Temporal Artery Biopsy

Article Author:
Elizabeth Chase
Article Editor:
Michael Ramsey
Updated:
6/1/2019 11:33:02 PM
PubMed Link:
Temporal Artery Biopsy

Introduction

Temporal arteritis (giant cell arteritis) is an inflammatory vasculopathy that affects medium and large-sized arteries which are usually branches of the carotid artery. While the superficial temporal branch is highly susceptible, other arteries may be affected. Temporal arteritis is a granulomatous panarteritis with mononuclear cell infiltrates and giant cell formation within the vessel wall. This histologic characteristic confirms the diagnosis of temporal arteritis in biopsy specimens of the temporal artery.[1][2][3][4]

Anatomy

Understanding the anatomy of the superficial temporal fascia, superficial temporal artery, superficial temporal nerve and the safe and danger zones these structures create is crucial to perform a temporal artery biopsy safely. The superficial temporal fascia lies deep in the subcutaneous adipose of the skin; it is contiguous with the superficial musculoaponeurotic system (SMAS) of the face inferiorly and the frontalis-galea complex superiorly. Within the superficial temporal fascia, the superficial temporal artery travels cephalad within the preauricular cheek and then bifurcates into a frontal and parietal branch roughly 3 cm superior to the zygoma. The temporal branch of the facial nerve exits the parotid gland at a depth of 0.9 cm but then travels superficially over the middle third of the zygoma on the underneath surface of the superficial temporal fascia in the temple region to reach the frontalis and orbicularis oculi muscles which it innervates. The distal rami of the temporal branch of the facial nerve always travel deep to the muscles they innervate. Furthermore, the anterior temporal hairline lies lateral to the frontalis muscle, so dissecting superior or posterior to the anterior hairline during a temporal artery biopsy is not likely to produce injury to the temporal branch of the facial nerve. However, because there are no muscles of facial expression but rather only the thin superficial temporal fascia in the temple region, the temporal branch of the facial nerve is particularly susceptible to injury over the zygoma and within the temple region. One group of authors defines the temporal danger zone for the temporal branch of the facial nerve by outlining a region bounded by an inferior line from the earlobe to the lateral eyebrow and a superior line from the intertragic notch or earlobe to the lateral edge of the highest forehead crease. Additionally, one group defined the area 1.5 cm posterior to the lateral orbital rim and  1cm anterior to the attachment of the helix along the level of the zygoma as safe zones to avoid nerve injury.[5][6][7][8]

Indications

Patients with temporal arteritis (giant cell arteritis) may present with visual disturbances including temporary or permanent blindness which necessitates an efficient diagnosis. While a number of clinical changes such as head or neck pain, jaw claudication, polymyalgia, temple tenderness on palpation, and lab alterations such as elevated C-reactive proteins or erythrocyte sedimentation rate may suggest the diagnosis, unfortunately, no one cluster of these signs or symptoms demonstrates a sensitivity or specificity which approaches temporal artery biopsy (TAB). Given its greater than 90% positive predictive value, TAB is the gold standard test for diagnosing temporal arteritis and should be performed in anyone in which temporal arteritis is suspected. It is important to note that treatment with systemic corticosteroids should not be delayed until after TAB as up to 10 days of such therapy does not significantly affect sensitivity, and early steroid therapy reduces morbidity.

Contraindications

Biopsy contraindications include:

  • Patients who have had prolonged treatment with glucocorticoids. Diagnostic yield decreases after 30 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%.

Equipment

Equipment includes the following:

  • Nonsterile preparation stand
  • Water-based lubricating jelly
  • Marking pen
  • 4 x 4 gauze
  • Liposomal lidocaine cream 4%
  • Lidocaine 1% with 1:200,000 epinephrine
  • Bupivacaine 0.5% with 1:200,000 epinephrine
  • Needle, 18-gauge
  • Needle, 27-gauge (1-1/4 inch)
  • Syringe with 3-ring control, 10 mL Doppler ultrasound
  • Electric hair shaver
  • Specimen container with formalin
  • Benzalkonium chloride
  • Sterile Mayo stand
  • Scalpel, No. 15 blade
  • Single skin hook
  • Adson-Browns forceps
  • Bishop-Harmon forceps
  • Tenotomy scissors
  • Metzenbaum scissors
  • Suture scissors
  • Frazier suction, No. 10
  • Hemostat clamps
  • Castro-Viejo needle holder
  • Webster needle holder
  • Small Weitlaner self-retractors
  • Ruler
  • Towel clamps
  • Mono or bipolar cautery
  • 4.0 or 5.0 Polyglactin 910 suture
  • 5-0 Monocryl on RB-1
  • 5-0 Fast-absorbing gut on PC-1 needle
  • 3-0 Silk-free ties
  • Dressing
  • Aquaphor ointment
  • One-inch tape
  • Kerlix

Personnel

Operator and an assistant.

Preparation

Appropriate biopsy site selection may be helpful in confirming the diagnosis of temporal arteritis. The presence of local symptoms of temporal arteritis such as visual disturbances, headache, or a painful vessel assists the surgeon in selecting on which side, left or right, to perform the temporal artery biopsy. However, a physical examination is poorly correlated with biopsy results. After choosing a side, the portable Doppler ultrasound is employed to localize a peripheral segment of the frontal branch of the temporal artery which lies in the anatomic safe zone, often just posterior to the length of the anterior hairline allowing the scar to be camouflaged. After placing the patient in a reclined position, the surgeon marks the artery with a surgical pen through the transducer gel for at least 5 cm as an incision of 3 cm to 4 cm will be required to obtain a temporal artery specimen of adequate length.

