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Clinical & Experimental Optometry Sep 2020Temporal arteritis (TA), or giant cell arteritis, is a systemic autoimmune vasculitis affecting patients over 50 years of age. It can cause rapid, irreversible... (Review)
Review
Temporal arteritis (TA), or giant cell arteritis, is a systemic autoimmune vasculitis affecting patients over 50 years of age. It can cause rapid, irreversible bilateral vision loss in older adults and is therefore considered an ophthalmological emergency. Many of the symptoms and signs of TA can be vague, non-specific and gradual in onset, often leading to a delayed or inaccurate diagnosis. As such, it is important for a wide variety of primary optometrists and health practitioners to maintain a robust understanding of the clinical presentation, key investigations and time-sensitive management of this disease, as early initiation of treatment for TA can be vision- and life-saving.
Topics: Biopsy; Diagnosis, Differential; Disease Management; Giant Cell Arteritis; Humans; Positron Emission Tomography Computed Tomography; Temporal Arteries
PubMed: 31663193
DOI: 10.1111/cxo.12975 -
Swiss Dental Journal May 2018Vascular supply is key for maintenance of healthy tissue conditions but also with regard to healing following trauma or therapeutic interventions. The face is probably... (Review)
Review
Vascular supply is key for maintenance of healthy tissue conditions but also with regard to healing following trauma or therapeutic interventions. The face is probably the most exposed part of the body and any changes of vascularity are readily visible (skin blanching, ecchymosis, hematoma, edema). With regard to the arterial supply, all vessels reaching the facial skin originate from the bilateral common carotid arteries. The ophthalmic artery is considered the major arterial shunt between the internal and external carotid artery systems. Main arterial contributors to the face include the facial, transverse facial, and infraorbital arteries. In general, homonymous veins accompany the arteries, but there are some exceptions (inferior ophthalmic vein, retromandibular vein). Furthermore, the facial vein demonstrates a consistently more posterior course compared to the facial artery. Lymphatic vessels including lymph nodes play an important role for facial drainage.
Topics: Arteries; Carotid Artery, External; Carotid Artery, Internal; Face; Humans; Lymphatic System; Maxillary Artery; Ophthalmic Artery; Orbit; Reference Values; Skin; Temporal Arteries; Veins
PubMed: 29734800
DOI: No ID Found -
JAMA Internal Medicine Oct 2020Current clinical guidelines recommend selecting diagnostic tests for giant cell arteritis (GCA) based on pretest probability that the disease is present, but how pretest... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Current clinical guidelines recommend selecting diagnostic tests for giant cell arteritis (GCA) based on pretest probability that the disease is present, but how pretest probability should be estimated remains unclear.
OBJECTIVE
To evaluate the diagnostic accuracy of symptoms, physical signs, and laboratory tests for suspected GCA.
DATA SOURCES
PubMed, EMBASE, and the Cochrane Database of Systematic Reviews were searched from November 1940 through April 5, 2020.
STUDY SELECTION
Trials and observational studies describing patients with suspected GCA, using an appropriate reference standard for GCA (temporal artery biopsy, imaging test, or clinical diagnosis), and with available data for at least 1 symptom, physical sign, or laboratory test.
DATA EXTRACTION AND SYNTHESIS
Screening, full text review, quality assessment, and data extraction by 2 investigators. Diagnostic test meta-analysis used a bivariate model.
MAIN OUTCOME(S) AND MEASURES
Diagnostic accuracy parameters, including positive and negative likelihood ratios (LRs).
RESULTS
In 68 unique studies (14 037 unique patients with suspected GCA; of 7798 patients with sex reported, 5193 were women [66.6%]), findings associated with a diagnosis of GCA included limb claudication (positive LR, 6.01; 95% CI, 1.38-26.16), jaw claudication (positive LR, 4.90; 95% CI, 3.74-6.41), temporal artery thickening (positive LR, 4.70; 95% CI, 2.65-8.33), temporal artery loss of pulse (positive LR, 3.25; 95% CI, 2.49-4.23), platelet count of greater than 400 × 103/μL (positive LR, 3.75; 95% CI, 2.12-6.64), temporal tenderness (positive LR, 3.14; 95% CI, 1.14-8.65), and erythrocyte sedimentation rate greater than 100 mm/h (positive LR, 3.11; 95% CI, 1.43-6.78). Findings that were associated with absence of GCA included the absence of erythrocyte sedimentation rate of greater than 40 mm/h (negative LR, 0.18; 95% CI, 0.08-0.44), absence of C-reactive protein level of 2.5 mg/dL or more (negative LR, 0.38; 95% CI, 0.25-0.59), and absence of age over 70 years (negative LR, 0.48; 95% CI, 0.27-0.86).
