Pathological features of temporal arteries in patients with giant cell arteritis presenting with permanent visual loss

Chatelain, Denis; Duhaut, P.; Schmidt, J.; Loire, R; Bosshard, S.; Guernou, Mohamed; Pellet, H; Pietté, J.C.; Sevestre, Henri; Ducroix, J.P.

doi:10.1136/ard.2007.084947

Cited by 74 publications

(53 citation statements)

References 22 publications

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“…In an early series of 90 cases from neurology and ophthalmology clinics, up to 60% of patients presented with permanent loss of vision attributable to either ischaemic papillopathy or retinal artery occlusion; 23 other cases presenting primarily to physicians demonstrated a much lower risk of sight loss of 7.4% to 19.1%. [24][25][26][27] The risk of sight loss associated with GCA has fallen 28 There is a small but significant risk of stroke, highlighted as possibly being between 2.8% and 6% in two recent studies. 29,30 Therefore, an early diagnosis and initiation of immunosuppressive treatment with high doses of steroids is required, making the condition a medical emergency.…”

Section: Clinical Presentation Of Giant Cell Arteritismentioning

confidence: 99%

The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study

Luqmani

Lee

Singh

et al. 2016

Health Technol Assess

387

404

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Background Giant cell arteritis (GCA) is a relatively common form of primary systemic vasculitis, which, if left untreated, can lead to permanent sight loss. We compared ultrasound as an alternative diagnostic test with temporal artery biopsy, which may be negative in 9–61% of true cases. Objective To compare the clinical effectiveness and cost-effectiveness of ultrasound with biopsy in diagnosing patients with suspected GCA. Design Prospective multicentre cohort study. Setting Secondary care. Participants A total of 381 patients referred with newly suspected GCA. Main outcome measures Sensitivity, specificity and cost-effectiveness of ultrasound compared with biopsy or ultrasound combined with biopsy for diagnosing GCA and interobserver reliability in interpreting scan or biopsy findings. Results We developed and implemented an ultrasound training programme for diagnosing suspected GCA. We recruited 430 patients with suspected GCA. We analysed 381 patients who underwent both ultrasound and biopsy within 10 days of starting treatment for suspected GCA and who attended a follow-up assessment (median age 71.1 years; 72% female). The sensitivity of biopsy was 39% [95% confidence interval (CI) 33% to 46%], which was significantly lower than previously reported and inferior to ultrasound (54%, 95% CI 48% to 60%); the specificity of biopsy (100%, 95% CI 97% to 100%) was superior to ultrasound (81%, 95% CI 73% to 88%). If we scanned all suspected patients and performed biopsies only on negative cases, sensitivity increased to 65% and specificity was maintained at 81%, reducing the need for biopsies by 43%. Strategies combining clinical judgement (clinician’s assessment at 2 weeks) with the tests showed sensitivity and specificity of 91% and 81%, respectively, for biopsy and 93% and 77%, respectively, for ultrasound; cost-effectiveness (incremental net monetary benefit) was £485 per patient in favour of ultrasound with both cost savings and a small health gain. Inter-rater analysis revealed moderate agreement among sonographers (intraclass correlation coefficient 0.61, 95% CI 0.48 to 0.75), similar to pathologists (0.62, 95% CI 0.49 to 0.76). Limitations There is no independent gold standard diagnosis for GCA. The reference diagnosis used to determine accuracy was based on classification criteria for GCA that include clinical features at presentation and biopsy results. Conclusion We have demonstrated the feasibility of providing training in ultrasound for the diagnosis of GCA. Our results indicate better sensitivity but poorer specificity of ultrasound compared with biopsy and suggest some scope for reducing the role of biopsy. The moderate interobserver agreement for both ultrasound and biopsy indicates scope for improving assessment and reporting of test results and challenges the assumption that a positive biopsy always represents GCA. Future work Further research should address the issue of an independent reference diagnosis, standards for interpreting and reporting test results and the evaluation of ultrasound training, and should also explore the acceptability of these new diagnostic strategies in GCA. Funding The National Institute for Health Research Health Technology Assessment programme.

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Section: Clinical Presentation Of Giant Cell Arteritismentioning

confidence: 99%

The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study

Luqmani

Lee

Singh

et al. 2016

Health Technol Assess

387

404

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“…On the other hand, one study (60) showed an increased frequency of visual ischemic events in patients with ESR values ranging between 70 and 100 mm/h at the time of disease diagnosis. Similarly, another survey (63), found no increased risk of visual loss or other cranial ischemic events in patients with low ESR (< 40 mm/h). Histologically, the presence of giant cell cells has been associated with increased risk of visual loss (64), but this finding needs to be confirmed.…”

Section: Ophthalmologic Manifestationsmentioning

confidence: 88%

“…GCA with normal ESR has, however, been reported (175,176,177), even in patients with visual disturbances (176,178) and devastating central nervous system complications (179). Interestingly, when patients with GCA and normal ESR were followed-up, these patients were never able to mount a high ESR during subsequent episodes of inflammation caused by infection which may imply a genetically determined blunted cytokine response to inflammation (63). ESR and CRP are relatively lower in patients with occult GCA according to some observations (14).…”

Section: Laboratory Investigationsmentioning

confidence: 99%

See 1 more Smart Citation

Diagnosis and Treatment of Giant Cell Arteritis (Temporal Arteritis) – Past, Current and Future Aspects

Gran¹

2011

Advances in the Diagnosis and Treatment of Vasculitis

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“…Die Autoren weisen jedoch ausdrücklich darauf hin, dass die Immunhistochemie nicht dem Ziel dienen sollte, eine eigentlich negative Biopsie zwanghaft der klinischen Erwartung einer Riesenzellarteriitis anzunähern. Zudem besteht in der Literatur kein Konsens bezüglich der Frage, ob nun die Dichte und die Zusammensetzung des Entzündungs-zellinfiltrates mit dem klinischen Schweregrad oder den laborchemischen Verän-derungen der Riesenzellarteriitis korrelieren [2,16].…”

Section: Histologische Diagnosekriterienunclassified

Riesenzellarteriitis

Schaefer

Lehr²

2012

Pathologe

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Giant cell arteritis is a potentially systemic disease of medium-sized and large caliber arteries, showing a preferential manifestation in the extracranial branches of the carotid artery. The diagnosis is oriented to clinical and histomorphological criteria which will be critically reviewed. Particular emphasis is placed on the differentiation from normal aging processes and from healing stages under steroid therapy. In addition, the advances in our understanding of the disease pathomechanism during the last 10 years will be briefly presented as the basis for the hitherto empiric steroid treatment.

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Pathological features of temporal arteries in patients with giant cell arteritis presenting with permanent visual loss

Abstract: Giant cells are strongly associated with PVL, with a significant gradient between great risk and large number of giant cells. However, PVL was neither associated with the intensity of the inflammatory infiltrate, nor with the presence of arterial thrombosis.

Cited by 74 publications

References 22 publications

The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study

The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study

Diagnosis and Treatment of Giant Cell Arteritis (Temporal Arteritis) – Past, Current and Future Aspects

Riesenzellarteriitis

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