Three Tesla 3D High-Resolution Vessel Wall MRI of the Orbit may Differentiate Arteritic From Nonarteritic Anterior Ischemic Optic Neuropathy:

Reproducibility and accuracy of vessel wall MRI in diagnosing giant cell arteritis: a study with readers of varying expertise

OBJECTIVE

To evaluate the reproducibility of vessel wall magnetic resonance imaging (VW-MRI) in diagnosing giant cell arteritis (GCA) among groups of radiologists with varying levels of expertise.

METHODS

This institutional review board-approved retrospective single-center study recruited patients with suspected GCA between December 2014 and September 2021. Patients underwent 3 -T VW-MRI before temporal artery biopsy. Ten radiologists with varying levels of expertise, blinded to all data, evaluated several intracranial and extracranial arteries to assess GCA diagnosis. Interobserver reproducibility and diagnostic performance were evaluated.

RESULTS

Fifty patients (27 women and 23 men) with a mean age of 75.9 ± 9 years were included. Thirty-one of 50 (62%) had a final diagnosis of GCA.VW-MRI had an almost perfect reproducibility among expert readers (kappa = 0.93; 95% CI 0.77-1) and substantial reproducibility among all readers, junior and non-expert senior readers (kappa = 0.7; 95% CI 0.66-0.73; kappa = 0.67 95% CI 0.59-0.74; kappa = 0.65; 95% CI 0.43-0.88 respectively) when diagnosing GCA. Substantial interobserver agreement was observed for the frontal branch of superficial temporal artery. Moderate interobserver agreement was observed for the superficial temporal artery and its parietal branch, as well as ophthalmic arteries in all groups of readers. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy varied depending on the group of readers.

CONCLUSION

VW-MRI is a reproducible and accurate imaging modality for detecting GCA, even among less-experienced readers. This study advocates for the use of VW-MRI when diagnosing GCA even in less-experienced centers.

CLINICAL RELEVANCE STATEMENT

VW-MRI is a reproducible and accurate imaging modality for detecting GCA, even among less-experienced readers, and it could be used as a first-line diagnostic tool for GCA in centers with limited expertise in GCA diagnosis.

KEY POINTS

• Vessel wall magnetic resonance imaging (VW-MRI) is a reproducible and accurate imaging modality for detecting giant cell arteritis (GCA) in both extracranial and intracranial arteries. • The reproducibility of vessel wall magnetic resonance imaging for giant cell arteritis diagnosis was high among expert readers and moderate among less-experienced readers. • The use of vessel wall magnetic resonance imaging for giant cell arteritis diagnosis can be recommended even in centers with less-experienced readers.

Altered functional connectivity of the default mode network in non-arteritic anterior ischaemic optic neuropathy

The functional connectivity of the default mode network is important in understanding the neuro-pathophysiological abnormalities in patients with non-arteritic anterior ischaemic optic neuropathy. Independent component analysis can effectively determine within and between network connectivity of different brain components. Therefore, in order to explore the association between the default mode network and other brain regions, we utilized independent component analysis to investigate the alteration of functional connectivity of the default mode network. Thirty-one patients with non-arteritic anterior ischaemic optic neuropathy and 31 healthy controls, matched for age, sex and years of education, were recruited. For patients and healthy controls, functional connectivity within and between the default mode network and other brain regions were evaluated by independent component analysis. Compared with healthy controls, patients with non-arteritic anterior ischaemic optic neuropathy showed reduced functional connectivity within the default mode network in the right cerebellar tonsil and left cerebellum posterior lobe and increased functional connectivity in the left inferior temporal and right middle frontal gyri. Furthermore, patients with non-arteritic anterior ischaemic optic neuropathy showed reduced functional connectivity between the default mode network and other brain regions in the left cerebellar tonsil and increased functional connectivity in the right putamen, left thalamus, right middle temporal and left middle frontal gyri. In conclusion, negative correlations between several clinical parameters and functional connectivity of the default mode network were observed. The study contributes to understanding the mechanism of functional reorganization in non-arteritic anterior ischaemic optic neuropathy.