CONCLUSIONS AND RELEVANCE
This study identifies the clinical and laboratory features that are most informative for a diagnosis of GCA, although no single feature was strong enough to confirm or refute the diagnosis if taken alone. Combinations of these symptoms might help direct further investigation, such as vascular imaging, temporal artery biopsy, or seeking evaluation for alternative diagnoses.
Topics: Biopsy; Blood Sedimentation; Clinical Laboratory Techniques; Giant Cell Arteritis; Humans; Physical Examination; Positron-Emission Tomography; Temporal Arteries; Ultrasonography
PubMed: 32804186
DOI: 10.1001/jamainternmed.2020.3050 -
JAMA Nov 2011Patients with symptomatic atherosclerotic internal carotid artery occlusion (AICAO) and hemodynamic cerebral ischemia are at high risk for subsequent stroke when treated... (Randomized Controlled Trial)
Randomized Controlled Trial
CONTEXT
Patients with symptomatic atherosclerotic internal carotid artery occlusion (AICAO) and hemodynamic cerebral ischemia are at high risk for subsequent stroke when treated medically.
OBJECTIVE
To test the hypothesis that extracranial-intracranial (EC-IC) bypass surgery, added to best medical therapy, reduces subsequent ipsilateral ischemic stroke in patients with recently symptomatic AICAO and hemodynamic cerebral ischemia.
DESIGN
Parallel-group, randomized, open-label, blinded-adjudication clinical treatment trial conducted from 2002 to 2010.
SETTING
Forty-nine clinical centers and 18 positron emission tomography (PET) centers in the United States and Canada. The majority were academic medical centers.
PARTICIPANTS
Patients with arteriographically confirmed AICAO causing hemispheric symptoms within 120 days and hemodynamic cerebral ischemia identified by ipsilateral increased oxygen extraction fraction measured by PET. Of 195 patients who were randomized, 97 were randomized to receive surgery and 98 to no surgery. Follow-up for the primary end point until occurrence, 2 years, or termination of trial was 99% complete. No participant withdrew because of adverse events.
INTERVENTIONS
Anastomosis of superficial temporal artery branch to a middle cerebral artery cortical branch for the surgical group. Antithrombotic therapy and risk factor intervention were recommended for all participants.
MAIN OUTCOME MEASURE
For all participants who were assigned to surgery and received surgery, the combination of (1) all stroke and death from surgery through 30 days after surgery and (2) ipsilateral ischemic stroke within 2 years of randomization. For the nonsurgical group and participants assigned to surgery who did not receive surgery, the combination of (1) all stroke and death from randomization to randomization plus 30 days and (2) ipsilateral ischemic stroke within 2 years of randomization.
RESULTS
The trial was terminated early for futility. Two-year rates for the primary end point were 21.0% (95% CI, 12.8% to 29.2%; 20 events) for the surgical group and 22.7% (95% CI, 13.9% to 31.6%; 20 events) for the nonsurgical group (P = .78, Z test), a difference of 1.7% (95% CI, -10.4% to 13.8%). Thirty-day rates for ipsilateral ischemic stroke were 14.4% (14/97) in the surgical group and 2.0% (2/98) in the nonsurgical group, a difference of 12.4% (95% CI, 4.9% to 19.9%).
CONCLUSION
Among participants with recently symptomatic AICAO and hemodynamic cerebral ischemia, EC-IC bypass surgery plus medical therapy compared with medical therapy alone did not reduce the risk of recurrent ipsilateral ischemic stroke at 2 years.
TRIAL REGISTRATION
clinicaltrials.gov Identifier: NCT00029146.
Topics: Aged; Anastomosis, Surgical; Brain; Brain Ischemia; Carotid Artery, Internal; Carotid Stenosis; Early Termination of Clinical Trials; Female; Hemodynamics; Humans; Male; Middle Aged; Middle Cerebral Artery; Positron-Emission Tomography; Recurrence; Regional Blood Flow; Stroke; Temporal Arteries
PubMed: 22068990
DOI: 10.1001/jama.2011.1610 -
Journal of the Chinese Medical... Jul 2005Temporal arteritis, a chronic inflammatory vasculitis involving medium- and large-sized arteries, has rarely been reported in Asia. However, we report 2 cases, in which...
Temporal arteritis, a chronic inflammatory vasculitis involving medium- and large-sized arteries, has rarely been reported in Asia. However, we report 2 cases, in which the patients initially presented with headache. Physical examination disclosed engorged, hard and palpable vessels in the temporal areas. Temporal-artery biopsy revealed 2 different types of arteritis: the multinucleated giant cell type and the panarteritis type without multinucleated giant cells. One patient was positive for immunoglobulin G anticardiolipin antibody. The pathologic findings of the different subsets of temporal arteritis, and the relationship between anticardiolipin antibody and the extent of vascular complications of temporal arteritis, are discussed.
