Temporal Artery Biopsy In Patients Research Articles

The Effect of Corticosteroids on Temporal Artery Biopsy Positivity in Giant Cell Arteritis: Timing is Everything.

Temporal artery biopsy (TAB) remains the standard criterion for the diagnosis of giant cell arteritis (GCA). Temporal artery biopsy is suggested to be performed within 2 weeks from the initiation of corticosteroids. However, the effects of TAB timing on the sensitivity of its findings still warrant further investigation. We reviewed the medical records of patients with GCA from a tertiary medical center in Germany over an 8-year period. We analyzed data from 109 patients with a median age of 76 years and a median time from glucocorticoid treatment to TAB of 4 days. Approximately 60% of biopsies were positive. Our analysis yielded a nonsignificant trend toward shorter duration of corticosteroid treatment in the TAB(+) group ( p = 0.06). A more than 7 days' duration of steroid treatment was independently linked with lower rates of positive TAB (adjusted odds ratio, 0.33; 95% confidence interval, 0.11-1.00). We conclude that the duration of corticosteroid treatment seems to affect the positivity of TAB in patients with suspected GCA. Further larger studies are required to confirm the generalizability of our findings.

P006 The potential of colour Doppler ultrasound in reducing temporal artery biopsies in suspected giant cell arteritis

Abstract Background/Aims Giant cell arteritis (GCA) is an emergency. The initial treatment with high dose glucocorticoids (GC) is often started on clinical suspicion without waiting for temporal artery biopsy (TAB) results. Colour Doppler ultrasound (CDUS) is a simple, non-invasive test which is readily available. However, like any other ultrasound, it is operator dependent. Non-compressible ‘halo sign’ is the most specific abnormality on CDUS. British society for Rheumatology (BSR) guidelines advises to avoid TAB in patients with low clinical probability and negative CDUS as well as in high clinical probability and positive CDUS. Methods We adopted the quality improvement methodology for assessment. Retrospective data of suspected GCA patients was collected over the last two years. CDUS was introduced to investigative plan midway, after eleven months. Two rheumatology consultants were trained in CDUS. Results were compared before and after the introduction of ultrasound as a diagnostic tool. In collecting the data, our main focus for documentation was based on clinical symptoms, CDUS and TAB results. Patient were divided into high, medium and low probability groups based on clinical assessment by a rheumatologist. Final diagnosis was decided on the basis of clinical assessment at 6 months. Results It was a retrospective review from January 2018 to November 2019, 101 patients were referred with suspected GCA. Median age was 72 years (50 - 91 years) with male to female ratio of 1:3. Thirty five patients were referred in the first 11 months and 28.6% were diagnosed with GCA. CDUS and TAB was done in 20% and 49% of patients respectively. Sixty six patients were referred in the next 12 months after CDUS was introduced and 21.2% were diagnosed as GCA. CDUS and TAB were done in 82% and 38% of the patients respectively. We reviewed all TABs in the second phase of QIP (38%). As per current BSR guideline, 8 TABs could have been avoided in patients with positive CDUS and high probability of GCA or negative CDUS and low probability of GCA. Even if we deduct these 8 TABs from total of 25, 26% of our suspected GCA referrals would still require TAB for diagnostic workup. Conclusion After the routine introduction of CDUS, the percentage of patients requiring TAB has declined. Approximately one fourth patients would still require TAB as per BSR guidelines. To improve the clinical relevance of biopsies further we recommended; the routine use of GCA probability score, improve CDUS skills and arrange availability of urgent slots in clinic for CDUS. We also noticed that the number of patients referred has almost doubled. This might be due to better education and awareness at the primary and secondary care level which was done as part of the project. Disclosure A.A. Sidhu: None. A. Nandagudi: None. A. Bharadwaj: None.

Retraction Note: Ultrasound versus temporal artery biopsy in patients with Giant cell arteritis: a prospective cohort study

An amendment to this paper has been published and can be accessed via the original article.

