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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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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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Penet T, Lambert M, Baillet C, Outteryck O, Hénon H, Morell-Dubois S, Hachulla E, Launay D, Pokeerbux MR. Giant cell arteritis-related cerebrovascular ischemic events: a French retrospective study of 271 patients, systematic review of the literature and meta-analysis. Arthritis Res Ther 2023; 25:116. [PMID: 37420252 PMCID: PMC10326952 DOI: 10.1186/s13075-023-03091-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 06/10/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND Cerebrovascular ischemic events (CIE) are among the most severe complications of giant cell arteritis (GCA). Heterogeneity between different studies in the definition of GCA-related CIE leads to uncertainty regarding their real prevalence. The aim of our study was to evaluate the prevalence and describe the characteristics of GCA-related CIE in a well-phenotyped cohort completed by a meta-analysis of the existing literature. METHODS In this retrospective study performed in the Lille University Hospital, all consecutive patients with GCA according to American College of Rheumatology (ACR) diagnostic criteria were included from January 1, 2010, to December 31, 2020. A systematic review of the literature using MEDLINE and EMBASE was performed. Cohort studies of unselected GCA patients reporting CIE were included in the meta-analysis. We calculated the pooled summary estimate of GCA-related CIE prevalence. RESULTS A total of 271 GCA patients (89 males, mean age 72 ± 9 years) were included in the study. Among them, 14 (5.2%) presented with GCA-related CIE including 8 in the vertebrobasilar territory, 5 in the carotid territory, and 1 patient having multifocal ischemic and hemorrhagic strokes related to intra-cranial vasculitis. Fourteen studies were included in the meta-analysis, representing a total population of 3553 patients. The pooled prevalence of GCA-related CIE was 4% (95% CI 3-6, I2 = 68%). Lower body mass index (BMI), vertebral artery thrombosis on Doppler US (17% vs 0.8%, p = 0.012), vertebral arteries involvement (50% vs 3.4%, p < 0.001) and intracranial arteries involvement (50% vs 1.8%, p < 0.001) on computed tomography angiography (CTA) and/or magnetic resonance angiography (MRA), and axillary arteries involvement on positron emission computed tomography (PET/CT) (55% vs 20%, p = 0.016) were more frequent in GCA patients with CIE in our population. CONCLUSIONS The pooled prevalence of GCA-related CIE was 4%. Our cohort identified an association between GCA-related CIE, lower BMI, and vertebral, intracranial, and axillary arteries involvement on various imaging modalities.
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Affiliation(s)
- Thomas Penet
- Univ. Lille, Inserm, CHU Lille, Service de Médecine Interne Et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord Et Nord-Ouest de France (CeRAINO), U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000 Lille, France
- Service de Médecine Interne et Immunologie Clinique, CHU Lille, Rue Michel Polonovski, F-59037 Lille Cedex, France
| | - Marc Lambert
- Univ. Lille, Inserm, CHU Lille, Service de Médecine Interne Et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord Et Nord-Ouest de France (CeRAINO), U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000 Lille, France
| | - Clio Baillet
- Nuclear Medicine Department, CHU Lille, Lille, France
| | - Olivier Outteryck
- Department of Neuroradiology, Univ. Lille, INSERM, CHU Lille, U1172 – Lille Neurosciences Institute, 59000 Lille, France
| | - Hilde Hénon
- Univ. Lille, Inserm, CHU Lille, U1172 - LilNCog-Lille Neuroscience & Cognition, Lille, France
| | - Sandrine Morell-Dubois
- Univ. Lille, Inserm, CHU Lille, Service de Médecine Interne Et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord Et Nord-Ouest de France (CeRAINO), U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000 Lille, France
| | - Eric Hachulla
- Univ. Lille, Inserm, CHU Lille, Service de Médecine Interne Et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord Et Nord-Ouest de France (CeRAINO), U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000 Lille, France
| | - David Launay
- Univ. Lille, Inserm, CHU Lille, Service de Médecine Interne Et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord Et Nord-Ouest de France (CeRAINO), U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000 Lille, France
| | - Mohammad Ryadh Pokeerbux
- Univ. Lille, Inserm, CHU Lille, Service de Médecine Interne Et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord Et Nord-Ouest de France (CeRAINO), U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000 Lille, France
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Prünte MKR, Naumann A, Christ M, Naumann M, Bayas A. Giant cell arteritis with vertebral artery involvement-baseline characteristics and follow-up of a monocentric patient cohort. Front Neurol 2023; 14:1188073. [PMID: 37435161 PMCID: PMC10331602 DOI: 10.3389/fneur.2023.1188073] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/30/2023] [Indexed: 07/13/2023] Open
Abstract
Vertebral artery (VA) involvement in giant cell arteritis (GCA) has rarely been reported. We aimed to evaluate the prevalence, patients' characteristics, and immunotherapies used in patients with GCA and VA involvement at diagnosis and 1 year follow-up, retrospectively including patients being diagnosed between January 2011 and March 2021 in our department. Clinical features, laboratory data, VA imaging, immunotherapy, and 1 year follow-up data were analyzed. Baseline characteristics were compared to GCA patients without VA involvement. Among all 77 cases with GCA, 29 patients (37.7%) had VA involvement, as diagnosed by imaging and/or clinical signs and symptoms. Gender distribution and erythrocyte sedimentation rate (ESR) were significantly different in the groups with and without VA involvement, with more women being affected (38/48 patients, 79.2%) and a significantly higher median ESR in patients without VA involvement (62 vs. 46 mm/h; p = 0.012). MRI and/or CT showed vertebrobasilar stroke at GCA diagnosis in 11 cases. 67/77 patients (87.0%) received high-dose intravenous glucocorticosteroids (GCs) at diagnosis, followed by oral tapering. Six patients were treated with methotrexate (MTX), one with rituximab, and five with tocilizumab (TCZ). 2/5 TCZ patients achieved clinical remission after 1 year, vertebrobasilar stroke within the first year occurred in 2/5 patients. Diagnosis of VA involvement might be underrecognized in GCA patients. VA imaging should be performed in elderly patients with vertebrobasilar stroke presenting with GCA symptoms, not to miss GCA as the etiology of stroke. Efficacy of immunotherapies in GCA with VA affection and long-term outcomes need to be investigated further.