Combined Orbital and Cranial Vessel Wall Magnetic Resonance Imaging for the Assessment of Disease Activity in Giant Cell Arteritis

OBJECTIVE

Acute visual impairment is the most feared complication of giant cell arteritis (GCA) but is challenging to predict. Magnetic resonance imaging (MRI) evaluates orbital pathology not visualized by an ophthalmologic examination. This study combined orbital and cranial vessel wall MRI to assess both orbital and cranial disease activity in patients with GCA, including patients without visual symptoms.

METHODS

Patients with suspected active GCA who underwent orbital and cranial vessel wall MRI were included. In 14 patients, repeat imaging over 12 months assessed sensitivity to change. Clinical diagnosis of ocular or nonocular GCA was determined by a rheumatologist and/or ophthalmologist. A radiologist masked to clinical data scored MRI enhancement of structures.

RESULTS

Sixty-four patients with suspected GCA were included: 25 (39%) received a clinical diagnosis of GCA, including 12 (19%) with ocular GCA. Orbital MRI enhancement was observed in 83% of patients with ocular GCA, 38% of patients with nonocular GCA, and 5% of patients with non-GCA. MRI had strong diagnostic performance for both any GCA and ocular GCA. Combining MRI with a funduscopic examination reached 100% sensitivity for ocular GCA. MRI enhancement significantly decreased after treatment (P < 0.01).

CONCLUSION

In GCA, MRI is a sensitive tool that comprehensively evaluates multiple cranial structures, including the orbits, which are the most concerning site of pathology. Orbital enhancement in patients without visual symptoms suggests that MRI may detect at-risk subclinical ocular disease in GCA. MRI scores decreased following treatment, suggesting scores reflect inflammation. Future studies are needed to determine if MRI can identify patients at low risk for blindness who may receive less glucocorticoid therapy.

Temporal artery biopsy for suspected giant cell arteritis: A mini review

Giant cell arteritis (GCA) is a granulomatous inflammation involving medium and large vessels that can lead to serious clinical manifestations associated with tissue ischemia. Temporal artery biopsy (TAB) is currently the gold standard method for the diagnosis of GCA, with a specificity of 100% and a sensitivity of 77%. However, the false-negative rate for TAB ranges from 9% to 61%. False negatives may be related to the timing of biopsy, the length of specimen, and the existence of "skip lesions." We reviewed the relevant evidence for methods to improve the sensitivity and reduce the false-negative rate for TAB. To reduce the false-negative rate for TAB, it is recommended to perform TAB within 1 week of starting corticosteroid therapy. Although there is currently no consensus, we suggest that the temporal artery is cut to a length of 20‒30 mm and to prepare serial pathological sections. It is necessary to attach great importance to patients suspected of having GCA, and complete TAB should be performed as soon as possible while starting corticosteroid therapy promptly. We also discuss the clinical value of non-invasive vascular imaging technologies, such as DUS, CTA, MRA, and 18F-FDG-PET/CT, as auxiliary methods for GCA diagnosis that could partially replace TAB.

Non-arteritic anterior ischemic optic neuropathy combined with branch retinal vein obstruction: A case report

BACKGROUND

Non-arteritic anterior ischemic optic neuropathy (NAION) is an independent disease characterized by edematous optic discs. In eyes with branch retinal vein occlusion (BRVO), the arteries and veins in the ethmoid plate of the optic disc are relatively crowded; however, a combination of the two is clinically uncommon. Herein, we reported a patient with NAION and concealed BRVO, for which the treatment and prognosis were not similar to those for NAION alone.

