CLINICAL RISK REDUCTION
Giant cell arteritis G
Dr Rajan Madhok and Dr Nicola Alcorn offer advice on avoiding the potentially devastating consequences of GCA
IANT CELL ARTERITIS (GCA) is the commonest systemic vasculitis. Inflammation affects the extracranial branches of the carotid artery in patients
older than 50 years of age. Te aetiology is unknown but granuolomatous inflammation is seen on arterial biopsy. Te most recognisable presentation is that affecting the temporal arteries with visual loss being a feared complication. Te ultimate concern is of irreversible visual loss in a treatable condition, so giant cell arteritis is regarded as a true medical emergency. Each year the MDDUS receives complaints and claims of
clinical negligence in relation to the delayed or missed diagnosis of GCA. As with many conditions there is not one definitive sign or test upon which to irrevocably base the diagnosis but a careful history and clinical assessment coupled with an awareness of the atypical manifestations of this condition may prevent mistakes.
Epidemiology GCA is very rare before the age of 50, with the mean age of onset in the seventh decade. It is at least twice as common in females and is commoner in northern climates and Caucasians.
Symptoms Te patient complains of an abrupt onset of headache which is oſten unilateral but not always. Around 75 per cent of
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individuals will complain of headache which may be found in a new position and is of different or unusual character. Te quality of the pain has been described as boring and of moderate severity compared to a simple headache. Te pain is commonly felt in the temple but also rarely in the occiput if the occipital artery is involved. Associated scalp tenderness and jaw or tongue claudication are common features and show the highest positive predictive value for a positive temporal artery biopsy. Almost all patients with GCA will experience at least one
systemic feature, such as weight loss, fever, anaemia, fatigue and depression. As there is a close association with polymyalgia rheumatica, proximal limb girdle pain and stiffness may also be prevalent. Visual symptoms are seen in around a quarter of presentations. Te most frequent being aumorosis fugax, unilateral visual loss, double vision and blurred vision. Visual loss is the most worrying complication and can occur in up to a fiſth of cases. If one eye is affected then the chances of a second eye being involved can be between 20-50 per cent. Terefore a high index of suspicion is needed and a judicious use of treatment as this is a preventable cause of visual loss.
Signs Clinically the patient may seem unwell and have scalp tenderness as well as a palpable beaded or tortuous temporal artery. Te temporal arteries may lose pulsation and visual field loss may be demonstrable. Fundoscopy may reveal a pale
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