Magnetic Resonance Imaging Abnormalities of the Optic Nerve Sheath and Intracranial Internal Carotid Artery in Giant Cell Arteritis.

Giant cell arteritis (GCA) is an important diagnostic consideration in elderly patients with vision changes. Superficial temporal artery biopsy (TAB) has long been considered the gold standard diagnostic approach for GCA, but MRI has gained interest as an alternative diagnostic modality. Although most of the literature has focused on imaging abnormalities of branches of the external carotid artery, there have been a few reports of GCA-related inflammatory involvement of the orbit and internal carotid arteries (ICAs) on MRI. This was a retrospective cross-sectional study of patients undergoing TAB at a single tertiary referral center over a 5-year period. Patients who had undergone contrast-enhanced MRI of the brain and orbits within 1 month of biopsy were included. Fifty-four TAB-positive and 78 TAB-negative patients were reviewed, with the MRI studies of 7 TAB-positive and 6 TAB-negative patients deemed adequate for interpretation. MRI studies were reviewed by 2 masked neuroradiologists, and the findings were correlated with biopsy results and clinical findings. Intracranial ICA vessel wall enhancement was identified in 6 of 7 TAB-positive patients (sensitivity 86%), compared with 2 of 6 TAB-negative patients (specificity 67%). Optic nerve sheath enhancement was identified in 5 of 7 TAB-positive patients (sensitivity 71%) and in 2 of 6 TAB-negative patients (specificity 67%), bilateral in all such cases. The combination of both abnormal imaging findings was observed in 5 of 7 TAB-positive patients (sensitivity 71%) and in none of the 6 TAB-negative patients (specificity 100%). Intracranial ICA and optic nerve sheath enhancement were observed in a majority of patients with TAB-proven GCA, and the combination of these findings was highly specific for GCA. Identification of these abnormalities on MRI should raise concern for GCA and prompt a thorough review of systems, laboratory testing, and consideration of TAB in patients with ocular complaints potentially consistent with ischemia.

Predictive value of positive temporal artery biopsies in patients with clinically suspected giant cell arteritis considering temporal artery ultrasound findings.

To investigate the impact of ocular symptom, non-ocular symptom, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and temporal artery ultrasound (TAU) findings on the predictive value of a positive temporal artery biopsy (TAB) in patients with clinically suspected giant cell arteritis (GCA). In a retrospective, interventional study, data from 68 patients with clinically suspected GCA who underwent TAB between 2015 and 2017 were analysed. Analysis included five parameters: ocular symptom, non-ocular symptom, ESR, CRP level and TAU findings. Using a contingency table, each parameter was separately analysed for the predictive value of a positive TAB, and a discriminant analysis was applied to check for the predictive value of a positive TAB under consideration of all five parameters and of the three strongest predictive parameters. A positive TAB was significantly associated with a positive TAU in 15 of 15 patients (p < 0.001), an increased ESR in 37 of 53 patients (p < 0.001), an increased CRP level in 35 of 56 patients (p = 0.004) and non-ocular symptoms in 27 of 40 patients (p = 0.01). A positive TAB was not significantly associated with the presence of ocular symptoms (25 of 46 patients, p = 0.988). Using a discriminant analysis, the combined parameters TAU, ESR and CRP were able to predict a positive TAB in 97.3% of all patients. The positive predictive value was 78.3%, and the negative predictive value was 95.4%. Temporal artery biopsy to confirm the diagnosis of GCA may not be mandatory in patients who show an elevated ESR and CRP level and a positive TAU.