Technique

After hair has been clipped, the skin is scrubbed, draped, and anesthetized with 5 cc to 10 cc of 0.5% lidocaine with 1:200,000 epinephrine 1 cm lateral to the artery on either side. An incision through the dermis is made directly over the artery with a No. 15 scalpel blade such that the thin subcutaneous adipose tissue is barely visible. Using blunt tipped dissecting scissors along with skin hooks to separate the edges of the incision, dissection through the adipose to uncover the superficial temporal fascia is undertaken. The fascia is then grasped with forceps a few millimeters lateral to the artery, so it may be cut with the scissor tips before being enlarged to expose the artery. If it is difficult to visualize an obscure vessel, use of palpation may assist the surgeon.  The artery should be handled extremely gently during dissection of at least 3 cm of its length to provide sufficient tissue without histologic artifact to aide in the pathologist's interpretation. Using indirect electrocoagulation via forceps or suture to tie off any small branches before cutting them with scissors, the surgeon may proceed with the temporal artery biopsy in a relatively bloodless field. A figure eight pattern with 4.0 or 5.0 Polyglactin 910 suture is then employed to tie off the main proximal and distal portions of the temporal artery before transecting the vessel, placing it in formalin, and applying electrocoagulation to the remaining vessel ends. The skin edges are then closed with 5.0 Polyglactin 910 subcutaneous vertical mattress sutures and either a topical cyanoacrylate skin adhesive or 6.0 chromic gut superficial cutaneous sutures.

Complications

Challenges facing the practitioner interpreting TAB result include the possibility of false-negative results which may occur in 5% to 10% of cases. Therefore, it is crucial that the surgeon perform TAB keeping in mind proper biopsy site selection, tissue handling, and adequate specimen length to maximize diagnostic yield. The surgeon’s most feared complication is temporary or permanent nerve damage to the temporal branch of the facial nerve. Techniques to reduce the risk of injury include localization of the artery using Doppler ultrasonography, incisions directly superficial to the artery to protect the potentially deeper running nerve, and blunt dissection only within or above the superficial temporal fascia. Other than common surgical complications such as bleeding, infection, hematoma, and wound dehiscence, possible, albeit rare, complications include ischemic stroke and scalp or tongue necrosis which have been reported. Some authors recommend palpating and firmly holding a bounding temporal artery pulse for several minutes before proceeding with TAB or locating a major arterial branch other than that being biopsied via Doppler ultrasound to ensure sufficient collateral vascular supply to obviate the risk of ensuing stroke.

Clinical Significance

The gold standard for diagnosing temporal arteritis is a biopsy. A negative result does not definitively rule out the diagnosis. Currently, a biopsy is considered confirmatory for the clinical diagnosis of one of the diagnostic criteria.

Enhancing Healthcare Team Outcomes

While a surgeon usually performs a temporal artery biopsy, the healthcare provider should consult with a pathologist and neurologist when deciding treatment. Because of segmental disease, the surgeon must obtain 3-5 cm of the artery to be assessed. 


References

[1] Croci S,Bonacini M,Muratore F,Caruso A,Fontana A,Boiardi L,Soriano A,Cavazza A,Cimino L,Belloni L,Perry O,Fridkin M,Parmeggiani M,Blank M,Shoenfeld Y,Salvarani C, The therapeutic potential of tuftsin-phosphorylcholine in giant cell arteritis. Journal of autoimmunity. 2019 Jan 9;     [PubMed PMID: 30638709]
[2] Gokoffski KK,Chatterjee A,Khaderi SK, Seasonal incidence of biopsy-proven giant cell arteritis: a 20-year retrospective study of the University of California Davis Medical System. Clinical and experimental rheumatology. 2019 Jan 7;     [PubMed PMID: 30620274]
[3] de Miguel E,Monjo I, Response to: A Comparative Study of Doppler Ultrasound Against Temporal Artery Biopsy in the Diagnosis of Giant Cell Arteritis. Reumatologia clinica. 2018 Dec 23;     [PubMed PMID: 30587463]
[4] Macchioni P,Boiardi L,Muratore F,Restuccia G,Cavazza A,Pipitone N,Catanoso M,Mancuso P,Luberto F,Giorgi Rossi P,Salvarani C, Survival predictors in biopsy-proven giant cell arteritis: a northern Italian population-based study. Rheumatology (Oxford, England). 2018 Dec 4;     [PubMed PMID: 30517710]
[5] Conway R,Smyth AE,Kavanagh RG,O'Donohoe RL,Purcell Y,Heffernan EJ,Molloy ES,McNeill G,Killeen RP, Diagnostic Utility of Computed Tomographic Angiography in Giant-Cell Arteritis. Stroke. 2018 Sep;     [PubMed PMID: 30354972]
[6] Ing EB,Ing R, The Use of a Nomogram to Visually Interpret a Logistic Regression Prediction Model for Giant Cell Arteritis. Neuro-ophthalmology (Aeolus Press). 2018 Oct;     [PubMed PMID: 30258473]
[7] Braun J,Baraliakos X,Fruth M, The role of 18F-FDG positron emission tomography for the diagnosis of vasculitides. Clinical and experimental rheumatology. 2018 Sep-Oct;     [PubMed PMID: 30296989]
[8] Sammel AM,Fraser CL, Update on giant cell arteritis. Current opinion in ophthalmology. 2018 Nov;     [PubMed PMID: 30138144]