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Schmidt WA, Schäfer VS. Diagnosing vasculitis with ultrasound: findings and pitfalls. Ther Adv Musculoskelet Dis 2024; 16:1759720X241251742. [PMID: 38846756 PMCID: PMC11155338 DOI: 10.1177/1759720x241251742] [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: 02/11/2024] [Accepted: 04/10/2024] [Indexed: 06/09/2024] Open
Abstract
Rheumatologists are increasingly utilizing ultrasound for suspected giant cell arteritis (GCA) or Takayasu arteritis (TAK). This enables direct confirmation of a suspected diagnosis within the examination room without further referrals. Rheumatologists can ask additional questions and explain findings to their patients while performing ultrasound, preferably in fast-track clinics to prevent vision loss. Vascular ultrasound for suspected vasculitis was recently integrated into rheumatology training in Germany. New European Alliance of Associations for Rheumatology recommendations prioritize ultrasound as the first imaging tool for suspected GCA and recommend it as an imaging option for suspected TAK alongside magnetic resonance imaging, positron emission tomography and computed tomography. Ultrasound is integral to the new classification criteria for GCA and TAK. Diagnosis is based on consistent clinical and ultrasound findings. Inconclusive cases require histology or additional imaging tests. Robust evidence establishes high sensitivities and specificities for ultrasound. Reliability is good among experts. Ultrasound reveals a characteristic non-compressible 'halo sign' indicating intima-media thickening (IMT) and, in acute disease, artery wall oedema. Ultrasound can further identify stenoses, occlusions and aneurysms, and IMT can be measured. In suspected GCA, ultrasound should include at least the temporal and axillary arteries bilaterally. Nearly all other arteries are accessible except the descending thoracic aorta. TAK mostly involves the common carotid and subclavian arteries. Ultrasound detects subclinical GCA in over 20% of polymyalgia rheumatica (PMR) patients without GCA symptoms. Patients with silent GCA should be treated as GCA because they experience more relapses and require higher glucocorticoid doses than PMR patients without GCA. Scores based on intima-thickness (IMT) of temporal and axillary arteries aid follow-up of GCA, particularly in trials. The IMT decreases more rapidly in temporal than in axillary arteries. Ascending aorta ultrasound helps monitor patients with extracranial GCA for the development of aneurysms. Experienced sonologists can easily identify pitfalls, which will be addressed in this article.
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Affiliation(s)
- Wolfgang A. Schmidt
- Immanuel Krankenhaus Berlin, Medical Centre for Rheumatology Berlin-Buch, Lindenberger Weg 19, Berlin 13125, Germany
| | - Valentin S. Schäfer
- Department of Rheumatology and Clinical Immunology, Clinic of Internal Medicine III, University Hospital Bonn, Bonn, Nordrhein-Westfalen, Germany
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Bosch P, Espigol-Frigolé G, Cid MC, Mollan SP, Schmidt WA. Cranial involvement in giant cell arteritis. THE LANCET. RHEUMATOLOGY 2024; 6:e384-e396. [PMID: 38574747 DOI: 10.1016/s2665-9913(24)00024-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 01/18/2024] [Accepted: 01/23/2024] [Indexed: 04/06/2024]
Abstract
Since its first clinical description in 1890, extensive research has advanced our understanding of giant cell arteritis, leading to improvements in both diagnosis and management for affected patients. Imaging studies have shown that the disease frequently extends beyond the typical cranial arteries, also affecting large vessels such as the aorta and its proximal branches. Meanwhile, advances in comprehending the underlying pathophysiology of giant cell arteritis have given rise to numerous potential therapeutic agents, which aim to minimise the need for glucocorticoid treatment and prevent flares. Classification criteria for giant cell arteritis, as well as recommendations for management, imaging, and treat-to-target have been developed or updated in the last 5 years, and current research encompasses a broad spectrum covering basic, translational, and clinical research. In this Series paper, we aim to discuss the current understanding of giant cell arteritis with cranial manifestations, describe the clinical approach to this condition, and explore future directions in research and patient care.
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Affiliation(s)
- Philipp Bosch
- Department of Rheumatology and Immunology, Medical University of Graz, Graz, Austria.