CASE SUMMARY

Herein, we report a case of NAION with concealed BRVO that did not improve with oral medication. A week later, we switched to intravenous drug administration to improve circulation, and the patient's visual acuity and visual field recovered. Hormonal therapy was not administered throughout the study. This case suggested that: (1) Fundus fluorescein angiography (FFA) can help detect hidden BRVO along with the NAION diagnosis; (2) intravenous infusion of drugs to improve circulation has positive effects in treating such patients; and (3) NAION with concealed BRVO may not require systemic hormonal therapy, in contrast with the known treatment for simple NAION.

CONCLUSION

NAION may be associated with hidden BRVO, which can only be observed on FFA; intravenous therapy has proven effectiveness.

Intraorbital findings in giant cell arteritis on black blood MRI

OBJECTIVE

Blindness is a feared complication of giant cell arteritis (GCA). However, the spectrum of pathologic orbital imaging findings on magnetic resonance imaging (MRI) in GCA is not well understood. In this study, we assess inflammatory changes of intraorbital structures on black blood MRI (BB-MRI) in patients with GCA compared to age-matched controls.

METHODS

In this multicenter case-control study, 106 subjects underwent BB-MRI. Fifty-six patients with clinically or histologically diagnosed GCA and 50 age-matched controls without clinical or laboratory evidence of vasculitis were included. All individuals were imaged on a 3-T MR scanner with a post-contrast compressed-sensing (CS) T1-weighted sampling perfection with application-optimized contrasts using different flip angle evolution (SPACE) BB-MRI sequence. Imaging results were correlated with available clinical symptoms.

RESULTS

Eighteen of 56 GCA patients (32%) showed inflammatory changes of at least one of the intraorbital structures. The most common finding was enhancement of at least one of the optic nerve sheaths (N = 13, 72%). Vessel wall enhancement of the ophthalmic artery was unilateral in 8 and bilateral in 3 patients. Enhancement of the optic nerve was observed in one patient. There was no significant correlation between imaging features of inflammation and clinically reported orbital symptoms (p = 0.10). None of the age-matched control patients showed any inflammatory changes of intraorbital structures.

CONCLUSIONS

BB-MRI revealed inflammatory findings in the orbits in up to 32% of patients with GCA. Optic nerve sheath enhancement was the most common intraorbital inflammatory change on BB-MRI. MRI findings were independent of clinically reported orbital symptoms.

KEY POINTS

• Up to 32% of GCA patients shows signs of inflammation of intraorbital structures on BB-MRI. • Enhancement of the optic nerve sheath is the most common intraorbital finding in GCA patients on BB-MRI. • Features of inflammation of intraorbital structures are independent of clinically reported symptoms.

Biopsy-Proven Giant Cell Arteritis Associated Vision Loss in Chinese Subjects: A Case Series and Review of the Literature

Only a few case reports of biopsy-proven GCA (BpGCA)-associated vision loss in Chinese subjects have been published. We describe three elderly Chinese subjects with BpGCA who presented with vision loss. We also searched the literature in order to review BpGCA-associated blindness in Chinese subjects. Case 1 presented as simultaneous right ophthalmic artery occlusion and left anterior ischaemic optic neuropathy (AION). Case 2 presented as sequential bilateral AION. Case 3 presented as bilateral posterior ischaemic optic neuropathy and ocular ischaemic syndrome (OIS). The diagnosis was confirmed by temporal artery biopsy in all three. Magnetic resonance imaging (MRI) in Cases 1 and 2 demonstrated retrobulbar optic nerve ischaemia. Enhancement of the optic nerve sheath and inflammatory changes of the ophthalmic artery on enhanced orbital MRI was also noted in Cases 2 and 3. All of the subjects were treated with steroids, either intravenously or orally. In the literature review, 11 cases (17 eyes) of BpGCA-associated vision loss in Chinese subjects were found including AION, central retinal artery occlusion, combined AION and cilioretinal artery occlusion, and orbital apex syndrome. In the 14 cases (including ours), the median age at diagnosis was 77 years, and 9 (61.5%) were males. The most common extraocular manifestations were temporal artery abnormalities, headache, jaw claudication, and scalp tenderness. Thirteen (56.5%) eyes had visual acuity of no light perception at the initial visit and failed to respond to the treatment. Although rare, in elderly Chinese subjects with ocular ischaemic diseases, the diagnosis of GCA must be considered.

