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Andel PM, Diamantopoulos AP, Myklebust G, Haugeberg G. Vasculitis distribution and clinical characteristics in giant cell arteritis: a retrospective study using the new 2022 ACR/EULAR classification criteria. Front Med (Lausanne) 2023; 10:1286601. [PMID: 38020143 PMCID: PMC10681091 DOI: 10.3389/fmed.2023.1286601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Giant cell arteritis (GCA) is the most common vasculitis of the elderly. In recent years, advanced imaging has to a certain extent replaced temporal artery biopsy (TAB) to aid diagnosis in many institutions and helped to identify three major phenotypes of GCA, namely, cranial GCA (c-GCA), large-vessel non-cranial GCA (LV-GCA), and a combination of these two patterns called mixed-GCA, which all show different clinical patterns. Recent 2022 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria respect the changing conception and clinical practice during the last two decades. In this cohort study, we present vasculitis distribution and baseline characteristics using the 2022 ACR/EULAR classification criteria as well as the EULAR core data set. Methods In this retrospective study from Southern Norway, we identified all patients diagnosed with GCA between 2006 and 2019 in our single-center fast-track clinic (FTC). We included all patients who were examined using ultrasound (US) of cranial as well as non-cranial large vessels at diagnosis to depict vascular distribution. EULAR core data set, ACR 1990, and 2022 ACR/EULAR classification criteria were used to characterize the cohort. Results Seventy-seven patients were diagnosed with GCA at our institution in the aforementioned period. Seventy-one patients (92.2%) were diagnosed with the help of US and included in the further analysis. The 2022 ACR/EULAR classification criteria allocated 69 patients (97.2%), while the ACR 1990 classification criteria allocated 49 patients (69.0%) in our cohort as having GCA. Mixed-GCA was the most common type in 33 patients (46.5%). Weight loss was significantly more common in patients with large-vessel non-cranial vasculitis in LV-GCA and mixed-GCA. Headache, on the other hand, was significantly more common in patients with involvement of cranial vessels. Conclusion Mixed GCA was the most common form of GCA in our cohort. In our study, the 2022 ACR/EULAR classification criteria seem to be a more useful tool compared with the old ACR 1990 classification criteria to allocate GCA patients diagnosed and treated at our US-based FTC as having GCA.
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Affiliation(s)
- Peter M. Andel
- Division of Rheumatology, Department of Rheumatology, Surgery, Inflammation and Transplantation, Oslo University Hospital Rikshospitalet, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Research Department, Hospital of South East Norway, Kalnes, Norway
| | - Andreas P. Diamantopoulos
- Division of Internal Medicine, Department of Infectious Diseases, Akershus University Hospital, Lørenskog, Norway
| | | | - Glenn Haugeberg
- Division of Rheumatology, Department of Internal Medicine, Hospital of Southern Norway, Kristiansand, Norway
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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2
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Bilton EJ, Mollan SP. Giant cell arteritis: reviewing the advancing diagnostics and management. Eye (Lond) 2023; 37:2365-2373. [PMID: 36788362 PMCID: PMC9927059 DOI: 10.1038/s41433-023-02433-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 02/16/2023] Open
Abstract
Giant Cell Arteritis (GCA) is well known to be a critical ischaemic disease that requires immediate medical recognition to initiate treatment and where one in five people still suffer visual loss. The immunopathophysiology has continued to be characterised, and the influencing of ageing in the development of GCA is beginning to be understood. Recent national and international guidelines have supported the directed use of cranial ultrasound to reduce diagnostic delay and improve clinical outcomes. Immediate high dose glucocorticoids remain the standard emergency treatment for GCA, with a number of targeted agents that have been shown in clinical trials to have superior clinical efficacy and steroid sparing effects. The aim of this review was to present the latest advances in GCA that have the potential to influence routine clinical practice.
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Affiliation(s)
- Edward J Bilton
- Ophthalmology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
- INSIGHT Health Data Research hub for eye health, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK
| | - Susan P Mollan
- Ophthalmology Department, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.
- INSIGHT Health Data Research hub for eye health, University Hospitals Birmingham NHS Foundation Trust, Birmingham, B15 2TH, UK.
- Transitional Brain Science, Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, B15 2TT, UK.
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3
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Nakajima E, Moon FH, Junior NC, Macedo CR, de Souza AWS, Iared W. Accuracy of Doppler ultrasound in the diagnosis of giant cell arteritis: a systematic review and meta-analysis. Adv Rheumatol 2023; 63:5. [PMID: 36755336 DOI: 10.1186/s42358-023-00286-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/29/2023] [Indexed: 02/10/2023] Open
Abstract
BACKGROUND Giant cell arteritis (GCA) is the most common primary systemic vasculitis in people 50 years of age and over, and it is considered a medical emergency due to the potential risk of permanent visual loss. Color Doppler ultrasound (CDU) of the temporal arteries is a rapid, noninvasive method to diagnose GCA. This study aims to determine the diagnostic accuracy of the halo sign in temporal arteries by CDU in people with suspected GCA. METHODS The systematic literature review included the search for publications in the following electronic databases: PubMed, Embase, CENTRAL, LILACS, WHO ICTRP, ClinicalTrials.gov, gray literature up to December 2022, and no date or language restrictions were applied. We analyzed studies including patients over 50 years of age with suspected GCA evaluating CDU of temporal arteries as a diagnostic tool against clinical diagnosis as a standard reference. Paper titles and abstracts were selected by two investigators independently for all available records. The quality of the studies was assessed using the Quality of Diagnostic Accuracy Studies tool (QUADAS-2) and the R software (version 4.2.1) was used for data analysis. The protocol of this review is registered with PROSPERO (CRD42016033079). RESULTS Twenty-two studies including 2893 participants with suspected GCA who underwent temporal artery CDU were evaluated. The primary analysis results showed a sensitivity of 0.76 [95% confidence interval (95 CI) 0.69-0.81] and specificity of 0.93 (95 CI 0.89-0.95) when the halo sign was compared to clinical diagnosis. The sensitivity value of 0.84 (95 CI 0.72-0.92) and specificity of 0.95 (95 CI 0.88-0.98) were found in five studies involving 1037 participants that analyzed the halo sign and temporal artery compression sign. A sensitivity of 0.86 (95 CI 0.78-0.91) and specificity of 0.95 (95 CI 0.89-0.98) were found in four studies with 603 participants where the halo sign was evaluated CDU on temporal and axillary arteries. CONCLUSION The detection of the halo sign by CDU of temporal arteries has good accuracy for the diagnosis of cranial GCA. The compression sign in temporal arteries and the addition of axillary arteries assessment improves the diagnostic performance of CDU for GCA. TRIAL REGISTRATION PROSPERO CRD42016046860.
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Affiliation(s)
- Eliza Nakajima
- Department of Evidence-Based Health, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros, 865, São Paulo, 04024-002, Brazil.,Division of Vascular and Endovascular Surgery, Department of Surgery, Escola Paulista de Medicina - Universidade Federal de Sao Paulo, Rua Borges Lagoa, 754, Sao Paulo, 04038-002, Brazil
| | - Francisca Hatta Moon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Escola Paulista de Medicina - Universidade Federal de Sao Paulo, Rua Borges Lagoa, 754, Sao Paulo, 04038-002, Brazil
| | - Nelson Carvas Junior
- Department of Evidence-Based Health, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros, 865, São Paulo, 04024-002, Brazil
| | - Cristiane Rufino Macedo
- Department of Evidence-Based Health, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros, 865, São Paulo, 04024-002, Brazil
| | - Alexandre Wagner Silva de Souza
- Rheumatology Division, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua dos Otonis, 863, São Paulo, SP, 04025-002, Brazil.
| | - Wagner Iared
- Department of Evidence-Based Health, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Napoleão de Barros, 865, São Paulo, 04024-002, Brazil
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4
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Milchert M, Fliciński J, Brzosko M. Intima-media thickness cut-off values depicting "halo sign" and potential confounder analysis for the best diagnosis of large vessel giant cell arteritis by ultrasonography. Front Med (Lausanne) 2022; 9:1055524. [PMID: 36582293 PMCID: PMC9792608 DOI: 10.3389/fmed.2022.1055524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/15/2022] [Indexed: 12/15/2022] Open
Abstract
Background Vascular ultrasound enables fast-track diagnosis of giant cell arteritis (GCA), but this method remains subjective. We aimed to determine intima-media thickness (IMT) cut-off values for large vessel GCA (LV-GCA) and identify the clinically relevant factors influencing it. Methods We included 214 patients referred for ultrasound evaluation within a fast-track clinic due to suspected GCA. IMT was measured in axillary, brachial, subclavian, superficial femoral, and common carotid arteries (CCA), in a place without identifiable atherosclerotic plaques. IMT cut-off values for vasculitis were determined by comparing measurements in arteries classified as vasculitis vs. controls without GCA/polymyalgia rheumatica (PMR). Results Giant cell arteritis was diagnosed in 81 individuals, including extracranial LV-GCA in 43 individuals. Isolated PMR was diagnosed in 50 subjects. In 83 remaining patients, another diagnosis was confirmed, and they served as controls. The rounded optimal IMT cut-off values for the diagnosis of axillary vasculitis were 0.8 mm, subclavian-0.7 mm, superficial femoral-0.9 mm, CCA-0.7 mm, and brachial-0.5 mm. The IMT cut-off values providing 100% specificity for vasculitis (although with reduced sensitivity) were obtained with axillary IMT 1.06 mm, subclavian-1.35 mm, superficial femoral-1.55 mm, CCA-1.27 mm, and brachial-0.96 mm. Axillary and subclavian arteritis provided the best AUC for the diagnosis of GCA, while carotid and axillary were most commonly involved (24 and 23 patients, respectively). The presence of calcified atherosclerotic plaques was related to an increase of IMT in both patients and controls, while male sex, age ≥ 68, hypertension, and smoking increased IMT in controls but not in patients with GCA. Conclusion Cut-off values for LV-GCA performed best in axillary and subclavian arteritis but expanding examination to the other arteries may add to the sensitivity of GCA diagnosis (another location, e.g., brachial arteritis) and its specificity (identification of calcified atherosclerotic plaques in other arteries such as CCA, which may suggest applying higher IMT cut-off values). We proposed a more linear approach to cut-off values with two values: one for the most accurate and the other for a highly specific diagnosis and also considering some cardiovascular risk factors.
