A review of the indications , technique and complication of temporal artery biopsy, the gold standard test to diagnose Giant Cell Arteritis.

1. Temporal Artery
Biopsy
Raed Behbehani , MD FRCSC

2. Giant Cell Arteritis
• The most important medical ophthalmic
emergency.

3. Why TAB ?
• Early recognition and initiation of steroid
treatment for a sufficient duration,
• Treatment (systemic steroids) is
associated with high risk of morbidity.

4. Steroids is “double-
edged” sword
Duhaut P et al. Biopsy proven and biopsy negative temporal arteritis: differences in clinical
spectrum at the onset of the disease. Ann Rheum Dis 1999
• Series of 207 biopsy-proven and 85 biopsy-negative
GCA cases.
• Potentially iatrogenic steroid complications might explain
up to 20% of the observed deaths in their study group.

5. ACR Criteria for GCA
Age 50 years or older
New-onset localized headache
Temporal artery tenderness or decreased temporal artery
pulse,
Erythrocyte sedimentation rate (ESR) of at least
50 mm/hour,
Abnormal artery biopsy specimen characterized by mononuclear
infiltration or granulomatous inflammation.
3 of 5
Sensitivity of 93.5% and specificity of
91.2% for the classification of GCA compared with other
vasculitides

6. TAB
• ACR criteria differentiate patients who
have vasculitis from those who do not
have vasculitis for diagnostic purposes.
• ACR Diagnostic criteria to identify a
patient with GCA is better when the
prevalence is high (e.g. Rheumatology
clinic).

7. TAB vs ACR Criteria
(Murchison AP et al, Am J Ophth 2012)
• Twenty five percent of patients who had
a positive biopsy did not meet ACR
criteria.
• Twenty eight percent of patients who
met ACR criteria did not have a positive
biopsy.

8. Occult GCA
• Twenty percent of GCA patients have
only visual symptoms (Occult GCA) -
Transient visual loss , transient diplopia
(Simmons RJ, Cogan DG. Occult temporal arteritis. Arch Ophthalmol
1962)

9. GCA Diagnosis
• ESR , CRP
• Platelets
• Interleukin 8
• Color Duplex

10. Unilateral vs Bilateral
Danesh-Meyer HV et al . J Neuroophthalmology 2000
• In 90 (99%) of the 91 patients, the histologic diagnoses in the
left and right superficial temporal arteries were the same.
• A concordance rate of 98.9% (38 of 39 positive biopsy
results)
• Low yield in obtaining a biopsy on the contralateral side.

11. How long is enough ?
Murchison AP et al. Ophthal Plast Reconstr Surg. 2012
• Review of 62 TAB biopsy specimens.
• 4.61-mm mean shrinkage with 2.97-mm
standard deviation
• A 27.58-mm specimen would have to be
obtained to consistently get 20 mm length
specimen

12. Indication of TAB
• Any patient who with clinical signs and
symptoms of GCA.
• Biopsy should be performed if clinical
suspicion is high regardless of
laboratory results.

13. Superficial Temporal
Artery

14. STA Anatomy

15. Technique
• Palpation is critical.
• Hand-held doppler.
• Consider using local anesthetic without
epinephrine to avoid artery
vasoconstriction.

16. Technique
Use a hemostat for wide
dissection of superficial

17. Technique
Sharp dissection through the
Superficial temporal fascia

18. Technique
* 4.0 Silk traction sutures passed below artery for
traction
* Sharp and blunt dissection around the artery

19. Technique
At least 2 cm segment is preferable

20. Intraoperative Predictability of Temporal Artery Biopsy
Results
Cetinkaya, Altug M.D at al. Ophthalmic Plastic & Reconstructive Surgery, 2012
A. Nodular, thickened artery that appears pale throughout
the entire section->“grossly positive,”
B. The lumen is completely occluded.
No back-bleeding from anastomotic branches during
dissection.

21. Technique
Skin closure is with running baseball or
vertical mattress with 6.0 non-absorbable

22. Technique

23. Complications of TAB
• Brow ptosis
• Wrong biopsy (vein or nerve)
• Bleeding/echymosis
• Stroke ( extremely rare)

24. Brow Ptosis
• Injury to upper temporal branch of facial
nerve.
• Facial nerve runs deep to temporal branch
of STA beneath the fascia.
• Avoid dissection very deep to artery and
fascia.
• Don’t dissect close to lateral orbital rim or
brow.

25. Brow Ptosis
“danger zone”: contains temporal branches traveling
superficially and therefore presumably more susceptible
to injury.
Scott KR et al. Temporal artery biopsy technique: a clinico-anatomical approach.

26. Safety Line
• “Safety line”: from the tragus to a point 2.0 cm from
the most lateral brow cilia.
2 cm

27. Brow Ptosis after Temporal Artery Biopsy
Incidence and Associations
Ann P. Murchison et al. Ophthalmology 2012
Only 1 of 35 patients with incision > 35 mm from brow developed brow ptosis

28. Brow Ptosis
Ann P. Murchison et al. Ophthalmology 2012
One week Six months

29. Wrong biopsy
• Artery has a thicker wall smaller in
diameter and is whiter than a vein.

30. Hematoma
Ann P. Murchison et al. Ophthalmology 2012

31. Stroke
• Extremely rare.
• In case if severely narrowed ICA since
there areas of anastomosis between
ICA supraorbital artery) and ECA
(STA).

32. Wound Dehiscence
• Can be avoided by meticulous skin
closure technique.

33. Summary
• TAB is an easy , low-risk procedure to
confirm GCA diagnosis (gold-standard).
• Good communication with the
pathologist is important.
• Complications (brow ptosis) can be
minimized by careful technique.