[Eosinophilic granulomatosis with polyangiitis presenting with ischemic optic neuropathy]

A 60-year-old man with a history of bronchial asthma and nasal polyp presented with loss of vision in the right eye. His visual loss progressed within a single day, and he presented to our hospital 5 days after the onset of the symptom. Fundoscopy showed swelling and hemorrhage of the right optic disc. Blood tests revealed increased eosinophils, C-reactive protein, and perinuclear anti-neutrophil cytoplasmic antibody. Cerebrospinal fluid was normal. Cranial MRI showed local enhancement of the right optic disc and posterior ciliary arteries. He was diagnosed with arteritic anterior ischemic optic neuropathy caused by eosinophilic granulomatosis with polyangiitis (EGPA). High dose intravenous methylprednisolone was started on presentation, but the patient showed no improvement in visual function. Although a rare complication, ischemic optic neuropathy associated with EGPA should be noted, as this is an emergent condition and requires prompt diagnosis and treatment.

Use of Retinal Angiography and MRI in the Diagnosis of Giant Cell Arteritis With Early Ophthalmic Manifestations

BACKGROUND

Giant cell arteritis (GCA) is a vasculitis often revealed by visual signs. Diagnosis is challenging and urgent. Retinal angiography (RA) and MRI allow effective diagnosis. We compared those and proposed an imaging-based approach to diagnose GCA in ophthalmological practice.

METHODS

We conducted a retrospective study based on the data collected from patients suspected to have GCA on ophthalmological findings. Fluorescein (FA) and indocyanine green (ICG) RAs and MRI were performed and compared with final diagnosis.

RESULTS

Among the 41 patients included, 25 were diagnosed with GCA. Sensitivities and specificities of FA and ICG were not different. MRI showed a higher sensitivity and specificity. The approach consisting in performing RA followed by MRI provided a better accuracy.

CONCLUSION

Our study shows that RA can be supplemented by MRI in a specialized center to provide the most accurate diagnosis in GCA revealed by visual signs.

Vessel Wall Magnetic Resonance Imaging in Cerebrovascular Diseases

Cerebrovascular diseases are a leading cause of disability and death worldwide. The definition of stroke etiology is mandatory to predict outcome and guide therapeutic decisions. The diagnosis of pathological processes involving intracranial arteries is especially challenging, and the visualization of intracranial arteries’ vessel walls is not possible with routine imaging techniques. Vessel wall magnetic resonance imaging (VW-MRI) uses high-resolution, multiparametric MRI sequences to directly visualize intracranial arteries walls and their pathological alterations, allowing a better characterization of their pathology. VW-MRI demonstrated a wide range of clinical applications in acute cerebrovascular disease. Above all, it can be of great utility in the differential diagnosis of atherosclerotic and non-atherosclerotic intracranial vasculopathies. Additionally, it can be useful in the risk stratification of intracranial atherosclerotic lesions and to assess the risk of rupture of intracranial aneurysms. Recent advances in MRI technology made it more available, but larger studies are still needed to maximize its use in daily clinical practice.

Validity of high resolution magnetic resonance imaging in detecting giant cell arteritis: a meta-analysis

OBJECTIVES

This study was designed to evaluate the performance of high-resolution magnetic resonance imaging (HR-MRI) in detecting giant cell arteritis (GCA), evaluate superficial extracranial artery and other MRI abnormalities, and compare three-dimensional (3D) and two-dimensional (2D) techniques.

