Can a temporal artery biopsy (TAB) be performed now to rule out giant cell arteritis (GCA) in a patient who had an ischemic cerebrovascular accident (CVA) 2 weeks ago and underwent subclavian stent placement?

From the Guidelines

Yes, a temporal artery biopsy (TAB) can be performed now to rule out giant cell arteritis (GCA) in a patient who had an ischemic cerebrovascular accident 2 weeks ago and underwent subclavian stent placement. The procedure is generally safe even in patients with recent cerebrovascular events and vascular interventions. However, the patient's antiplatelet or anticoagulation therapy (likely prescribed after the CVA and stent placement) should be carefully managed in consultation with the vascular surgeon and neurologist, as suggested by the 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of giant cell arteritis and Takayasu arteritis 1. Typically, aspirin can be continued during the biopsy, but more potent agents like clopidogrel or anticoagulants may need temporary adjustment. The biopsy should be performed as soon as possible, ideally within 2 weeks of starting corticosteroid treatment for suspected GCA, as treatment can alter the histopathological findings, according to the 2021 guideline 1. If GCA is strongly suspected clinically, treatment with prednisone (typically 40-60mg daily) should not be delayed while waiting for the biopsy, as emphasized in the 2024 EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice: 2023 update 1. The TAB procedure is minimally invasive, performed under local anesthesia, and complications are rare. The recent subclavian stent does not directly interfere with the temporal artery biopsy as they involve different vascular territories. Key considerations include:

• Careful management of antiplatelet or anticoagulation therapy
• Performance of the biopsy as soon as possible, ideally within 2 weeks of starting corticosteroid treatment
• Not delaying treatment with prednisone if GCA is strongly suspected clinically
• The use of imaging tests, such as ultrasound or MRI, may support the clinical diagnosis of GCA, but TAB is also an adequate option, particularly when imaging is not readily available or expertise with imaging in GCA is insufficient, as stated in the 2024 EULAR recommendations 1. It is essential to follow the most recent guidelines, such as the 2024 EULAR recommendations 1 and the 2021 American College of Rheumatology/Vasculitis Foundation guideline 1, to ensure the best possible outcome for the patient.

From the Research

Temporal Artery Biopsy (TAB) for Giant Cell Arteritis (GCA) Diagnosis

• The decision to perform a TAB to rule out GCA in a patient who had an ischemic CVA 2 weeks ago and underwent subclavian stent placement should be based on clinical grounds and the patient's overall condition 2, 3.
• Studies suggest that TAB is not required in all cases of suspected GCA, and treatment is often started based on clinical findings, with TAB results frequently not influencing patient management 2.
• The American College of Rheumatology (ACR) criteria for GCA can help identify patients who may benefit from TAB, with a prebiopsy ACR score of 2 or 3 indicating a potential benefit from the procedure 2.

Clinical Predictors of TAB Results

• Clinical predictors of TAB results, such as temporal artery thickening, decreased pulse, jaw claudication, and scalp tenderness, can help improve the effectiveness of the diagnostic procedure 4.
• A study found that excluding patients with no evidence of temporal artery abnormalities, scalp tenderness, or jaw claudication could lead to a decrease in the percentage of negative biopsies 4.

Timing and Technique of TAB

• The timing of TAB is crucial, with a recommendation to perform the procedure within 1 week of starting corticosteroid therapy to reduce the false-negative rate 5.
• The length of the temporal artery specimen is also important, with a recommended length of 20-30 mm and preparation of serial pathological sections to improve the sensitivity of the procedure 5.

Alternative Diagnostic Methods

• Non-invasive vascular imaging technologies, such as DUS, CTA, MRA, and 18F-FDG-PET/CT, may be used as auxiliary methods for GCA diagnosis and could potentially replace TAB in some cases 5.
• However, TAB remains the gold standard method for diagnosing GCA, with a specificity of 100% and a sensitivity of 77% 5.