Arteritis de células gigantes: ¿Cómo debutan pacientes chilenos? Análisis de casos y revisión de la literatura / Giant cell arteritis. Experience in 32 patients

BACKGROUND: Giant cell Arteritis (GCA) is the most common systemic vasculitis in patients over 50 years. Diagnosis is based on clinical, laboratory, imaging and biopsy. Temporal artery biopsy (TAB) may be inconclusive in up to 40% of patients. AIM: To describe disease features of patients diagnosed with GCA. MATERIAL AND METHODS: Review of pathology reports of giant cell arteritis and clinical records of patients seen with the diagnosis between 2000 and 2019. Demographic, clinical, laboratory, histopathology, imaging, treatment and follow-up variables were analyzed. RESULTS: We fetched 32 patients with a median age at diagnosis of 70.5 years (range 57-90), 81% women. Twenty eight percent had polymyalgia. 72% had only cranial symptoms, 12% had extracranial involvement and 13% exclusive extracranial involvement. The median time from onset of symptoms to diagnosis was two months (range 0.5-8). All had elevated erythrocyte sedimentation rate and c reactive protein. A TAB was performed in 27 patients and in 17 (65.4%) it confirmed the diagnosis. Transmural inflam- mation was the most frequent finding. All patients received steroids. Follow-up information was available from 25 patients and 92% received a steroid-spa- ring agent, usually methotrexate (74%). Ninety two percent achieved clinical remission in the first year and 59% had minor relapses during steroid tapering. CONCLUSIONS: Our patients showed frequent extracranial involvement and TAB was a useful diagnostic tool.

Calcifilaxis de la arteria temporal simulando arteritis temporal / Calciphylaxis of the temporal artery simulating temporal arteritis

La calcifilaxis se caracteriza por una intensa deposición de calcio en pequeños vasos sanguíneos, piel y otros órganos, descripta principalmente en pacientes con insuficiencia renal crónica, trasplante renal o disfunción paratiroidea. Hasta la fecha, solo hay siete casos descriptos en la literatura de calcifilaxis que imita arteritis de células gigantes (ACG). En esta revisión presentamos el octavo caso documentado patológicamente.

Calciphylaxis is characterized by intense deposition of calcium in small blood vessels, skin, and other organs, described mainly in patients with chronic renal insufficiency, renal transplant of parathyroid dysfunction. To date, there are only seven cases described in literature of calciphylaxis mimicking giant cell arteritis (GCA). In this review, we present the eighth case pathologically documented.

Superficial-Temporal-Artery-To-Middle-Cerebral-Artery Bypass in Cerebrovascular Occlusive Disease and Hemodynamic-Related Ischemia: Illustrative Case and Literature Review

Stroke is the third most common cause of death worldwide. About 10% to 15% of strokes related to the territory of the carotid artery are associated with its complete occlusion. There is an important subgroup of patients with cerebrovascular occlusive diseases who might benefit from an external-carotid-to-internal-carotid bypass. In the present study, we report a case of a 53-year-old male patient with stenosis of the M2 branch of themiddle cerebral artery (MCA), with a history of 20 episodes of transient ischemic accidents (TIA)s, in whom an anastomosis of the M4 branch of the superficial temporal artery-MCA was performed. The patient was discharged in three days, and in the two years of follow-up, they were no more TIAs.We also conducted a review of the literature on cerebrovascular occlusive disease and extracranial-intracranial bypass surgery. New methods to evaluate cerebral hemodynamics made it possible to classify a new subgroup of patients with symptomatic cerebrovascular disease and documented cerebrovascular compromise in whom the drug therapy fails, who can benefit from the extracranial-intracranial bypass. Our case report illustrates the advantages of revascularization in these selected patients.