METHODS

PubMed, Web of Science, and Cochrane Library were screened up to March 7, 2021, and further selection was performed according to the eligibility criteria. Quality Assessment of Diagnostic Accuracy Studies-2 was used for quality assessment, and heterogeneity assessment and statistical calculations were also performed.

RESULTS

In total, 1851 records were retrieved from online databases, and 15 studies were finally included. Regarding the performance of HR-MRI, the superficial extracranial artery had 75% sensitivity and 89% specificity, respectively, with an area under the receiver operating characteristic curve (AUC) of 0.91. Positive and negative post-test possibilities were 86% and 20%, respectively, with clinical diagnosis as reference. When referenced with temporal artery biopsy, the sensitivity was 91%, specificity was 78%, AUC was 0.92, and positive and negative post-test possibilities were 78% and 10%, respectively. 3D HR-MRI and 2D HR-MRI had 70% and 72% sensitivity, respectively, and 91% and 84% specificity, respectively.

CONCLUSIONS

HR-MRI is a valuable imaging modality for GCA diagnosis. It provided high accuracy in the diagnosis of GCA and played a potential role in identifying GCA-related ischemic optic neuropathy. 3D HR-MRI had better specificity than 2D HR-MRI.

KEY POINTS

HR-MRI helps clinicians to diagnose GCA. Superficial extracranial arteries and other MRI abnormalities can be assessed with HR-MRI. HR-MRI can help in assessing GCA-related optic neuropathy.

Early diffusion-weighted MRI at 3 Tesla detects ischemic changes of the optic nerve in anterior ischemic optic neuropathy

OBJECTIVES

To assess the impact of timing from visual symptoms' onset to diffusion-weighted (DW) 3 T MRI completion to detect ischemic changes of the optic disc and optic nerve in AION patients.

METHODS

This IRB-approved retrospective single-center study included 3 T MRI data from 126 patients with AION and 111 controls with optic neuritis treated between January 2015 and May 2020. Two radiologists blinded to all data individually analyzed imaging. A senior neuroradiologist resolved any discrepancies by consensus. The primary judgment criterion was the restricted diffusion of the optic disc and/or the optic nerve assessed subjectively on the ADC maps. ADC values were also measured. Spearman rank correlations were used to examine the relationships between timing from visual symptoms' onset to MRI completion and both the restricted diffusion and the ADC values.

RESULTS

One hundred twenty-six patients (47/126 [37.3%] women and 79/126 [62.7%] men, mean age 69.1 ± 13.7 years) with AION were included. Restricted diffusion of the optic disc in AION eyes was more frequent in the early MRI group than in the late MRI group: 35/49 (71.4%) eyes versus 3/83 (3.6%) eyes, p < 0.001. ADC values of the pathological optic discs and optic nerves were lower in the early MRI group than in the late MRI group: 0.61 [0.52-0.94] × 10^-3 mm²/s versus 1.28 [1.01-1.44] × 10^-3 mm²/s, p < 0.001, and 0.74 [0.61-0.88] × 10^-3 mm²/s versus 0.89 [0.72-1.10] × 10^-3 mm²/s, p < 0.001, respectively.

CONCLUSIONS

DWI MRI showed good diagnostic performance to detect AION when performed early after the onset of visual symptoms.

KEY POINTS

• Restricted diffusion of the optic disc in eyes affected by AION was significantly more likely to be observed in patients who had undergone MRI within 5 days after onset of visual symptoms. • ADC values of the pathological optic discs and optic nerves were significantly lower in patients who had undergone MRI within 5 days after onset of visual symptoms of AION: 0.61 × 10^-3 mm²/s versus 1.28 × 10^-3 mm²/s, p < 0.001, and 0.74 × 10^-3 mm²/s versus 0.89 × 10^-3 mm²/s, p < 0.001, respectively. • The optimal threshold for timing from visual symptoms' onset to MRI completion to detect restricted diffusion of the optic disc and/or optic nerve was 5 days, with an AUC of 0.88 (CI_95%: 0.82-0.94).

