Biopsy of the Parietal Branch of the Superficial Temporal Artery for the Diagnosis of Giant Cell Arteritis

Biopsy of the superficial temporal artery (STA) is central to the diagnosis of giant cell arteritis (GCA), but determining the ideal biopsy site along the course of the STA continues to be a challenge. Traditionally, the frontal branch or preauricular region of the STA is biopsied because of their accessibility, but biopsy at these locations can produce visible cosmetic defects and social disruption that can be distressing to patients, as well as increase the likelihood of adverse events such as injury to the facial nerve. The authors describe a surgical technique of biopsy of the parietal branch of the STA to improve the patient's perioperative and postoperative experience.

Surgeons’ Corner Section Editor: Michael J. Gilhooley, MA, MB, BChir, DPhil Biopsy of the Parietal Branch of the Superficial Temporal Artery for the Diagnosis of Giant Cell Arteritis Ebby Elahi, MD, MBA, FACS, Evan E. Afshin, MD, Susan Zoltan, MD, FACS, Karen Y. Hu, MD Background: Biopsy of the superficial temporal artery (STA) is central to the diagnosis of giant cell arteritis (GCA), but determining the ideal biopsy site along the course of the STA continues to be a challenge. Traditionally, the frontal branch or preauricular region of the STA is biopsied because of their accessibility, but biopsy at these locations can produce visible cosmetic defects and social disruption that can be distressing to patients, as well as increase the likelihood of adverse events such as injury to the facial nerve. The authors describe a surgical technique of biopsy of the parietal branch of the STA to improve the patient’s perioperative and postoperative experience. Methods: In this retrospective review, 24 patients with clinical suspicion of GCA who underwent biopsy of the parietal branch of the STA were identified. Patients underwent mapping of the branches of the STA with Doppler ultrasound before the procedure. Biopsy of the parietal branch of the STA was conducted using a CO2 laser. Results: Twenty-four patients underwent biopsy of the parietal branch of the STA. Two patients were diagnosed on histopathology with GCA. All patients tolerated the procedure well and without complications. Conclusion: Application of preoperative Doppler ultrasound mapping, use of a CO2 laser for incisions and hemostasis, and selection of the parietal branch allowed for improved cosmetic outcomes, no associated adverse events, and improved overall patient experience. The authors advocate biopsy of the parietal branch of the superficial temporal artery for the diagnosis of GCA in the absence of contraindications. Journal of Neuro-Ophthalmology 2023;43:e41–e44 doi: 10.1097/WNO.0000000000001631 © 2022 by North American Neuro-Ophthalmology Society Department of Ophthalmology (EE, SZ), Icahn School of Medicine at Mount Sinai, New York, New York; Department of Otolaryngology (EE), Icahn School of Medicine at Mount Sinai, New York, New York; Department of Environmental Medicine and Public Health (EE), Icahn School of Medicine at Mount Sinai, New York, New York; Department of Physiology and Biophysics (EEA), Weill Cornell Medicine, New York, New York; Illinois Eye and Ear Infirmary, Department of Ophthalmology and Visual Sciences, University of Illinois, Chicago, Illinois. The authors report no conflicts of interest. Address correspondence to Ebby Elahi, MD, MBA, FACS, Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, 1034 Fifth Avenue, New York, NY 10028; E-mail: [e-mail] Elahi et al: J Neuro-Ophthalmol 2023; 43: e41-e44 G iant cell arteritis (GCA) is the most common vasculitis of medium-sized and large-sized arteries, typically affecting individuals around age 70 years with a greater prevalence in women and individuals of Northern European descent (1). GCA can be vision-threatening and lifethreatening because it displays a tissue tropism for the external carotid artery and its branches, including the posterior ciliary arteries that supply blood to the optic nerve. Superficial temporal artery (STA) biopsy remains the most specific diagnostic test and the gold standard for diagnosis of GCA (2) and is a minimally invasive, well-tolerated procedure that is typically performed on an outpatient basis. Complications are relatively uncommon and include scarring, hematoma, wound infection and dehiscence, facial nerve injury, and, extremely rarely, blindness and cerebrovascular accident (3). Traditionally, the frontal branch or preauricular segment of the STA is biopsied because they are anterior to the hairline and often covered by only a thin layer of subcutaneous fat, increasing ease of access (4). However, this can produce visible scars, resulting in an unpleasant postoperative experience for patients, and increase the risk of injury to the facial nerve and brow