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5
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Noumegni SR, Jousse-Joulin S, Hoffmann C, Cornec D, Devauchelle-Pensec V, Saraux A, Bressollette L. Comparison of halo and compression signs assessed by a high frequency ultrasound probe for the diagnosis of Giant Cell Arteritis. J Ultrasound 2022; 25:837-845. [PMID: 35426608 PMCID: PMC9705675 DOI: 10.1007/s40477-021-00618-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/18/2021] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE To evaluate the diagnosis performances of halo and compression signs alone and combined, assessed by a high frequency 22-MHz probe, and test their agreement in giant cell arteritis (GCA). METHODS In this cross-sectional study on patients suspected with GCA, halo sign was defined as hypo or iso-echogenic circumferential aspect of the vessel wall in transverse or longitudinal view; and compression sign was defined as visibility of the vessel wall upon transducer-imposed compression of the artery. Agreement of the two signs was tested using the Cohen's kappa statistic. RESULTS A total of 80 patients (50% women) were included with a mean age of 74.4 years. Twenty participants (25%) were ultimately treated for GCA. Halo and compression signs have respective prevalences of 35% and 48%, with respective sensitivity and specificity of 80% and 80% for the halo sign; and 85% and 65% for the compression sign. The kappa coefficient for the global agreement of the two signs was 0.67 (95% confident interval: 0.54-0.85). Combination of the two signs give a sensitivity of 80% and a specificity of 81.7%. CONCLUSION Halo and compression signs assessed by a high frequency probe, show a good level of agreement for the diagnosis of GCA and improve ultrasound specificity when combined together.
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Affiliation(s)
- Steve Raoul Noumegni
- Vascular Medicine Department, Brest Teaching Hospital, Brest University, EA 3878 GETBO, Brest, France.
- EA3878 (GETBO), Brest University, Brest, France.
| | - Sandrine Jousse-Joulin
- Rheumatology Department, Brest Teaching Hospital, Brest University, INSERM, LBAI, UMR1227 Brest, Brest, France
| | - Clément Hoffmann
- Vascular Medicine Department, Brest Teaching Hospital, Brest University, EA 3878 GETBO, Brest, France
- EA3878 (GETBO), Brest University, Brest, France
| | - Divi Cornec
- Rheumatology Department, Brest Teaching Hospital, Brest University, INSERM, LBAI, UMR1227 Brest, Brest, France
| | - Valérie Devauchelle-Pensec
- Rheumatology Department, Brest Teaching Hospital, Brest University, INSERM, LBAI, UMR1227 Brest, Brest, France
| | - Alain Saraux
- Rheumatology Department, Brest Teaching Hospital, Brest University, INSERM, LBAI, UMR1227 Brest, Brest, France
| | - Luc Bressollette
- Vascular Medicine Department, Brest Teaching Hospital, Brest University, EA 3878 GETBO, Brest, France
- EA3878 (GETBO), Brest University, Brest, France
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6
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Kirby C, Flood R, Mullan R, Murphy G, Kane D. Evolution of ultrasound in giant cell arteritis. Front Med (Lausanne) 2022; 9:981659. [PMID: 36262280 PMCID: PMC9574015 DOI: 10.3389/fmed.2022.981659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/26/2022] [Indexed: 11/13/2022] Open
Abstract
Ultrasound (US) is being increasingly used to diagnose Giant Cell Arteritis (GCA). The traditional diagnostic Gold Standard has been temporal artery biopsy (TAB), but this is expensive, invasive, has a false-negative rate as high as 60% and has little impact on clinical decision-making. A non-compressible halo with a thickened intima-media complex (IMC) is the sonographic hallmark of GCA. The superficial temporal arteries (STA) and axillary arteries (AA) are the most consistently inflamed arteries sonographically and imaging protocols for evaluating suspected GCA should include at least these two arterial territories. Studies evaluating temporal artery ultrasound (TAUS) have varied considerably in size and methodology with results showing wide discrepancies in sensitivity (9–100%), specificity (66–100%), positive predictive value (36–100%) and negative predictive value (33–100%). Bilateral halos increase sensitivity as does the incorporation of pre-test probability, while prior corticosteroid use decreases sensitivity. Quantifying sonographic vasculitis using Halo Counts and Halo Scores can predict disease extent/severity, risk of specific complications and likelihood of treatment response. Regression of the Halo sign has been observed from as little as 2 days to as late as 7 months after initiation of immunosuppressive treatment and occurs at different rates in STAs than AAs. US is more sensitive than TAB and has comparable sensitivity to MRI and PET/CT. It is time-efficient, cost-effective and allows for the implementation of fast-track GCA clinics which substantially mitigate the risk of irreversible blindness. Algorithms incorporating combinations of imaging modalities can achieve a 100% sensitivity and specificity for a diagnosis of GCA. US should be a standard first line investigation in routine clinical care of patients with suspected GCA with TAB reserved only for those having had a normal US in the context of a high pre-test probability.
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Affiliation(s)
- Colm Kirby
- Department of Rheumatology, Tallaght University Hospital and Trinity College Dublin, Dublin, Ireland,Department of Rheumatology, Cork University Hospital and University College Cork, Cork, Ireland,*Correspondence: Colm Kirby
| | - Rachael Flood
- Department of Rheumatology, Tallaght University Hospital and Trinity College Dublin, Dublin, Ireland
| | - Ronan Mullan
- Department of Rheumatology, Tallaght University Hospital and Trinity College Dublin, Dublin, Ireland
| | - Grainne Murphy
- Department of Rheumatology, Cork University Hospital and University College Cork, Cork, Ireland
| | - David Kane
- Department of Rheumatology, Tallaght University Hospital and Trinity College Dublin, Dublin, Ireland
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7
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Zarka F, Rhéaume M, Belhocine M, Goulet M, Febrer G, Mansour AM, Troyanov Y, Starnino T, Meunier RS, Chagnon I, Routhier N, Bénard V, Ducharme-Bénard S, Ross C, Makhzoum JP. Colour Doppler ultrasound and the giant cell arteritis probability score for the diagnosis of giant cell arteritis: a Canadian single-centre experience. Rheumatol Adv Pract 2021; 5:rkab083. [PMID: 34859177 PMCID: PMC8633428 DOI: 10.1093/rap/rkab083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 10/22/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives The aim was to compare the accuracy of colour Doppler ultrasonography (CDUS) and temporal artery biopsy (TAB) to establish the final diagnosis of GCA and to determine how the GCA probability score (GCAPS) performs as a risk stratification tool. Methods Descriptive statistics were performed on a retrospective cohort of patients referred to our vasculitis referral centre between 1 July 2017 and 1 October 2020 for suspected GCA. CDUS, TAB, centre-specific TAB (vasculitis centre vs referring hospitals) and GCAPS were compared against the final diagnosis of GCA as determined by a GCA expert; CDUS was also compared with TAB results. Results Data from 198 patients were included: 60 patients with GCA and 138 patients without GCA. Sixty-two patients had a TAB. Using the final diagnosis by a GCA expert as a reference, the sensitivity, specificity, positive predictive value and negative predictive value were 93.3%, 98.5%, 96.6% and 97.1% for CDUS and 69.2%, 100%, 100% and 81.8% for TAB, respectively. The false-negative rate was 6.7% for CDUS and 30.8% for TAB. False-negative TAB mostly occurred when performed in referring hospitals (57.1%) as opposed to our vasculitis centre (21.1%). With a cut-off at 9.5 points, sensitivity for GCAPS was 98.3% and specificity 74.3%. Conclusion CDUS of the temporal and axillary arteries showed a high sensitivity and specificity and helped to diagnose GCA in patients with negative TAB. We validated that GCAPS is a useful clinical tool, with a score of <9.5 making the diagnosis of GCA improbable.
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Affiliation(s)
| | | | | | | | | | | | - Yves Troyanov
- Division of Rheumatology, Department of Medicine, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, Quebec, Canada
| | - Tara Starnino
- Division of Rheumatology, Department of Medicine, Hôpital du Sacré-Coeur de Montréal, University of Montreal, Montreal, Quebec, Canada
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8
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Sebastian A, Coath F, Innes S, Jackson J, van der Geest KSM, Dasgupta B. Role of the halo sign in the assessment of giant cell arteritis: a systematic review and meta-analysis. Rheumatol Adv Pract 2021; 5:rkab059. [PMID: 34514295 PMCID: PMC8421813 DOI: 10.1093/rap/rkab059] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/09/2021] [Indexed: 02/06/2023] Open
Abstract
Objectives This systematic review and meta-analysis aimed to evaluate the diagnostic value of the halo sign in the assessment of GCA. Methods A systematic literature review was performed using MEDLINE, EMBASE and Cochrane central register databases up to August 2020. Studies informing on the sensitivity and specificity of the US halo sign for GCA (index test) were selected. Studies with a minimum of five participants were included. Study articles using clinical criteria, imaging such as PET-CT and/or temporal artery biopsy (TAB) as the reference standards were selected. Meta-analysis was conducted with a bivariate model. Results The initial search yielded 4023 studies. Twenty-three studies (patients n = 2711) met the inclusion criteria. Prospective (11 studies) and retrospective (12 studies) studies in academic and non-academic centres were included. Using clinical diagnosis as the standard (18 studies) yielded a pooled sensitivity of 67% (95% CI: 51, 80) and a specificity of 95% (95% CI: 89, 98%). This gave a positive and negative likelihood ratio for the diagnosis of GCA of 14.2 (95% CI: 5.7, 35.5) and 0.375 (95% CI: 0.22, 0.54), respectively. Using TAB as the standard (15 studies) yielded a pooled sensitivity of 63% (95% CI: 50, 75) and a specificity of 90% (95% CI: 81, 95). Conclusion The US halo sign is a sensitive and specific approach for GCA assessment and plays a pivotal role in diagnosis of GCA in routine clinical practice. Registration PROSPERO 2020 CRD42020202179.