Topics: Aged; Antibodies, Anticardiolipin; Biopsy; Giant Cell Arteritis; Humans; Male; Temporal Arteries
PubMed: 16038374
DOI: 10.1016/S1726-4901(09)70170-4 -
Current Opinion in Infectious Diseases Jun 2016Giant cell arteritis (GCA) is a serious disease and the most common cause of vasculitis in the elderly. Here, studies describing the recent discovery of varicella zoster... (Review)
Review
PURPOSE OF REVIEW
Giant cell arteritis (GCA) is a serious disease and the most common cause of vasculitis in the elderly. Here, studies describing the recent discovery of varicella zoster virus (VZV) in the temporal arteries of patients with GCA are reviewed.
RECENT FINDINGS
GCA is characterized by severe headache/head pain and scalp tenderness. Many patients also have a history of vision loss, jaw claudication, polymyalgia rheumatica, fever, night sweats, weight loss, and fatigue. The erythrocyte sedimentation rate and C-reactive protein are usually elevated. Diagnosis is confirmed by temporal artery biopsy, which reveals vessel wall damage and inflammation, with multinucleated giant cells and/or epithelioid macrophages. Skip lesions are common. Importantly, temporal artery biopsies are pathologically negative in many clinically suspect cases. The present review highlights recent virological findings in temporal arteries from patients with pathologically verified GCA and in temporal arteries from patients who manifest clinical and laboratory features of GCA but whose temporal artery biopsies are pathologically negative for GCA. Virological analysis revealed that VZV is present in most GCA-positive and GCA-negative temporal artery biopsies, particularly in skip areas that correlate with adjacent GCA disease.
SUMMARY
The presence of VZV in GCA-positive and GCA-negative temporal arteries reflects the possible role of VZV in triggering the immunopathology of GCA and indicates that both groups of patients should be treated with antivirals in addition to corticosteroids. Whether oral antiviral agents and steroids are as effective as intravenous acyclovir and steroids, and the dosage and duration of treatment, remain to be determined.
Topics: Aged; Aged, 80 and over; Female; Giant Cell Arteritis; Herpesviridae Infections; Herpesvirus 3, Human; Humans; Male; Middle Aged; Temporal Arteries
PubMed: 26871403
DOI: 10.1097/QCO.0000000000000258 -
Current Opinion in Rheumatology Jul 2016Giant cell arteritis (GCA) is a severe form of vasculitis in the elderly. The recent discovery of varicella zoster virus (VZV) in the temporal arteries and adjacent... (Review)
Review
PURPOSE OF REVIEW
Giant cell arteritis (GCA) is a severe form of vasculitis in the elderly. The recent discovery of varicella zoster virus (VZV) in the temporal arteries and adjacent skeletal muscle of patients with GCA, and the rationale and strategy for antiviral and corticosteroid treatment for GCA are reviewed.
RECENT FINDINGS
The clinical features of GCA include excruciating headache/head pain, often with scalp tenderness, a nodular temporal arteries and decreased temporal artery pulsations. Jaw claudication, night sweats, fever, malaise, and a history of polymyalgia rheumatica (aching and stiffness of large muscles primarily in the shoulder girdle, upper back, and pelvis without objective signs of weakness) are common. ESR and CRP are usually elevated. Diagnosis is confirmed by temporal artery biopsy which reveals vessel wall damage and inflammation, with multinucleated giant cells and/or epithelioid macrophages. Skip lesions are common. Importantly, temporal artery biopsies are pathologically negative in many clinically suspect cases. This review highlights recent virological findings in temporal arteries from patients with pathologically verified GCA and in temporal arteries from patients who manifest clinical and laboratory features of GCA, but whose temporal artery biopsies (Bx) are pathologically negative for GCA (Bx-negative GCA). Virological analysis revealed that VZV is present in most GCA-positive and GCA-negative temporal artery biopsies, mostly in skip areas that correlate with adjacent GCA pathology.
SUMMARY
The presence of VZV in Bx-positive and Bx-negative GCA temporal arteries indicates that VZV triggers the immunopathology of GCA. However, the presence of VZV in about 20% of temporal artery biopsies from non-GCA postmortem controls also suggests that VZV alone is not sufficient to produce disease. Treatment trials should be performed to determine if antiviral agents confer additional benefits to corticosteroids in both Bx-positive and Bx-negative GCA patients. These studies should also examine whether oral antiviral agents and corticosteroids are as effective as intravenous acyclovir and corticosteroids. Appropriate dosage and duration of treatment also remain to be determined.
Topics: Antiviral Agents; Aortitis; Biopsy; Giant Cell Arteritis; Herpes Zoster; Herpesvirus 3, Human; Humans; Temporal Arteries
PubMed: 27224742
DOI: 10.1097/BOR.0000000000000292 -
Tidsskrift For Den Norske Laegeforening... Jan 2021Neurosyphilis is a rare cause of vision loss that can mimic the presentation of other diseases, including giant cell arteritis.
BACKGROUND
Neurosyphilis is a rare cause of vision loss that can mimic the presentation of other diseases, including giant cell arteritis.
CASE PRESENTATION
A man in his sixties presented to the university hospital with a four-day history of right eye vision loss. He experienced a headache, myalgia and fatigue. Right eye vision was limited to finger counting at 2 metres and a relative afferent pupillary defect was present. He was tender over the right temporal area and had a decreased pulse in the right temporal artery. A pink maculopapular rash was present on the trunk. Laboratory testing showed elevated inflammatory parameters with ESR 50. Ischaemic optic neuropathy caused by giant cell arteritis was suspected, and treatment with high dose steroids was initiated. Expanded history revealed travel to Thailand five months prior to presentation and unprotected sex with multiple female partners. A non-painful sore had developed on his penis that resolved after 14 days.
INTERPRETATION
Neurosyphilis was suspected and the diagnosis was subsequently confirmed. The patient received appropriate antibiotic therapy, and four months later his vision had almost normalised.
Topics: Female; Giant Cell Arteritis; Humans; Male; Optic Nerve; Syphilis; Temporal Arteries; Vision Disorders
PubMed: 33433102
DOI: 10.4045/tidsskr.20.0707 -
Annals of the Royal College of Surgeons... May 2014Temporal artery biopsy is considered the gold standard investigation of giant cell arteritis and is recommended in suspected cases despite a sensitivity of 81-91%. This... (Review)
Review
Temporal artery biopsy is considered the gold standard investigation of giant cell arteritis and is recommended in suspected cases despite a sensitivity of 81-91%. This review highlights the potential risk of facial nerve injury during temporal artery biopsy and introduces recent advances in the emerging role of imaging modalities. When these non-invasive techniques are used in conjunction with American College of Rheumatology scoring, which includes clinical features and biochemical test results, temporal artery biopsy may be avoided in selected cases.
Topics: Biopsy; Facial Nerve Injuries; Giant Cell Arteritis; Humans; Risk Factors; Temporal Arteries
PubMed: 24780014
DOI: 10.1308/003588414X13814021679438 -
International Journal of Rheumatic... Apr 2022To assess the diagnostic accuracy of temporal artery ultrasound compared with temporal artery biopsy and clinical diagnosis in patients with suspected giant cell...
AIM
To assess the diagnostic accuracy of temporal artery ultrasound compared with temporal artery biopsy and clinical diagnosis in patients with suspected giant cell arteritis (GCA) over 10 years in an Australian center.
METHOD
Patients presenting to Westmead Hospital with possible GCA from March 2011 to December 2020 were retrospectively identified. The following parameters were obtained from the medical record: clinical presentation, inflammatory markers, temporal artery ultrasound findings, and temporal artery biopsy report. Data were assembled in a 2 × 2 table; sensitivity and specificity of temporal artery ultrasound compared with temporal artery biopsy and clinical diagnosis were calculated.
RESULTS
Over the 10-year study period, 65 temporal artery ultrasounds were performed in 63 patients (n = 65; 61.9% female) with a mean ± standard deviation age of 69.6 ± 12.3 years. Thirteen out of 65 (20%) temporal artery ultrasounds had findings suggestive of GCA. Twenty patients (31.7%) had a clinical diagnosis of GCA irrespective of sonographic or biopsy findings. Compared with temporal artery biopsy, temporal artery ultrasound had a sensitivity of 71.4% and specificity of 93.3%. Compared with clinical diagnosis made by the treating rheumatologist, temporal artery ultrasound had a sensitivity of 55% and specificity of 95.3%.
CONCLUSION
Temporal artery ultrasound is a useful non-invasive investigation in the assessment of suspected GCA. If positive in the setting of a suggestive clinical presentation, a temporal artery ultrasound probably avoids the need for a temporal artery biopsy. Temporal artery ultrasound could be more widely used in the clinical management of GCA.
Topics: Aged; Aged, 80 and over; Australia; Biopsy; Female; Giant Cell Arteritis; Humans; Male; Middle Aged; Retrospective Studies; Temporal Arteries
PubMed: 35064750
DOI: 10.1111/1756-185X.14288