Bilateral scalp necrosis as a rare but devastating complication of giant cell arteritis

A Review of the Dermatological Complications of Giant Cell Arteritis

Giant cell arteritis (GCA) is characterized by granulomatous inflammation of large and medium-sized vessels. It is the most common vasculitis among elderly people in Europe and North America. GCA usually presents with ischemic cranial manifestations such as headache, scalp tenderness, visual manifestations, and claudication of the tongue and jaw. Thickness and tenderness of temporal arteries are the most recognizable signs of GCA on physical examination. Laboratory tests usually show raised acute phase reactants. Skin manifestations are uncommon in GCA and are rarely found as a presenting symptom of GCA. Necrosis of the scalp and tongue is the most common ischemic cutaneous manifestation of GCA. Although infrequent, when present it reflects severe affection and poor prognosis of GCA. Panniculitis-like lesions have been reported in the setting of GCA, with nodules being the most common finding. Other entities, such as generalized granuloma annulare or basal cell carcinoma have been occasionally described in GCA patients. Prompt recognition and initiation of therapy are crucial to prevent serious complications of GCA. When high suspicion of GCA exists, immediate administration of glucocorticoids is recommended. It is advisable to refer the patient to a specialist GCA team for further multidisciplinary assessment.

Bilateral Scalp Necrosis in Giant Cell Arteritis

ABSTRACT

Giant cell arteritis (GCA) is a medium-to-large vessel vasculitis of the elderly. Common constitutional clinical features include headache, scalp tenderness, and jaw claudication. Severe unilateral or bilateral visual loss is the most feared ophthalmic complication of GCA. Scalp necrosis is a known ischemic complication of GCA with approximately 100 cases reported in the literature to date. We report a case of scalp pain and an erythematous cutaneous lesion in the distribution of ophthalmic division of the trigeminal nerve that mimicked herpes zoster ophthalmicus. A temporal artery biopsy was positive for GCA, and small vessel arteritis was seen at the time of simultaneous skin biopsy. To the best of our knowledge, this is the first such report in the English language ophthalmic literature.

[Giant cell arteritis: Ischemic complications]

GCA ischemic complications occur generally in patients with a yet undiagnosed or uncontrolled disease. When disease control is fair, ischemic complications may be due mostly to atheromatosis. Ophtalmic complications are most frequent and are dominated by anterior ischemic optic neuropathy. Vasculitic strokes occur essentially in the vertebrobasilar arterial territory. Overt vasculitic coronary disease is exceptional. The diagnosis of upper and lower limbs ischemic complications benefit from advances in echography (halo sign) and positron emission tomography imaging. Treatment relies on corticosteroids (initially 1mg/kg prednisone or more, preceded by intravenous methylprednisolone gigadoses if necessary), the control of cardiovascular risk factors and antiplatelet drugs; heparin may be indicated for threatening limbs ischemia.

Novel Hemicraniectomy Technique for Malignant Middle Cerebral Artery Infarction: Technical Note

BACKGROUND AND IMPORTANCE

Decompressive hemicraniectomy (DH) is the mainstay of treatment for malignant middle cerebral artery infarction (MMI). Although this operation significantly reduces mortality and improves functional outcomes, the conventional technique involves a reverse question mark incision starting anterior to the tragus that can injure the scalp's major blood supply, the superficial temporal artery (STA), which increases the risk of postoperative complications.

CLINICAL PRESENTATION

We developed a modified DH technique to reduce surgical morbidity associated with injury to the STA, accommodate a large bone window for effective decompression, and improve operative speed. After performing hospital chart review, a total of 34 patients were found who underwent this DH technique for MMI. Of these, 22 patients had this performed for right-sided MMI and 12 patients had this performed for left-sided MMI.

CONCLUSION

In each case, our approach preserved the STA and thereby minimized the risk for ischemic necrosis of the scalp flap. Since our technique avoids dissection of the preauricular temporalis muscle, we believe operative times can be decreased while still accommodating a large bone window to allow for effective decompression of the infarcted brain parenchyma.

[Neurological manifestations of giant cell arteritis]

The article describes clinical, including neurological manifestations, of giant cell arteritis (GCA) - granulomatous vasculitis of large and medium-sized vessels, predominantly craniofacial, including precerebral and cerebral, arteries. Histopathological features of GCA are illustrated by the schemes of panarteritis and «postarteritis» (proliferative and fibrotic changes in the intima, underlying the development of cerebrovascular disorders). The main clinical manifestations of GCA are described as 3 groups of symptoms: general constitutional symptoms; manifestations of vasculitis of craniofacial, precerebral and cerebral arteries; polymyalgia rheumaticа. The authors present their own version of the taxonomy of visual disturbances in patients with GCA. Diagnostic steps in patients with suggestive signs of GCA are described. Therapeutic regimens of use of glucocorticoids for suggestion/diagnosis of GCA are presented.