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Affiliation(s)
- Alwin Sebastian
- Department of Rheumatology, Southend University Hospital, Mid and South Essex University Hospital Groups, Westcliff-On-Sea.,School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester, Essex
| | - Fiona Coath
- Department of Rheumatology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, Norfolk, UK
| | - Sue Innes
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester, Essex
| | - Jo Jackson
- School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester, Essex
| | - Kornelis S M van der Geest
- Department of Rheumatology and Clinical Immunology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Bhaskar Dasgupta
- Department of Rheumatology, Southend University Hospital, Mid and South Essex University Hospital Groups, Westcliff-On-Sea.,School of Sport, Rehabilitation and Exercise Sciences, University of Essex, Colchester, Essex
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9
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Chrysidis S, Terslev L, Christensen R, Fredberg U, Larsen K, Lorenzen T, Døhn UM, Diamantopoulos AP. Vascular ultrasound for the diagnosis of giant cell arteritis: a reliability and agreement study based on a standardised training programme. RMD Open 2021; 6:rmdopen-2020-001337. [PMID: 32978303 PMCID: PMC7539855 DOI: 10.1136/rmdopen-2020-001337] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/29/2020] [Accepted: 09/05/2020] [Indexed: 12/17/2022] Open
Abstract
Objective To evaluate the impact of a standardised training programme including equipment adjustment for experienced musculoskeletal ultrasonographers without previous experience in vascular ultrasound (US) on the reliability of US in the diagnosis of giant cell arteritis (GCA). Methods In this prospective, non-interventional observational cohort study, patients suspected of GCA were evaluated by US by one of five rheumatologists with long-standing experience in musculoskeletal US (>8 years), trained using a standardised training programme including equipment adjustment. Images of cranial and large vessels were subsequently evaluated first by the performing ultrasonographer and thereafter by a blinded external expert (gold standard). Results In three Danish centres, 112 patients suspected of GCA were included. According to the external expert, vasculitis changes were seen in 66 patients, in 45 of them with only cranial involvement, in 14 with both cranial and large vessel involvement, while in seven patients isolated large vessel vasculitis was found. The reliability was excellent between the local ultrasonographer and the US expert for the overall GCA diagnosis regarding the diagnosis of cranial and for large vessel GCA, with an interobserver agreement of 95–96%, mean kappa values of 0.88–0.92 (95% CI 0.78 to 0.99). Excellent reliability (mean kappa 0.86–1.00) was also found for the US examination of the individual arteries (temporal, facial, common carotid and axillary). Conclusion The US training programme resulted in excellent agreement between trainees and an expert in patients suspected of GCA and may thus be applicable for implementation of vascular US in clinical practice.
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Affiliation(s)
- Stavros Chrysidis
- Department of Rheumatology, Southwest Jutland Hospital Esbjerg, Esbjerg, Denmark .,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Lene Terslev
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet Glostrup, Glostrup, Denmark
| | - Robin Christensen
- Musculoskeletal Statistics Unit, Frederiksberg Hospital Parker Institute, Frederiksberg, Denmark.,Research Unit of Rheumatology, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Ulrich Fredberg
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Knud Larsen
- Department of Ear Nose and Throat , Southwest Jutland Hospital Esbjerg, Esbjerg, Denmark
| | - Tove Lorenzen
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
| | - Uffe Møller Døhn
- Copenhagen Center for Arthritis Research, Center for Rheumatology and Spine Diseases, Rigshospitalet Glostrup, Glostrup, Denmark
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10
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Sebastian A, Tomelleri A, Kayani A, Prieto-Pena D, Ranasinghe C, Dasgupta B. Probability-based algorithm using ultrasound and additional tests for suspected GCA in a fast-track clinic. RMD Open 2021; 6:rmdopen-2020-001297. [PMID: 32994361 PMCID: PMC7547539 DOI: 10.1136/rmdopen-2020-001297] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/22/2020] [Accepted: 09/05/2020] [Indexed: 12/27/2022] Open
Abstract
Objectives Clinical presentations of giant cell arteritis (GCA) are protean, and it is vital to make a secure diagnosis and exclude mimics for urgent referrals with suspected GCA. The main objective was to develop a joined-up, end-to-end, fast-track confirmatory/exclusionary, algorithmic process based on a probability score triage to drive subsequent investigations with ultrasound (US) and any appropriate additional tests as required. Methods The algorithm was initiated by stratifying patients to low-risk category (LRC), intermediate-risk category (IRC) and high-risk category (HRC). Retrospective data was extracted from case records. The Southend pretest probability score (PTPS) overall showed a median score of 9 and a 75th percentile score of 12. We, therefore, classified LRC as PTPS <9, IRC 9–12 and HRC >12. GCA diagnosis was made by a combination of clinical, US, and laboratory findings. The algorithm was assessed in all referrals seen in 2018–2019 to test the diagnostic performance of US overall and in individual categories. Results Of 354 referrals, 89 had GCA with cases categorised as LRC (151), IRC (137) and HRC (66). 250 had US, whereas 104 did not (score <7, and/or high probability of alternative diagnoses). In HRC, US showed sensitivity 94%, specificity 85%, accuracy 92% and GCA prevalence 80%. In LRC, US showed sensitivity undefined (0/0), specificity 98%, accuracy 98% and GCA prevalence 0%. In IRC, US showed sensitivity 100%, specificity 97%, accuracy 98% and GCA prevalence 26%. In the total population, US showed sensitivity 97%, specificity 97% and accuracy 97%. Prevalence of GCA overall was 25%. Conclusions The Southend PTPS successfully stratifies fast-track clinic referrals and excludes mimics. The algorithm interprets US in context, clarifies a diagnostic approach and identifies uncertainty, need for re-evaluation and alternative tests. Test performance of US is significantly enhanced with PTPS.
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Affiliation(s)
- Alwin Sebastian
- Rheumatology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK
| | - Alessandro Tomelleri
- Rheumatology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK.,Unit of Immunology, Rheumatology, Allergy and Rare Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Abdul Kayani
- Rheumatology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK
| | - Diana Prieto-Pena
- Rheumatology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK.,Rheumatology, Marques de Valdecilla University Hospital, Santander, Spain
| | - Chavini Ranasinghe
- Rheumatology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK
| | - Bhaskar Dasgupta
- Rheumatology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, UK
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11
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Imaging Tests in the Early Diagnosis of Giant Cell Arteritis. J Clin Med 2021; 10:jcm10163704. [PMID: 34442002 PMCID: PMC8397068 DOI: 10.3390/jcm10163704] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Revised: 08/06/2021] [Accepted: 08/17/2021] [Indexed: 12/23/2022] Open
Abstract
Early recognition of giant cell arteritis (GCA) is crucial to avoid the development of ischemic vascular complications, such as blindness. The classic approach to making the diagnosis of GCA is based on a positive temporal artery biopsy, which is among the criteria proposed by the American College of Rheumatology (ACR) in 1990 to classify a patient as having GCA. However, imaging techniques, particularly ultrasound (US) of the temporal arteries, are increasingly being considered as an alternative for the diagnosis of GCA. Recent recommendations from the European League Against Rheumatism (EULAR) for the use of imaging techniques for large vessel vasculitis (LVV) included US as the first imaging option for the diagnosis of GCA. Furthermore, although the ACR classification criteria are useful in identifying patients with the classic cranial pattern of GCA, they are often inadequate in identifying GCA patients who have the extracranial phenotype of LVV. In this sense, the advent of other imaging techniques, such as magnetic resonance imaging (MRI), computed tomography (CT), and positron emission tomography (PET)/CT, has made it possible to detect the presence of extracranial involvement of the LVV in patients with GCA presenting as refractory rheumatic polymyalgia without cranial ischemic manifestations. Imaging techniques have been the key elements in redefining the diagnostic work-up of GCA. US is currently considered the main imaging modality to improve the early diagnosis of GCA.
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12
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Venhoff N, Schmidt WA, Lamprecht P, Tony HP, App C, Sieder C, Legeler C, Jentzsch C, Thiel J. Efficacy and safety of secukinumab in patients with giant cell arteritis: study protocol for a randomized, parallel group, double-blind, placebo-controlled phase II trial. Trials 2021; 22:543. [PMID: 34404463 PMCID: PMC8369438 DOI: 10.1186/s13063-021-05520-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/06/2021] [Indexed: 12/03/2022] Open
Abstract
Background One key pathological finding in giant cell arteritis (GCA) is the presence of interferon-gamma and interleukin (IL)-17 producing T helper (Th) 1 and Th17 cells in affected arteries. There is anecdotal evidence of successful induction and maintenance of remission with the monoclonal anti-IL-17A antibody secukinumab. Inhibition of IL-17A could therefore represent a potential new therapeutic option for the treatment of GCA. Methods This is a randomized, parallel-group, double-blind, placebo-controlled, multi-center, phase II study in which patients, treating physicians, and the associated clinical staff as well as the sponsor clinical team are blinded. It is designed to evaluate efficacy and safety of secukinumab compared to placebo in combination with an open-label prednisolone taper regimen. Patients included are naïve to biological therapy and have newly diagnosed or relapsing GCA. Fifty patients are randomly assigned in a 1:1 ratio to receive either 300 mg secukinumab or placebo subcutaneously at baseline, weeks 1, 2 and 3, and every 4 weeks from week 4. Patients in both treatment arms receive a 26-week prednisolone taper regimen. The study consists of a maximum 6-week screening period, a 52-week treatment period (including the 26-week tapering), and an 8-week safety follow-up, with primary and secondary endpoint assessments at week 28. Patients who do not achieve remission by week 12 experience a flare after remission or cannot adhere to the prednisolone tapering will enter the escape arm and receive prednisolone at a dose determined by the investigator’s clinical judgment. The blinded treatment is continued. Two optional imaging sub-studies are included (ultrasound and contrast-media enhanced magnetic resonance angiography [MRA]) to assess vessel wall inflammation and occlusion before and after treatment. The primary endpoint is the proportion of patients in sustained remission until week 28 in the secukinumab group compared to the proportion of patients in the placebo group. A Bayesian approach is applied. Discussion The trial design allows the first placebo-controlled data collection on the efficacy and safety of secukinumab in patients with GCA. Trial registration ClinicalTrials.gov NCT03765788. Registration on 5 December 2018, prospective registration, EudraCT number 2018-002610-12; clinical trial protocol number CAIN457ADE11C.