Validation of a multimodal algorithm for diagnosing giant cell arteritis with imaging

PURPOSE

The purpose of this study was to identify which combination of imaging modalities should be used to obtain the best diagnostic performance for the non-invasive diagnosis of giant cell arteritis (GCA).

MATERIALS AND METHODS

This IRB-approved prospective single-center study enrolled participants presenting with a suspected diagnosis of GCA from December 2014 to October 2017. Participants underwent high-resolution 3T magnetic resonance imaging (MRI), temporal and extra-cranial arteries ultrasound and retinal angiography (RA), prior to temporal artery biopsy (TAB). Diagnostic accuracy of each imaging modality alone, then a combination of several imaging modalities, was evaluated. Several algorithms were constructed to test optimal combinations using McNemar test.

RESULTS

Forty-five participants (24 women, 21 men) with mean age of 75.4 ± 16 (SD) years (range: 59-94 years) were enrolled; of these 43/45 (96%) had ophthalmological symptoms. Diagnosis of GCA was confirmed in 25/45 (56%) patients. Sensitivity and specificity of MRI, ultrasound and RA alone were 100% (25/25; 95% CI: 86-100) and 86% (19/22; 95% CI: 65-97), 88% (22/25; 95% CI: 69-97) and 84% (16/19; 95% CI: 60-97), 94% (15/16; 95% CI: 70-100) and 74% (14/19; 95% CI: 49-91), respectively. Sensitivity, specificity, positive predictive and negative predictive values ranged from 95 to 100% (95% CI: 77-100), 67 to 100% (95% CI: 38-100), 81 to 100% (95% CI: 61-100) and 91 to 100% (95% CI: 59-100) when combining several imaging tests, respectively. The diagnostic algorithm with the overall best diagnostic performance was the one starting with MRI, followed either by ultrasound or RA, yielding 100% sensitivity (22/22; 95% CI: 85-100%) 100% (15/15; 95% CI: 78-100) and 100% accuracy (37/37; 95% CI: 91-100).

CONCLUSION

The use of MRI as the first imaging examination followed by either ultrasound or RA reaches high degrees of performance for the diagnosis of GCA and is recommended in daily practice.

Arteritic anterior ischaemic optic neuropathy: An update

Ischaemic optic neuropathy (ION) is a major cause of blindness. The clinical approach and management is a matter of debate for the treating neurologist and the ophthalmologist. Of the two broad varieties namely the posterior (PION) and anterior ischaemic optic neuropathy (AION), the arteritic variety of the AION (AAION) is usually due to giant cell arteritis. Giant cell arteritis may only present with visual loss in up to 25% of cases. AAION is a neuro-ophthalmic emergency. Early recognition and differentiation from AAION is imperative in order to prevent further devastating visual loss. A literature search was conducted on pubmed using key words as AAION, arteritic anterior ischaemic optic neuropathy, giant cell arteritis (GCA) and articles from the year 2000 till date were included. In any case very few reviews are available on AAION. The literature search on pubmed provided holistic overview about this clinical significant entity and the same is compiled in this review. Moreover the histopathologic features of a temporal artery biopsy have been described with its microscopic images. In any case reviews are mostly available on the Non arteritic variety of AION. This review recapitulates the diagnostic and management protocol of a patient presenting with AAION.

High-resolution MRI demonstrates signal abnormalities of the 3rd cranial nerve in giant cell arteritis patients with 3rd cranial nerve impairment

OBJECTIVE

To determine the sensitivity and specificity of high-resolution (HR) MRI for detecting signal abnormalities of cranial nerves (CN) in giant cell arteritis (GCA) patients presenting with diplopia.

