Magnetic resonance imaging in the diagnosis and follow up of Takayasu's arteritis in children

Real-World Biomarkers for Pediatric Takayasu Arteritis

Childhood-onset Takayasu arteritis (TA) is a rare, heterogeneous disease with limited diagnostic markers. Our objective was to identify and classify all candidates for biomarkers of TA diagnosis in children reported in the literature. A systematic literature review (PRISMA) of MEDLINE, EMBASE, Wiley Cochrane Library, ClinicalTrias.gov, and WHO ICTRP for articles related to TA in the pediatric age group between January 2000 and August 2023 was performed. Data on demographics, clinical features, laboratory measurements, diagnostic imaging, and genetic analysis were extracted. We identified 2026 potential articles, of which 52 studies (81% case series) met inclusion criteria. A total of 1067 TA patients were included with a peak onset between 10 and 15 years. Childhood-onset TA predominantly presented with cardiovascular, constitutional, and neurological symptoms. Laboratory parameters exhibited a low sensitivity and specificity. Imaging predominantly revealed involvement of the abdominal aorta and renal arteries, with magnetic resonance angiography (MRA) being the preferred imaging modality. Our review confirms the heterogeneous presentation of childhood-onset TA, posing significant challenges to recognition and timely diagnosis. Collaborative, multinational efforts are essential to better understand the natural course of childhood-onset TA and to identify accurate biomarkers to enhance diagnosis and disease management, ultimately improving patient outcomes.

Takayasu Arteritis with Severe Renal Artery Stenosis and an Aberrant Renal Artery in a Child: A Case Report and Discussion

Takayasu arteritis (TA) is a chronic, idiopathic large vessel vasculitis mainly affecting the aorta and its major branches. It is one of the common causes of reno-vascular hypertension in Indian children. We report a ten-year-old boy who presented with hypertensive encephalopathy, proteinuria, and haematuria without any renal dysfunction. He was initially diagnosed to be a case of acute post streptococcal glomerulonephritis, but detailed clinical examination and haemato-radiological investigations revealed Takayasu arteritis, type V (P+). He had unilateral severe renal artery stenosis along with a small kidney and an aberrant renal artery on left side. He is found to have resistant hypertension, unresponsive to multiple anti-hypertensive drugs, and had a fatal outcome. This case illustrates renal involvement in TA and the significance of four-limb blood pressure measurement in any non-obese child with hypertension. Furthermore, the possible role of aberrant renal artery in the pathogenesis of resistant hypertension is discussed.

Overview of imaging in adult- and childhood-onset Takayasu arteritis

Takayasu Arteritis is an idiopathic large vessel vasculitis, that affects young adults and children and can lead to ischemia and end-organ damage. Vascular imaging is crucial for diagnosis, assessment of disease extent and management of the disease. In this article, we critically review evidence for the clinical use of the different imaging modalities conventional angiography, magnetic resonance imaging, computed tomography, Doppler ultrasound and ¹⁸fluorodeoxyglucose positron emission tomography. We thereby focus on their clinical applicability, challenges and specific use in children.

Wind of Change in the Treatment of Childhood-Onset Takayasu Arteritis: a Systematic Review

PURPOSE OF REVIEW

We lack evidence-based data for the treatment of childhood-onset Takayasu arteritis (c-TA) since it is a rare disease in children. In this systematic literature review, we aimed to evaluate the treatment choices in c-TA patients and integrate our experience for the treatment of our patients in the recent years/in the biologic era.