ptosis (4–6). Moreover, cadavers demonstrating atrophic or absent frontal branches (7) and patients with stenotic collateral vessels (8) have been documented in the literature, and the frontal branch is often absent or diminished in patients who have undergone previous procedures (such as a rhytidectomy) in the temporal region of the face. Here, the authors present their experience with biopsy of the parietal branch of the STA, demonstrating a broadly applicable technique with excellent cosmetic outcomes. METHODS A retrospective chart review was performed on patient records. Patients were recruited and treated in a private practice setting, and as such, this study was determined to be exempt from an IRB. All research adhered to the tenets e41 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Surgeons’ Corner of the Declaration of Helsinki. Collection and evaluation of protected health information were compliant according to HIPAA. All patient photographs have signed consent by the patient, which have been archived by the authors. Surgical Technique A handheld Doppler ultrasound is used to identify and map the STA through the frontal and parietal branches on the side of the patient’s predominant symptoms (Fig. 1A). An electric shaver is used to shorten the hair along the course of the parietal branch. Local anesthesia is obtained by injecting 0.5 cc of lidocaine 1% with epinephrine with 1:10 parts of bicarbonate and ropivacaine using a blunt cannula (STERiGLIDE, TSK) to avoid sharp injury to the vessel (Fig. 1B). The area is prepped with a clear chlorhexidine solution and isolated with a 1,020 drape (3M, VJD501). The surgery is performed using wide-field loupes. An incision is made through the skin and dermis with a CO2 laser at 5 W continuous pulse to expose the tissue superficially to the STA (Fig. 1C). Further hemostasis is obtained with bipolar cautery if necessary. The vessel is dissected bluntly with opposing cotton tip applicators and tied on all ends with interrupted 4-0 silk sutures (Fig. 1D). A segment of tied vessel—at least 1 cm in length—is cut and sent in formalin for a pathologic assessment. The wound is closed internally with interrupted 4-0 Vicryl Rapide (Ethicon) sutures and externally with skin adhesive (Dermabond, Ethicon) or running 5-0 Prolene (Ethicon) sutures and covered with bacitracin or SteriStrips. Patients are discharged on the same day. RESULTS Between January 2014 and June 2021, 24 patients underwent a biopsy of the parietal branch of STA for suspicion of GCA. Table 1 summarizes the patient demographic information. There were 8 male patients and 16 female patients. The mean age at surgery was 75 years. The parietal branch of the STA was identified in all cases. Two patients were diagnosed with GCA on histopathology. All patients reported temporal headache or scalp tenderness, and 42% of the patients reported eye pain or visual disturbances. Fifty percent of the patients presented with an American College of Rheumatology (ACR) classification criteria score of 2 and 50% presented with a score of 3. All surgical sites healed normally, without infection, significant pain, hematoma formation, wound dehiscence, or excessive scarring. Patients reported satisfaction with the lack of scarring visible anterior to the hairline. No cases of GCA were missed following evaluation of clinical records. DISCUSSION Superficial temporal artery biopsy remains central to the diagnosis of GCA, and physicians have long sought ways to improve biopsy yield and decrease complications. Through this novel approach with biopsy of the parietal branch, the authors attempt to (1) minimize complications, (2) improve the patient’s perioperative experience by creating a less visible wound and subsequent scarring, (3) preserve the use of STA biopsy for those patients who have an absent or diminished FIG. 1. Parietal superficial temporal artery biopsy approach. Intraoperative photographs demonstrating (A) use of a handheld Doppler ultrasound to identify and map the superficial temporal artery, (B) local anesthesia is obtained by injecting 0.5 cc of lidocaine 1% with epinephrine with 1:10 parts of bicarbonate and ropivacaine using a blunt cannula, (C) an incision through the skin and dermis with a CO2 laser at 5 W continuous pulse, and (D) isolation of the parietal branch of the left superficial temporal artery with minimal blood loss. e42 Elahi et al: J Neuro-Ophthalmol 2023; 43: e41-e44 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Surgeons’ Corner TABLE 1. Patient demographics Age at Sx Gender Comorbidities Steroids Before Biopsy 1 2 68 93 M F None None Yes Yes 3 83 F HTN 4 5 6 83 70 75 F M F 7 8 92 78 M F None Hypothyroidism Sjogren, scleroderma, and fibromyalgia HTN HTN and asthma Yes 9 74 F None 10 75 F 11 71 M 12 76 F 13 14 15 86 75 78 F M F 16 17 58 81 M M DM, HLD, and hypothyro idism Pericarditis