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Affiliation(s)
- Nils Venhoff
- Department Innere Medizin, Klinik für Rheumatologie und Klinische Immunologie, Vaskulitiszentrum Freiburg, Universitätsklinikum Freiburg, Hugstetterstrasse 55, D-79106, Freiburg, Germany
| | - Wolfgang A Schmidt
- Immanuel Krankenhaus Berlin, Klinik für Innere Medizin, Abteilung Rheumatologie und Klinische Immunologie in Berlin-Buch, Lindenberger Weg 19, D-13125, Berlin, Germany
| | - Peter Lamprecht
- Universität zu Lübeck, Klinik für Rheumatologie und klinische Immunologie, Ratzeburger Allee 160, D-23538, Lübeck, Germany
| | - Hans-Peter Tony
- Medizinische Klinik II, Universitätsklinik, Rheumatology/Immunology, Oberduerrbacher Strasse 6, D-97080, Wuerzburg, Germany
| | - Christine App
- Department of Immunology, Hepatology & Dermatology, Novartis Pharma GmbH, Roonstrasse 25, D-90429, Nuremberg, Germany
| | - Christian Sieder
- Department of Immunology, Hepatology & Dermatology, Novartis Pharma GmbH, Roonstrasse 25, D-90429, Nuremberg, Germany
| | - Carolin Legeler
- Department of Immunology, Hepatology & Dermatology, Novartis Pharma GmbH, Roonstrasse 25, D-90429, Nuremberg, Germany.
| | | | - Jens Thiel
- Department Innere Medizin, Klinik für Rheumatologie und Klinische Immunologie, Vaskulitiszentrum Freiburg, Universitätsklinikum Freiburg, Hugstetterstrasse 55, D-79106, Freiburg, Germany
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13
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Bajko Z, Balasa R, Maier S, Motataianu A, Barcutean L, Andone S, Stoian A, Filep RC. Stroke secondary to giant-cell arteritis: A literature review. Exp Ther Med 2021; 22:876. [PMID: 34194554 PMCID: PMC8237390 DOI: 10.3892/etm.2021.10308] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 03/31/2021] [Indexed: 11/06/2022] Open
Abstract
Stroke is a leading cause of death and disability worldwide. In addition to the classical etiologies of stroke as atherosclerosis and cardioembolism there are many unusual, rare causes, which require a high level of clinical suspicion and further investigations for correct and early diagnosis and adequate treatment. Giant-cell arteritis or temporal arteritis, the most frequent vasculitis in the elderly population is one of the uncommon causes of stroke. In the setting of giant-cell arteritis, stroke more likely affects the vertebrobasilar territory and is the main cause of mortality. Duplex ultrasound examination is a routine investigation for stroke patients and may be key to the diagnosis if the classical hypoechoic ‘halo sign’ is recognized at the level of vertebral arteries. In this situation the ultrasound evaluation of temporal arteries and temporal artery biopsy are mandatory. The Giant-cell arteritis-related stroke is a rare condition; therefore, there are no evidence-based guidelines or standard recommendations for the treatment. In the present review, the main characteristics of giant-cell arteritis-related stroke are discussed.
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Affiliation(s)
- Zoltan Bajko
- Department of Neurology, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Rodica Balasa
- Department of Neurology, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Smaranda Maier
- Department of Neurology, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Anca Motataianu
- Department of Neurology, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Laura Barcutean
- Department of Neurology, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Sebastian Andone
- Department of Neurology, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Adina Stoian
- Department of Pathophysiology, 'George Emil Palade' University of Medicine, Pharmacy, Sciences and Technology, 540136 Targu Mures, Romania
| | - Rares Cristian Filep
- Department of Interventional Radiology, Mures County Clinical Emergency Hospital, 540136 Targu Mures, Romania
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14
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Stenzl A, Ikenberg B, Mogler C, Moog P, Röper K, Stimmer H, Wollenberg B, Hofauer B, Roth A. [Tongue pain and blindness-an unusual combination]. HNO 2021; 70:304-307. [PMID: 33851231 DOI: 10.1007/s00106-021-01044-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Anna Stenzl
- Klinik und Poliklinik für Hals‑, Nasen- und Ohrenheilkunde, Klinikum rechts der Isar der TU München, Ismaninger Straße 22, 81675, München, Deutschland
| | - Benno Ikenberg
- Neurologische Klinik und Poliklinik, Klinikum rechts der Isar der TU München, München, Deutschland
| | - Carolin Mogler
- Institut für allgemeine Pathologie und pathologische Anatomie, Klinikum rechts der Isar der TU München, München, Deutschland
| | - Philipp Moog
- Abteilung für Nephrologie, Klinikum rechts der Isar der TU München, München, Deutschland
| | - Kristin Röper
- Klinik und Poliklinik für Augenheilkunde, Klinikum rechts der Isar der TU München, München, Deutschland
| | - Herbert Stimmer
- Institut für diagnostische und interventionelle Radiologie, Klinikum rechts der Isar der TU München, München, Deutschland
| | - Barbara Wollenberg
- Klinik und Poliklinik für Hals‑, Nasen- und Ohrenheilkunde, Klinikum rechts der Isar der TU München, Ismaninger Straße 22, 81675, München, Deutschland
| | - Benedikt Hofauer
- Klinik und Poliklinik für Hals‑, Nasen- und Ohrenheilkunde, Klinikum rechts der Isar der TU München, Ismaninger Straße 22, 81675, München, Deutschland
| | - Andreas Roth
- Klinik und Poliklinik für Hals‑, Nasen- und Ohrenheilkunde, Klinikum rechts der Isar der TU München, Ismaninger Straße 22, 81675, München, Deutschland.
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15
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16
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Monti S, Bartoletti A, Bellis E, Delvino P, Montecucco C. Fast-Track Ultrasound Clinic for the Diagnosis of Giant Cell Arteritis Changes the Prognosis of the Disease but Not the Risk of Future Relapse. Front Med (Lausanne) 2020; 7:589794. [PMID: 33364248 PMCID: PMC7753207 DOI: 10.3389/fmed.2020.589794] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 10/19/2020] [Indexed: 01/17/2023] Open
Abstract
Background: Color Duplex sonography (CDS) of temporal arteries and large vessels (LV) is a recently validated diagnostic methodology for Giant Cell Arteritis (GCA). CDS combined with a fast-track approach (FTA) has improved the early diagnosis of the disease. Objectives: To assess FTA effects on the prevention of permanent visual loss (PVL), relapse and late complications of GCA compared to conventional practice. To assess the impact of COVID-19 pandemic on outcomes of GCA patients assessed with FTA. Methods: GCA patients diagnosed up to June 2020 at the Rheumatology Department, University of Pavia, were included. FTA was implemented since October 2016. FTA consists in the referral within 1 working day of a suspected GCA case to an expert rheumatologist who performs clinical evaluation and CDS. Results: One hundred sixty patients were recruited [female 120 (75%), mean age 72.4 ± 8.2 years]. Sixty-three (39.4%) evaluated with FTA, 97 (60.6%) with conventional approach. FTA patients were older (75.1 ± 7.6 vs. 70.6 ± 8.2 years old; p < 0.001). Median follow-up duration was shorter in the FTA group compared to the conventional one (0.9 vs. 5.0 years; p < 0.001). There was no difference between the two cohorts regarding major vessel district involvement (LV-GCA 17.5% vs. 22.7%; p = 0.4). PVL occurred in 8 (12.7%) FTA patients and 26 (26.8%) conventional ones (p = 0.03). The relative risk of blindness in the conventional group was 2.11 (95% C.I. 1.02–4.36; P = 0.04) as compared to FTA. Median symptom latency of patients experiencing PVL was higher in the conventional group (23 days IQR 12–96 vs. 7 days IQR 4–10, p = 0.02). During COVID-19 there was a significant increase in the occurrence of PVL (40%) including bilateral blindness despite a regularly operating FTA clinic. Cumulative incidence of relapses and time to first relapse did not change after FTA introduction (P = 0.2). No difference in late complications (stenosis/aneurysms) was detected. Conclusions: FTA including CDS evaluation contributed to a substantial reduction of PVL in GCA by shortening the time to diagnosis and treatment initiation. Relapse rate did not change upon FTA introduction, highlighting the need for better disease activity monitoring and treatment strategies optimization based on risk stratification that would predict the occurrence of relapse during glucocorticoid de-escalation.
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Affiliation(s)
- Sara Monti
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy.,PhD in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Alice Bartoletti
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Elisa Bellis
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Paolo Delvino
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy.,PhD in Experimental Medicine, University of Pavia, Pavia, Italy
| | - Carlomaurizio Montecucco
- Rheumatology Department, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
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17
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Sebastian A, Kayani A, Prieto-Pena D, Tomelleri A, Whitlock M, Mo J, van der Geest N, Dasgupta B. Efficacy and safety of tocilizumab in giant cell arteritis: a single centre NHS experience using imaging (ultrasound and PET-CT) as a diagnostic and monitoring tool. RMD Open 2020; 6:rmdopen-2020-001417. [PMID: 33161376 PMCID: PMC7856116 DOI: 10.1136/rmdopen-2020-001417] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 10/03/2020] [Accepted: 10/21/2020] [Indexed: 11/03/2022] Open
Abstract
Tocilizumab (TCZ), an IL-6 receptor blocker, is approved for relapsing, refractory giant cell arteritis (GCA). We report real-life clinical experience with TCZ in GCA including assessment of responses on imaging (ultrasound (US) and 18F-Fluorodeoxyglucose Positron Emission Tomography-computed Tomography (18FDG-PET-CT)) during the first year of treatment. We included 22 consecutive patients with GCA treated with TCZ where EULAR core data set on disease activity, quality of life (QoL) and treatment-related complications were collected. Pre-TCZ US and 18FDG-PET/CT findings were available for 21 and 4 patients, respectively, where we determined the effect on US halo thickness, temporal and axillary artery Southend Halo Score and Total Vascular Score on 18FDG-PET-CT. The 22 patients with GCA (10 cranial, 10 large vessel, 2 both) had a median disease duration of 58.5 (range, 1-370) weeks prior to initiation of TCZ. Half had used prior conventional synthetic disease-modifying antirheumatic drug (csDMARDs). TCZ was initiated for refractory (50%), ischaemic (36%) or relapsing (14%) disease. Median follow-up was 43 (12-52) weeks. TCZ was discontinued due to serious adverse events (SAEs) in two patients. On treatment with TCZ, 4 discontinued prednisolone, 11 required doses ≤2.5 mg, 2 required daily dose of 2.5-5 mg and 5 needed prednisolones ≥5 mg daily. QoL improved by 50%. Total US halo thickness decreased in 38 arterial segments, median temporal artery Halo Score decreased from 11 to 0, axillary artery Halo Score remained stable. Median Total Vascular Score on FDG-PET/CT reduced from 11.5 to 6.5. In our experience, TCZ showed an excellent response with acceptable safety in GCA, with improvement on US and FDG-PET/CT imaging.