RECENT FINDINGS

We reviewed 24 articles addressing treatments of 413 c-TA patients. Steroids were given to 352 patients (85.2%) as the main immunosuppressive therapy. Other immunosuppressive agents included methotrexate (37.3%), cyclophosphamide (24.5%), azathioprine (16.9%), and mycophenolate mofetil (7.9%). Besides, various biological agents were used, including tumor necrosis factor-alpha inhibitors in 70 of 107 c-TA patients (65.4%) and interleukin-6 inhibitors in 33 of them (30.8%). Biologics are increasingly used in our center as well. Even in severe patients, CYC is switched to either anti-TNF or antiIL6 once disease control is achieved. Recently, in addition to conventional immunosuppressants, biologics are increasingly used in c-TA. We have revised our treatment protocol to start with 1-3 doses of high-dose steroids and CYC, in a child with TA with types III-V involvement and high acute phase reactants; once clinical features subside and CRP normalizes, biologics should be started to replace CYC while decreasing the steroid dose.

Neuroimaging of Children With Takayasu Arteritis

OBJECTIVE

Takayasu arteritis is a rare granulomatous chronic vasculitis that affects the aorta and its main branches. Neurologic manifestations can accompany the disease; however, there is no study on neuroimaging in children with Takayasu arteritis. Therefore, we aimed to evaluate cranial magnetic resonance imaging (MRI) in pediatric Takayasu arteritis patients.

MATERIALS AND METHODS

Demographic, clinical, and laboratory data were obtained retrospectively.

RESULTS

The study included 15 pediatric Takayasu arteritis patients. All patients presented with constitutional symptoms. Additionally, 6 patients suffered from headache, 2 had syncope, 1 had loss of consciousness, and 1 had convulsion. All patients underwent cranial and diffusion MRI a median 12 months after diagnosis. Cranial MRI findings were normal in 12 patients, whereas 3 patients had abnormal findings, as follows: stenosis in the M1 and M2 segments of the left middle cerebral artery (n = 1); diffuse thinning of the right internal carotid, middle cerebral, and right vertebral and basilar artery (n = 1); as a sequela, areas of focal gliosis in both the lateral ventricular and posterior periventricular regions (n = 1). Among these 3 patients, 1 had no neurologic complaints.

CONCLUSION

Abnormal MRI findings can be observed in pediatric Takayasu arteritis patients, even those that are asymptomatic; therefore, clinicians should carefully evaluate neurologic involvement in all pediatric Takayasu arteritis patients.

Aggressive progression of Takayasu's arteritis in infancy: a case report

Takayasu’s arteritis (TA) affects the aorta and its branches. Immunosuppressants are the usual course of therapy, while surgery has been used in acute cases. There is only scant information on TA in infancy, and the nonspecific symptoms in the initial stage of the disease make the diagnosis difficult and delayed, thus increasing the mortality rate. We describe a case of aggressive progression of TA in an infant. This child was the youngest to be affected with the disease as reported in the literature. A 3.5-month-old boy presented with cyanosis of both legs, tachycardia and antithrombin III deficiency. Computed tomography angiography (CTA) revealed thrombosis of distal aorta and both iliac arteries. Thrombectomy was performed at the level of both common femoral arteries. In addition, thigh amputation of the left leg had to be performed. TA was diagnosed postmortem with thrombosis of the distal aorta, its branches and upper mesenteric artery which was not occluded on previous CTA, glomerulonephritis and pulmonary parenchymal granulomatous infiltrations.

Takayasu Arteritis

Takayasu arteritis is an idiopathic granulomatous vasculitis of the aorta and its main branches and it constitutes one of the more common vasculitides in children. Inflammation and intimal proliferation lead to wall thickening, stenotic or occlusive lesions, and thrombosis, while destruction of the elastica and muscularis layers originates aneurysms and dissection. Carotid artery tenderness, claudication, ocular disturbances, central nervous system abnormalities, and weakening of pulses are the most frequent clinical features. The diagnosis is usually confirmed by the observation of large vessel wall abnormalities: stenosis, aneurysms, occlusion, and evidence of increased collateral circulation in angiography, MRA or CTA imaging. The purpose of this revision is to address the current knowledge on pathogenesis, investigations, classification, outcome measures and management, and to emphasize the need for timely diagnosis, effective therapeutic intervention, and close monitoring of this severe condition.