Fístula arteriovenosa traumática em região temporal: um desafio terapêutico / Traumatic arteriovenous fistula in the temporal region: a therapeutic challenge

Resumo As fistulas arteriovenosas podem ser congênitas ou traumáticas, sendo as primeiras mais comuns e diagnosticadas na infância e as últimas mais raras e com diagnóstico mais tardio. Ambas necessitam de tratamento intervencionista, que pode ser endovascular ou correção cirúrgica, sendo que cada caso deve ser estudado individualmente. Este artigo apresenta o caso de um paciente de 46 anos, com fístula arteriovenosa na artéria temporal superficial esquerda com suas veias correspondentes decorrente de trauma contuso na região temporal na infância. O diagnóstico foi confirmado por exame de imagem, e o paciente foi submetido a tratamento cirúrgico convencional, apresentando melhora dos sintomas. O caso chama atenção para uma afecção rara, sua investigação diagnóstica e condutas terapêuticas. As fistulas arteriovenosas traumáticas apresentam baixa incidência, ocorrem em variadas localizações e podem causar sintomas, requerendo tratamento, às vezes desafiador, com melhora da qualidade de vida do paciente.

Abstract Arteriovenous fistulas can be congenital or traumatic, the former being more common and diagnosed in childhood, and the latter being rarer and diagnosed later in life. Both require interventional treatment, which may be endovascular, or surgical repair and each case must be studied individually. This article presents the case of a 46-year-old patient with an arteriovenous fistula (AVF) between the left temporal artery and its corresponding veins resulting from a blunt trauma to the parietal region during childhood. The diagnosis was confirmed by imaging examination and he underwent conventional surgical treatment with improvement of symptoms. The case calls attention to a rare condition, its diagnostic investigation, and therapeutic approaches. The incidence of traumatic arteriovenous fistulas is low. They can occur in a variety of ways and can cause symptoms, requiring treatment, which is sometimes challenging, resulting in improvement in the patient's quality of life.

Isquemia de extremidades inferiores secundaria a arteritis de la arteria temporal

Giant cell arteritis is more common in women older than 60 years, is associated with systemic inflammation symptoms and mainly involves the aortic arch and cranial arteries, specially the temporal artery. Symptomatic lower extremity arterial stenosis or occlusion is uncommon and can lead to limb loss. We report a 73-year-old woman presenting with a one-month history of lower extremity intermittent claudication of sudden onset. She also complained of fever, malaise, headache and weight loss. A non-invasive vascular study showed moderate femoral popliteal occlusive disease, with and abnormal ankle-brachial index (0.68 and 0.83 on right and left sides, respectively). An angio-computed tomography showed thickening of the aortic wall and severe stenosis in both superficial femoral arteries. Steroidal treatment was started, and a temporal artery biopsy was performed confirming giant cell arteritis. Six weeks after steroid therapy the patient had a complete remission of symptoms. A serologic exacerbation was subsequently treated with a humanized monoclonal antibody against the interleukin-6 receptor Tocilizumab, obtaining long time remission.

Unusual branching pattern and termination of facial artery and its clinical implications for facial operations / Padrão anômalo de ramificação e terminação da artéria facial e implicações clínicas para cirurgias da face

The facial artery is the main artery of the face and variations in its origin and its branching pattern have been documented. We report herein multiple facial artery branch variations in the face. A large posterior (premasseteric) branch originated from the left facial artery and coursed upwards behind the main trunk of the facial artery. This artery presented with a straight course and was closely related to the anterior border of the masseter. The branch then terminated by supplying the adjacent connective tissue below the parotid duct. It was also observed that the facial artery was very thick and tortuous and terminated as the superior labial artery. Knowledge of this variation is of great clinical significance in facial operations, especially for maxillofacial surgeons and plastic surgeons, because it forms the anatomical basis for the facial artery musculo-mucosal flap

A artéria facial é a principal artéria da face, e variações da sua origem e padrão de ramificação têm sido documentadas. Este artigo descreve múltiplas variações de ramificações da artéria facial. Um ramo posterior grande (pré-massetérico) teve origem na artéria facial esquerda e cursou para cima por trás do tronco principal da artéria facial. Essa artéria apresentou um curso reto e intimamente relacionado com a borda anterior do masseter. O ramo terminou suprindo o tecido conjuntivo adjacente abaixo do ducto parotídeo. Também se observou que a artéria facial tinha grande calibre, era tortuosa e terminava na artéria labial superior. Conhecer essa variação é de grande significância clínica em cirurgias da face, principalmente para cirurgiões maxilofaciais e plásticos, tendo em vista que ela forma a base anatômica para o retalho músculo-mucoso da artéria facial

Concurrent bilateral juvenile temporal arteritis and hypereosinophilic syndrome: a case report and review of the literature