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Affiliation(s)
- Alwin Sebastian
- Rheumatology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea,UK.,School of Sport, Rehabilitation and Exercise Science, University of Essex, Colchester, UK
| | - Abdul Kayani
- Rheumatology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea,UK
| | - Diana Prieto-Pena
- Rheumatology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea,UK.,Rheumatology, Marques De Valdecilla University Hospital, Santander, Spain
| | - Alessandro Tomelleri
- Rheumatology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea,UK.,Unit of Immunology, Rheumatology, Allergy and Rare Diseases, San Raffaele Scientific Institute, Milan, Italy
| | - Madeline Whitlock
- Rheumatology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea,UK
| | - Jonathan Mo
- Radiology, Southend Hospital NHS Trust, Westcliff-on-sea,UK
| | - Niels van der Geest
- Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Bhaskar Dasgupta
- Rheumatology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea,UK .,School of Sport, Rehabilitation and Exercise Science, University of Essex, Colchester, UK
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18
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van der Geest KSM, Sandovici M, Brouwer E, Mackie SL. Diagnostic Accuracy of Symptoms, Physical Signs, and Laboratory Tests for Giant Cell Arteritis: A Systematic Review and Meta-analysis. JAMA Intern Med 2020; 180:1295-1304. [PMID: 32804186 PMCID: PMC7432275 DOI: 10.1001/jamainternmed.2020.3050] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE Current clinical guidelines recommend selecting diagnostic tests for giant cell arteritis (GCA) based on pretest probability that the disease is present, but how pretest probability should be estimated remains unclear. OBJECTIVE To evaluate the diagnostic accuracy of symptoms, physical signs, and laboratory tests for suspected GCA. DATA SOURCES PubMed, EMBASE, and the Cochrane Database of Systematic Reviews were searched from November 1940 through April 5, 2020. STUDY SELECTION Trials and observational studies describing patients with suspected GCA, using an appropriate reference standard for GCA (temporal artery biopsy, imaging test, or clinical diagnosis), and with available data for at least 1 symptom, physical sign, or laboratory test. DATA EXTRACTION AND SYNTHESIS Screening, full text review, quality assessment, and data extraction by 2 investigators. Diagnostic test meta-analysis used a bivariate model. MAIN OUTCOME(S) AND MEASURES Diagnostic accuracy parameters, including positive and negative likelihood ratios (LRs). RESULTS In 68 unique studies (14 037 unique patients with suspected GCA; of 7798 patients with sex reported, 5193 were women [66.6%]), findings associated with a diagnosis of GCA included limb claudication (positive LR, 6.01; 95% CI, 1.38-26.16), jaw claudication (positive LR, 4.90; 95% CI, 3.74-6.41), temporal artery thickening (positive LR, 4.70; 95% CI, 2.65-8.33), temporal artery loss of pulse (positive LR, 3.25; 95% CI, 2.49-4.23), platelet count of greater than 400 × 103/μL (positive LR, 3.75; 95% CI, 2.12-6.64), temporal tenderness (positive LR, 3.14; 95% CI, 1.14-8.65), and erythrocyte sedimentation rate greater than 100 mm/h (positive LR, 3.11; 95% CI, 1.43-6.78). Findings that were associated with absence of GCA included the absence of erythrocyte sedimentation rate of greater than 40 mm/h (negative LR, 0.18; 95% CI, 0.08-0.44), absence of C-reactive protein level of 2.5 mg/dL or more (negative LR, 0.38; 95% CI, 0.25-0.59), and absence of age over 70 years (negative LR, 0.48; 95% CI, 0.27-0.86). CONCLUSIONS AND RELEVANCE This study identifies the clinical and laboratory features that are most informative for a diagnosis of GCA, although no single feature was strong enough to confirm or refute the diagnosis if taken alone. Combinations of these symptoms might help direct further investigation, such as vascular imaging, temporal artery biopsy, or seeking evaluation for alternative diagnoses.
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Affiliation(s)
- Kornelis S M van der Geest
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Maria Sandovici
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Elisabeth Brouwer
- Department of Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Sarah L Mackie
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, NIHR (National Institute for Health Research) Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS (National Health Service) Trust, University of Leeds, Leeds, United Kingdom
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19
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Sebastian A, van der Geest KSM, Coath F, Gondo P, Kayani A, Mackerness C, Hadebe B, Innes S, Jackson J, Dasgupta B. Halo score (temporal artery, its branches and axillary artery) as a diagnostic, prognostic and disease monitoring tool for Giant Cell Arteritis (GCA). BMC Rheumatol 2020; 4:35. [PMID: 32821876 PMCID: PMC7433165 DOI: 10.1186/s41927-020-00136-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 05/03/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Giant cell arteritis (GCA) is a common large vessel vasculitis of the elderly, often associated with sight loss. Glucocorticoids (GC remain the mainstay of treatment, although biologic treatments have been approved. Biomarkers predicting disease severity, relapse rates and damage are lacking in GCA.EULAR recommends ultrasound (US) as the first investigation for suspected GCA. The cardinal US finding, a non-compressible halo, is currently categorised as either negative or positive. However, the extent and severity of this finding may vary.In this study, we hypothesise whether the extent and severity of the halo sign [calculated as a single composite Halo score (HS)] of temporal and axillary arteries may be of diagnostic, prognostic and monitoring importance; whether baseline HS is linked to disease outcomes, relapses and damage; whether HS can stratify GCA patients for individual treatment needs; whether HS can function as an objective monitoring tool during follow up. METHODS This is a prospective, observational study. Suspected GCA Participants will be selected from the GCA FTC at the participating centres in the UK. Informed consent will be obtained, and patients managed as part of standard care. Patients with GCA will have HS (temporal and axillary arteries) measured at baseline and months 1,3,6 and 12 long with routine clinical assessments, blood sampling and patient-reported outcomes (EQ5D). Non-GCA patients will be discharged back to the referral team and will have a telephone interview in 6 months.We aim to recruit 272 suspected GCA referrals which should yield 68 patients (25% of referrals) with confirmed GCA. The recruitment will be completed in 1 year with an estimated total study period of 24 months. DISCUSSION The identification of prognostic factors in GCA is both timely and needed. A prognostic marker, such as the HS, could help to stratify GCA patients for an appropriate treatment regimen. Tocilizumab, an IL-6R blocking agent, switches off the acute phase response (C-Reactive Protein), making it difficult to measure the disease activity. Therefore, an independent HS, and changes in that score during treatment and follow-up, maybe a more objective measure of response compare to patient-reported symptoms and clinical assessment alone.
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Affiliation(s)
- Alwin Sebastian
- Rheumatology, Mid and South Essex University Hospital Groups, Southend University Hospital, Westcliff-On-Sea, Essex, UK
- University of Essex, Colchester, UK
| | - Kornelis S M van der Geest
- Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Fiona Coath
- Norfolk and Norwich University hospitals NHS Foundation Trust, Colney Ln, Norwich, UK
| | - Prisca Gondo
- R&D, Mid and South Essex University Hospital Groups, Southend University Hospital, Westcliff-On-Sea, Essex, UK
| | - Abdul Kayani
- Rheumatology, Mid and South Essex University Hospital Groups, Southend University Hospital, Westcliff-On-Sea, Essex, UK
| | - Craig Mackerness
- R&D, Mid and South Essex University Hospital Groups, Southend University Hospital, Westcliff-On-Sea, Essex, UK
| | - Bernard Hadebe
- R&D, Mid and South Essex University Hospital Groups, Southend University Hospital, Westcliff-On-Sea, Essex, UK
| | - Sue Innes
- School of Sport, Rehabilitation and exercise sciences, Colchester campus, University of Essex, Colchester, UK
| | - Jo Jackson
- School of Sport, Rehabilitation and exercise sciences, Colchester campus, University of Essex, Colchester, UK
| | - Bhaskar Dasgupta
- Rheumatology, Mid and South Essex University Hospital Groups, Southend University Hospital, Westcliff-On-Sea, Essex, UK
- University of Essex, Colchester, UK
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21
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van der Geest KSM, Borg F, Kayani A, Paap D, Gondo P, Schmidt W, Luqmani RA, Dasgupta B. Novel ultrasonographic Halo Score for giant cell arteritis: assessment of diagnostic accuracy and association with ocular ischaemia. Ann Rheum Dis 2020; 79:393-399. [PMID: 31900304 PMCID: PMC7034352 DOI: 10.1136/annrheumdis-2019-216343] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/18/2019] [Accepted: 12/16/2019] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Ultrasound of temporal and axillary arteries may reveal vessel wall inflammation in patients with giant cell arteritis (GCA). We developed a ultrasound scoring system to quantify the extent of vascular inflammation and investigated its diagnostic accuracy and association with clinical factors in GCA. METHODS This is a prospective study including 89 patients suspected of having GCA, of whom 58 had a confirmed clinical diagnosis of GCA after 6 months follow-up. All patients underwent bilateral ultrasound examination of the three temporal artery (TA) segments and axillary arteries, prior to TA biopsy. The extent of vascular inflammation was quantified by (1) counting the number of TA segments and axillary arteries with a halo and (2) calculating a composite Halo Score that also incorporated the thickness of each halo. RESULTS Halo counts and Halo Scores showed moderate diagnostic accuracy for a clinical diagnosis of GCA. They correlated positively with systemic inflammation. When compared with the halo count, the Halo Score correlated better with C-reactive protein (CRP) levels and allowed to firmly establish the diagnosis of GCA in more patients. Higher halo counts and Halo Scores were associated with a higher risk of ocular ischaemia. They allowed to identify subgroups of patients with low risk (≤5%) and high risk of ocular ischaemia (>30%). CONCLUSIONS Ultrasound halo scoring allows to quantify the extent of vascular inflammation in GCA. Extensive vascular inflammation on ultrasound may provide strong diagnostic confirmation and associates with ocular ischaemia in GCA.