Early diagnosis and follow-up of chronic active Epstein-Barr-virus-associated cardiovascular complications with cardiovascular magnetic resonance imaging: A case report

INTRODUCTION

Chronic active Epstein-Barr virus (EBV) infection (CAEBV) is characterized as chronic or recurrent mononucleosis-like symptoms and elevated EBV deoxyribonucleic acid (EBV-DNA) copies. Cardiovascular complications have high morbidity and mortality. The treatment regimen for CAEBV has not been established yet, resulting in poor prognoses. Herein, we present a case of cardiovascular magnetic resonance imaging (CMRI) evaluation with a series of sequences for CAEBV-associated cardiovascular involvement, which has never been reported.

CASE PRESENTATION

A 16-year-old female (body weight, 55 kg) developed a persistent fever and a positive EBV-DNA level of 28,000 copies/mL. Computed tomography angiography (CTA) showed aneurysms involving the aorta and its major branches, as well as multiple aneurysms and stenoses of the coronary arteries. CMRI of the coronary arteries depicted the dilution and stenosis of the arterial lumen as well as the thickening of the arterial wall. Late gadolinium enhancement (LGE) showed subendocardial and transmural delayed enhancement of the left ventricle, suggesting myocardial infarction.CAEBV and associated cardiovascular complications were diagnosed. After treatment with Medrol and Leflunomide, the clinical manifestation and serological parameters reversed to normal. However, the EBV-DNA level increased again to 13,900 copies/mL 2 months later. A follow-up with aorta CTA showed that the arterial walls of the bilateral common iliac artery aneurysms were thicker with new-onset mural thrombi. The aorta CTA also showed new-onset occlusion of the right coronary artery, but a follow-up of CMRI at the same day did not find new-onset delayed enhancement lesion.

CONCLUSION

This case reminds clinicians of the vital importance of early diagnosis and close follow-up of CAEBV-associated cardiovascular complications. With cine imaging, coronary artery imaging, LGE imaging, and other novel techniques, CMRI can effectively and comprehensively reveal the early and dynamic changes, and act as an important tool in the field of cardiovascular diseases.

Takayasu arteritis in childhood: retrospective experience from a tertiary referral centre in the United Kingdom

Introduction

Takayasu arteritis (TA) is an idiopathic large-vessel vasculitis affecting the aorta and its major branches. Although the disease rarely affects children, it does occur, even in infants. The objective of this study was to evaluate the clinical features, disease activity, treatment and outcome of childhood TA in a tertiary UK centre.

Methods

We analysed a retrospective case series of children fulfilling the TA classification criteria of the European League against Rheumatism, the Paediatric Rheumatology European Society and the Paediatric Rheumatology International Trials Organisation. Data regarding demographics, clinical features, treatments and outcomes were recorded. Descriptive statistics are expressed as median and range. Fisher’s exact test was used for group comparisons. The Paediatric Vasculitis Activity Score (PVAS), Paediatric Vasculitis Damage Index (PVDI), Disease Extent Index-Takayasu (DEI.Tak) and Indian Takayasu Arteritis Activity Score (ITAS2010) were calculated retrospectively.

Results

A total of 11 children (64% female) with age at diagnosis of 11.8 (1.3 to 17) years were identified over a 23-year period. The median time to diagnosis was 17 (0 to 132) months. The most common clinical features at presentation were arterial hypertension (72.7%), systemic features (36%) and cardiovascular (45%), neurological (36%), pulmonary (27%), skin (9%), renal (9%) and gastrointestinal (9%) involvement. At presentation, PVAS was 5/63 (1 to 13); DEI.Tak was 7/81 (2 to 12) and ITAS2010 was 9/57 (6 to 20). Treatment included corticosteroids (81.8%), combined with methotrexate in most cases (72.7%). Cyclophosphamide (36.4%) and biologic agents (45.5%) were reserved for severe and/or refractory cases. PVDI at latest follow-up was 5.5/72 (3 to 15). Mortality was 27%. Young age at disease onset (<5 years old) and permanent PVDI scores ≥3 were significantly associated with mortality risk (P = 0.024).