and prostate Ca HTN, HLD, and lung Yes Ca HTN and DM CAD, HLD, and afib Yes HLD, HTN, migraine, No and OA HTN and gout No DM, HTN No 18 89 F 19 58 M 20 70 F 21 60 F HTN, migraine, and torn vertebral artery HTN, HLD, DM, afib, and renal disease DM, brain aneurysm, OA, and asthma None 22 23 60 77 F F HLD and ovarian ca None Yes Yes 24 63 F HTN, HLD, OA, and seizures No No No Yes No Presenting Symptoms L temporal headache and eye pain R temporal headache and visual disturbance R scalp tenderness and temporal headache R temporal headache L scalp tenderness and headache L scalp tenderness and headache ACR Criteria Biopsy Biopsy Adverse Score Side Result Events 2 2 L R Negative None Negative None 3 R Negative None 3 2 2 R L L Negative None Negative None Negative None L scalp tenderness and headache L temporal headache, scalp tenderness, and visual disturbances R temporal headache, eye pain, and visual disturbance L temporal headache 2 3 L L Negative None Positive None 3 R Negative None 2 L Negative None L eye pain and visual disturbances 3 L Negative None L temporal headache and eye pain 3 L Negative None R scalp tenderness and headache L scalp tenderness and headache L temporal headache, eye pain, and visual disturbance L temporal headache R temporal headache, visual disturbance L temporal headache 3 2 3 R L L Negative None Negative None Negative None 2 3 L R Negative None Positive None 3 L Negative None 2 L Negative None 3 L Negative None 2 R Negative None 2 3 R L Negative None Negative None 2 L Negative None L scalp tenderness and temporal headache L temporal headache and occipital headache R scalp tenderness and visual disturbance R scalp tenderness and headache L scalp tenderness and headache and fever L temporal headache, scalp tenderness, and eye pain Summary of patient demographic information. frontal branch (7) and (4) minimize interference with possible future surgeries (8) by biopsy of the parietal branch of the STA. Recent studies have shown an emerging understanding of GCA as a heterogeneous disease that is both more widespread and more varied in presentation than initially believed (9), with documented cases of GCA where histological inflammation is being confined to the frontal (10,11) or parietal branch (12) while sparing the other or confined to other arteries while Elahi et al: J Neuro-Ophthalmol 2023; 43: e41-e44 sparing the STA entirely (13). For example, Bley et al demonstrated heterogeneity of branch involvement using MRI imaging, a technology which could be valuable in directing biopsyrelated decision-making in the future (13). Based on the diversity of affected vessels in the literature, it seems that consistent biopsy of 1 branch alone will not result in an ideal yield, but we are not aware of any studies that rigorously characterize the prevalence of GCA in the different branches of the STA. As e43 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Surgeons’ Corner such, we agree with Kyung et al, who advocate further study in this area to guide the development of biopsy conventions (10). Until such information is available, it remains that expert clinical judgment must be applied on a case-by-case basis regarding whether to proceed with a STA biopsy and if determined to do so, which side, artery, and length should be biopsied (12). For instance, in patients with a history of rhytidectomy, it may be difficult to localize the parietal branch. The authors advocate biopsy of the parietal branch of the STA where clinically applicable because it results in an improved patient experience from a cosmetic, emotional, and social standpoint and diminishes the probability of adverse effects such as damage to the facial nerve. In addition, we encourage further research in imaging technology that would facilitate preoperative identification of involved arterial segments. We believe these advances will help maximize biopsy yield and improve patient experiences. The authors recognize the limitations of the study which is retrospective in nature and involves a small number of cases without standardized controls. A larger prospective study is likely necessary to confirm our conclusions. STATEMENT OF AUTHORSHIP Conception and design: E. Elahi; Acquisition of data: E. E. Afshin, K. Hu; Analysis and interpretation of data: E. E. Afshin, E. Elahi; Drafting the manuscript: E. E. Afshin, K. Hu; Revising the manuscript for intellectual content: E. Elahi, S. Zoltan; Final approval of the completed manuscript: E. Elahi, E. E Afshin, S. Zoltan, K. Hu. e44 REFERENCES 1. Stamatis P. Giant cell arteritis versus takayasu arteritis: an update. Mediterr J Rheumatol. 2020;31:174–182. 2. Frohman L, Wong AB, Matheos K, Leon-Alvarado LG, DaneshMeyer HV. New developments in giant cell arteritis. Surv Ophthalmol. 2016;61(4):400–421. 3. Schlezinger NS, Schatz NJ. 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