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Affiliation(s)
- Kornelis S M van der Geest
- Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Rheumatology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, Essex, UK
| | - Frances Borg
- Rheumatology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, Essex, UK
| | - Abdul Kayani
- Rheumatology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, Essex, UK
| | - Davy Paap
- Rheumatology and Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.,Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Prisca Gondo
- Rheumatology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, Essex, UK
| | - Wolfgang Schmidt
- Medical Centre for Rheumatology Berlin-Buch, Immanuel-Krankenhaus GmbH, Berlin, Germany
| | - Raashid Ahmed Luqmani
- Rheumatology, University of Oxford Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, Oxford, Oxfordshire, UK
| | - Bhaskar Dasgupta
- Rheumatology, Southend University Hospital NHS Foundation Trust, Westcliff-on-Sea, Essex, UK
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22
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Will imaging change the diagnosis and management of giant cell arteritis? ACTA ACUST UNITED AC 2019; 57:341-344. [PMID: 31120860 DOI: 10.2478/rjim-2019-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Indexed: 11/20/2022]
Abstract
Giant cell arteritis is a common systemic vasculitis affecting the elderly, with maximum prevalence in the 7th decade of age, targeting aortic derived medium and large vessels of the neck and head. Diagnosis is established on a biopsy specimen of the temporal artery wall, through pathological confirmation of panarteritis, typically characterized by mononuclear cell infiltrate, with the 1990 ACR criteria often used in clinical practice. We present the case of a patient with a new onset headache and systemic inflammation, who did not fulfil the classical diagnostic criteria, nor did the temporal artery biopsy (TAB) provide a positive result. However, the ultrasonographical features, clinical evolution and response to corticosteroid therapy confirmed the diagnosis. This patient had bilateral presence of the halo sign on color duplex ultrasonography (CDUS), cited as a highly specific feature, when compared to the ACR criteria as a standard reference. We employed its positive likelihood-ratio (LR+) of 43 as previously estimated, while considering a low pre-test probability for a positive diagnosis (15%), to calculate a post-test probability of 88%, leading to our decision to treat him as having giant cell arteritis. Remission of the headache and rebound phenomena when tapered off steroid therapy substantially contributed to the positive diagnosis, underlining the importance of future studies needing to use clinical evolution as a reference standard.
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23
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The Impact of Temporal Artery Biopsy at a UK Tertiary Plastic Surgery Unit. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2541. [PMID: 31942316 PMCID: PMC6908368 DOI: 10.1097/gox.0000000000002541] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 10/03/2019] [Indexed: 12/30/2022]
Abstract
Guidelines recommend temporal artery biopsy (TAB) for patients suspected of having giant cell arteritis (GCA). We evaluated the impact of TAB on the diagnosis and management of patients with suspected GCA at a tertiary plastic surgery unit. Methods A retrospective review of all TAB procedures performed at our centre over 7 years was performed. One hundred and one patients were included in the study. Patients were classified into 3 diagnostic groups: confirmed (positive TAB), presumed (negative TAB with high clinical suspicion) and unlikely (negative TAB with low clinical suspicion). The clinical presentation and management for each group were compared. Results The average American College of Rheumatology (ACR) score was 3.07. The number of patients with an ACR score of ≥3 before TAB was 72 (71.3%) and remained the same after TAB. The number of patients who remained on steroid therapy was lower in the group with an unlikely diagnosis of GCA compared to the group with a confirmed diagnosis (p<0.05). Conversely, there was no significant difference in steroid therapy between those with a presumed and confirmed diagnosis (p>0.05). Conclusions This study found a significant difference in steroid treatment between those with confirmed GCA and those where the diagnosis was unlikely showing that TAB may support decisions regarding steroid therapy. However, TAB was inappropriately requested for patients whose pre-TAB ACR score was ≥3 as this score is sufficient for the diagnosis of GCA. Therefore, the use of TAB should be limited to cases of diagnostic uncertainty.
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24
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Sangolli PM, Lakshmi DV. Vasculitis: A Checklist to Approach and Treatment Update for Dermatologists. Indian Dermatol Online J 2019; 10:617-626. [PMID: 31807439 PMCID: PMC6859757 DOI: 10.4103/idoj.idoj_248_18] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Vasculitis poses a great diagnostic, investigative and therapeutic challenge to the treating physician. The classification of vasculitides itself still eludes universal acceptance. Comprehensive management comprises establishing the diagnosis of true vasculitis after ruling out vasculitis mimics, finding the etiology if feasible, assessing the caliber of the vessels involved, deciphering the pathological process of vessel damage, investigating for the existence and extent of systemic involvement and finally planning the therapy in the background of co-morbidities. Successful management also entails regular monitoring to foresee complications arising from the disease process itself as well as complications of immunosuppressive treatment. Although steroids remain first line drug, biologics are emerging as popular agents in the treatment of immune-mediated vasculitis. Triphasic treatment is the best plan of action comprising induction, maintenance of remission and treatment of relapses.
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25
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Schmidt WA, Hartung W. [Imaging diagnostics in large vessel vasculitis]. Z Rheumatol 2019; 78:847-858. [PMID: 31541286 DOI: 10.1007/s00393-019-00711-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Imaging procedures have become an important diagnostic tool in vasculitis. In large vessel vasculitides, such as giant-cell arteritis (GCA) and Takayasu arteritis, ultrasound, magnetic resonance imaging (MRI), computed tomography (CT) and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) can depict specific abnormalities of the arterial wall. A clinically suspected diagnosis can be confirmed by imaging if performed by a trained specialist using appropriate equipment, without histological investigations. Ultrasound, MRI and CT show a homogeneous, concentric thickening of the arterial wall and PET can detect increased glucose metabolism of the arterial wall. Ultrasound is the method of choice, especially in predominantly cranial GCA. Imaging should be performed before or within the first few days of glucocorticoid treatment as the PET findings of all arteries as well as ultrasound and MRI findings in temporal arteries normalize quickly with treatment. A planned imaging examination must not delay initiation of glucocorticoid treatment.
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Affiliation(s)
- W A Schmidt
- Rheumaklinik Berlin-Buch, Immanuel Krankenhaus Berlin, Lindenberger Weg 19, 13125, Berlin, Deutschland.
| | - W Hartung
- Klinik für Rheumatologie und klinische Immunologie, Asklepios Klinik, Bad Abbach, Deutschland
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26
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Abstract
Ultrasound (US) and Doppler are often the first imaging to be carried out for arterial disease, and with good reason. US is noninvasive, free of radiation exposure and crucial for follow up imaging. The review that follows aims to highlight the various applications of US in imaging of the arterial system.
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Affiliation(s)
- Prashant Gupta
- Department of Radiology, Scunthorpe General Hospital, Northern Lincolnshire and Goole NHS Foundation Trust, UK
| | - Shannon Lyons
- Division of Cardiovascular Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sandeep Hedgire
- Division of Cardiovascular Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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27
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Advantages in diagnosis of giant cell arteritis by ultrasound. Postepy Dermatol Alergol 2019; 36:25-28. [PMID: 30858775 PMCID: PMC6409876 DOI: 10.5114/ada.2019.82823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/13/2017] [Indexed: 12/30/2022] Open
Abstract
Giant cell arteritis is the most common systemic vasculitis. It selectively affects large- and medium-sized arteries. Arterial wall inflammation leads to luminal occlusion and tissue ischemia, which cause the clinical manifestations of this vasculitis. Susceptible sites include the vascular bed of the cranial nerves and scalp including the temporal arteries, optic nerve, masseter muscles, and the posterior circulation of the central nervous system. Involvement can extend to the aorta and its primary and secondary branches, including the subclavian and axillary arteries, which leads to upper-extremity ischemia. The article presents a review of epidemiology, clinical presentation and especially ultrasound diagnostics of giant cell arteritis.
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28
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Aschwanden M, Schegk E, Imfeld S, Staub D, Rottenburger C, Berger CT, Daikeler T. Vessel wall plasticity in large vessel giant cell arteritis: an ultrasound follow-up study. Rheumatology (Oxford) 2018; 58:792-797. [DOI: 10.1093/rheumatology/key383] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Revised: 11/01/2018] [Indexed: 01/18/2023] Open
Abstract
Abstract
Objectives
To assess changes of arterial vessel wall morphology in large vessel GCA patients (LV-GCA) by repeated US.
Methods
Patients with LV-GCA on US examination were followed up 6, 12 and 24 months after diagnosis by US of the temporal, vertebral, carotid (common, internal, external), subclavian, axillary, femoral (deep, superficial and common) and popliteal arteries. Clinical and laboratory data were assessed at each visit. Vessel wall thickening was classified as moderate, marked or arteriosclerotic.
Results
A total of 42 patients (26 female) with a median age of 75 years at diagnosis had in median 2 (range 1–3) US follow-up exams. Twenty-eight had both LV and temporal artery involvement and 14 had LV-GCA only. The common carotid, subclavian, axillary, popliteal and/or superficial femoral artery were most commonly involved. Reduction of LV wall thickening occurred in 45% of patients during follow-up, corresponding to 71 of the 284 (25%) initially ‘vasculitic’ LV segments. In contrast, a reduction of vessel wall thickening in the temporal artery was found in 85% of patients. Of the LVs, the vertebral, axillary, subclavian and deep femoral arteries were most likely to improve. There was no difference in relapses or the received cumulative steroid dose between patients with or without a reduction of vessel wall thickening (temporal artery or LV) during follow-up.
Conclusion
Regression of wall thickening within the LV is significantly less common than in the temporal artery and irrespective of clinical remission. Morphological regression does not seem to be a useful predictor for relapses.
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Affiliation(s)
- Markus Aschwanden
- Department of Angiology, University Hospital Basel, Basel, Switzerland
| | - Elke Schegk
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
| | - Stephan Imfeld
- Department of Angiology, University Hospital Basel, Basel, Switzerland
| | - Daniel Staub
- Department of Angiology, University Hospital Basel, Basel, Switzerland
| | | | - Christoph T Berger
- Departments of Biomedicine and Internal Medicine, Translational Immunology and Medical Outpatient Clinic, University Hospital Basel, Basel, Switzerland
| | - Thomas Daikeler
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
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29
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Monti S, Floris A, Ponte C, Schmidt WA, Diamantopoulos AP, Pereira C, Piper J, Luqmani R. The use of ultrasound to assess giant cell arteritis: review of the current evidence and practical guide for the rheumatologist. Rheumatology (Oxford) 2018; 57:227-235. [PMID: 28460064 DOI: 10.1093/rheumatology/kex173] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Indexed: 11/14/2022] Open
Abstract
Colour duplex sonography (CDS) of temporal arteries and large vessels is an emerging diagnostic tool for GCA. CDS can detect wall oedema, known as a halo, throughout the length of the vessel and shows higher sensitivity compared with biopsy. Specificity reaches 100% in case of bilateral halos. A positive compression sign has been demonstrated to be a robust marker with excellent inter-observer agreement. The assessment of other large vessels, particularly the axillary arteries, is recognized to further increase the sensitivity and to reliably represent extra-cranial involvement in other areas. Nevertheless, CDS use is still not widespread in routine clinical practice and requires skilled sonographers. Moreover, its role in the follow-up of patients still needs to be defined. The aim of this review is to provide the current evidence and technical parameters to support the rheumatologist in the CDS evaluation of patients with suspected GCA.
