Temporal Arteritis

• Temporal arteritis (also known as giant cell arteritis) is a systemic vasculitis that can affect both large and medium-sized vessels
• Typically affects the extracranial branches of the carotid artery - including the ophthalmic artery
• Temporal arteritis most commonly affects women aged over 50 and is associated with polymyalgia rheumatica.
• Temporal arteritis is a chronic vasculitis characterised by granulomatous inflammation of the walls of medium and large arteries
• Typical symptoms of temporal arteritis include:

  • A subacute onset unilateral headache typically affecting the temporal region.
  • 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 flag in a headache history and temporal arteritis should be actively ruled out if this 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 stiffness and pelvic girdle pain, with symptoms typically being worse in the morning.
• Typical clinical findings of temporal arteritis can include:4

  • 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.
• Lab investigations:

  • 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 significant. ESR levels may be lower if the patient has used glucocorticoids prior to testing.
  • Liver function tests (LFTs): alkaline phosphatase and transaminases may be mildly elevated.
• Imaging:

  • Temporal artery ultrasound: may show thickening of the wall of the affected blood vessel (known as the ‘Halo sign’).
• • Temporal artery biopsy: will demonstrate mononuclear cell infiltration or granulomatous inflammation usually with multinucleated giant cells. Temporal artery biopsy is the definitive test for diagnosing GCA and should be performed on the symptomatic side. The biopsy result can sometimes produce a false negative due to the presence of skip lesions as a result of patchy inflammation.
• 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.
• Treatment without vision loss:

  •  a dose of  40 – 60mg of prednisolone per day should be prescribed.
• Patients with vision loss:

  • a one-off dose of 60mg – 100mg prednisolone should be administered in primary care prior to same day ophthalmology review.
  • 500mg – 1g of intravenous methylprednisolone once daily is typically administered for 3 consecutive days
• Ongoing management:

  • Gradually taper the dose of prednisolone down to zero over a period of 12-18 months.
  • Current guidelines suggest reviewing the patient at least every 2-8 weeks for the first 6 months. In the first 2 weeks of starting prednisolone, the patient should be assessed for hypertension and hyperglycaemia.
  • The side effects of prednisolone should also be mitigated. Consider starting a proton pump inhibitor (PPI) in patients who are at risk of gastrointestinal bleeding. In patients with a risk of developing osteoporosis, prophylaxis should be considered.
• The complications of temporal arteritis include:

  • Irreversible vision loss
  • Aortic dissections, aortic aneurysms, and large artery stenosis
  • Cardiovascular events (e.g. stroke and myocardial infarction) are more common in patients with temporal arteritis.
• Risk factors:

  • Age over 50
  • Female
  • Polymyalgia rheumatica