| | - Georgina Espigol-Frigolé
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Insitut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain
| | - Maria C Cid
- Department of Autoimmune Diseases, Hospital Clinic, University of Barcelona, Insitut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain
| | - Susan P Mollan
- Birmingham Neuro-Ophthalmology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK; Translational Brain Science, Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Wolfgang A Schmidt
- Department of Rheumatology, Immanuel Hospital Berlin, Medical Centre for Rheumatology Berlin-Buch, Berlin, Germany
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González-Gay MÁ, Heras-Recuero E, Blázquez-Sánchez T, Caraballo-Salazar C, Rengifo-García F, Castañeda S, Largo R. Broadening the clinical spectrum of giant cell arteritis: from the classic cranial to the predominantly extracranial pattern of the disease. Expert Rev Clin Immunol 2024:1-12. [PMID: 38757894 DOI: 10.1080/1744666x.2024.2356741] [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: 02/02/2024] [Accepted: 05/14/2024] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Giant cell arteritis (GCA) is a large vessel (LV) vasculitis that affects people aged 50 years and older. Classically, GCA was considered a disease that involved branches of the carotid artery. However, the advent of new imaging techniques has allowed us to reconsider the clinical spectrum of this vasculitis. AREASCOVERED This review describes clinical differences between patients with the cranial GCA and those with a predominantly extracranial LV-GCA disease pattern. It highlights differences in the frequency of positive temporal artery biopsy depending on the predominant disease pattern and emphasizes the relevance of imaging techniques to identify patients with LV-GCA without cranial ischemic manifestations. The review shows that so far there are no well-established differences in genetic predisposition to GCA regardless of the predominant phenotype. EXPERT COMMENTARY The large branches of the extracranial arteries are frequently affected in GCA. Imaging techniques are useful to identify the presence of 'silent' GCA in people presenting with polymyalgia rheumatica or with nonspecific manifestations. Whether these two different clinical presentations of GCA constitute a continuum in the clinical spectrum of the disease or whether they may be related but are definitely different conditions needs to be further investigated.
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Affiliation(s)
- Miguel Ángel González-Gay
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, Madrid, Spain
- Department of Medicine and Psychiatry, University of Cantabria, Santander, Spain
| | | | | | | | | | - Santos Castañeda
- Division of Rheumatology, Hospital Universitario de La Princesa, IIS-Princesa, Madrid, Spain
| | - Raquel Largo
- Division of Rheumatology, IIS-Fundación Jiménez Díaz, Madrid, Spain
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Estrada P, Moya P, Narváez J, Moragues C, Navarro V, Camacho O, Roig D, Cerdà D, Heredia S, Reina D, Corominas H. Utility of applying a diagnostic algorithm in giant cell arteritis based on the level of clinical suspicion. Med Clin (Barc) 2024:S0025-7753(23)00755-8. [PMID: 38278759 DOI: 10.1016/j.medcli.2023.11.021] [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: 09/14/2023] [Revised: 11/16/2023] [Accepted: 11/18/2023] [Indexed: 01/28/2024]
Abstract
INTRODUCTION To reach the diagnosis of giant cell arteritis (GCA), signs, symptoms, laboratory tests, imaging findings, and occasionally anatomopathological results from temporal artery biopsy are evaluated. This study describes the results of an algorithm analysis based on clinical and ultrasound evaluation of patients with suspected GCA, highlighting its diagnostic utility by contrasting its use in different clinical suspicion scenarios. METHOD Prospective multicenter study evaluating patients referred with suspected GCA through a preferential circuit (fast track), grouping them according to low or high clinical suspicion of GCA. Each of these scenarios is evaluated by biopsy and ultrasound for all patients, resulting in positive, indeterminate, or negative outcomes, yielding six possible groups. Potential areas of improvement are explored, emphasizing that, following a negative or indeterminate ultrasound, 18-FDG-PET-CT could be recommended. We analyze the results and application of a diagnostic algorithm, confirming its efficiency and applicability based on whether there is high or low clinical suspicion. RESULTS Sixty-nine patients (41 in the high suspicion group and 28 in the low suspicion group). There were 41 new diagnoses of GCA: 35 in the high suspicion group and 6 in the low suspicion group. Using ultrasound alone, the initial algorithm has an overall diagnostic efficiency of 72.5%, which improves to 80.5% when including 18F-FDG-PET/CT. The negative predictive value of ultrasound in patients with low clinical suspicion is 84.6%, and the positive predictive value of ultrasound in patients with high suspicion is 100%, improving sensitivity from 57.1% to 80.8% with 18F-FDG-PET/CT in this scenario. Temporal artery biopsy was performed on all patients, with no differences in sensitivity or specificity compared to ultrasound. In cases where all three tests - ultrasound, biopsy, and 18F-FDG-PET/CT - are performed, sensitivity increases to 92.3% in patients with high clinical suspicion. CONCLUSION In situations of high clinical suspicion, the algorithm provides sufficient information for the diagnosis of GCA if ultrasound is positive. A negative ultrasound is sufficient to rule out the diagnosis in the context of low clinical suspicion. 18-FDG-PET-CT may be useful in patients with high suspicion and negative or indeterminate ultrasound results.