Most of temporal arteritis occurs in the older patient over 50 years old, and the histopathologic finding shows a granulomatous inflammation, so this called giant cell arteritis. However, the young patients also present with a nodular lesion in their temple, and juvenile temporal arteritis (JTA) should be considered as one of the differential diagnosis, although it is very rare. For both diagnosis and treatment of JTA, excisional biopsy is essential. The pathologic finding of the temporal artery shows panarteritis with lymphoeosinophilic infiltrates, but no giant cell or granulomatous lesion. JTA is a localized disease with low level of systemic inflammatory marker, so the symptom is usually relieved by excision of affected lesion. Peripheral blood eosinophilia present in some cases of JTA, but its relation with clinical course and prognosis is not yet been known. Herein, we report the case of a 24-year-old man diagnosed with concurrent JTA and hypereosinophilic syndrome. We also reviewed the literature of JTA focusing on the impact of combined peripheral eosinophilia on the course of the disease. Combined peripheral eosinophilia may increase the risk of recurrence of JTA after local treatment such as excision only.

Reconstruction of a scalp defect due to cochlear implant device extrusion using a temporoparietal fascia flap and a split-thickness skin graft from the scalp

Cochlear implant extrusion, which is a common complication of cochlear implants, is generally repaired by a well visualized soft-tissue flap. A 61-year-old female patient with a medical history of schizophrenia who had a skin ulcer that caused cochlear implant extrusion, but that would be a stronger statement was referred to our department for removal of the implant and reconstruction of the resultant scalp defect. Accordingly, the broad defect was covered via rotation of a temporoparietal fascia flap (TPFF) using the superficial temporal artery, with the pedicle in the preauricular region as the pivot point. Coverage of TPFF was achieved with a split-thickness skin graft using the scalp as the donor site, which led to a quick recovery after the operation and satisfactory results in terms of aesthetics. This case suggests that a TPFF might be used as a flexible flap with low donor site morbidity for reconstructing cases of cochlear implant extrusion accompanied by a large full-layer scalp defect.

Extended temporalis flap for skull base reconstruction

Traditionally, a galeal flap has been used for skull base reconstruction. In addition to the galeal flap, several other flaps, such as the temporalis muscle flap or the free vascularized flap, can be options for skull base reconstruction, and each option has advantages and disadvantages. Certain cases, however, can be challengeable in the application of these flaps. We successfully managed to cover a skull base defect using an extended temporalis flap. Herein, we present the case and introduce this novel method.

Arterial Spin Labeling MRI for Quantitative Assessment of Cerebral Perfusion Before and After Cerebral Revascularization in Children with Moyamoya Disease

OBJECTIVE: To determine the correlation between cerebral blood flow (CBF) on arterial spin labeling (ASL) MRI and the degree of postoperative revascularization assessed on digital subtraction angiography in children with moyamoya disease (MMD). MATERIALS AND METHODS: Twenty-one children (9 boys and 12 girls; mean age, 8.4 ± 3.6 years; age range, 3–16 years) with MMD who underwent both pseudocontinuous ASL MRI at 1.5T and catheter angiography before and after superficial temporal artery encephaloduroarteriosynangiosis were included in this retrospective study. The degree of revascularization in the middle cerebral artery (MCA) territory was evaluated on external carotid angiography and was graded on a 3-point scale. On ASL CBF maps, regions of interest were manually drawn over the MCA territory of the operated side at the level of the centrum semi-ovale and over the cerebellum. The normalized CBF (nCBF) was calculated by dividing the CBF of the MCA territory by the CBF of the cerebellum. Changes in nCBFs were calculated by subtracting the preoperative nCBF values from the postoperative nCBF values. The correlation between nCBF changes measured with ASL and the revascularization grade from direct angiography was evaluated. RESULTS: The nCBF value on the operated side increased after the operation (p = 0.001). The higher the degree of revascularization, the greater the nCBF change was: poor revascularization (grade 1), −0.043 ± 0.212; fair revascularization (grade 2), 0.345 ± 0.176; good revascularization (grade 3), 0.453 ± 0.182 (p = 0.005, Jockheere-Terpstra test). The interobserver agreement was excellent for the measured CBF values of the three readers (0.91–0.97). CONCLUSION: The nCBF values of the MCA territory obtained from ASL MRI increased after the revascularization procedure in children with MMD, and the degree of nCBF change showed a significant correlation with the degree of collateral formation evaluated via catheter angiography.

