Temporal arteritis

Overview

Temporal arteritis (TA), also known as giant cell arteritis (GCA), is a common form of systemic vasculopathy affecting patients older than 5 years. Although typically affecting the superficial temporal arteries, this inflammatory process has been shown to involve medium- and large-sized vessels, including the aorta, carotid, subclavian, vertebral, and iliac arteries. Therefore, “giant cell arteritis” may be more appropriate than “temporal arteritis” to identify this type of vasculitis, though both terms are used interchangeably.

Symptoms

Headache is the most common chief complaint and presents in over two thirds of patients with temporal arteritis. The headache tends to be new or different in character than previous headaches and is typically sudden in onset, localizing to the temporal region. However, pain with temporal arteritis can occur diffusely through the occipital, frontal, or parietal regions as well. Therefore, any new headache in patients older than 5 years warrants a consideration of temporal arteritis. Because temporal arteritis tends to affect the branches of the carotid artery, clinical manifestations vary depending on the distribution of the ischemic vessel. For example, superficial temporal artery involvement can lead to severe scalp tenderness during such simple acts as resting the head on a pillow, combing hair, or wearing hats and eyeglasses. Patients may also present with visible areas of scalp necrosis. Similarly, jaw claudication while speaking or chewing is observed in patients with involvement of the maxillary artery, which can occur in half of patients with temporal arteritis. Visual loss may also be a presenting symptom and can be sudden and painless. Initial visual symptoms are usually transient and intermittent, typically manifesting as unilateral visual loss or occasionally diplopia. However, if left untreated, permanent blindness frequently results. Constitutional symptoms due to systemic inflammation are common. These nonspecific symptoms include fever, malaise, memory impairment, anorexia, weight loss, fatigue, and depression. Additionally, polymyalgia rheumatica symptoms are present in about half of all cases of temporal arteritis and may be the initial complaint in many patients.

Diagnosis

A thorough physical and neurological examination should be performed to exclude other possible causes of headache and visual disturbances. The head and face should be examined for inflamed and thickened arteries, tenderness to palpation, tender scalp nodules, or necrotic areas of the scalp. Inflamed vessels may be tender and warm. They may also appear thickened and dilated, such that the examiner may be able to roll the artery between the fingers and the skull. Cranial nerve palsies, particularly of the sixth nerve, should also be noted. A complete eye examination should be performed, including visual acuity, visual field check, and funduscopic as well as a slit lamp examinations. Special attention should be paid to the retinal vessels, as other causes of loss of vision such as central retinal artery or vein occlusion can cause a markedly abnormal funduscopic examination result. In temporal arteritis, the funduscopic examination result may be normal or can show dilated retinal veins.