and daylight hours. Results: 27 studies representing 46,580 patients were investigated. Whilst there is no consensus within the literature, several large studies suggest a statistically significant seasonal variation in the incidence of aortic aneurysm rupture, with winter months broadly conferring a greater degree of risk. There is also some evidence for an association with atmospheric pressure. Associations with temperature and daylight hours, however, remain more controversial. Conclusions: Meteorological and seasonal variables may affect the haemodynamic stability of aortic aneurysms. This may have implications on the epidemiology of aneurysm rupture, and thus influence the provision of vascular services and timing of surgical intervention. 0803: IS TEMPORAL ARTERY BIOPSY (TAB) ALWAYS NECESSARY IN SUSPECTED GIANT CELL ARTERITIS (GCA)? Eva Andreotti, Nicholas Farkas *, Emma Rose McGlone, Aziz Anjum. Epsom and St Helier University Hospitals NHS Trust, Surrey, UK. Introduction: In the diagnosis of GCA, an American College of Rheumatology (ACR) criteria score of three or more has very high sensitivity and specificity. Current guidelines recommend early TAB of sufficient length in all cases of suspected GCA, however recent studies suggest that TAB does not change management in the majority of cases. This retrospective audit aimed to investigate the safety of restricting TAB to only those with indeterminate pre-biopsy ACR score. Methods: We identified 45 consecutive patients undergoing TAB from April 2012 onwards. Notes were analysed for indications for, timing, length and results of TAB, and subsequent patient management. Results: Of those started immediately on steroids, 8/40 (20%) underwent TAB within one week. 21/45 specimens (48%) were one centimetre or longer. Seven patients (16%) had their management changed following biopsy result; of these, 2/17 (11.7%) had pre-biopsy ACR score of 2, 4/19 (21%) of 3, and 1/9 (11%) of 4. Conclusions: In our trust, TAB changes management in patients with prebiopsy ACR score of 2, 3 or 4. Guidelines for specimen length and timing are poorly adhered to, which may influence interpretation of results. At present, TAB cannot be restricted to those with indeterminate pre-biopsy ACR score. 0830: LENGTH OF THE EXTRACRANIAL INTERNAL CAROTID ARTERY AND DEGREE OF STENOSIS: ARE THEY RELATED? Emma Wilton , Naomi Warner *, Patrick Lintott . Oxford University Hospitals NHS Trust, Oxford, UK; Buckinghamshire Healthcare NHS Trust, High Wycombe, Buckinghamshire, UK. Introduction: To determine if the degree of stenosis within the internal carotid artery (ICA) is related to the length of the extracranial ICA. Methods: Retrospective analysis of patients that underwent carotid endarterectomy between September 2009 and August 2013, in one institution, was carried out. Magnetic resonance angiography time-of-flight images were reviewed and the distance between the carotid bifurcation and the base of the skull was recorded bilaterally. The degree of internal carotid artery stenosis measured on preoperative carotid artery duplex scanning, according to the North American Symptomatic Carotid Endarterectomy Trial (NASCET) criteria, was also recorded. The results were analysed using Pearson's product-moment correlation. Results: A total of 369 patients underwent carotid endarterectomy within the study period. 175 patients were excluded due to insufficient imaging. 194 patients were included (mean age ± SEM 1⁄4 73±1 year; 125 male, 69 female) and their images andcarotidduplex scan resultswere reviewed. 361 pairs of data were analysed using Pearson's correlation (r1⁄40.06, p1⁄40.23). Conclusions: We showed no significant correlation between the length of the extracranial ICA and the degree of stenosis that may develop within it. 0832: MORTALITY FOLLOWING ACUTE NATIVE ARTERY EMBOLECOTMY FOR ARTERIAL EMBOLISM UNRELATED TO PERIPHERAL ARTERIAL DISEASE (PAD): 18 YEAR REVIEW Joel Lambert *, Sobath Premaratne, Anthony Jaipersad, Andy Houghton, Anthony Fox, Kate Merriman. Shrewsbury & Telford NHS Trust, Shrewsbury,

Audit of Superficial Temporal Artery Biopsies (TAB) for Suspected Giant Cell Arteritis (GCA)

between VTE and postoperative complications, length of stay, mortality and costs in Head and Neck Cancer (HNCA) surgery. The medical records of 50 patients that underwent major HNCA surgery over a 12 months period were reviewed and the data collected on patient demographics, risk of VTE at pre-assessment, risk of bleeding, type of VTE prophylaxis, timing of VTE prophylaxis, and complications. Seventy two percent of patients were assessed for VTE at pre-assessment and 58% within 24 hrs of admission. Ninety three percent were given Thrombo-embolic deterrant stockings and 58% were prescribed pharmacological VTE prophylaxis 6-12 hrs after surgery. Ten percent of patients developed complications.We also present on the type and timing of chemical VTE prophylaxis and the cost incurred and financial loss due to lack of compliance to VTE assessment. We propose recommendations to improve VTE assessment and prophylaxis in HNCA patients.

Comparison of Histopathological Findings with Duplex Sonography of the Temporal Arteries in Suspected Giant Cell Arteritis

In clinical practice the temporal artery biopsy (TAB) in suspected giant cell arteritis (GCA) is still believed to be the "gold standard". The purpose of this study was to compare the histopathological findings of the TAB with duplex sonography of the temporal artery. In our retrospective study we analysed 85 consecutive patients (52 female, mean age 71.5, range 55 - 91 years; 33 male, mean age 71.6, range 44 - 91 years) with suspected GCA who underwent TAB in our clinic between January 1999 - February 2011. All patients received a preoperative duplex sonography, 57 patients including description of the temporal arteries. 38 of 85 (44.7 %) of the artery biopsies were proven positive for GCA by histopathology. Interpretation of the duplex sonography was congruent of histopathological interpretation of the biopsy in 39 patients (68.4 %) and incongruent in 18 patients (31.6 %). Sensitivity of duplex-sonography was 44.4 %, specificity 90 %, positive predictive value 80 %. Duplex sonography is a non-invasive and very helpful diagnostic tool to guide the clinician in cases of suspected GCA but needs considerable skills. It shows a good specificity and relatively high positive predictive value as there are only few false positive results. A negative report however does not rule out GCA, so that in our opinion the TAB - at least in those cases - should still be performed.

Temporal Artery Biopsy is not Required in all Cases of Suspected Giant Cell Arteritis

Temporal artery biopsy (TAB) is performed during the diagnostic workup for giant cell arteritis (GCA), a vasculitis with the potential to cause irreversible blindness or stroke. However, treatment is often started on clinical grounds, and TAB result frequently does not influence patient management. The aim of this study was to assess the need for TAB in cases of suspected GCA. We performed a retrospective review of 185 TABs performed in our institution from 1990 to 2010. Patients were identified through the Hospital In-Patient Enquiry database and theater records. Clinical findings, erythrocyte sedimentation rate, steroid treatment preoperatively, American College of Rheumatology (ACR) criteria for GCA score, biopsy result, and follow-up were recorded. Fifty-eight (31.4%) biopsies were positive for GCA. Presence of jaw claudication (P = 0.001), abnormal fundoscopy (P = 0.001), and raised erythrocyte sedimentation rate (P = 0.001) were significantly associated with GCA. The strongest association with positive biopsy was seen with the prebiopsy ACR score (P < 0.001). Twenty-four (13.7%) patients had undergone biopsy, despite no potential for meeting ACR criteria preoperatively. None of these were positive. Overall, 29 (16.4%) patients had management altered by TAB result. Our results confirm that TAB does not affect management in the majority of patients with suspected GCA. We conclude that TAB has benefit only for patients who score 2 or 3 on the ACR criteria for GCA without biopsy.

Suspected giant cell arteritis: a study of referrals for temporal artery biopsy

Background: The purpose of this study is to describe the nature of cases undergoing temporal artery biopsy (TAB) for suspected giant cell arteritis (GCA). Methods: A retrospective review of case notes was undertaken for all patients on whom ophthalmologists had performed TAB in 2 teaching hospitals between 1995 and 2001. Presenting symptoms, referring specialty, TAB result, treatment, and discharge diagnosis were recorded. Results: Ophthalmologists performed TAB on 110 patients for suspected GCA. A variety of specialties referred patients to ophthalmology for TAB; presenting symptoms varied with referral source. Of the 110 TABs, 21 (19%) were reported as positive for GCA, 84 (76%) were negative, and 5 (4.5%) were reported as inadequate. The symptoms most commonly associated with a positive TAB were visual disturbance (15/21) and headache (15/21).The odds ratios for having a positive TAB result rather than a negative result were 1.0 for the presence of headache, 4.1 for visual disturbance, and 6.7 for jaw claudication. Interpretation: Physicians were faced with a different population of GCA suspects than ophthalmologists. While physicians should be alert to the significance of visual symptoms or jaw claudication, ophthalmologists should be ready to facilitate prompt TABs when appropriate. TAB should be performed promptly and an adequate length of artery taken for biopsy. An argument can be made that TAB is not needed in cases of suspected GCA. However, a positive result provides firm justification for the use of steroids. We feel that TAB has a useful role and we make reference to methods to maximize its usefulness.

Low diagnostic yield with second biopsies in suspected giant cell arteritis.

The clinical diagnosis of giant cell arteritis may be confirmed with a biopsy of the superficial temporal artery. Because of "skip lesions," a histologic diagnosis of giant cell arteritis may be missed with a unilateral biopsy. The authors report a study that investigates whether a biopsy of the contralateral superficial temporal artery provides any additional information for confirmation of a diagnosis of giant cell arteritis. Available medical records of 91 consecutive patients who underwent bilateral superficial temporal artery biopsy procedures were reviewed. Information that was abstracted included sequence of biopsy procedures, length specimens, and histologic diagnosis. Microslides from all biopsy specimens were retrieved and reexamined in a masked fashion by the ocular pathologist (RCE) who had made the original diagnoses. Seventy-two bilateral simultaneous superficial temporal artery biopsies and 19 bilateral sequential biopsies were performed. The mean length of biopsy specimens was 23 mm, and the mean length of the total artery removed from each patient was 33 mm. The pathologist's original diagnosis and the diagnosis at reexamination were in 100% agreement. In 90 (99%) of the 91 patients, the histologic diagnoses in the left and right superficial temporal arteries were the same. This is a concordance rate of 98.9% (38 of 39 positive biopsy results) among the positive biopsy results. There is a low yield of information from a second temporal artery biopsy in patients with suspected giant cell arteritis. This suggests that patients who present to the ophthalmologist with possible giant cell arteritis will, in most cases, have a similar diagnosis on both temporal artery biopsies if the specimens are adequate.