Temporal arteritis Information for patients from the Vascular Surgery Service This leaflet tells you about an autoimmune disease known as temporal arteritis (TA) which is a sub-type of giant cell arteritis (GCA). What is temporal arteritis? Autoimmune diseases are conditions in which our white blood cells mistakenly attack our own cells instead of bacterial or virus cells. Arteritis and vasculitis are terms used when arteries become inflamed due to this immune attack or from other causes. In arteritis, the cells attacked are in our arteries and, in GCA, particularly those large central arteries closest to the heart. In TA, the arteries that run across our temples are involved. The inflammation causes the artery walls to swell which narrows the channel for blood to flow and can cause blockage of affected arteries. Blocked arteries can cause loss of blood supply to the tissues involved resulting in serious problems such as, in TA, loss of blood supply to the eye causing blindness. What causes GCA and TA? The exact cause of GCA and TA is not known but it affects up to one in 5000 people over 50 years of age per year and is the commonest type of vasculitis at this age. This adds up to around one in 360 of those over 50 years and becomes commoner with increasing age. It is two to three times commoner in women. Around half of those with GCA will also have symptoms of polymyalgia rheumatica, a condition causing muscle pain and stiffness again due to inflammation. However, polymyalgia is commoner so only one in five with this condition also develops GCA. 1
What are the symptoms of TA/GCA? To diagnose GCA can be challenging because symptoms can be mild or absent and not occur until late in the course of the disease. Furthermore, the list of possible symptoms is confusingly long. Common symptoms include: low grade temperature a new headache, especially over the temples pain in the jaw muscles while chewing scalp tenderness, especially over the temples swollen arteries over the temples disturbances of vision, such as a curtain in the field of vision, double vision, or loss of vision poor appetite and weight loss aching and stiffness of shoulders and hips. Less common symptoms include: cramping or aching in the arms or legs when exercising, relieved by resting dry cough or sore throat stroke-like symptoms hearing your own pulse in the neck, armpits, or groins widening of arteries called aneurysm, including of the main aorta. How is TA/GCA diagnosed? Diagnosis is based on the symptoms and an examination looking for the features above supported by laboratory tests. The tests include blood tests called ESR and CRP to look for inflammation and a biopsy of the temporal artery showing inflammation. If bruits (noisy blood flow heard in a stethoscope) or reduced or absent pulses are found, special pictures of the arteries called an angiogram with either CT or MRI can sometimes be helpful. A positive temporal artery biopsy is the gold standard, meaning that a small operation is needed though the condition is usually managed by medical doctors rather than surgeons. How is TA/GCA treated? Like all inflammatory conditions, TA/GCA is treatable with steroids (usually prednisolone) which damp down inflammation. A small daily dose of 75mg aspirin can also help to keep the arteries flowing. It is usual to need up to two years of the drug treatment, sometimes longer. Other drugs can also be used to decrease the immune attack if required and research may bring further new treatments in the future. With treatment, people suffering from GCA or TA usually have a normal life expectancy unless one of the major arteries swells and ruptures before the diagnosis is made. Having a positive biopsy is helpful because doctors are reluctant to prescribe steroids without good reason due to their side effects. These include weight gain, diabetes, blood pressure, thinning of the bones and skin, cataracts, and psychiatric problems, amongst others. However, because of the potentially serious consequences of the disease, steroids are usually started as soon as the diagnosis is suspected and before a biopsy can be arranged. Biopsy needs to be done as soon as possible because the chance of a positive result drops quickly after only a couple of weeks on steroids. 2
What is a temporal artery biopsy? This is a small operation to remove a 2cm piece of a temporal artery for investigation in the pathology department to examine for inflammation under a microscope. It is usually done under local anaesthetic, an injection in the skin over the artery to make this numb and painless, and we may need to shave a little hair from the temple. What happens before the biopsy? Before the operation can begin, your surgeon will explain the procedure and make sure that you have been informed of the risks and benefits before asking you to sign a consent form giving permission to proceed. You need to make no special preparations and so should eat and drink as normal. You should take any medications as usual unless specifically asked to stop, for