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Show Journal of Clinical NCliro- ophthal", ology 11( 3): 202- 204, 1991. Superficial Temporal Artery Biopsy A Simplified Technique Robert L. Tomsak, M. D., ph. D. © 1991 Raven Press, Ltd., New York A simplification of the method for superficial temporal artery biopsy is presented. The main trunk of the artery is taken preferentially because of its more constant anatomic location. An improvement in the technique for performing the subcutaneous dissection is also discussed. Key Words: Superficial temporal artery biopsyTemporal arteritis-- Giant cell arteritis. From the Division of Neuro- ophthalmology, University Hospitals of Cleveland, and Departments of Ophthalmology and Neurology, Case Western Reserve University School of Medicine, Cleveland, Ohio, U. s. A. Address correspondence and reprint requests to Dr. R. Tomsak, 2074 Abington Road, Lakeside 3200A, Cleveland, OH 44106, U. S. A 202 The diagnosis of giant cell ( or temporal) arteritis is made unequivocally by a positive superficial temporal artery ( STA) biopsy ( 1,2). Superficial temporal artery biopsy seems to be a deceptively simple procedure ( 3- 5). Most experts recommend taking the frontal branch of the artery ( 3,4,6); however, all too often the frontal branch of the artery is difficult to locate if it is not palpable or visible ( 6), and its location sometimes requires the use of Doppler instrumentation ( 7,8). In about 16% of cases, the frontal branch is atrophic or absent ( 9), and after local anesthesia is given, the local anatomy of the STA is often distorted- especially if a hematoma occurs subcutaneously following the injection. Lastly, if the incision is carried deep into the temporalis muscle and bypasses the artery on the way down, the correct level for creating a horizontal plane of dissection is often difficult to choose. By approaching the main trunk of the artery using a controlled superficial dissection technique and loupe magnification the STA biopsy is simple and safe. TECHNIQUE 1. The course of the main trunk of the STA is marked with a pen or dye after the area has been shaved for exposure. Beginning approximately 1 em in front of the mid- tragus of the ear, the mark is carried up, curving slightly forward for a distance of at least 3 em. This area is chosen because of the anatomy of the vessel in this region, which is quite constant [ Fig. 1 ( 9)]. 2. Two to 4 cc of 1% or 2% Xylocaine with 1: 200,000 epinephrine are slowly infiltrated adjacent and parallel to the mark, using a long 25or 27- gauge needle. A slow injection results in less discomfort. 3. The area is prepared and draped, taking care SUPERFICIAL TEMPORAL ARTERY BIOPSY 203 FIG. 2. Blade is used just until subcutaneous fat is encountered. DISCUSSION holed with blunt Wescott scissors ( Fig. 5). The fascial incision is extended to visualize fully the artery and the superficial temporal vein ( STV), which usually runs with the STAin this location. Diseased arteries often look thick, pale, and rope- like. Healthy arteries are pink, but clearly cylindrical and usually measure about 3 mm in diameter in this area ( 9). The vein always looks deep purple. The wall of the vein is very friable and care should be taken to dissect it free before isolating the artery ( Fig. 6). 9. The lower end of the STA and its upper bifurcation point, if exposed, are ligated with 4- 0 single silk ties. After excision of the arterial segment, the remaining ends are cauterized before closing the skin. 10. Wound closure is done with subcutaneous interrupted 5- 0 Vicryl; 6- 0 mild chromic interrupted sutures are used to close the skin. The wound is dressed with an antibiotic ointment like Neosporin followed by a large Band- Aid or small Telfa pad. A pressure dressing is not needed. The main advantage of the STA biopsy technique described above is ease of identification and FIG. 4. Hemostat with tips curving up is tunneled below subcutaneous fat, but above the superficial temporalis fascia. After lifting and spreading, the incision is extended with a blade. FIG. 3. Mosquito hemostat is held vertical and perpendicular to the incision. Blunt dissection is carried to the level of the superficial temporalis muscle fascia. ( '~ I not to wipe away the mark line. 4. Operating loupes are always used. 5. A superficial scratch- down incision is made through the epidermis and dermis midway along the planned incision just until subcutaneous fat presents in the wound ( Fig. 2). 