Giant cell arteritis

Last revised by Bouhouche Abdeldjalil on 1 Jul 2023

Giant cell arteritis (GCA) (plural: arteritides) is a common granulomatous vasculitis affecting medium to large-sized arteries. It is also known as temporal arteritis or cranial arteritis, given its propensity to involve the extracranial external carotid artery branches such as the superficial temporal artery

Giant cell arteritis is the most common primary systemic vasculitis. It has an incidence of 200 per million persons per year 6. It typically affects older individuals with patients usually being older than 50, with a peak incidence between the ages of 70 and 80 3. There is a recognized female predilection 17.

There are many possible clinical features that present in a subacute fashion 10:

It is histologically similar to other large vessel vasculitides (such as Takayasu arteritis) showing granulomatous inflammation of arteries with infiltration predominantly by histiocytes, lymphocytes, and multinucleated giant cells. The characteristic multinucleated giant cells are only found in ~50% of cases 1.

Areas of normal superficial temporal artery interspersed within inflamed sections of artery, known as skip lesions, result in false negatives in up to 8-28% of cases 12,13,15.

In a study of 285 patients with biopsy-proven giant cell arteritis there were 4 main histological patterns 12:

  1. adventitial pattern: inflammatory cells restricted to the adventitia

  2. adventitial invasive pattern: local invasion of the media with preservation of the intima

  3. concentric bilayer pattern: inflammatory infiltration of adventitia and intima with preservation of the media

  4. panarteritic pattern: inflammatory infiltrates in the three arterial layers

Can potentially affect any medium to large-sized vessels, affecting the aorta (~20% of cases 7) and its major branches, particularly the extracranial branches of the carotid artery 6.

  • increased diameter of the superficial temporal artery and hypoechoic wall thickening (halo sign)

    • with duplex ultrasound, sensitivity is 87% and specificity is 96% 9

    • more specific for giant cell arteritis if bilateral 8

    • reversible under corticosteroid treatment; this is reflected in the normalization of the sonographic features

  • edematous wall swelling of superficial temporal artery 16

  • stenosis may be present but is not a specific sign for giant cell arteritis 8

Findings on CT include:

  • wall thickening of affected segments

  • calcification

  • mural thrombi

Arterial phase CT (angiography) is useful for assessing luminal abnormalities:

  • stenoses

  • occlusions

  • dilatations

  • aneurysm formation

  • T1 C+ (Gd)

    • best sequence for assessment

    • shows mural inflammation very well 2,4

    • mean wall thickness increased in the affected region

    • luminal diameter correspondingly decreased in the affected region

    • reported approximate sensitivity and specificity is 80% and 97%, respectively 2 

Treatment is with corticosteroid therapy and aspirin 11. Methotrexate may be used in combination with corticosteroid therapy initially, or as a corticosteroid-sparing drug 14. Interleukin-6 (IL-6) levels are elevated in patients with GCA which is thought to play a pathogenic role by activation of T-cells and release of cytokines, particularly IFN-gamma 17. The IL-6 inhibitor tocilizumab, may be used as a treatment alternative in patients intolerant of corticosteroids 17

Imaging differential considerations include:

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Cases and figures

  • Case 1: temporal arteritis
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  • Case 2: halo sign
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  • Case 3: baseline study
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  • Case 3 :changes after therapy
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  • Case 4: on right
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  • Case 5: on left
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  • Case 6: aortitis
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  • Case 7
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