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Affiliation(s)
- Paula Estrada
- Servicio de Reumatología,Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, Universitat de Barcelona (UB), Barcelona, España.
| | - Patricia Moya
- Servicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, España
| | - Javier Narváez
- Servicio de Reumatología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| | - Carmen Moragues
- Servicio de Reumatología, Hospital Universitari de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| | - Vanessa Navarro
- Servicio de Reumatología,Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, Universitat de Barcelona (UB), Barcelona, España
| | - Oscar Camacho
- Servicio de Reumatología,Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, Universitat de Barcelona (UB), Barcelona, España
| | - Daniel Roig
- Servicio de Reumatología,Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, Universitat de Barcelona (UB), Barcelona, España
| | - Dacia Cerdà
- Servicio de Reumatología,Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, Universitat de Barcelona (UB), Barcelona, España
| | - Sergi Heredia
- Servicio de Reumatología,Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, Universitat de Barcelona (UB), Barcelona, España
| | - Delia Reina
- Servicio de Reumatología,Complex Hospitalari Universitari Moisès Broggi, Sant Joan Despí, Universitat de Barcelona (UB), Barcelona, España
| | - Hèctor Corominas
- Servicio de Reumatología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, España
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Ayo-Martin O, Garcia-Garcia J, Hernandez-Fernandez F, Palao M, Poyatos-Herraiz B, Barahona-Espinal TH, Gonzalez-Romero A, Marin-Conesa E, Serrano-Serrano B, Paya M, Segura T. Increased vertebral canal diameter measured by ultrasonography as a sign of vasculitis in patients with giant cell arteritis. Front Med (Lausanne) 2023; 10:1283285. [PMID: 38020125 PMCID: PMC10664249 DOI: 10.3389/fmed.2023.1283285] [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: 08/25/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction The diagnosis of giant cell arteritis (GCA) by ultrasonography including large vessels, apart from the temporal artery increases the sensibility of the study and informs about the risk of specific complications. However, there is less information about the study of these arteries, whose affection carries higher proportion of severe complications. Objectives To describe and analyze the value of the diameter of the cervical vertebral canal of the vertebral artery (VA) as a sign of vertebral vasculitis (VV) related to GCA and estimate the risk of stroke complications. Materials and methods Observational study of a population that includes patients with GCA with and without VA vasculitis as well as healthy subjects. We evaluated whether there were differences in VA diameter in the groups and, if so, we estimated the diagnostic capacity of the variable that best defines VA diameter using a ROC curve. Cut-off points with their associated reliability chosen thereafter. Results There were 347 subjects included:107 with GCA of whom 37 had vertebral vasculitis, 240 healthy controls. In patients with GCA and VV, the VA diameter was increased (No GCA 3.4 mm, GCA without VV 3.6 mm, GCA with VV 5.2 mm p < 0.01). According to the ROC curves, the variable defining vertebral diameter with best diagnostic accuracy is the sum of both sides (area under the curve of 0.98). With a cut-off point of 8.45 mm, the reliability values are: sensitivity 94.1%, specificity 94.5%, PPV 82.1% and NPV 98.4%. With a cut-off point of 9.95 mm, the sensitivity is 52.9% and the specificity is 100%. Likewise, VA diameter is independently associated with the presence of stroke in the vertebrobasilar territory (OR 1.6, range 1.2-2.2). Conclusion The VA diameter, measured as the sum of both sides, is an objectively measurable sign with very high reliability for detect vertebral vasculitis in patients with GCA. It is proposed here as a novel echographic sign, which can aid the detection of the involvement of an artery where the complications are especially serious.
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Affiliation(s)
- Oscar Ayo-Martin
- Laboratory of Neurosonology, Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
- Instituto de Investigación en Discapacidades Neurológicas (IDINE), Universidad de Castilla-La Mancha, Albacete, Spain
- Faculty of Medicine, Universidad de Castilla-La Mancha, Albacete, Spain
| | - Jorge Garcia-Garcia
- Laboratory of Neurosonology, Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
- Instituto de Investigación en Discapacidades Neurológicas (IDINE), Universidad de Castilla-La Mancha, Albacete, Spain
- Faculty of Medicine, Universidad de Castilla-La Mancha, Albacete, Spain
| | - Francisco Hernandez-Fernandez
- Laboratory of Neurosonology, Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Maria Palao
- Laboratory of Neurosonology, Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | | | | | | | - Ester Marin-Conesa
- Department of Neurology, Hospital Militar de Honduras and Hospital DIME, Tegucigalpa, Honduras
| | - Blanca Serrano-Serrano
- Laboratory of Neurosonology, Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Maria Paya
- Laboratory of Neurosonology, Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Tomas Segura
- Laboratory of Neurosonology, Department of Neurology, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
- Instituto de Investigación en Discapacidades Neurológicas (IDINE), Universidad de Castilla-La Mancha, Albacete, Spain
- Faculty of Medicine, Universidad de Castilla-La Mancha, Albacete, Spain
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