11/14/24, 10\:41 AM Temporal Arteritis

Temporal Arteritis

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Key points ⚡
Succinct notes to superpower your revision
Temporal arteritis\: systemic vasculitis a
of carotid artery; medical emergency requiring prompt management to prevent vision loss.
Commonly a
Aetiology\: not fully understood; involves chronic vasculitis with granulomatous in
a
Risk factors\: age >50, female sex, PMR (50% of patients with temporal arteritis have PMR).
Clinical features\:
History\: unilateral headache (temporal region), tongue/jaw claudication, scalp tenderness, painless vision loss, diplopia;
systemic symptoms (malaise, fatigue, weight loss, fever, anorexia, depression).
Examination\: scalp/temporal artery tenderness, reduced/absent temporal artery pulse, fundoscopy (optic disc
oedema/pallor), auscultation (axillary, brachial, carotid bruits), asymmetrical BP.
Investigations\:
Laboratory\: normochromic normocytic anaemia, increased platelets, elevated CRP and ESR (≥50mm/hour), mild elevation
of LFTs.
Imaging\: temporal artery ultrasound (thickened wall,
'Halo sign').
Other\: temporal artery biopsy (mononuclear cell in
lesions may cause false negatives).
Management\:
Initial\: urgent rheumatologist referral; same-day ophthalmology review if vision loss; oral prednisolone (60-100mg for visual
symptoms, 40-60mg for no visual symptoms); IV methylprednisolone (500mg-1g) for visual loss.
Ongoing\: taper prednisolone over 12-18 months; regular monitoring every 2-8 weeks for
prednisolone side e
Complications\: irreversible vision loss, aortic dissections/aneurysms, large artery stenosis, cardiovascular events (stroke,
MI); steroid treatment complications (bruising, diabetes, hypertension, osteoporosis).
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Introduction

Temporal arteritis (also known as giant cell arteritis) is a systemic vasculitis that can a
vessels. The condition typically a
requires prompt management to prevent severe complications such as permanent vision loss. 1
Temporal arteritis most
commonly a

Aetiology

The aetiology of temporal arteritis is not fully understood. Di
have been implicated in its aetiology. Temporal arteritis is a chronic vasculitis characterised by granulomatous
in
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a
branches of the aorta can also be involved.

Risk factors

The risk factors for temporal arteritis include\:
Age\: patients presenting with temporal arteritis are mostly aged over 50.
Female sex
Polymyalgia rheumatica (PMR)\: approximately 50% of patients with temporal arteritis have PMR.

Clinical features

History 3
Temporal arteritis can present in several di
temporal arteritis include\:
A subacute onset unilateral headache typically a
Tongue and jaw claudication which can be caused by talking or chewing (due to ischaemia of the masseter muscle).
Scalp tenderness\: this feature is a red
symptom is present. Scalp tenderness may present as pain whilst brushing hair or when the patient rests their head on a
pillow.
Painless complete or partial loss of vision in one or both eyes
Diplopia
Other important areas to cover in the history include\:
Systemic features\: the patient may experience systemic symptoms such as malaise, fatigue, weight loss, fever, anorexia,
and depression. All of which can be asked in the review of systems.
Past medical history\: it is important to ask whether the patient has polymyalgia rheumatica (PMR) as approximately 50%
of patients will have features of PMR. These features include bilateral shoulder sti
symptoms typically being worse in the morning.
Clinical examination 4
Typical clinical
Scalp/temporal artery tenderness.
Reduced or absent temporal artery pulse.
Fundoscopy\: oedema and pallor of the optic disc.
Auscultation\: axillary, brachial, and carotid bruits may be heard.
Asymmetrical blood pressure.
Table 1. A summary of the history and examination
2
History Clinical examination
Headache\: unilateral, subacute course
Tongue/jaw claudication Scalp
pain/tenderness Visual symptoms\:
diplopia, vision loss Systemic features\:
malaise, weight loss, anorexia, fever,
depression.
Scalp tenderness Reduced or absent
temporal pulse Fundoscopy\: pallor,
oedema of the optic disc Auscultation\:
axillary, brachial, and carotid bruits
Asymmetric blood pressure