METHODS

This IRB-approved retrospective single-center study included GCA patients who underwent 3-T HR MRI from December 2014 to January 2020. Two radiologists, blinded to all data, individually assessed for the presence of enhancement of the 3rd, 4th, and/or 6th CN on post-contrast HR imaging and high signal intensity on HR T2-WI, for signal abnormalities of extraocular muscles and the brainstem, and for inflammatory changes of the ophthalmic and extracranial arteries. A Fisher's exact test was used to compare patients with or without diplopia.

RESULTS

In total, 64 patients (42/64 (66%) women and 22/64 (34%) men, mean age 76.3 ± 8 years) were included. Of the 64 patients, 14 (21.9%) presented with diplopia. Third CN enhancement was detected in 7/8 (87.5%) patients with 3rd CN impairment, as compared to no patients with 4th or 6th CN impairment or to patients without diplopia (p < 0.001). Third CN abnormal high signal intensity on HR T2-WI was detected in 4/5 patients (80%) with 3rd CN impairment versus none of other patients (p < 0.001). Sensitivity, specificity, positive predictive value, and negative predictive value for detecting 3rd CN signal abnormalities were of 0.88, 1, 1, and 0.99 and 0.8, 1, 1, and 0.98 for post-contrast HR imaging and HR T2-WI, respectively.

CONCLUSIONS

HR MRI had excellent diagnostic sensitivity and specificity when detecting signal abnormalities of the 3rd CN in GCA patients presenting with 3rd CN impairment.

KEY POINTS

• Third cranial nerve enhancement was detected in all patients with 3rd cranial nerve impairment except for one with transient diplopia. • The "check mark sign" might be useful to identify 3rd cranial nerve signal abnormalities in the orbital apex. • No signal abnormalities of the 4th or 6th cranial nerves could be detected on high-resolution MRI.

Radioanatomic Characteristics of the Posteromedial Intraconal Space: Implications for Endoscopic Resection of Orbital Lesions

BACKGROUND AND PURPOSE

Imaging is essential in the diagnostic work-up of patients with orbital lesions. The position of an orbital lesion relative to the inferomedial muscular trunk of the ophthalmic artery determines endoscopic resectability, anticipated technical difficulty, and patient morbidity. Although the inferomedial muscular trunk is not readily identifiable on preoperative imaging, we hypothesize that it is spatially approximate to the location where the ophthalmic artery crosses the optic nerve. Our aim was to determine whether the ophthalmic artery-optic nerve crosspoint anatomically approximates the inferomedial muscular trunk in a cadaver study and can be appreciated on imaging of known posteromedial orbital lesions.

MATERIALS AND METHODS

Dissection was performed on 17 fresh-frozen cadaver orbits to assess the relationship between the inferomedial muscular trunk and ophthalmic artery-optic nerve crosspoint. Retrospective review of imaging in 9 patients with posteromedial orbital lesions assessed posteromedial orbital compartment characteristics and the ability to locate the ophthalmic artery-optic nerve crosspoint.

RESULTS

In our cadaver study, the mean distance between the ophthalmic artery-optic nerve crosspoint and the inferomedial muscular trunk was 1.21 ± 0.64 mm. Retrospectively, the ophthalmic artery-optic nerve crosspoint was identifiable in 9/9 patients, whereas the inferomedial muscular trunk was not identifiable in any patient. Total or partial effacement of the posteromedial intraconal fat triangle was observed in 9/9 patients.

CONCLUSIONS

This study of neurovascular relationships within the posteromedial orbit demonstrates that the ophthalmic artery-optic nerve crosspoint closely approximates the inferomedial muscular trunk and can be seen in patients with posteromedial orbital lesions. Posteromedial intraconal fat effacement may help to localize these lesions. These findings may facilitate multidisciplinary communication and help predict lesion resectability and patient outcomes.

[Delays in the management of ocular complications of giant cell arteritis: A retrospective monocentric study of 33 patients]

INTRODUCTION

Ocular complications of giant cell arteritis (GCA) can lead to irreversible bilateral blindness and represent a therapeutic emergency. Recommendations for the management of GCA have recently been updated. The objective of the study was to evaluate delays in appropriate management of the ocular complications of GCA and its determinants.