6. The scalpel is exchanged for a curved mosquito hemostat, and this instrument is held vertically. The jaws of the hemostat are spread perpendicular to the course of the incision to deepen and enlarge the wound to the level of the superficial temporalis muscle fascia ( Fig. 3). The STA lies enveloped within this fascia [ Fig. 1 ( 3- 5)]; therefore this approach insures that the incision has not been carried too deeply. 7. The hemostat is turned parallel to the incision with its tips curving up. The hemostat is tunneled below the subcutaneous fat, but above the superficial temporalis fascia. The instrument is lifted and the tips are spread. Using the point of a scalpel blade, the incision is deepened and extended along its full planned length ( Fig. 4). 8. Self- retaining or manual retractors are used at this point to expand the wound. The STA is usually directly visible through its thin fascial envelopment. If the STA is not immediately visible at this point, a 0.3 Castroviejo toothed forceps is used to tent the fascia, which is carefully button- Skin Fat F . ~~.... ~~~ ascla .- Artery Muscle Bone FIG. 1. Regional and subcutaneous anatomy of preauricular STA main trunk. I Gin Neuro- ophthalmol, Vol. 11, No. 3. 1991 204 R. L. TOMSAK FIG. 5. Toothed forceps are used to tent the fascia, which is then carefully buttonholed. isolation of the artery, even if it is not initially visible or palpable. The relative invariability of STA main trunk anatomy ( 9) makes it more easily identified than the more variable course of the frontal branch ( 6,9). The extra care taken with the skin incision and subcutaneous dissection minimizes the chances of accidentally transecting the STA or STY, or bypassing the artery by going deep into the temporalis muscle. Concern about sparing the main trunk of the artery for future STA- to- middlecerebral- artery bypass operations is no longer appropriate, because this procedure has been shown to be ineffective in reducing the risk of ischemic stroke in selected patients with carotid artery disease ( 10). My method of STA biopsy also allows the use of epinephrine with the local anesthetic, because direct visualization of the artery is always accomplished. Thus, vasospasm causing the artery to stop pulsating ( 3,4) is not a practical problem, and the additional hemostasis gained by epinephrine is welcomed. I have never had postoperative hemorrhage ( 3) after cauterizing the cut ends of the STA. A pres- FIG. 6. Isolation of STA. ' 1 " 10 . .3. 1991 sure dressing, as recommended by others ( 3,4), is therefore not needed. Lastly, the need for obtaining long segments of STA for histologic analysis ( 3,5,11) has been refuted by the observations of Chambers and Bernardino ( 12). They found that an STA segment as small as 4 mm, if serially sectioned properly, results in a false negative result less than 1% of the time. My technique usually yields a gross specimen 1- 2 cm in length. The incision can be extended more anteriorly during the procedure to obtain a larger specimen, if needed. Acknowledgment: I thank Nancy Burgard for doing the illustrations. Bernd F. Remler, M. D., provided and translated reference 6. REFERENCES 1. Hunder GG, Bloch DA, Michel BA, Stevens, MB, et aI. The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis. Arthritis Rheum 1990; 33: 1122- 8. 2. Healey LA, Wilske KR. The systemic manifestations of temporal arteritis. NY: Grune & Stratton, 1978. 3. Brennan J, McCrary JA III. Diagnosis of superficial temporal arteritis. Ann OphthalmoI1975; 7: 1125- 9. 4. O'Connor PS. Ancillary Clinical Procedures. In: Kline LB, Bajandas FJ, eds. Neuro- ophthalmology review manual. 3rd ed. Thorofare NJ: Slack, 1988: 175- 7. 5. Miller NR. Vasculitis. In: Walsh and Hoyt's Clinical Neuroophthalmology. 4th ed, vol 4. Baltimore: Williams & Wilkins, 1991: 2624. 6. Damann C, Putz R, Schmidt D. The course of the superficial temporal artery: the anatomical background to the performance of arterial biopsy. Klin Mbl Augenheilk 1989; 194: 37- 41 ( in German). 7. Bienfang DC. Use of the Doppler probe to detect the course of the superficial temporal artery. Am J Ophthalmol 1984; 97: 526- 7. 8. Beckman RL, Hartmann BM. The use of a Doppler flow meter to identify the course of the temporal artery ( letter). J Clin Neuro- ophthalmol 1990; 10: 304. 9. Marano SR, Fischer DW, Gaines C, Sonntag YKH. Anatomical study of the superficial temporal artery. Neurosurg 1985; 16: 786- 90. 10. The EC- IC Bypass Study Group. Failure of extracranialintracranial arterial bypass to reduce the risk of ischemic stroke: results of an international randomized trial. N Engl J Med 1985; 313: 1191- 200. 11. Lie JT et al. Illustrated histopathologic classification criteria for selected vasculitis syndromes. Arthritis Rheum 1990; 33: 1074- 87. 12. Chambers W, Bernardino V. Specimen length in temporal artery biopsies. J Clin Neuro- ophthalmol 1988; 8: 121- 5. |