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Affiliation(s)
- Sara Monti
- Rheumatology Department, NDORMS, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK.,Department of Rheumatology, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy
| | - Alberto Floris
- Rheumatology Unit, University Clinic and AOU of Cagliari, Cagliari, Italy
| | - Cristina Ponte
- Department of Rheumatology, Hospital de Santa Maria, Lisbon, Portugal.,Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Lisbon Academic Medical Centre, Lisbon, Portugal
| | - Wolfgang A Schmidt
- Medical Centre for Rheumatology Berlin-Buch, Immanuel Krankenhaus Berlin, Berlin, Germany
| | | | - Claudio Pereira
- Rheumatology Department, NDORMS, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
| | - Jennifer Piper
- Rheumatology Department, NDORMS, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
| | - Raashid Luqmani
- Rheumatology Department, NDORMS, Nuffield Orthopaedic Centre, University of Oxford, Oxford, UK
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30
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Chrysidis S, Duftner C, Dejaco C, Schäfer VS, Ramiro S, Carrara G, Scirè CA, Hocevar A, Diamantopoulos AP, Iagnocco A, Mukhtyar C, Ponte C, Naredo E, De Miguel E, Bruyn GA, Warrington KJ, Terslev L, Milchert M, D'Agostino MA, Koster MJ, Rastalsky N, Hanova P, Macchioni P, Kermani TA, Lorenzen T, Døhn UM, Fredberg U, Hartung W, Dasgupta B, Schmidt WA. Definitions and reliability assessment of elementary ultrasound lesions in giant cell arteritis: a study from the OMERACT Large Vessel Vasculitis Ultrasound Working Group. RMD Open 2018; 4:e000598. [PMID: 29862043 PMCID: PMC5976098 DOI: 10.1136/rmdopen-2017-000598] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 03/04/2018] [Accepted: 03/06/2018] [Indexed: 11/21/2022] Open
Abstract
Objectives To define the elementary ultrasound (US) lesions in giant cell arteritis (GCA) and to evaluate the reliability of the assessment of US lesions according to these definitions in a web-based reliability exercise. Methods Potential definitions of normal and abnormal US findings of temporal and extracranial large arteries were retrieved by a systematic literature review. As a subsequent step, a structured Delphi exercise was conducted involving an expert panel of the Outcome Measures in Rheumatology (OMERACT) US Large Vessel Vasculitis Group to agree definitions of normal US appearance and key elementary US lesions of vasculitis of temporal and extracranial large arteries. The reliability of these definitions on normal and abnormal blood vessels was tested on 150 still images and videos in a web-based reliability exercise. Results Twenty-four experts participated in both Delphi rounds. From originally 25 statements, nine definitions were obtained for normal appearance, vasculitis and arteriosclerosis of cranial and extracranial vessels. The ‘halo’ and ‘compression’ signs were the key US lesions in GCA. The reliability of the definitions for normal temporal and axillary arteries, the ‘halo’ sign and the ‘compression’ sign was excellent with inter-rater agreements of 91–99% and mean kappa values of 0.83–0.98 for both inter-rater and intra-rater reliabilities of all 25 experts. Conclusions The ‘halo’ and the ‘compression’ signs are regarded as the most important US abnormalities for GCA. The inter-rater and intra-rater agreement of the new OMERACT definitions for US lesions in GCA was excellent.
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Affiliation(s)
- Stavros Chrysidis
- Department of Rheumatology, Hospital of Southwest Jutland, Esbjerg, Denmark
| | - Christina Duftner
- Department of Internal Medicine, Clinical Division of Internal Medicine II, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Dejaco
- Department of Rheumatology, Medical University of Graz, Graz, Austria.,Department of Rhematology, Hospital of Bruneck, Bruneck, Italy
| | - Valentin S Schäfer
- III. Medical Clinic, Department of Oncology, Hematology and Rheumatology, University Hospital Bonn, Berlin, Germany
| | - Sofia Ramiro
- Leiden University Medical Center, Leiden, The Netherlands
| | - Greta Carrara
- Epidemiology Unit, Italian Society for Rheumatology (SIR), Milan, Italy
| | - Carlo Alberto Scirè
- Epidemiology Unit, Italian Society for Rheumatology (SIR), Milan, Italy.,Department of Rheumatology, University of Ferrara, Ferrara, Italy
| | - Alojzija Hocevar
- Department of Rheumatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Annamaria Iagnocco
- Dipartimento Scienze Cliniche e Biologiche - Reumatologia, Università degli Studi di Torino, Torino, Italy
| | - Chetan Mukhtyar
- Department of Rheumatology, Norfolk and Norwich University Hospital, Norwich, UK
| | - Cristina Ponte
- Hospital de Santa Maria - CHLN, Lisbon Academic Medical Centre, Lisbon, Portugal
| | | | | | | | | | - Lene Terslev
- Copenhagen Center for Arthritis Research (COPECARE), Copenhagen, Denmark
| | - Marcin Milchert
- Department of Rheumatology and Internal Medicine, Pomeranian Medical University, Szczecin, Poland
| | | | | | | | - Petra Hanova
- Department of Rheumatology, First Faculty of Medicine, Charles University of Prague, Prague, Czech Republic
| | | | - Tanaz A Kermani
- Department of Rheumatology, University of California, Los Angeles, California, USA
| | - Tove Lorenzen
- Diagnostic Centre Region Hospital Silkeborg, Silkeborg, Denmark
| | - Uffe Møller Døhn
- Copenhagen Center for Arthritis Research (COPECARE), Copenhagen, Denmark
| | - Ulrich Fredberg
- Diagnostic Centre Region Hospital Silkeborg, Silkeborg, Denmark.,Department of Rheumatology, Odense University Hospital, Odense, Denmark
| | | | - Bhaskar Dasgupta
- Southend University Hospital NHS Foundation Trust & Anglia Ruskin University, Southend-on-Sea, UK
| | - Wolfgang A Schmidt
- Medical Centre for Rheumatology, Immanuel Krankenhaus Berlin, Berlin, Germany
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31
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Luqmani R, Lee E, Singh S, Gillett M, Schmidt WA, Bradburn M, Dasgupta B, Diamantopoulos AP, Forrester-Barker W, Hamilton W, Masters S, McDonald B, McNally E, Pease C, Piper J, Salmon J, Wailoo A, Wolfe K, Hutchings A. The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study. Health Technol Assess 2018; 20:1-238. [PMID: 27925577 DOI: 10.3310/hta20900] [Citation(s) in RCA: 253] [Impact Index Per Article: 42.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Giant cell arteritis (GCA) is a relatively common form of primary systemic vasculitis, which, if left untreated, can lead to permanent sight loss. We compared ultrasound as an alternative diagnostic test with temporal artery biopsy, which may be negative in 9-61% of true cases. OBJECTIVE To compare the clinical effectiveness and cost-effectiveness of ultrasound with biopsy in diagnosing patients with suspected GCA. DESIGN Prospective multicentre cohort study. SETTING Secondary care. PARTICIPANTS A total of 381 patients referred with newly suspected GCA. MAIN OUTCOME MEASURES Sensitivity, specificity and cost-effectiveness of ultrasound compared with biopsy or ultrasound combined with biopsy for diagnosing GCA and interobserver reliability in interpreting scan or biopsy findings. RESULTS We developed and implemented an ultrasound training programme for diagnosing suspected GCA. We recruited 430 patients with suspected GCA. We analysed 381 patients who underwent both ultrasound and biopsy within 10 days of starting treatment for suspected GCA and who attended a follow-up assessment (median age 71.1 years; 72% female). The sensitivity of biopsy was 39% [95% confidence interval (CI) 33% to 46%], which was significantly lower than previously reported and inferior to ultrasound (54%, 95% CI 48% to 60%); the specificity of biopsy (100%, 95% CI 97% to 100%) was superior to ultrasound (81%, 95% CI 73% to 88%). If we scanned all suspected patients and performed biopsies only on negative cases, sensitivity increased to 65% and specificity was maintained at 81%, reducing the need for biopsies by 43%. Strategies combining clinical judgement (clinician's assessment at 2 weeks) with the tests showed sensitivity and specificity of 91% and 81%, respectively, for biopsy and 93% and 77%, respectively, for ultrasound; cost-effectiveness (incremental net monetary benefit) was £485 per patient in favour of ultrasound with both cost savings and a small health gain. Inter-rater analysis revealed moderate agreement among sonographers (intraclass correlation coefficient 0.61, 95% CI 0.48 to 0.75), similar to pathologists (0.62, 95% CI 0.49 to 0.76). LIMITATIONS There is no independent gold standard diagnosis for GCA. The reference diagnosis used to determine accuracy was based on classification criteria for GCA that include clinical features at presentation and biopsy results. CONCLUSION We have demonstrated the feasibility of providing training in ultrasound for the diagnosis of GCA. Our results indicate better sensitivity but poorer specificity of ultrasound compared with biopsy and suggest some scope for reducing the role of biopsy. The moderate interobserver agreement for both ultrasound and biopsy indicates scope for improving assessment and reporting of test results and challenges the assumption that a positive biopsy always represents GCA. FUTURE WORK Further research should address the issue of an independent reference diagnosis, standards for interpreting and reporting test results and the evaluation of ultrasound training, and should also explore the acceptability of these new diagnostic strategies in GCA. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Raashid Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ellen Lee
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Surjeet Singh
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Mike Gillett
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Wolfgang A Schmidt
- Immanuel Krankenhaus Berlin, Medical Centre for Rheumatology Berlin-Buch, Berlin, Germany
| | - Mike Bradburn
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Bhaskar Dasgupta
- Department of Rheumatology, Southend University Hospital NHS Foundation Trust, Southend, UK
| | | | - Wulf Forrester-Barker
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - William Hamilton
- Primary Care Diagnostics, University of Exeter Medical School, Exeter, UK
| | - Shauna Masters
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Brendan McDonald
- Department of Neuropathology and Ocular Pathology, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Eugene McNally
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Colin Pease
- Department of Rheumatology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jennifer Piper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - John Salmon
- Oxford Eye Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Allan Wailoo
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Konrad Wolfe
- Department of Pathology, Southend University Hospital NHS Foundation Trust, Southend, UK
| | - Andrew Hutchings
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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32
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Duftner C, Dejaco C, Sepriano A, Falzon L, Schmidt WA, Ramiro S. Imaging in diagnosis, outcome prediction and monitoring of large vessel vasculitis: a systematic literature review and meta-analysis informing the EULAR recommendations. RMD Open 2018. [PMID: 29531788 PMCID: PMC5845406 DOI: 10.1136/rmdopen-2017-000612] [Citation(s) in RCA: 182] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Objectives To perform a systematic literature review on imaging techniques for diagnosis, outcome prediction and disease monitoring in large vessel vasculitis (LVV) informing the European League Against Rheumatism recommendations for imaging in LVV. Methods Systematic literature review (until 10 March 2017) of diagnostic and prognostic studies enrolling >20 patients and investigating ultrasound, MRI, CT or positron emission tomography (PET) in patients with suspected and/or established primary LVV. Meta-analyses were conducted, whenever possible, obtaining pooled estimates for sensitivity and specificity by fitting random effects models. Results Forty-three studies were included (39 on giant cell arteritis (GCA), 4 on Takayasu arteritis (TAK)). Ultrasound ('halo' sign) at temporal arteries (8 studies, 605 patients) and MRI of cranial arteries (6 studies, 509 patients) yielded pooled sensitivities of 77% (95% CI 62% to 87%) and 73% (95% CI 57% to 85%), respectively, compared with a clinical diagnosis of GCA. Corresponding specificities were 96% (95% CI 85% to 99%) and 88% (95% CI 81% to 92%). Two studies (93 patients) investigating PET for GCA diagnosis reported sensitivities of 67%-77% and specificities of 66%-100% as compared with clinical diagnosis or temporal artery biopsy. In TAK, one study each evaluated the role of magnetic resonance angiography and CT angiography for diagnostic purposes revealing both a sensitivity and specificity of 100%. Studies on outcome prediction and monitoring disease activity/damage were limited and mainly descriptive. Conclusions Ultrasound and MRI provide a high diagnostic value for cranial GCA. More data on the role of imaging for diagnosis of extracranial large vessel GCA and TAK, as well as for outcome prediction and monitoring in LVV are warranted.