Conclusion

TA is a rare and potentially life-threatening large-vessel vasculitis. Improved awareness of TA is essential to secure a timely diagnosis. Although the evidence base for the treatment of TA in children is weak, we found that it is essential to treat it aggressively because our data emphasise that the mortality and morbidity in the paediatric population remains high.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0545-1) contains supplementary material, which is available to authorized users.

Vasculitis in children

Primary systemic vasculitides of the young are relatively rare diseases, but are associated with significant morbidity and mortality, particularly if there is diagnostic delay. We provide an overview of paediatric vasculitides with emphasis on key differences in vasculitis presentation and management between children and adults. Significant advances in the field of paediatric vasculitis research include the development of classification criteria and disease outcome tools for paediatric disease; inclusion of paediatric patients in international multicentre randomized controlled trials of therapies in vasculitis; and development of rare disease trial designs for therapeutic trials of paediatric vasculitis. The continuation of unmet needs as well as the exploration of potential therapeutic avenues and considerations in the design of future trials are also discussed.

Takayasu arteritis as a cause of arterial hypertension. Case report and literature review

We report a 16-year-old girl in whom Takayasu arteritis (TA) was manifested mainly by severe arterial hypertension on her right arm, which was detected during a routine examination at school. Her systolic blood pressure on the right arm was significantly higher than that on the left one. There was also a pressure difference between the right arm and legs. The pulse of the left external carotid artery and that of the left radial artery was absent. Vascular bruits over interscapular and right supra- and subclavian areas were heard on auscultation. The diagnosis of TA was confirmed by a spiral computed tomography angiography, which showed a thickened thoracic aortic wall and narrowing of its lumen. In addition, complete occlusion of the left common carotid artery and the left subclavian artery was observed.

CONCLUSION

The rarity of the disorder and the heterogeneous nature of its clinical manifestation predispose to a late diagnosis and delayed treatment. Our report highlights the fact that the condition can and does occur in a pediatric population in Europe and hence must be considered in patients presenting with suggestive symptoms and signs, especially in young patients with unexplained hypertension. Clinical suspicion and proper imaging are crucial for the correct diagnosis and management of patients with TA. A brief review of literature completes this report.

Time to focus on outcome assessment tools for childhood vasculitis

Childhood systemic vasculitides are a group of rare diseases with multi-organ involvement and potentially devastating consequences. After establishment of new classification criteria (Ankara consensus conference in 2008), it is now time to establish measures for proper definition of activity and damage in childhood primary vasculitis. By comparison to adult vasculitis, there is no consensus for indices of activity and damage assessment in childhood vasculitis. Assessment of disease activity is likely to become a major area of interest in pediatric rheumatology in the near future. After defining the classification criteria for primary systemic childhood vasculitis, the next step was to perform a validation study using the original Birmingham vasculitis activity score as well as the disease extent index to measure disease activity in childhood vasculitis. Presently, there are efforts in place to develop a pediatric vasculitis activity score. This paper reviews the current understanding about the assessment tools (i.e., clinical features, laboratory tests, radiologic assessments, etc.) widely used for evaluation of the disease activity and damage status of the children with vasculitis.

The limited role of MRI in long-term follow-up of patients with Takayasu's arteritis

INTRODUCTION

MRI and MRA are used for diagnosis and activity determination of patients with Takayasu's arteritis (TA). However, there is a limited experience regarding the role of MRI in long-term follow-up of those patients. The aim of the present study was to evaluate the clinical usefulness of MRI in the long-term follow-up of patients with Takayasu's disease.