METHOD

Retrospective, monocentric study, conducted over the period January 2013-November 2018. All consecutive patients with a final diagnosis of GCA and related visual impairment (permanent visual loss and/or alteration of visual field) were included.

RESULTS

Thirty-three patients were included (women: 21, men: 12; mean age at diagnosis: 79). Twenty-seven patients (82%) presented with symptoms suggestive of ACG prior to the visual complication, ranging from a few weeks to several months. Seventeen patients (52%) had a known biological inflammatory syndrome (median CRP at 64 mg/L) prior to hospital consultation. The median time from the onset of permanent ophthalmologic manifestations to appropriate corticosteroid management was 3 days (range: 0-134). Two of the 21 patients who consulted an out-of-hospital ophthalmologist received corticosteroid therapy before referral to hospital. Three patients (9%) were treated within 24 h of the onset of the disorders.

CONCLUSION

There is a significant delay in the appropriate management of ophthalmological complications of ACG and deviations from current recommendations. Numerous actions must therefore be taken to improve the visual prognosis of patients with ACG, both preventively (i.e. early diagnosis and treatment of ACG before the possible occurrence of visual complications), and curatively (rapid recognition and immediate treatment of ocular complications). These elements support the relevance of specific fast-track pathways for GCA.

Increased diagnostic accuracy of giant cell arteritis using three-dimensional fat-saturated contrast-enhanced vessel-wall magnetic resonance imaging at 3 T

OBJECTIVES

To compare the diagnostic accuracy of 3D versus 2D contrast-enhanced vessel-wall (CE-VW) MRI of extracranial and intracranial arteries in the diagnosis of GCA.

METHODS

This prospective two-center study was approved by a national research ethics board and enrolled participants from December 2014 to October 2017. A protocol including both a 2D and a 3D CE-VW MRI at 3 T was performed in all patients. Two neuroradiologists, blinded to clinical data, individually analyzed separately and in random order 2D and 3D sequences in the axial plane only or with reformatting. The primary judgment criterion was the presence of GCA-related inflammatory changes of extracranial arteries. Secondary judgment criteria included inflammatory changes of intracranial arteries and the presence of artifacts. A McNemar's test was used to compare 2D to 3D CE-VW MRIs.

RESULTS

Seventy-nine participants were included in the study (42 men and 37 women, mean age 75 (± 9.5 years)). Fifty-one had a final diagnosis of GCA. Reformatted 3D CE-VW was significantly more sensitive than axial-only 3D CE-VW or 2D CE-VW when showing inflammatory change of extracranial arteries: 41/51(80%) versus 37/51 (73%) (p = 0.046) and 35/50 (70%) (p = 0.03). Reformatted 3D CE-VW was significantly more specific than 2D CE-VW: 27/27 (100%) versus 22/26 (85%) (p = 0.04). 3D CE-VW showed higher sensitivity than 2D CE-VW when detecting inflammatory changes of intracranial arteries: 10/51(20%) versus 4/50(8%), p = 0.01. Interobserver agreement was excellent for both 2D and 3D CE-VW MRI: κ = 0.84 and 0.82 respectively.

CONCLUSIONS

3D CE-VW MRI supported more accurate diagnoses of GCA than 2D CE-VW.

KEY POINTS

• 3D contrast-enhanced vessel-wall magnetic resonance imaging is a high accuracy, non-invasive diagnostic tool used to diagnose giant cell arteritis. • 3D contrast-enhanced vessel-wall imaging is feasible for clinicians to complete within a relatively short time, allowing immediate assessment of extra and intracranial arteries. • 3D contrast-enhanced vessel-wall magnetic resonance imaging might be considered a diagnostic tool when intracranial manifestation of GCA is suspected.