Physical Examination or Duplex Ultrasonography for the Diagnosis of Giant-Cell Arteritis

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The summary below is from the full report titled "Is Duplex Ultrasonography Useful for the Diagnosis of Giant-Cell Arteritis?" It is in the 20 August 2002 issue of Annals of Internal Medicine (volume 137, pages 232-238). The authors are C Salvarani, M Silingardi, A Ghirarduzzi, G Lo Scocco, P Macchioni, G Bajocchi, M Vinceti, F Cantini, I Iori, and L Boiardi.

What is the problem and what is known about it so far?

Giant-cell arteritis is an inflammation of blood vessels on the sides of the forehead. It can cause headaches; tenderness of the scalp; pain in the side of the face that is worse with chewing; and swollen, tender forehead vessels. Persons with giant-cell arteritis also can have pain and stiffness in the shoulders and hips (polymyalgia rheumatica). Doctors first suspect giant-cell arteritis from the patient's symptoms and from examination of the forehead vessels. The vessels may be tender to the touch and have weak or even absent pulsations. Before starting treatment (with steroid drugs), doctors sometimes perform a biopsy of forehead vessels to confirm the presence of inflammation and abnormal arteries. Color duplex ultrasonographic scans may be less painful than a biopsy for confirming giant-cell arteritis. These scans look at vessel walls and blood flow by using short pulses of sound waves that are transmitted from a device placed on the surface of the skin. The scans sometimes detect dark halos around inflamed vessels. The halos seem to indicate swelling in the vessel wall. Although scans sound like a good idea, we do not really know whether they are any better than a careful clinical examination for detecting giant-cell arteritis.

Why did the researchers do this particular study?

To see whether duplex ultrasonographic scans are better than clinical examination for detecting giant-cell arteritis.

Who was studied?

86 adults with suspected giant-cell arteritis or polymyalgia rheumatica.

How was the study done?

An expert physician examined all patients. He checked forehead vessels for tenderness and abnormal pulses. Researchers who did not know the results of the physical examination then did ultrasonographic scans of the forehead vessels. Finally, in all patients, biopsies of forehead vessels were performed. Results of the scan were used to select places to perform the biopsy. If the scan showed a dark halo, the biopsy was done at that spot. Researchers then looked at how accurately the physician's examination and the results of the ultrasonographic scan confirmed biopsy findings.

What did the researchers find?

Fifteen patients had positive biopsy results for giant-cell arteritis. For 6 of these 15 patients (40%), ultrasonography revealed dark halos. For 15 of 71 patients (21%) who had negative biopsy results, dark halos were present. Patients with biopsy-proven giant-cell arteritis had abnormal findings on physical examination (tender vessels with or without abnormal pulses) more often than they had halos on ultrasonography (67% vs. 40%).

What were the limitations of the study?

The researchers used biopsy as the "gold standard" for diagnosis of giant-cell arteritis. Biopsies are an accepted but imperfect standard because they are not 100% accurate for detecting giant-cell arteritis.

What are the implications of the study?

Color duplex ultrasonography is no better than a careful physical examination for detecting biopsy-proven giant-cell arteritis.