MATERIALS AND METHODS

The clinical data of 11 TA patients, who obtained two or more follow-up MRI scans, was matched with the imaging results. MRI examinations were considered positive for disease activity when one of the following findings was noted: new arterial wall enhancement or interval appearance of anatomical changes (interval dilatation, stenosis or occlusion or new arterial wall irregularity). Conversely, MRI examinations were considered to show signs of improvement when local enhancement disappeared, or when a stenosis was relieved. Disease activity was determined by the combination of worsening localizing ischemic signs and symptoms, systemic signs and symptoms (malaise, fever, etc.), and elevated blood markers (CRP and ESR).

RESULTS

A total of 47 MRI examinations were performed in 11 patients (1 male, mean age 28, range 14-53 years) with a total follow-up time ranging between 12 and 56 months (average 36 months). MRI was positive for active disease at least once in nine out of the 11 patients (82%). The most commonly affected arteries were the aortic arch, the left subclavian artery and the left common carotid artery. No statistically significant correlation was found between clinical activity and MRI signs of activity.

CONCLUSION

Although MRI is a well established modality for primary diagnosis of TA, the present study suggests that it has a limited clinical role in the long-term follow-up of those patients when reactivation of disease is suspected.

Clinical characteristics, interdisciplinary treatment and follow-up of 14 children with Takayasu arteritis

BACKGROUND

Pediatric patients with Takayasu arteritis were studied by analyzing clinical presentation, diagnostic images, response to multimodal therapy, and long-term outcome.

METHODS

Fourteen consecutive children and adolescents (mean age: 10 years) were diagnosed with Takayasu arteritis at our institution between 1995 and 2007. They were subjected to clinical and diagnostic studies including color ultrasonography, MRI and angiography, and received interdisciplinary treatment.

RESULTS

The median time lag between the first onset of symptoms and diagnosis was 7.7 weeks. The majority of patients presented with acute severe clinical symptoms and extensive vascular lesions. Hypertension was the most common finding on first presentation (93%), followed by headache (64%), nausea (64%) and palpitation (50%). Ten patients (71%) had reduced or absent carotid, brachial or femoral pulses in one or more locations. C-reactive protein was elevated in 79% of the patients and erythrocyte sedimentation rate in 64%. Cardiovascular imaging showed extensive vasculitis of both sides of the diaphragm in 86%. Complications included renal artery stenosis (n=7), aortic dissection, thoracic aortic aneurysm and infrarenal aneurysm (all n=1). Conservative drug treatment was effective in 50%. Interventional dilatation of stenosis and surgical therapy, including aortic bypass, resection of aneurysms and nephrectomy, were necessary in the remaining patients. Follow-up for 25 months to 12 years showed that all children are well without disease-related mortality.

CONCLUSIONS

Takayasu arteritis is a rare and potentially life-threatening disease in children, likely with a prolonged subclinical course. Rapid diagnosis and interdisciplinary management help to prevent life-threatening complications.

Takayasu arteritis--advances in diagnosis and management

Takayasu arteritis, a rare granulomatous vasculitis affecting young people, is associated with considerable morbidity and premature mortality. In most patients the diagnosis is delayed until after the development of substantial arterial injury. Studies of noninvasive imaging techniques suggest that these approaches might facilitate earlier diagnosis and have a role in monitoring disease progress; however, they remain limited in their ability to accurately quantify inflammatory disease activity in the arterial wall. A lack of controlled clinical trial data complicates the choice of therapy for Takayasu arteritis, and clinical indices for monitoring disease activity are currently suboptimal. Increasing knowledge of the pathogenesis of the large vessel vasculitides might eventually lead to novel targeted therapies. Preliminary data from open-label trials of anti-tumor necrosis factor therapy are encouraging, but there is an urgent need for controlled clinical trials to establish optimum therapeutic approaches for this disease. These trials should include a prospective assessment of the use of noninvasive imaging modalities in the diagnosis and subsequent management of Takayasu arteritis.