RETRACTED ARTICLE: Ultrasound versus temporal artery biopsy in patients with Giantcell arteritis: a prospective cohort study

BackgroundDiagnosis of giant cell arteritis by temporal artery biopsy istime-consuming and visual loss lies in the first week after its diagnosis. Thepurpose of the study was to test the hypothesis that ultrasound can reduce therisk of overdiagnosis and overtreatment in giant cell arteritis.MethodsData regarding physical/ clinical features examinations, temporalartery biopsy examinations, ultrasound findings, and magnetic resonance imagingexaminations of 980 suspected patients for giant cell arteritis were included inthe study. Decision curve analysis was applied to get a beneficial score forselected diagnostic modalities. Cost analysis was performed for eachpatient.ResultsFewer numbers of false positive giant cell arteritis results werereported under physical/ clinical features examinations following ultrasounddetection than physical/clinical features examinations following temporal arterybiopsy examinations (45 vs. 127, p < 0.0001). The working area that detects giant cell arteritisat least one time for physical/ clinical features examinations followingultrasound detection and physical/ clinical features examinations followingtemporal artery biopsy examinations were 0–91% and 0–86%. No significantdifference for true negative results between magnetic resonance imaging andphysical and clinical features examinations following ultrasound detection(p = 0.007). Physical and clinicalfeatures examinations following ultrasound detection were less expensive methodthan physical/ clinical features examinations following temporal artery biopsyexaminations (14,023 ± 982 ¥/patient vs. 18,551 ± 1231 ¥/patient, p < 0.0001) and MRI.ConclusionPhysical and clinical features examinations following ultrasound arerecommended for diagnosis of patients with suspected giant cellarteritis.

CD3 immunohistochemistry is helpful in the diagnosis of giant cell arteritis.

To evaluate whether CD3 staining performed routinely on temporal artery biopsy specimens might improve the sensitivity of temporal artery biopsy in patients with biopsy-negative GCA. Two hundred and seventy biopsies were considered for this study, stained with haematoxylin and eosin and with an anti-CD3 antibody. The addition of CD3 staining modified the sensibility and the specificity of the histologic examination in 89.47 and 95.00%, respectively, with a positive and negative predictive values of 97.00 and 79.78% . The addition of CD3 immunostaining to the classic histologic evaluation is accompanied by a significant increase in the sensibility with a comparable specificity.

Full blood count as an ancillary test to support the diagnosis of giant cell arteritis.

Temporal artery biopsy is considered the investigation of choice to diagnose definitively giant cell arteritis (GCA) in patients with compatible symptoms. However it is invasive and not completely sensitive. Serum markers, particularly erythrocyte sedimentation rate (ESR), can be supportive, but are not definitive in individual cases. To investigate whether indices derived from the full blood count, including neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) were associated with a positive biopsy in patients with suspected GCA. The clinical and pathological details of 537 patients undergoing temporal artery biopsy at our institution from 1992 to 2015 were reviewed. In univariate analysis high platelets (odds ratio (OR) 4.44, P < 0.001), NLR (OR 1.81, P = 0.02), PLR (OR 3.25, P < 0.001), C-reactive protein (CRP) (OR 3.00, P < 0.001), ESR (OR 3.62, P < 0.001) and increased age (OR 1.03, P = 0.006) were strongly associated with a positive biopsy. In multivariate modelling only high platelets (P < 0.001) and ESR (P = 0.049) maintained significance. We conclude that the presence of thrombocytosis and high NLR, PLR, ESR and CRP can all be used clinically to support the diagnosis of GCA prior to biopsy. Of particular note, in multivariate modelling the presence of thrombocytosis is a stronger predictor of a positive temporal artery biopsy than ESR. Therefore, careful consideration of the findings in a full blood count can be used to predict the likelihood of a positive temporal artery biopsy in patients with suspected GCA.

The role of ultrasound biomicroscopy in predicting the result of temporal artery biopsy in temporal arteritis patients: A preliminary study.

