Screening for

Giant Cell Arteritis in the

Vascular LaboratoryMOLLY ZACCARDI MHA, RVT

D.E. STRANDNESS VASCULAR LABORATORY

UNIVERSITY OF WASHINGTON MEDICAL CENTER

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Giant Cell Arteritis (GCA) is an inflammatory

vasculopathy affecting medium and large- sized

arteries.

Referred to as temporal arteritis – often affects branches

of the carotid artery.

Superficial temporal artery branch is particularly

susceptible to inflammation of the vessel wall.

TA is among the most common causes of acute

blindness due to inflammation and blockage of blood

vessels that supply the main nerve of the eyes

GCA/TA is a medical emergency

Blindness occurs in 1/5 of patients with GCA

3Giant Cell Arteritis

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5Normal artery Giant cell arteritis

E. Jernberg

Demographics:

Elderly patients

Female > male

Northern European

Giant Cell Arteritis

GCA / TA is difficult to diagnose

10-20% False negative biopsies

skip lesions or

being treated with steroids

Delay of treatment >6 days can result in blindness

Treatment is corticosteroids-unpleasant side effects

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Dr. Diamantopoulos’ question

Is there a better way to diagnose and follow up 7

Giant Cell Arteritis8

Bucerius J, Q J Nucl Med Mol Imaging 2016, Mossa Basha M, Stroke 2015, Arida A, BMC Musculoskeletal Disorders 2010,Karassa FB, Ann Int Med 2005, Diamantopoulos AP Arthritis Care Res 2014

Norway Data

Giant Cell Arteritis9

Giant Cell Arteritis10

Giant Cell Arteritis

DISADVANTAGES OF ULTRASOUND

Operator dependent- not universally reproducible

Imaging is dependent on transducer selection

Sensitivity and specificity reduces quickly after introduction of treatment (>4 days: US 50% and MRI 56% )

Hauenstein C, Rheumatology (Oxford) 2012

Giant Cell Arteritis12

Include IMT measurement

Add other susceptible vessels

Sensitivity Specificity

Temporal artery evaluation 96% 90%

Temporal

Axillary /subclavian arteries98% 91%

Temporal

Axillary /subclavian arteries

Carotid arteries

100% 95%

13Pathology

Temporal Artery

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Temporal Artery

Pathology

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Axillary ArteryCourtesy Dr S Chrysidis

Pathology

Schäfer VS, et al. Ann Rheum Dis 2016 (Abstract FRI0393)

Artery N IMT in mm

Cut-off

in mm

Sensitivity Specificity Correctly

classified

Common

superficial

temporal artery

40 C: r. 0.23 (SD 0.03)

l. 0.23 (SD 0.04) r. 0.42

l. 0.45

100 %

100 %

100 %

100 %

100 %

100 % 28 P: r. 0.66 (SD 0.18)

l. 0.65 (SD 0.19)

Frontal branch 40 C: r. 0.19 (SD 0.03)

l. 0.19 (SD 0.04) r. 0.35

l. 0.34

100 %

100 %

100 %

100 %

100 %

100 % 26 P: r. 0.53 (SD 0.19)

l. 0.55 (SD 0.18)

Parietal branch 40 C: r. 0.19 (SD 0.03)

l. 0.20 (SD 0.03) r. 0.32

l. 0.29

100 %

94.4 %

100 %

100 %

100 %

98.3 % 23 P: r. 0.51 (SD 0.18)

l. 0.48 (SD 0.16)

Facial artery 40 C: r. 0.24 (SD 0.05)

l. 0.23 (SD 0.05) r. 0.37

l. 0.40

92.3 %

81.8 %

100 %

97.5 %

98.1 %

94.1 % 15 P: r. 0.55 (SD 0.19)

l. 0.51 (SD 0.19)

Axillary artery 40 C: r. 0.59 (SD 0.10)

l. 0.59 (SD 0.10) r. 1.1

l. 1.0

100 %

100 %

100 %

100 %

100 %

100 % 26 P: r. 1.80 (SD 0.41)

l. 1.62 (SD 0.39)

0.4 mm

0.35 mm

0.3 mm

0.4 mm

1.0 mm

IMT Criteria

Temporal Artery-Anatomy

Lumen Vessel wall Vmax

mm mm cm/s

Parietal 0.8 0.7 57

Frontal distal 0.8 0.7 54

(> 2 cm fra bifurcation)

Frontal proximal branch 0.7 0.7 52

(< 2 cm fra bifurcation)

Common superficial 1.7 59

Schmidt WA, et al. N Engl J Med 1997;337:1336-42

T Parietalis

Facialis transv

Carotis interna

A. Occipitalis

T frontalis

Temporalis com

Carotis externa

Facialis

Examination Technique

Diamantopoulos AP: Ultrasound in Vasculitis. In: Musculoskeletal Ultrasound Review. Springer 2016

Examination Technique

Common temporal artery

Parietal temporal artery

Examination Technique

Diamantopoulos AP: Ultrasound in Vasculitis. In: Musculoskeletal Ultrasound Review. Springer 2016

Frontal temporal artery

Diamantopoulos AP: Ultrasound in Vasculitis. In: Musculoskeletal Ultrasound in Rheumatology. Springer 2016, in print

Examination Technique

Occipital artery

Examination Technique

Diamantopoulos AP: Ultrasound in Vasculitis. In: Musculoskeletal Ultrasound Review. Springer 2016

Facial artery

Carotid

Examination Technique

Assess for stenosis in the

common, internal, external

and vertebral

Measure IMT in the

common carotid and

proximal internal carotid

Diamantopoulos AP: Ultrasound in Vasculitis. In: Musculoskeletal Ultrasound Review. Springer 2016

Examination Technique

Axillary and

Subclavian arteries

The examination should be continued distally until the

brachial artery is visible in the

upper arm

Measure peak systolic

velocities (PSV)and intima

media thickness (IMT)

Diamantopoulos AP: Ultrasound in Vasculitis. In: Musculoskeletal Ultrasound Review. Springer 2016

Fast Track Clinic

Diagnosis and follow up

Dr. Diamantopoulos

performs ultrasound

exams at each clinic

visit.

May decrease steroids

if patient is stable or in

remission.

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Giant Cell Arteritis and

The UWMC Experience 27

5 patients with known TA

4 vendors with range of transducer frequencies

12 MHz

15 MHz

22 MHz

24 MHz

40 MHz

70 MHz

RVT’s practiced scanning temporal artery branches

Giant Cell Arteritis and

The UWMC Experience 28

Invited 5 patients with known TA

Had 4 vendors with range of transducer frequencies

12 MHz

15 MHz

22 MHz

24 MHz

40 MHz

70 MHz

Vascular Technologists practiced scanning temporal artery branches

Summary-

Screening for Giant Cell Arteritis

With proper equipment, Vascular Laboratories have a role

Diagnose Giant Cell Arteritis

Follow up and monitor treatment

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Many of the slides in this presentation were

borrowed from Andreas Diamantopoulous, MD and Elizabeth Jernberg, MD

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Thank you for your attention