Takayasu arteritis in children and adolescents

Takayasu arteritis is a devastating vasculitis of the aorta and its major branches. The clinical manifestations in paediatric patients are less specific than in adults: in children the disease presents with fever, arthralgias and hypertension. Intramural inflammation results in narrowing of the blood vessel lumen and therefore hypoperfusion of the parenchyma. Conventional angiography is the gold standard diagnostic procedure. Corticosteroids, cyclophosphamide, MTX and biological therapies such as TNF-α blocking agents are treatment options.

Systemic vasculitis in childhood

Systemic vasculitis is a group of disorders with multiorgan involvement. These disorders have diverse clinical manifestations associated with significant morbidity and mortality. The most common vasculitides in children--Henoch-Schönlein purpura and Kawasaki disease--are self-limiting conditions. The lifelong and chronic vasculitides (eg, giant cell arteritis, Wegener's granulomatosis, microscopic polyangiitis, Churg-Strauss syndrome, polyarteritis nodosa, and Takayasu arteritis) are rarely seen in children. Therefore, the outcome in general is more favorable in children. This article offers an overview of the epidemiologic, etiologic, pathophysiologic, and clinical features of vasculitis in children, with emphasis on common conditions.

Imaging for large-vessel vasculitis

PURPOSE OF REVIEW

Ultrasonography, MRI, and PET are increasingly studied in large-vessel vasculitis. They have broadened our knowledge on these disorders and have a place in the diagnostic approach of these patients.

RECENT FINDINGS

Temporal artery ultrasonography can be used to guide the surgeon to that artery segment with the clearest 'halo' sign to perform a biopsy, or in experienced hands can even replace biopsy. The distal subclavian, axillary, and brachial arteries can also be examined. High-resolution MRI depicts superficial cranial and extracranial involvement patterns in giant cell arteritis (GCA). Contrast enhancement is prominent in active inflammation and decreases under successful steroid therapy. Presence of aortic complications such as aneurysm or dissection can be ruled out within the same investigation. Large thoracic vessel FDG-uptake is seen in the majority of patients with GCA, especially at the subclavian arteries and the aorta. FDG-PET cannot predict which patients are bound to relapse, and once steroids are started, interpretation is hazardous, which makes its role in follow-up uncertain. Increased thoracic aortic FDG-uptake at diagnosis of GCA may be a bad prognostic factor for later aortic dilatation. In patients with isolated polymyalgia rheumatica - who have less intense vascular FDG uptake - symptoms are caused by inflammation around the shoulders, hips, and spine.

SUMMARY

Ultrasonography, MRI, and PET remain promising techniques in the scientific and clinical approach of large-vessel vasculitis.

Takayasu arteritis in children

Takayasu arteritis (TA) is a large vessel vasculitis that usually affects young female patients during the second and third decades of life, but has been reported in children as young as 24 months of age. Aim of this report was to describe four children (two girls) with TA, as well as summarizing main published studies. The mean age at presentation of our cases was 11 years (range 8-15). Three patients were Caucasians and one Asian. Arterial hypertension was the commonest mode of presentation followed by systemic symptoms. Other related symptoms were due to ischemia and consisted of abdomen, chest, and limb pain. An abdominal bruit was noted in only one patient. Inflammation markers were always abnormal. Angiography was performed in all cases; left subclavian artery and common carotid artery were more frequently involved. Renal artery stenosis was observed in two patients. One boy was diagnosed as having an associated immune deficiency (Wiskott-Aldrich syndrome). Treatment modalities included prednisone (n = 4), methotrexate (n = 3), and mycophenolate mofetil (MMF) (n = 1). Surgery was required in two patients. Follow-up ranged from 3 to 10 years since diagnosis. In three cases antihypertensive drugs and methotrexate were stopped, and prednisone was reduced to 7.5 mg/day.

