Temporal Artery Biopsy – gold standard for the diagnosis of temporal (giant cell) arteritis
The patient is examined for prominence of the superficial temporal artery at either temple. Palpation at the temples is necessary to check for an enlarged or inflamed artery. It is also important to check for a pulse and any tenderness. Once the artery is identified, it is marked with a pen either by following the pulse or by using a Doppler. Any hair around the intended incision is shaved away. Then under sedation, after prepping and draping, lidocaine 2% with epinephrine is infiltrated underneath the skin along the intended incision site. Plan to incise the skin for about 1 inch or 2 – 3 cm in length. The incision is carried out with a 15 blade. The subcutaneous plane is then dissected with Westcott scissors. The temporal artery is then identified coursing underneath the temporalis fascia. Dissection parallel to the artery is carried out, and a muscle hook is used to hold the artery. Dissection is carried out from one end of the incision to the other using sharp and dull Westcott scissors. 4-0 silk ties are then used to tie off the artery at each end. Westcott scissors are then used to excise the temporal artery specimen taking care not to damage the tissue. The temporal artery biopsy specimen is then placed in formalin and sent to pathology. Cautery is used to the ends of the artery in the wound. It is important to ensure that hemostasis has been achieved. Next, 3 interrupted vertical mattress sutures are placed using 5-0 Vicryl. The skin is closed using a running 6-0 prolene suture. Triple antibiotic ointment is applied to the wound, and a pressure patch is taped over the incision.
The temporal artery biopsy is performed to rule out temporal (giant cell) arteritis. Classic symptoms of temporal arteritis include headaches, scalp tenderness, and jaw claudication. Lab tests including ESR and CRP may be elevated. Blindness can occur in one or both eyes. Therefore, the temporal artery biopsy is performed on an urgent basis to make a diagnosis; prednisone treatment is started immediately in order to prevent blindness in the fellow eye.
In the literature, the diagnostic yield has been shown to decrease significantly in patients who have received thirty days of corticosteroid therapy. A relative contraindication is a negative result of a properly performed biopsy - the rate of a positive contralateral biopsy is approximately 1%.
Instruments include 15 blade scalpel, .3 or .5 forceps, Westcott scissors, muscle hook, and needle driver. The temporal artery biopsy can be performed in the operating room or minor procedure room depending on local preferences. The patient is prepped and draped with betadine scrub, and the procedure is performed with sterile technique.
Workup for temporal arteritis includes lab tests including ESR, CRP, and platelets. A thorough history looking for the classic symptoms of headache, scalp tenderness, and jaw claudication, as well as a dilated eye examination are carried out before biopsy.
It is preferred that the temporal artery biopsy be performed on the temple or forehead approximately 2 finger breadths above the lateral canthus of the involved eye. This is safer compared to the preauricular region where a larger artery and adjacent facial nerve may be encountered.
The advantages of the temporal artery biopsy include it being a simple procedure that can be performed in the operating room or the minor procedure room of the clinic. By performing the procedure 2 finger breadths above the lateral canthus on the lateral forehead, the risk of bleeding or encountering the facial nerve is lessened. The disadvantages of the procedure include it being invasive and having the risks of infection, bleeding, and scar.
The complications of temporal artery biopsy are few and include small risks of bleeding, infection, and scar.
The authors have no conflicts of interest.
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