Temporal artery biopsy is considered the gold standard for the diagnosis of temporal arteritis (TA). However, complications following this procedure may occur. The goal of this study is to evaluate if ultrasound biomicroscope (UBM) findings are useful in predicting the result (positive or negative) of temporal artery biopsy in patients with TA. Twenty-six consecutive patients with clinical diagnosis of TA seen at the Department of Ophthalmology, Royal Victoria Hospital, Montreal, Canada, were involved in this study. All patients were submitted to UBM before temporal artery biopsy. Eight patients presented histopathologic findings consistent with the diagnosis of TA. Thus, UBM findings of these patients were compared with those from 18 patients with negative biopsy. On UBM we searched for the presence of a hypoechoic effect surrounding the walls of the temporal arteries, the so-called halo sign, as well as an intra-arterial middle reflexive filling, the so-called intra-arterial filling. The halo sign and/or the intra-arterial filling were found in 8 (100%) of 8 patients with biopsy-proven TA. However, 10 (55.5%) of 18 patients with a negative biopsy presented one or both of these two UBM findings. On the other hand, the absence of these two parameters on the UBM of a patient with TA strongly suggests that the temporal artery biopsy will be negative (negative predictive value=100%). This preliminary work suggests that UBM may play a role in predicting a negative result of the temporal artery biopsy in patients with TA. In the present series approximately 30% of the patients could be spared this surgical procedure and its possible complications.

Development of a predictive model for temporal artery biopsies

ObjectiveTemporal artery biopsy is a critical, relatively safe, and reliable test in the diagnosis of temporal arteritis. Yet, a clarification of the pre-test probabilities may provide clarity on which patients with suspected giant cell arteritis would benefit from this invasive diagnostic procedure. DesignA prospective case series ParticipantsA consecutive case series of patients referred to the Ophthalmology service for temporal artery biopsy. MethodsAll subjects underwent standardized serum testing, and signs and symptoms assessment. Predictive models were created and evaluated. Results119 patients were analyzed. This exploratory study found that a simple model including platelet count, erythrocyte sedimentation rate, and c-reactive protein was able to define a subset of patients with a pre-test probability of a positive biopsy of 0% or 100%. 40% (95% confidence interval 31%-49%) of patients fell into this category. ConclusionsUtilizing a simple clinically applicable predictive model of the pretest probability of a temporal artery biopsy in patients with suspected giant cell arteritis, up to 31%-49% of temporal artery biopsies may be avoided. This study was a single site exploratory study with data-driven thresholds - therefore these results need to be validated with an independent sample prior to clinical use.

FRI0216 Does ultrasonography guidance increase the yield of temporal artery biopsy in patients with giant cell arteritis? Results from a single-blinded randomized study

BackgroundTemporal artery biopsy (TAB) is the gold standard to diagnose giant cell arteritis (GCA), but is negative in approximately 20% of patientsObjectivesThe study aimed to establish whether Color-doppler-ultrasonography (CDU)-guided TAB...

Morphological Features of Temporal Arteritis

Although it varies from center to center, the frequency of temporal artery biopsy in patients suspected of having temporal arteritis (TA) is relatively small. Most commonly, patients suspected of having TA are placed on prednisone for varying periods of time, and if symptoms disappear or lessen the diagnosis is made. During a recent 13-year period at Baylor University Medical Center at Dallas, 15 patients with TA had the diagnosis of TA confirmed by histological examination of a biopsy of one temporal artery. The length of the biopsied artery varied from 0.7 to 5.5 cm (mean 2.7). The 15 patients ranged in age from 68 to 94 years (mean 82, median 85), and 11 (73%) were women. In 13 of the 15 patients (87%), the lumen of the temporal artery was narrowed >95% in cross-sectional area by the panarteritis, and the temporal artery was associated with giant cells in 11 patients (73%). Large collections of erythrocytes were present in the inflamed arterial walls in 5 patients (33%). All 15 patients were treated with varying doses of prednisone with favorable response in each. Eight patients (53%) died from 1 to 105 months (mean 52, median 57) after biopsy of the temporal artery. We have neither positive nor negative evidence that the TA played a role in the patients' death. Despite the present study and numerous others in the last 70 years, the cause of TA remains a mystery.