Takayasu arteritis: Role of cardiovascular magnetic imaging

Takayasu arteritis (TA) is a primary arteritis of unknown cause that commonly affects the aorta and its main branches. Traditionally, X-ray contrast angiography has been the gold standard for diagnosis and review of this chronic disease but recent developments suggest that non-invasive imaging with multiplanar cardiovascular magnetic resonance imaging (CMR) and magnetic resonance angiography (MRA) have a number of advantages for use in routine care. This review utilises a series of cases referred for imaging at the Royal Brompton Hospital, London to illustrate these points of development.

MR imaging of the pulmonary vasculature—an update

Although the advent of multi-detector row computed tomography (CT) angiography has been at the heart of improving the diagnostic management of pulmonary vascular disease, MR technology has also moved forward. This review outlines the current state of affairs of MR techniques for the assessment of pulmonary vascular diseases such as pulmonary hypertension, pulmonary arteritis and arteriovenous malformations. It highlights the main areas of MR angiography and MR perfusion imaging and discusses novel methods, such as non-contrast enhanced direct thrombus imaging, and will discuss its merits in the context of other diagnostic modalities.

Radiologic investigation of rheumatic diseases

This article reviews the current use of the wide variety of imaging modalities now available, presenting the imaging features of common and important causes of acute and chronic rheumatic disorders including juvenile idiopathic arthritis, spondyloarthropathies/enthesitis-related arthritis, sepsis, autoimmune diseases, vasculitis, and osteoporosis.

Dorsalgies révélant une maladie de Takayasu

Takayasu arteritis is an uncommon inflammatory arteritis especially in children. We report a case.

CASE REPORT

A 11-year-old boy presented dorsalgia with inflammatory syndrome. One year later, the investigation of an hypertension with asymmetric blood pressure revealed an aortic coarctation and a bilateral renal arteries stenosis leading to Takayasu's arteritis diagnosis.

CONCLUSION

Takayasu's arteritis must be evokated in young children in case of associated hypertension and inflammatory syndrome.

Les aortites inflammatoires

PRINCIPLE AND OTHER CAUSES: Takayasu's arteritis, giant cell arteritis and Behçet's disease are the three main causes of inflammatory aortitis. More rarely, aortitis can be observed in Cogan's syndrome, atrophic polychondritis, sarcoidosis, ankylosing spondylitis and in rheumatoid arthritis. RISKS OF PROGRESSION: Takayasu's arteritis is distinct with the development of stenotic lesions of the aorta. With the other causes, aortitis can be complicated by ectasia or even aneurysm, with the risk of rupture. Indeed, during giant cell arteritis, patients are 17 times more likely to develop thoracic aortic aneurysm. Aortic regurgitation is a frequent complication of inflammatory aortitis. Sometimes, aortitis is only manifested by general signs such as fever or an inflammatory syndrome. SUPPLEMENTARY EXPLORATIONS: Recent advances in diagnosis and follow-up of patients with inflammatory aortitis concern the use of non-invasive imaging techniques: Doppler ultrasonography, computed tomography with injection of a contrast product and magnetic resonance imaging, which currently replace the aortography.

DIAGNOSTIC PROBLEMS

Infectious aortitis, inflammatory atheromatous aneurysm and retroperitoneal fibrosis are sometimes misleading differential diagnoses.

Imagerie des pathologies vasculaires spécifiques

The diagnosis of vascularitis should be proposed when a concentric and regular thickening of the wall of the aorta or one of its branches is observed or when there is late enhancement of the arterial wall, on sites which are usually free from atheromatous lesions and in a young patient. The radiologist must be aware of the associated clinical signs: oral and genital ulcerative lesions in the Behçet syndrome; finger necrosis in a young male smoker in Buerger disease; hip and shoulder arthropathy and headache in a 70 Year old female and Horton disease; pulseless upper limbs and inflammatory syndrome in a young adult for the Takayasu arteritis. The diagnosis of popliteal entrapment or adventitial cyst should be proposed in young patients without atheromatous lesions.