example, blood thinners such as warfarin which you will start again after the operation. How long will the biopsy take? You will go home just an hour or so after the surgery which usually takes only 30 to 60 minutes, occasionally longer if the artery is difficult to find. What happens during the biopsy? Once in the operating theatre, when the skin is numb and has been cleaned with antiseptic, a cut is made along the artery on the temple sufficient to remove the necessary 2cm piece. The cut ends of the artery left behind are tied off (ligated) to prevent bleeding and the cut skin is closed with a buried, dissolvable suture before a simple adhesive dressing is applied. Then you are returned to the ward and can have refreshments, if desired, before going home. What happens after the biopsy? It is a good idea to have someone to help you home as some can feel shaky even after a simple operation. Once at home, you should continue with life as normal, including taking your medications and the prednisolone, but taking care when washing your face and hair for a week or so until the cut has healed. The result from the laboratory is sent to the original doctor who first saw you and the surgeon will have no further involvement. How will I feel after the procedure? The cut is not usually very painful afterwards but you should take a mild painkiller, such as paracetamol, if needed for this or any headache. 3
What are the risks of the operation? Temporal artery biopsy is generally a safe procedure but, like all medical interventions, carries a small risk of complications and will leave a scar. Possible complications include: wound infection - if the wound becomes more red and swollen or develops a discharge, you may need an antibiotic from your doctor bleeding may happen soon after or later with an infection and should be controlled by applying pressure then a clean dressing once stopped; blood-thinning drugs, such as aspirin, clopidogrel, warfarin, or other anticoagulants make this more likely nerve injury temporary or permanent damage to unseen nerves around the temple which can produce numbness or a drooping brow, this is rare. Are there alternatives to biopsy? There are no other current tests which can definitively make this important diagnosis so, without a positive biopsy, your doctor will need to decide with you whether or not to take the prednisolone and accept its side effects regardless of the absence of proof of the condition. Where can I get more information? Vasculitis Foundation - www.vasculitisfoundation.org Useful numbers and contacts If you have any questions or concerns, please contact one of the following: during the working day, first try the vascular nurse or, if unable to get through or out of hours ask the hospital switchboard for the vascular registrar on call. Vascular Nurse Practitioners, K&C Telephone: 01227 864137 (in working hours) Email: ekh-tr.vascular-nurse@nhs.net Kent and Canterbury Hospital (K&C) Telephone: 01227 766877 (out of hours for Registrar on call) Kent (Vascular) Ward, K&C Telephone: 01227 783102 4
Any complaints, comments, concerns, or compliments If you have other concerns please talk to your doctor or nurse. Alternatively please contact our Patient Advice and Liaison Service (PALS) on 01227 783145 or 01227 864314, or email ekh-tr.pals@nhs.net Further patient information leaflets In addition to this leaflet, East Kent Hospitals has a wide range of other patient information leaflets covering conditions, services, and clinical procedures carried out by the Trust. For a full listing please go to www.ekhuft.nhs.uk/patientinformation or contact a member of staff. After reading this information, do you have any further questions or comments? If so, please list below and bring to the attention of your nurse or consultant. Would you like the information in this leaflet in another format or language? We value equality of access to our information and services and are therefore happy to provide the information in this leaflet in Braille, large print, or audio - upon request. If you would like a copy of this document in your language, please contact the ward or department responsible for your care. Pacjenci chcący uzyskać kopię tego dokumentu w swoim języku ojczystym powinni skontaktować się z oddziałem lub działem odpowiedzialnym za opiekę nad nimi. Ak by ste chceli kópiu tohto dokumentu vo vašom jazyku, prosím skontaktujte nemocničné pracovisko, alebo oddelenie zodpovedné za starostlivosť o vás. Pokud byste měli zájem o kopii tohoto dokumentu ve svém jazyce, kontaktujte prosím oddělení odpovídající za Vaši péči. Чтобы получить копию этого документа на вашем родном языке, пожалуйста обратитесь в отделение, ответственное за ваше лечение. We have allocated parking spaces for disabled people, automatic doors, induction loops, and can provide interpretation. For assistance, please contact a member of staff. This leaflet has been produced with and for patients Information produced by the Vascular Surgery Service Date: December 2016 Review date: April 2019 Web 353 5