Temporal artery biopsy for giant cell arteritis: retrospective audit

ObjectivesTemporal artery biopsy (TAB) is performed in suspected cases of sight-threatening giant cell arteritis (GCA). We aimed to determine the feasibility of TAB in patients who are suspected of having GCA.Design, setting and participantsA retrospective audit of all patients undergoing TAB at a single teaching hospital between 2005 and 2011, identified from the histopathology database.Main outcome measures(1) Clinical profile and biochemical criteria associated with positive histology. (2) Proportion of negative histology patients who were commenced on steroid therapy.ResultsOne hundred and fifty-three TAB were performed (mean age 70.8 years, men:women = 3:2, 110 Caucasian: 43 Asian). Thirty-two biopsies were positive for GCA and 121 were negative. In total, 68 (61%) of 112 negative TAB patients were clinically diagnosed with GCA despite histological findings (P < 0.001). Nine out of 153 biopsies were non-arterial. Histologically positive TAB patients were of higher mean age (77.1 [95% CI 74.5–79.7] versus 69.1 [95% CI 66.7–71.6]; P < 0.001) and had a higher erythrocyte sedimentation rate (ESR) (60 [95% CI 46.1–73.9] versus 39.8 [95% CI 34.2–45.3]; P < 0.01)] than those with negative histology.ConclusionsRaised ESR and higher age may be the most useful indicators of GCA. Many histologically negative individuals were nevertheless clinically diagnosed and managed as GCA.

Temporal Artery Biopsy as a Means of Diagnosing Giant Cell Arteritis: Is There Over-Utilization?

Temporal artery biopsy (TAB) is often recommended for patients suspected of having temporal arteritis. The sensitivity of TAB varies widely and is dependent upon a number of factors (e.g., number of biopsy specimens, corticosteroid pretreatment, specimen length). The purpose of this study was to determine the clinical utility of TAB in patients who are suspected of having giant cell arteritis (GCA). A retrospective review of patients who underwent TAB at Spectrum Health from January 1, 1998 to December 31, 2007 was performed. Forty-seven patients, ranging in age from 25 to 87 years (mean: 70.7 years), underwent 53 TABs. Females accounted for 72.3 per cent of the subjects. Positive biopsy results showing signs of GCA were obtained in 38.3 per cent of patients. Of patients who underwent biopsy, 78 per cent could have been excluded from the procedure based upon individual diagnostic criteria. Positive and negative biopsies had average lengths of 1.84 cm and 1.29 cm, respectively (P < 0.05). In the community hospital setting, patients suspected of having GCA are frequently recommended to undergo unnecessary TAB. We advocate for more careful selection of patients to undergo this diagnostic surgical procedure. In cases where TAB is needed, we recommend a biopsy length of > 2 cm to increase the accuracy of diagnosis.

Biopsy-negative giant cell arteritis: Does anti-CD83 immunohistochemistry advance the diagnosis?

Background In situ maturation of adventitial dendritic cells (DC) with expression of CD83 has been proposed as an early event in the pathogenesis of giant cell arteritis (GCA), preceding the appearance of an inflammatory infiltrate. The aim of this study was to evaluate the added value of anti-CD83 staining of temporal artery biopsy (TAB) specimens in patients with biopsy-negative temporal arteritis. Methods Fourteen patients with TAB performed in our medical center since 2001 and considered negative for GCA due to the absence of any inflammatory infiltrate were identified by a computerized search of patient records. Their paraffin-embedded TAB specimens were retrieved, reprocessed, and stained with anti-CD83 monoclonal antibody (Serotec, 1:40). Three TAB specimens of patients with biopsy-proven GCA served as positive controls and three specimens of popliteal and/or tibial arteries of patients with atherosclerotic peripheral vascular disease were used as negative controls. Follow-up of the patients was confirmed by personal contact with their rheumatologists and analysis of their hospital charts. Results Follow-up was available for 12 of 14 patients. Five of these patients were considered to have biopsy-negative GCA: they satisfied the ACR classification criteria, were successfully treated with glucocorticosteroids, and had a follow-up of at least 10 months with no alternative diagnosis established. Anti-CD83 staining was negative in all but one patient who demonstrated a single CD83-positive cell adjacent to the internal elastic membrane. Positive anti-CD83 staining of the inflammatory infiltrate throughout the arterial wall was observed in all patients with biopsy-proven GCA (positive controls). Negative controls did not show any CD83-positive cells. Conclusions In this pilot study, anti-CD83 immunohistochemical staining of paraffin-embedded specimens did not improve the yield of TAB in patients with suspected GCA.