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Affiliation(s)
- Mona Klara Ros Prünte
- Department of Neurology and Clinical Neurophysiology, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Anne Naumann
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Monika Christ
- Department of Neurology and Clinical Neurophysiology, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Markus Naumann
- Department of Neurology and Clinical Neurophysiology, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Antonios Bayas
- Department of Neurology and Clinical Neurophysiology, Faculty of Medicine, University of Augsburg, Augsburg, Germany
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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Bull Haaversen AC, Brekke LK, Kermani TA, Molberg Ø, Diamantopoulos AP. Extended ultrasound examination identifies more large vessel involvement in patients with giant cell arteritis. Rheumatology (Oxford) 2023; 62:1887-1894. [PMID: 35997556 DOI: 10.1093/rheumatology/keac478] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/11/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To compare limited with a more extended ultrasound examination (anteromedial ultrasound, A2-ultrasound) to detect large vessel (LV) involvement in patients with newly diagnosed GCA. METHODS Patients with new-onset GCA were included at the time of diagnosis. All patients were examined using limited ultrasound (ultrasound of the axillary artery as visualized in the axilla) and an extended A2-ultrasound method (which also includes the carotid, vertebral, subclavian and proximal axillary arteries), in addition to temporal artery ultrasound. RESULTS One hundred and thirty-three patients were included in the study. All patients fulfilled the criteria according to a proposed extension of the 1990 ACR classification criteria for GCA and had a positive ultrasound examination at diagnosis. Ninety-three of the 133 GCA patients (69.9%) had LV involvement when examined by extended A2-ultrasound, compared with only 56 patients (42.1%) by limited ultrasound (P < 0.001). Twelve patients (9.0%) had vasculitis of the vertebral arteries as the only LVs involved. Five patients (3.8%) would have been missed as having GCA if only limited ultrasound was performed. Forty patients (30.0%) had isolated cranial GCA, 21 patients (15.8%) had isolated large vessel GCA and 72 patients (54.1%) had mixed-GCA. CONCLUSION Extended A2-ultrasound examination identified more patients with LV involvement than the limited ultrasound method. However, extended A2-ultrasound requires high expertise and high-end equipment and should be performed by ultrasonographers with adequate training.
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Affiliation(s)
| | - Lene Kristin Brekke
- Department of Rheumatology, Hospital for Rheumatic Diseases, Haugesund, Norway
| | - Tanaz A Kermani
- Department of Rheumatology, University of California, Los Angeles, CA, USA
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Oerding C, Uhlmann F, Wollmann J, Kaden I, Wohlfarth K. Carotid Artery Stenosis and Ischemic Strokes in Patients with Giant Cell Arteritis: A Characteristic Pattern-Literature Review and Case Report. TH OPEN : COMPANION JOURNAL TO THROMBOSIS AND HAEMOSTASIS 2022; 6:e40-e49. [PMID: 35112048 PMCID: PMC8801894 DOI: 10.1055/a-1704-0741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/28/2021] [Indexed: 11/25/2022]
Abstract
Purpose Ischemic stroke is a relatively rare complication of giant cell arteritis often accompanied by vessel stenosis. Our purpose was to compare the location of internal carotid artery stenosis in GCA patients by performing a literature review suggesting a specific and characteristic pattern. Methods We performed a PubMed research including all articles and cited articles reporting cases and case series about giant cell arteritis patients with internal carotid artery stenosis and ischemic strokes. Results In this case series 39 cases were included. We found a clear tendency of giant cell arteritis-related stenosis to be in the intracranial segments (35/39 (89.7%)). Only in 8/39 (20.5%) patients there was further involvement of extracranial segments. Many cases (27/39 [69.2%]) showed a bilateral involvement. Discussion This literature review reveals a specific pattern of internal carotid artery involvement in patients with giant cell arteritis and ischemic strokes. To our knowledge this pattern has not been reported as a sign strongly pointing toward giant cell arteritis before. We have not found case reports mentioning other common types of vasculitis reporting this involvement pattern. Conclusion Internal carotid artery stenosis and ischemic stroke is a rare complication in patients with giant cell arteritis. Considering the characteristic features of bilateral distal internal carotid artery stenosis giant cell arteritis should be suspected which potentially leads to an early diagnosis and immunotherapy.
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Affiliation(s)
- Clemens Oerding
- Department of Neurology, BG-Hospital Bergmannstrost, Halle (Saale), Germany,Address for correspondence Clemens Oerding, MD Department of Neurology, BG-Hospital BergmannstrostMerseburger Str. 165, 06112 Halle (Saale)Germany
| | - Frank Uhlmann
- Department of Neurology, BG-Hospital Bergmannstrost, Halle (Saale), Germany
| | - Johannes Wollmann
- Department of Neurology, BG-Hospital Bergmannstrost, Halle (Saale), Germany
| | - Ingmar Kaden
- Department of Radiology, BG-Hospital Bergmannstrost, Halle (Saale), Germany
| | - Kai Wohlfarth
- Department of Neurology, BG-Hospital Bergmannstrost, Halle (Saale), Germany
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