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Affiliation(s)
- Christina Duftner
- Department of Internal Medicine, Clinical Division of Internal Medicine II, Medical University Innsbruck, Innsbruck, Austria
| | - Christian Dejaco
- Rheumatology Service, South Tyrolean Health Trust, Hospital of Bruneck, Bruneck, Italy.,Department of Rheumatology and Immunology, Medical University Graz, Graz, Austria
| | - Alexandre Sepriano
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands.,NOVA Medical School, Universidade Nova de Lisboa, Lisboa, Portugal
| | - Louise Falzon
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York City, New York, USA
| | | | - Sofia Ramiro
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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33
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Treitl KM, Maurus S, Sommer NN, Kooijman-Kurfuerst H, Coppenrath E, Treitl M, Czihal M, Hoffmann U, Dechant C, Schulze-Koops H, Saam T. 3D-black-blood 3T-MRI for the diagnosis of thoracic large vessel vasculitis: A feasibility study. Eur Radiol 2016; 27:2119-2128. [PMID: 27510630 DOI: 10.1007/s00330-016-4525-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 07/19/2016] [Accepted: 07/21/2016] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To evaluate the feasibility of T1w-3D black-blood turbo spin echo (TSE) sequence with variable flip angles for the diagnosis of thoracic large vessel vasculitis (LVV). METHODS Thirty-five patients with LVV, diagnosed according to the current standard of reference, and 35 controls were imaged at 3.0T using 1.2 × 1.3 × 2.0 mm3 fat-suppressed, T1w-3D, modified Volumetric Isotropic TSE Acquisition (mVISTA) pre- and post-contrast. Applying a navigator and peripheral pulse unit triggering (PPU), the total scan time was 10-12 min. Thoracic aorta and subclavian and pulmonary arteries were evaluated for image quality (IQ), flow artefact intensity, diagnostic confidence, concentric wall thickening and contrast enhancement (CWT, CCE) using a 4-point scale. RESULTS IQ was good in all examinations (3.25 ± 0.72) and good to excellent in 342 of 408 evaluated segments (83.8 %), while 84.1 % showed no or minor flow artefacts. The interobserver reproducibility for the identification of CCE and CWT was 0.969 and 0.971 (p < 0.001) with an average diagnostic confidence of 3.47 ± 0.64. CCE and CWT were strongly correlated (Cohen's k = 0.87; P < 0.001) and significantly more frequent in the LVV-group (52.8 % vs. 1.0 %; 59.8 % vs. 2.4 %; P < 0.001). CONCLUSIONS Navigated fat-suppressed T1w-3D black-blood MRI with PPU-triggering allows diagnosis of thoracic LVV. KEY POINTS • Cross-sectional imaging is frequently applied in the diagnosis of LVV. • Navigated, PPU-triggered, T1w-3D mVISTA pre- and post contrast takes 10-12 min. • In this prospective, single-centre study, T1w-3D mVISTA accurately depicted large thoracic vessels. • T1w-3D mVISTA visualized CWT/CCW as correlates of mural inflammation in LVV. • T1w-3D mVISTA might be an alternative diagnostic tool without ionizing radiation.
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Affiliation(s)
- Karla Maria Treitl
- Institute for Clinical Radiology, LMU Munich, Ziemssenstr. 1, 80336, Munich, Germany. .,German Center for Cardiovascular Disease Research (DZHK e. V.), Pettenkoferstr. 8a, 80336, Munich, Germany.
| | - Stefan Maurus
- Institute for Clinical Radiology, LMU Munich, Ziemssenstr. 1, 80336, Munich, Germany
| | - Nora Narvina Sommer
- Institute for Clinical Radiology, LMU Munich, Ziemssenstr. 1, 80336, Munich, Germany
| | | | - Eva Coppenrath
- Institute for Clinical Radiology, LMU Munich, Ziemssenstr. 1, 80336, Munich, Germany
| | - Marcus Treitl
- Institute for Clinical Radiology, LMU Munich, Ziemssenstr. 1, 80336, Munich, Germany
| | - Michael Czihal
- Division of Vascular Medicine, Medical Clinic and Policlinic IV, LMU Munich, Pettenkoferstr. 8a, D-80336, Munich, Germany
| | - Ulrich Hoffmann
- Division of Vascular Medicine, Medical Clinic and Policlinic IV, LMU Munich, Pettenkoferstr. 8a, D-80336, Munich, Germany
| | - Claudia Dechant
- Division of Rheumatology and Clinical Immunology, Medical Clinic and Policlinic IV, LMU Munich, Pettenkoferstr. 8a, D-80336, Munich, Germany
| | - Hendrik Schulze-Koops
- Division of Rheumatology and Clinical Immunology, Medical Clinic and Policlinic IV, LMU Munich, Pettenkoferstr. 8a, D-80336, Munich, Germany
| | - Tobias Saam
- Institute for Clinical Radiology, LMU Munich, Ziemssenstr. 1, 80336, Munich, Germany.,German Center for Cardiovascular Disease Research (DZHK e. V.), Pettenkoferstr. 8a, 80336, Munich, Germany
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Abstract
Much progress has been made in the use of imaging as a diagnostic tool in giant cell arteritis (GCA), which assists in the management of patients where the initial diagnosis is unclear. This includes patients with atypical cranial symptoms, or with predominantly systemic, constitutional or limb symptoms. Ultrasound and magnetic resonance imaging are capable of visualising both the cranial and extracranial large vessel circulation, with vessel wall thickening and stenotic lesions being visualised. Computed tomographic angiography is helpful in visualising the aorta for aneurysm complicating GCA but can also detect vessel wall thickening in established large vessel vasculitis. PET-CT is a very sensitive test for early vascular inflammation in extracranial large vessel vasculitis, before aneurysmal or stenotic lesions have developed, of use in the patient with unexplained constitutional symptoms. The place of imaging in the follow-up of GCA is being investigated, and repeated imaging may be useful in select cases. Generally, vascular abnormalities become less defined once glucocorticoid treatment has been started, and therefore, imaging studies must be conducted early as part of a GCA fast-track assessment.
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Affiliation(s)
- Asad Khan
- Department of Rheumatology, Southend University Hospital NHS Foundation Trust, Prittlewell Chase, Westcliff-on-Sea, Essex, SS0 0RY, UK
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Schmidt WA. Role of ultrasound in the understanding and management of vasculitis. Ther Adv Musculoskelet Dis 2014; 6:39-47. [PMID: 24688604 DOI: 10.1177/1759720x13512256] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Vasculitis is characterized by a circumferential vessel-wall thickening ('halo'), which can be visualized by modern imaging techniques. In particular, the resolution of ultrasound has increased to 0.1 mm. Ultrasound detects abnormalities that are pathognomonic even in arteries with a diameter below 1 mm. It is particularly helpful in the diagnosis of large-vessel vasculitides, such as classic temporal arteritis, large-vessel giant-cell arteritis (GCA), Takayasu arteritis and idiopathic aortitis. Echocardiography is important for determining cardiac involvement in Takayasu arteritis and also for examining the coronary arteries of children with suspected Kawasaki disease, which is a medium-vessel vasculitis. In small vessel vasculitides ultrasound has only a role for determining the distribution or organ involvement. Fast-track clinics for the diagnosis of GCA help to initiate treatment before complications such as blindness occur; patients receive appointments within 24 h in these clinics. Clinical examination and ultrasound of temporal and axillary arteries are performed by an experienced rheumatologist. In most cases this is able to determine if GCA is present. Temporal artery biopsy can be still carried out in ambivalent cases. The wall swelling of temporal arteries disappears after 2-3 weeks of glucocorticoid treatment. After 3 days of treatment, diagnosis becomes more difficult with ultrasound in some cases. In larger arteries, such as the axillary arteries, wall thickening disappears within months. It tends to be darker (more hypoechoic) in acute disease because of oedema.
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Affiliation(s)
- Wolfgang A Schmidt
- Immanuel Krankenhaus Berlin, Medical Centre for Rheumatology Berlin-Buch, Lindenberger Weg 19, 13125 Berlin, Germany
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