Utilidad de la ecotomografía doppler en el diagnóstico de la arteritis de células gigantes / Utility of the doppler ultrasound in the diagnostic approach of giant cell arteritis

Resumen: La arteritis de células gigantes es una vasculitis sistémica frecuente, especialmente en mayores de 50 años. Ante la sospecha clínica el diagnóstico debe ser confirmado con histología o estudios de imágenes. La biopsia de arteria temporal se considera el gold standard, sin embargo, tiene sus limitaciones, una de ellas es la alta tasa de falsos negativos. El estudio por ecotomografía Doppler permite la visualización de las arterias temporales y en manos experimentadas puede constituir un procedimiento diagnóstico alternativo a la biopsia en el estudio inicial de esta entidad. Esta técnica es de fácil acceso, bajo costo, sin riesgos y no expone al paciente a radiación ionizante. En este trabajo revisamos la utilidad clínica de la ecotomografía Doppler en el estudio de la arteria temporal y sus hallazgos imagenológicos en la aproximación diagnóstica a la arteritis de células gigantes, siendo las características de compromiso el engrosamiento parietal arterial hipoecogénico, habitualmente concéntrico, no compresible.

Abstract: Giant cell arteritis is a frequent systemic vasculitis, especially in patients older than 50 years old. When clinically suspected, the diagnosis should be made on the basis of histology or imaging methods. Temporal artery biopsy is considered the gold standard for the diagnosis but it has some caveats, especially the existence of false negatives. Doppler ultrasound study is a low cost, accessible tool that allows visualization of temporal arteries and, in experienced hands, can replace the biopsy in the initial evaluation of the disease, without the risks of ionizing radiation. In this article we review the clinical utility of the temporal artery Doppler ultrasound and its findings in the diagnostic approach of giant cell arteritis, being characteristic a non-compressible, hypoechoic, most commonly concentric arterial wall thickening.

Arteritis de células gigantes en el sistema vertebrobasilar, isquemias cerebelo-occipitales y parálisis III par: caso clínico / Giant cell arteritis of the vertebrobasilar system, posterior ischemia and palsy of the third nerve: report of one case

Giant cell arteritis is the most common vasculitis in patients aged over 50 years. We report an 89-year-old woman with significant weight loss and persistent frontal-occipital headaches lasting two months. The neurological examination at admission identified a decrease in visual acuity of the left eye, paralysis of the third cranial nerve of the right eye and alterations of body motility without objective signs of damage of the motor or sensitive pathways. Magnetic resonance imaging showed changes of the temporal artery wall and in both vertebral arteries, as well as bilateral cerebellar and occipital ischemic lesions. The Doppler ultrasound of the temporal arteries was compatible with Giant cell arteritis. Treatment with steroids was started. While receiving oral prednisone, the patient suffered new infarcts of the posterior territory, documented with a CAT scan.

Pseudoaneurisma traumático de la arteria temporal superficial, reporte de un caso / Traumatic pseudoaneurysm of the superficial temporal artery, report of a case

Los pseudoaneurismas son una causa infrecuente de masa palpable en cabeza y cuello, habitualmente secundarios a procedimientos intervencionales; trauma e infeccioso son casos aislados. Caso Clínico. Se presenta el caso de un niño de 14 años que luego de haber sufrido un trauma contuso cortante en la región preauricular izquierda intervenido quirúrgicamente, desarrolla al mes un aumento de volumen pulsátil tras un trauma menor en la zona. En la ecografía se aprecia el signo del yin yang, indicador de pseudoaneurisma. Se realiza en pabellón el vaciamiento del pseudoaneurisma y posterior sutura vascular sin incidentes. Discusión. Pese a la baja frecuencia de pseudoaneurisma como causa de masa en cabeza y cuello, se debe considerar como diagnóstico diferencial en el contexto de masas pulsátiles post traumáticas, de horas a días de evolución. El estudio de elección es la ecografía doppler y el Gold Standard del manejo es quirúrgico con sutura vascular.

Pseudoaneurysms are an infrequent cause of palpable mass in the head and neck; usually secondary to invasive procedures; trauma and infectious causes are rare. Clinical Case. We present the case of a 14-year-old boy who, after suffering a blunt contusive trauma in the left preauricular region surgically treated, develops a month later a pulsatile volume increase after a minor trauma in the area. Ultrasound shows the yin yang sign, indicator of pseudoaneurysm. The emptying of the pseudoaneurysm and subsequent vascular suture was performed without incident. Discussion. Despite the low frequency of pseudoaneurysm as a cause of mass in the head and neck, it should be considered as a differential diagnosis in the context of post-traumatic pulsatile masses, from hours to days of evolution. The study of choice is Doppler ultrasound and the Gold Standard treatment is surgery with vascular suture.

Pseudoaneurisma da artéria temporal superficial: relato de três casos / Pseudoaneurysms of the superficial temporal artery: three case reports

O pseudoaneurisma da artéria temporal superficial é um evento raro. Ocorre principalmente em homens jovens em decorrência de traumatismo craniano fechado. A maioria dos casos é assintomática, podendo eventualmente haver associação com sintomas vagos. A rotura do pseudoaneurisma e o desenvolvimento de déficits neurológicos são complicações esporádicas. Os autores relatam três casos de pseudoaneurisma de artéria temporal superficial pós-traumatismo craniano fechado. Os pacientes foram manejados com sucesso por ligadura e ressecção dos pseudoaneurismas

Pseudoaneurysms of the superficial temporal artery are rare events. They primarily occur in young men as a consequence of blunt head traumas. The majority of cases are asymptomatic, although there are sometimes vague symptoms. Ruptured pseudoaneurysms and development of neurological deficits are occasional complications. The authors describe three cases of pseudoaneurysm of the superficial temporal artery after blunt head trauma. Patients were successfully managed with ligature and resection of the pseudoaneurysms

STA-Distal ACA Bypass Using a Contralateral STA Interposition Graft for Symptomatic ACA Stenosis

Intracranial arterial stenosis usually occurs due to atherosclerosis and is considered the most common cause of stroke worldwide. Although the effectiveness of bypass surgery for ischemic stroke is controversial, the superficial temporal artery to the middle cerebral artery bypass for ischemic stroke is a common procedure. In our report, a 50-year-old man presented with sudden-onset left side weakness and dysarthria. An angiogram showed significant stenosis in the junction of the right cavernous-supraclinoid internal carotid artery and right pericallosal artery. Symptoms altered between improvement and deterioration. Magnetic resonance imaging showed a repeated progression of anterior cerebral artery (ACA) infarction despite maximal medical therapy. We performed a STA-ACA bypass with contralateral STA interposition. Postoperative course was uneventful with no further progression of symptoms. Thus, bypass surgery may be considered in patients with symptomatic stenosis or occlusion of the ACA, especially when patients present progressive symptoms despite maximal medical therapy.

Diagnostic Accuracy of Temporal Artery Temperatures Measurements / 임상간호연구

PURPOSE: This study compared the temporal artery temperature (TAT) measured by infrared temporal artery thermometers to the axillary temperature (AT) measured by standard mercury-in-glass thermometers, and evaluated accuracy of the TAT measurement for clinical practice. METHODS: A total of 247 adult inpatients in general wards in a tertiary medical center located in Seoul participated in the study. The TAT was measured within one minute after the AT measurement. Data were analyzed using descriptive statistics, paired t-test, Pearson correlation coefficient, linear regression, and the Bland-Altman plot. RESULTS: There was a significant difference in mean temperature between AT and TAT, 36.89℃ (SD=0.70) versus 37.35℃ (SD=0.72). The Bland-Altman plots demonstrated the difference between the AT and TAT as −1.29 to +0.33. The specificity and sensitivity of the TAT in detecting fever were high. The positive predictive values were 57.5% and 71.0% when the AT were higher than 38.0℃ and the TAT fever cutoff levels were 38.0℃ and 38.3℃ respectively. CONCLUSION: TAT and AT were highly correlated and agreeable, indicating that TAT is as accurate as AT. The findings suggested that TAT measurement can be used in clinical practice. For accurate communication between medical personnel, medical institutions need to provide guidelines for temperature measurement, especially for the use of thermometer and measurement sites.

