Temporal Artery Duplex Ultrasound or Biopsy for the Diagnosis of Giant Cell Arteritis: Which one? Why? and Why Bother?
Alexander Varzari, Jonathan Swisher, MD, Christine Ou, DO, David Dexter, MD, Animesh Rathore, MD, Jean Panneton, MD.
Eastern Virginia Medical School, Norfolk, VA, USA.
Objectives: The gold standard diagnostic modality for temporal arteritis (TA) is temporal artery biopsy (TAB) before initiation of steroid therapy. Literature supports TA duplex ultrasound (DUS) as a replacement for TAB. We sought to evaluate the clinical practice patterns for diagnosis and treatment of TA in a large multispecialty group.
Methods: Our retrospective multicenter study analyzed any adult (>17 years) patient who underwent temporal DUS or TAB from March 18, 2011 to June 28, 2017. Any patients diagnosed or treated without either test were excluded. Statistical analysis was carried out using SPSS (IBM Armonk, NY).
Results: We identified 398 unique patients who underwent DUS or TAB. There were 285 female (71.6%) and 113 male patients (28.4%) with ages ranging from 28 to 94 (mean 69). The most common clinical indications for testing were headache (70.1%), ESR>50 (32.7%), visual changes (34.4%) and temporal pain (12.3%).
A total of 330 patients (82.9%) received DUS, with 20 positive (6.1%) and 310 (93.9%) negative ultrasounds. Of these, 15 of 20 (75%) positive and 82 of 310 (26.5%) negative studies received treatment with prolonged steroids (P<0.01). A total of 110 patients (27.6%) underwent TAB, resulting in 18 positive tests (16.4%). Of these, 13 of 18 positive (72.2%) and 49 of 92 negative biopsy patients (53.3%) were treated with steroids (P=0.138).
Forty-two patients (10.2%) underwent both TAB and a DUS. Of those, we identified 9 positive ultrasounds and 4 positive biopsies. Only 2 patients had both a positive DUS and positive biopsy (P=0.143). We identified 11 patients (26.2%) who had either DUS or TAB positive and 31 patients (73.8%) with both studies negative. In patients who had both studies, either study being positive lead to steroid treatment in 8 of 11 patients (72.7%). Two negative studies lead to treatment in 13 of 31 cases (41.9%) (P=0.079).
Conclusions: We challenge the impact of DUS and TAB in the diagnoses and management of TA. We found that despite negative test results physicians chose to continue steroid therapy in a large cohort of patients. We justify DUS as the primary diagnostic modality over biopsy for its noninvasive nature and comparable impact on clinical decisions. Further study of the clinical practices of TA is needed to truly determine the best diagnostic strategy for this disease.
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