0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Research Letters |

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

Sung-eun E. Kyung, MD, PhD; Michael K. Yoon, MD; J. Brooks Crawford, MD; Jonathan C. Horton, MD, PhD
[+] Author Affiliations

Author Affiliations: Department of Ophthalmology, School of Medicine, Dankook University, Cheonan, South Korea (Dr Kyung); Massachusetts Eye and Ear Infirmary, Boston (Dr Yoon); and Departments of Ophthalmology, Neurology, and Physiology, University of California, San Francisco (Drs Crawford and Horton).


Arch Ophthalmol. 2012;130(10):1347-1348. doi:10.1001/archophthalmol.2012.1204.
Text Size: A A A
Published online

Biopsy 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.

A 69-year-old woman had a 5-week history of neck stiffness and malaise. The erythrocyte sedimentation 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 evidence of arteritis (Figure 1). Two days later, a 30-mm section of the frontal branch of the left superficial temporal artery was biopsied. Every section showed extensive granulomatous inflammation (Figure 2). The patient was treated with prednisone and her symptoms resolved.

Place holder to copy figure label and caption
Graphic Jump Location

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).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Representative sections from the frontal branch of the left superficial temporal artery, all showing granulomatous arteritis and mural thickening (hematoxylin-eosin, original magnification ×12).

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 examine 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 extreme example of a skip area: a parietal branch completely 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 branches of the superficial temporal artery. In fact, surgeons usually fail to specify which branch was biopsied when they submit specimens, and no histological data exist regarding which branch is more likely to demonstrate arteritis.

Recently, it was suggested that the parietal branch, rather than the frontal branch, should be biopsied in patients with suspected temporal arteritis.3 This approach eliminates the remote risk of facial nerve injury and usually hides the scar behind the hairline. However, this recommendation 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 compare 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, abnormalities were present in 14 patients in the frontal branch and in 6 patients in the parietal branch. On the right side, involvement was noted in 11 patients in each branch. These data hint that arteritis may be more prevalent in the frontal branch than the parietal branch. Notably, in the majority of patients who had imaging signs of temporal arteritis, abnormalities were present in one branch but not the other, at least on one side. Although neuroimaging is not equivalent to the gold standard of histopathological analysis, this result suggests that selective involvement of a single branch of the superficial temporal artery is not rare.

Bilateral temporal artery biopsy is sometimes performed to improve the chance of obtaining a positive result, especially if systemic symptoms are present. However, only a handful of patients will have a negative biopsy finding on one side and a positive biopsy finding on the other side.5,6 If a second biopsy is contemplated, it may be more fruitful to sample the other branch of the artery on the same side rather than the same branch on the other side. In the future, surgeons should record whether they have biopsied the frontal or parietal branch so that data can be gathered to determine which branch is inflamed most frequently. This information may increase the diagnostic yield of temporal artery biopsy.

Correspondence: Dr Horton, Beckman Vision Center, University of California, San Francisco, 10 Koret Way, San Francisco, CA 94143 (hortonj@vision.ucsf.edu).

Financial Disclosure: None reported.

Funding/Support: This work was supported by grants EY10217 (Dr Horton) and EY02162 (Beckman Vision Center) from the National Eye Institute and by Research to Prevent Blindness.

Stacy RC, Rizzo JF, Cestari DM. Subtleties in the histopathology of giant cell arteritis.  Semin Ophthalmol. 2011;26(4-5):342-348
PubMed   |  Link to Article
Albert DM, Ruchman MC, Keltner JL. Skip areas in temporal arteritis.  Arch Ophthalmol. 1976;94(12):2072-2077
PubMed   |  Link to Article
Yoon MK, Horton JC, McCulley TJ. Facial nerve injury: a complication of superficial temporal artery biopsy.  Am J Ophthalmol. 2011;152(2):251-255, e1
PubMed   |  Link to Article
Bley TA, Weiben O, Uhl M,  et al.  Assessment of the cranial involvement pattern of giant cell arteritis with 3T magnetic resonance imaging.  Arthritis Rheum. 2005;52(8):2470-2477
PubMed   |  Link to Article
Hall JK, Volpe NJ, Galetta SL, Liu GT, Syed NA, Balcer LJ. The role of unilateral temporal artery biopsy.  Ophthalmology. 2003;110(3):543-548
PubMed   |  Link to Article
Boyev LR, Miller NR, Green WR. Efficacy of unilateral vs bilateral temporal artery biopsies for the diagnosis of giant cell arteritis.  Am J Ophthalmol. 1999;128(2):211-215
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Graphic Jump Location

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).

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Representative sections from the frontal branch of the left superficial temporal artery, all showing granulomatous arteritis and mural thickening (hematoxylin-eosin, original magnification ×12).

Tables

References

Stacy RC, Rizzo JF, Cestari DM. Subtleties in the histopathology of giant cell arteritis.  Semin Ophthalmol. 2011;26(4-5):342-348
PubMed   |  Link to Article
Albert DM, Ruchman MC, Keltner JL. Skip areas in temporal arteritis.  Arch Ophthalmol. 1976;94(12):2072-2077
PubMed   |  Link to Article
Yoon MK, Horton JC, McCulley TJ. Facial nerve injury: a complication of superficial temporal artery biopsy.  Am J Ophthalmol. 2011;152(2):251-255, e1
PubMed   |  Link to Article
Bley TA, Weiben O, Uhl M,  et al.  Assessment of the cranial involvement pattern of giant cell arteritis with 3T magnetic resonance imaging.  Arthritis Rheum. 2005;52(8):2470-2477
PubMed   |  Link to Article
Hall JK, Volpe NJ, Galetta SL, Liu GT, Syed NA, Balcer LJ. The role of unilateral temporal artery biopsy.  Ophthalmology. 2003;110(3):543-548
PubMed   |  Link to Article
Boyev LR, Miller NR, Green WR. Efficacy of unilateral vs bilateral temporal artery biopsies for the diagnosis of giant cell arteritis.  Am J Ophthalmol. 1999;128(2):211-215
PubMed   |  Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 1

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles