Colorful News for the Arteritic
Colorful News for the Arteritic
ABSTRACT & COMMENTARY
Synopsis: In assessment with color Doppler ultrasound, patients with temporal arteritis had a mean blood flow velocity that was roughly half that of those with polymyalgia rheumatica.
Source: Lauwerys BR, et al. J Rheumatol 1997;24:1570.
An elderly patient with headache, jaw claudication, and palpable, incompressible, pulseless, and tender temporal arteries does not present a particularly difficult diagnostic problem. The patient who lacks classic symptoms and has an unimpressive temporal artery on physical examination is more of a challenge. Lauwerys and colleagues have investigated a non-invasive aid with which to assess a patient in whom temporal arteritis is suspected. Color Doppler ultrasonography was used to assess temporal artery wall thickness and the velocity of blood flow through the proximal and distal temporal arteries of two groups of patients. One group met American College of Rheumatology criteria for polymyalgia rheumatica (PMR), while patients in the other group met criteria for temporal arteritis (TA). Six of seven patients who met the criteria for TA and who underwent temporal artery biopsy had pathologic evidence of temporal arteritis. When a cutoff value two standard deviations below the mean velocity of proximal temporal artery blood flow for normal subjects was used (34 mm/sec), 60% of TA patients had abnormal flow while none of the PMR patients had flow that slow. When a corresponding value (< 2 SD below the mean for normal) for the distal temporal artery (18 mm/sec) was used as the cutoff, 10 of 11 TA patients had abnormal results vs. only two of 21 patients with PMR. The authors point to the reduced distal flow velocity as the most "distinctive difference" between the two groups. They also demonstrated an increase in flow velocity after treatment with corticosteroids was begun in five of six patients with TA. The authors warn that decreased blood flow due to atherosclerotic disease cannot be distinguished from that due to narrowing caused by arteritis.
COMMENT BY JERRY M. GREENE, MD
Color Doppler ultrasonography has little to offer a patient with classic symptoms and a palpably abnormal temporal artery. Conversely, patients with PMR who have no symptoms to suggest temporal arteritis are at low risk of having temporal arteritis based upon the results of one large population study.1 I agree with the authors’ suggested use of color Doppler ultrasonography to choose an "ideal site" for TA biopsy when palpation of the vessels alone does not suggest a high yield site. The side with the slowest distal flow would be picked for biopsy. Although there is a potential that the technique could obviate the need for biopsy, the 9% rate of false-negatives and the approximately 9% rate of false-positives still present a headache for ultrasonographers, physicians, and patients alike.
Reference
1. Myklebust G, Gran JT. Br J Rheumatol 1996;35: 1161-1168.
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