Diagnostic imaging in Takayasu arteritis

PURPOSE OF REVIEW

New imaging modalities may help accurately diagnose and monitor Takayasu arteritis (TAK). Examination of the published literature on arterial imaging studies other than conventional angiography will help guide appropriate use of these studies in TAK. MRI, magnetic resonance angiography (MRA), Doppler ultrasound, CT, and positron emission tomography (PET) are all potentially useful for evaluation of TAK.

RECENT FINDINGS

MRI/A avoids the risks of arterial puncture, iodinated contrast load, and radiation exposure, while providing information on arterial wall anatomy and obtaining a generalized arterial survey in TAK. Ultrasound can be helpful in detecting sub-millimeter changes in wall thickness of the carotid arteries and in differentiating TAK from atherosclerotic disease based on minimal plaque content, concentric and long segmental involvement, and location of lesion. Like MRI, CT angiography can be used to detect areas of aortic wall thickening and obtain a generalized survey of the aorta and its proximal branches for areas of stenosis and without the risks associated with arterial puncture. However, CT provides less detailed resolution than ultrasound and incurs the risks of contrast administration. Finally, PET scanning may provide valuable information about cellular activity within an inflamed arterial wall before morphologic changes on other imaging studies.

SUMMARY

Although it is still unclear how often early arterial wall changes lead to stenotic lesions, use of these modalities in combination, for both routine monitoring and evaluation of new symptoms, may facilitate the detection of TAK disease activity at a more treatable stage.

Gadolinium-enhanced Three-dimensional MR Angiography of Takayasu Arteritis

Takayasu arteritis is a form of large vessel vasculitis with a possible autoimmune origin that may cause stenosis of the aorta and its major branches. Six types of Takayasu arteritis are recognized; the type depends on whether the ascending aorta, descending thoracic aorta, abdominal aorta, aortic cervicobrachial branches, or renal arteries are affected. The coronary and pulmonary arteries are also sometimes involved. Clinical features of the disease include diminished or absent pulses, claudication, hypertension, and mesenteric angina. Conventional angiography has been the standard imaging tool for diagnosis and evaluation of Takayasu arteritis, although it demonstrates only the lumen of the vessel. Less invasive cross-sectional methods such as computed tomographic angiography and, more recently, three-dimensional magnetic resonance (MR) angiography can effectively demonstrate thickening of the vessel wall, which may be the earliest manifestation of the disease, occurring before stenosis and dilatation. MR imaging in particular allows better soft-tissue differentiation and can show other signs of inflammation, including mural edema and increased mural vascularity. Other advantages of MR imaging are the lack of iodinated contrast material or ionizing radiation.

Hypertension and Elevated ESR as Diagnostic Features of Takayasu Arteritis in Children

Takayasu arteritis (TA) is an inflammatory disease of the aorta and its branches. Delay in diagnosis is a common problem for adults and children. Although early manifestations are nonspecific (i.e., malaise, fever, anorexia, weight loss, myalgia, arthralgia/arthritis, elevated acute phase reactants), the clinical features that lead to diagnosis often appear suddenly and are related to vascular involvement. Hypertension, which is rare in children, and elevated ESR are found in most patients with TA. The authors hypothesized that these features, then, could be used as way to raise the clinical suspicion of TA. A total of 190 young patients with TA were retrospectively analyzed from local records and the literature to find the signs and symptoms associated with the disease that could be used to educate caregivers about when to suspect TA and to provide a screening tool for the disease. Hypertension and elevated ESR are found in most patients with TA. For this local study group, the sensitivity of this combination was 67%. Including the literature sources for which patient-specific information was available, the overall sensitivity was 65%. Thus, the combination of hypertension and elevated ESR in pediatric patients should merit further screening for TA, particularly in those with systemic complaints. Physical examination should focus on pulse abnormalities. Further evaluation should involve extensive imaging of the vascular system.