Prevalence of a Normal C-Reactive Protein with an Elevated Erythrocyte Sedimentation Rate in Biopsy-Proven Giant Cell Arteritis

The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are laboratory tests that have been said to have a strong correlation with a positive temporal artery biopsy in patients with suspected giant cell arteritis (GCA). Published reports suggest that the CRP is a more sensitive diagnostic indicator of GCA and can be elevated when the ESR is normal. It is also clear that the CRP and ESR can both be normal or both be elevated in patients with biopsy-proven GCA and that the CRP can be elevated when the ESR is normal. The purpose of this study was to ascertain if the CRP can be normal when the ESR is elevated in biopsy-proven GCA. Retrospective, longitudinal, comparative study. One hundred nineteen patients from 6 major tertiary-care university-affiliated medical centers. The charts from 119 patients with temporal artery biopsies positive for GCA were reviewed for age, gender, pretreatment ESR, and pretreatment CRP. The ESR in millimeters per hour Westergren was graded as normal or abnormal based on 2 validated formulas. The CRP was graded as normal or abnormal based on established criteria set forth in the literature as well as at The Johns Hopkins Hematology laboratory. In this study, the ESR had a sensitivity of 76% to 86%, depending on which of 2 formulas were used, whereas an elevated CRP had a sensitivity of 97.5%. The sensitivity of the ESR and CRP together was 99%. Only 1 of the 119 patients (0.8%) presented with a normal ESR and normal CRP (double false negative); 2 patients (1.7%) had a normal CRP despite an elevated ESR according to both formulas. Although most patients with GCA have both an elevated ESR and CRP, there can be nonconcordance of the 2 blood tests. Although such nonconcordance is most often a normal ESR but an elevated CRP, the finding of an elevated ESR and a normal CRP also is consistent with GCA. The use of both tests provides a slightly greater sensitivity for the diagnosis of GCA than the use of either test alone.

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.

Temporal Arteritis in a Patient with Eosinophilia

We present the case of a 69-year-old man with fever of unknown origin, headache, elevated sedimentation rate and peripheral eosinophilia. A biopsy of the temporal artery revealed transmural inflammation with eosinophilia. Therapy with corticosteroids resulted in resolution of the fever, headache, and eosinophilia, as well as normalization of the sedimentation rate. There have been only rare cases of eosinophilia associated with temporal arteritis. All of these cases were seen in patients with either juvenile temporal arteritis, acquired immunodeficiency syndrome, or Buerger's disease. This is the only case, to our knowledge, of eosinophilic temporal arteritis without association with any of these conditions. Our patient underwent extensive diagnostic studies and therapeutic trials en route to a long delayed correct diagnosis. The presence of eosinophilia should not deter physicians from considering a temporal artery biopsy in patients presenting with symptoms suggestive of temporal arteritis.

Diagnostic Dilemmas in Polymyalgia Rheumatica

Polymyalgia rheumatica is a clinical syndrome of proximal muscle pain in older patients that often presents a diagnostic challenge because of the large differential diagnosis, lack of definitive diagnostic criteria, and relatively frequent "atypical" clinical findings, such as peripheral synovitis, distal extremity pain, normal erythrocyte sedimentation rate, and mild weakness. Despite an extensive differential diagnosis that includes endocarditis and steroid-responsive malignant neoplasms, routine laboratory testing should be limited, and a low-dose corticosteroid trial is useful as the final step in the evaluation. The clinical overlap with seronegative rheumatoid arthritis is striking, suggesting that these diagnoses may represent different presentations of a similar disease process. While concurrent asymptomatic temporal arteritis is common, there are no data to support obtaining a temporal artery biopsy in patients with pure polymyalgia rheumatica symptoms.