Superficial temporal artery flap for reconstruction of complex facial defects: A new algorithm

BACKGROUND: A variety of island flaps can be based on the superficial temporal artery with variable tissue composition. They can be used for defect reconstruction, cavity resurfacing, facial hair restoration, or contracture release. METHODS: Seventy-two patients underwent facial reconstruction using a superficial temporal artery island flap from October 2010 to October 2014. The defects had various etiologies, including trauma, burns, tumors, exposed hardware, and congenital causes. We classified the patients by indication into 5 groups: cavity resurfacing, contracture release, facial hair restoration, skin coverage, and combined. The demographic data of the patients, defect characteristics, operative procedures, postoperative results, and complications were retrospectively documented. The follow-up period ranged from 24 to 54 months. RESULTS: A total of 24 females and 48 males were included in this study. The mean age of the patients was 33.7±15.6 years. The flaps were used for contracture release in 13 cases, cavity resurfacing in 10 cases, skin coverage in 17 cases, facial hair restoration in 19 cases, and combined defects in 13 cases. No major complications were reported. Conclusion: Based on our experiences with the use of superficial temporal artery island flaps, we have developed a detailed approach for the optimal management of patients with composite facial defects. The aim of this article is to provide the reader with a systematic algorithm to use for such patients.

Bilateral Involvement of Juvenile Temporal Arteritis Associated with Kimura Disease

Juvenile temporal arteritis (JTA) is a localized nodular arteritis confined to the temporal artery without evidence of systemic inflammation, and it occurs mainly in patients younger than 50 years. From the first case report, the pathological features of JTA have been suspected to be the morphological equivalent of Kimura disease (KD), which has been supported further by the concurrent cases of JTA with KD. We present the first case of bilateral JTA accompanying KD, which was confirmed by histological and ultrasound evaluations and supports the hypothesis that JTA is a manifestation of KD. The un-excised JTA lesion was resolved completely after corticosteroid therapy with no recurrence.

Use of a helical composite free flap for alar defect reconstruction with a supermicrosurgical technique

The highly contoured nature of the nose and the abundant free margin makes it especially difficult to reconstruct. In this report, we describe the use of a new helical rim free flap technique for the reconstruction of full-thickness nasal alar defects via supermicrosurgery. Briefly, after a wide excision with a margin of 0.7 cm, an alar defect with a size of 1×1×0.5cm was obtained, which included the full thickness of the skin, mucosa, and lower lateral cartilage. Vessel dissection was performed in a straightforward manner, starting from the incision margin for flap harvest, without any further dissection for reach the greater trunk of the superficial temporal artery. The flap was inset in order to match the contour of the contralateral ala. We closed the donor site via rotation and advancement. No donor site morbidity was observed, despite the presence of a small scar that could easily be covered with hair. The alar contour was satisfactory, and the patient was satisfied with the results. The supermicrosurgical technique did not require further dissection to identify the vessels for anastomosis, leading to better cosmetic outcomes and a reduced operating time.

Superficial Temporal Artery-Sparing Mini-Pterional Approach for Cerebral Aneurysm Surgery

OBJECTIVE: The purposes of this study were to introduce a superficial temporal artery (STA)-sparing mini-pterional approach for the treatment of cerebral aneurysms and review the surgical results of this approach. METHODS: Between June 2010 and December 2015, we performed the STA-sparing mini-pterional approach for 117 patients with 141 unruptured intracranial aneurysms. We analyzed demographic, radiologic, and clinical variables including age, sex, craniotomy size, aneurysm location, height of STA bifurcation, and postoperative complications. RESULTS: The mean age of patients was 58.4 years. The height of STA bifurcation from the superior border of the zygomatic arch was 20.5 mm±10.0 (standard deviation [SD]). The craniotomy size was 1051.6 mm²±206.5 (SD). Aneurysm neck clipping was possible in all cases. Intradural anterior clinoidectomy was performed in four cases. Contralateral approaches to aneurysms were adopted for four cases. Surgery-related complications occurred in two cases. Permanent morbidity occurred in one case. CONCLUSION: Our STA-sparing mini-pterional approach for surgical treatment of cerebral aneurysms is easy to learn and has the advantages of small incision, STA sparing, and a relatively wide surgical field. It may be a good alternative to the conventional pterional approach for treating cerebral aneurysms.