Investigations

Laboratory, imaging and other investigations for temporal arteritis are discussed below.
5 Laboratory
Full blood count\: normochromic normocytic anaemia and an increased platelet count may be noted.
C-reactive protein (CRP)\: CRP is typically increased.
Erythrocyte sedimentation rate (ESR)\: an ESR of ≥50mm/hour is considered signi
patient has used glucocorticoids prior to testing.
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Liver function tests (LFTs)\: alkaline phosphatase and transaminases may be mildly elevated.

Imaging

Temporal artery ultrasound\: may show thickening of the wall of the a

Other investigations

Temporal artery biopsy\: will demonstrate mononuclear cell in
multinucleated giant cells. Temporal artery biopsy is the de
the symptomatic side. The biopsy result can sometimes produce a false negative due to the presence of skip lesions as
a result of patchy in

Management

Temporal arteritis is a medical emergency which requires prompt management. 6 Initial management
An urgent
referral to a rheumatologist should be made on the same working day. If there is temporary or permanent vision loss, a
same day ophthalmology review should be arranged. The patient should be treated with oral prednisolone. NICE
guidelines state for patients with visual symptoms, a one-o
in primary care prior to same day ophthalmology review. For patients without visual symptoms, a dose of 40 - 60mg of
prednisolone per day should be prescribed. For patients with visual loss, 500mg - 1g of intravenous methylprednisolone
Figure 1.A diagram summarising the initial management. Adapted from NICE guidelines.
5

Ongoing management

arteritis\:
Current NICE guidelines recommend the following ongoing management of temporal
Gradually taper the dose of prednisolone down to zero over a period of 12-18 months.
The patient should be monitored regularly after diagnosis. Current guidelines suggest reviewing the patient at least
every 2-8 weeks for the
hypertension and hyperglycaemia.
The side e
who are at risk of gastrointestinal bleeding. In patients with a risk of developing osteoporosis, prophylaxis should be
considered.

Complications

The complications of temporal arteritis include\:
3
Irreversible vision loss
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Aortic dissections, aortic aneurysms, and large artery stenosis
Cardiovascular events (e.g. stroke and myocardial infarction) are more common in patients with temporal arteritis.
Complications arising from steroid treatment of temporal arteritis include bruising, diabetes, hypertension, and
osteoporosis.

References

Ahmad Al-Sukaini & Mohsin Azam, Ash Samanta. R h e u m a t o l o g y \: A c l i n i c a l h a n d b o o k . Published in 2014.
Dejaco, C., Duftner, C., Buttgereit, F., Matteson, E. and Dasgupta, B., 2016. The spectrum of giant cell arteritis and
polymyalgia rheumatica\: revisiting the concept of the disease. R h e u m a t o l o g y , p.kew273. [LINK]
Patient.info. G i a n t C e l l A r t e r i t i s . Last updated 2016. Available from\: [LINK]
Bongartz T. Matteson E. L a r g e v e s s e l i n v o l v e m e n t i n G i a n t C e l l A r t e r i t i s . Published in 2006. Available from\: [LINK]
National Institute of Health and Care Excellence CKS. T e m p o r a l a r t e r i t i s M a n a g e m e n t . Last revised 2020. Available from\:
[LINK]
Mackie, S.L., Dejaco, C. and Appenzeller, S. et al. 2020. British Society for Rheumatology guideline on diagnosis and
treatment of giant cell arteritis. R h e u m a t o l o g y 59(3), e1-e23. Available from\: [LINK]

Reviewer

Dr Adrian Tang
Consultant Radiologist

Related notes

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Contents

Introduction
Aetiology
Risk factors
Clinical features
Investigations
Management
Complications
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