Temporal arteritis: Clinical sciences

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Introduction0:00–0:43

Temporal arteritis, also known as giant cell arteritis, is an inflammatory vasculitis of medium and large arteries. In temporal arteritis, there’s inflammation and thickening of the vessel wall, which eventually can result in ischemia and complications, such as vision loss.
Now, as the same suggests, the temporal artery is the most common vessel involved. But don’t let the name fool you!
Other intracranial and extracranial vessels can be affected as well, especially the vertebrobasilar arterial system. More remote sites of vascular involvement include the aorta and its proximal branches, like the carotid, subclavian, axillary, and brachial arteries.

Stable Patient0:43–2:37

Okay, if a patient presents with a chief concern suggesting temporal arteritis, first perform a focused history and physical exam, and order labs, including an erythrocyte sedimentation rate, or ESR, C-reactive protein or CRP, and complete blood cell count, or CBC.Your patient will generally be older than 50, and likely report a new onset of localized headache, typically described as unilateral pain in the temporal region that worsens over time.
These symptoms are often associated with scalp pain; as well as systemic symptoms like fatigue, malaise, fever, and unintentional weight loss.
In more severe cases, you might notice symptoms suggestive of ischemia, including sudden vision changes ranging from diplopia to complete vision loss.
There might also be pain with chewing, known as jaw claudication. Here’s a high-yield fact!
Temporal arteritis is closely associated with polymyalgia rheumatica, another inflammatory disorder that primarily affects the shoulders and hips.
These patients typically report morning pain and stiffness in the muscles of the neck, shoulders, and hips. So, if you have clinical suspicion of polymyalgia rheumatica, be sure to evaluate your patient for temporal arteritis too!Moving on physical exam findings, these may reveal an abnormal temporal artery exam, such as tenderness to palpation, ropiness, nodularity, and even decreased quality of pulse.
Additionally, fundoscopic examination might show optic disc pallor and edema early in the disease, and in more advanced cases, you may even find optic disc atrophy.
Finally, labs typically reveal elevated inflammatory markers, such as ESR and CRP, with CBC showing thrombocytosis and anemia.If your patient presents with these signs and symptoms, you should suspect temporal arteritis.

Assess Vision Changes2:37–3:34

Next, assess your patient for vision changes. If your patient is experiencing any vision changes, this is considered an ophthalmologic emergency!
Do not delay treatment, as this can lead to permanent vision loss. So, even if you haven’t confirmed the diagnosis, start the patient on high-dose intravenous glucocorticoids immediately, and obtain an emergent ophthalmology consultation.On the other hand, if your patient is not experiencing any vision changes, start high-dose oral glucocorticoids instead, which may help prevent further vascular inflammation that could ultimately lead to vision loss.
In addition, request a routine ophthalmology consultation. The key point is that glucocorticoids should not be delayed while confirming the diagnosis!Alright, now that you’ve started glucocorticoids and requested an ophthalmology consultation, your next step is to confirm the diagnosis by obtaining a temporal artery biopsy, preferably on the symptomatic side.Now, here’s a clinical pearl!

Temporal Artery Biopsy3:34–4:23

Since temporal arteritis affects the artery segmentally, a small tissue sample may lack pathologic findings, leading to false-negative biopsy results!
Additionally, keep in mind that a longer duration of glucocorticoid therapy is more likely to suppress the underlying inflammation, which could obscure the presence of temporal arteritis on biopsy, giving a false negative result.
For that reason, the biopsy should be obtained as quickly as possible after starting systemic glucocorticoids, ideally within 2 weeks.

Temporal arteritis4:23–6:25

Let’s start with a positive biopsy. If the temporal artery biopsy reveals transmural inflammation, multinucleated giant cells, and a mononuclear infiltrate, you can diagnose temporal arteritis.
Next, you should continue high-dose glucocorticoids! If intravenous glucocorticoids were given initially, you should stop these after 3 days and transition to oral therapy.
Continue oral glucocorticoids at high doses until acute symptoms resolve, then gradually taper off over at least a few months.
While glucocorticoid monotherapy is standard, you may need to add a steroid-sparing therapy, such as the interleukin-6 inhibitor, tocilizumab, or a disease-modifying antirheumatic drug or DMARD, like methotrexate or abatacept.
This addition will also allow you to lower your patient’s steroid dosage or taper the steroids more rapidly, which is helpful for patients with certain conditions like diabetes and osteoporosis.
Additionally, if your patient has evidence of significant vertebral or carotid arterial disease, consider starting aspirin as a protective measure against cerebrovascular events.
In addition, many patients on high-dose steroids will require prophylaxis against adverse systemic effects, such as bone loss, opportunistic infections, and peptic ulcer disease, but this will depend on the dose and duration.
Finally, don’t forget to obtain a rheumatology consultation.And here’s another clinical pearl! Symptomatic relapse, including severe symptoms like visual loss, is a common complication of temporal arteritis while tapering steroids.
If this occurs, immediately increase the steroid dose and start tocilizumab or a DMARD, if not already on one. Once acute symptoms resolve, continue the tocilizumab or DMARD, and this time do a longer steroid taper!

Temporal Artery Biopsy Negative6:25–7:05

Alright, let’s go back to the temporal artery biopsy. If the biopsy shows no evidence of transmural inflammation, multinucleated giant cells, or mononuclear infiltrate, the biopsy is considered negative.
However, since temporal arteritis doesn’t affect the arteries in a continuous way, a negative biopsy does not automatically rule out the disease!
So, if clinical suspicion remains high despite a negative biopsy, obtain imaging, such as a color duplex ultrasound, or CODUS, of the temporal artery, or an MRI with contrast of the cranial vessels.

Imaging: CODUS, MRI7:05–7:39

Let’s look at our imaging results. If imaging reveals findings consistent with vasculitis, you can diagnose temporal arteritis and initiate treatment with glucocorticoids.
You may also need to add tocilizumab and a DMARD, as well as aspirin, and prophylaxis against adverse systemic effects of steroids.
Again, don’t forget to obtain rheumatology consultation. On the flip side, if imaging findings are inconsistent with vasculitis, you should consider an alternative diagnosis, such as migraines or intracranial pathology.

Review7:39–8:38

Alright, as a quick recap… Temporal arteritis is a medium to large vessel vasculitis, commonly affecting the temporal arteries.
If you suspect temporal arteritis, you should immediately assess for vision changes. If symptoms are present, start high-dose intravenous glucocorticoids and consult the ophthalmology team emergently!
On the other hand, if these symptoms are absent, start oral glucocorticoids and obtain a non-emergent ophthalmology consultation.
For all cases of temporal arteritis, obtain a unilateral temporal artery biopsy. A positive biopsy is suggestive of temporal arteritis, so start the treatment with glucocorticoids.
Consider adding a monoclonal antibody, DMARDs, aspirin, and prophylaxis against adverse systemic effects of steroids, and don’t forget to consult your rheumatology team.
On the flip side, if the biopsy is negative, perform imaging with CODUS or an MRI, to rule out or confirm the diagnosis!