[Anti-IL-5 in severe asthma associated with eosinophilic granulomatosis with polyangiitis. Real-life study]

INTRODUCTION

Eosinophilic granulomatosis with polyangiitis (EGPA) is a form of necrotizing vasculitis affecting small vessels and typically characterized by severe glucocorticoid (GC)-dependent eosinophilic asthma. While mepolizumab, which is indicated at a dose of 100mg/4weeks in severe eosinophilic asthma, has been shown to be an effective treatment for EGPA-related asthma at a dose of 300mg/4weeks, it was only recently approved at this dose.

METHODS

This retrospective, single-center, observational study was conducted to investigate over a 5-year period (2014-2019) the effect of mepolizumab 100mg/4weeks at 12months in patients with EGPA and glucocorticoid-dependant severe asthma. Response to treatment was defined as reduction in daily dose of oral corticosteroids to at most 5mg/day or reduction in annual exacerbation by at least 50%.

RESULTS

Thirty patients were included, of whom twenty-three were treated (two were not fully evaluable). Among the 21 evaluable treated patients, 13 (62%) had responded at 12months. At baseline, non-responders had lower FEV1 levels and lower blood eosinophil levels than responders.

CONCLUSIONS

Mepolizumab at a "severe asthma" dose (100mg/4weeks) is effective in treatment of GC-dependent severe asthma in most patients with EGPA.

Off-label use of biologics for the treatment of refractory and/or relapsing granulomatosis with polyangiitis

OBJECTIVE

To describe the efficacy and safety of off-label use of biologics for refractory and/or relapsing granulomatosis with polyangiitis (GPA).

METHODS

We conducted a French retrospective study including GPA patients who received off-label biologics for refractory and/or relapsing disease after failure of conventional immunosuppressive regimens.

RESULTS

Among 26 patients included, 18 received infliximab (IFX), 2 adalimumab (ADA) and 6 abatacept (ABA). Biologics were initiated in median as 4th-line therapy (IQR 3-6) for relapsing and/or refractory disease in 23 (88%) and/or significant glucocorticoid-dependency in 8 cases (31%). At biologics initiation, median (IQR) BVAS and prednisone dose in anti- TNF-α and ABA recipients were 7 (3-8) and 2 (1-6), and 20 (13-30) mg/day and 20 (15-25) mg/day, respectively. Clinical manifestations requiring biologics were mainly pulmonary and ENT manifestations in 58% each. Anti-TNF-α and ABA were continued for a median duration of 8 months (IQR 6-13) and 11 months (IQR 6-18) respectively. Anti-TNF-α recipients showed remission, partial response and treatment failure in 10%, 30% and 60% at 6 months, and 25%, 20% and 55% at 12 months, respectively. ABA recipients showed remission, partial response and treatment failure in 17%, 33% and 50% at 6 months and 17%, 33% and 50% at 12 months. One patient treated with IFX experienced life-threatening reaction while one patient treated with ABA experienced a severe infection.

CONCLUSION

This real-life study suggests that off-label use of anti-TNF-α and abatacept shows efficacy in less than 50% of refractory and/or relapsing GPA.

[Update on treatments and innovations in systemic auto-immune diseases]

Many new drugs, sometimes promising, are now available to treat systemic auto-immune diseases. Treatment strategies and objectives are different according to each auto-immune disease. Major advances have been obtained in vasculitides treatments. In systemic lupus erythematosus, many drugs have been evaluated, targeting one of the multiple pathogenic mechanisms of the disease. Unfortunately, new drugs remain rare on the market and no major advances have been obtained. In systemic sclerosis, symptomatic treatments improved outcomes but effective drugs targeting all disease manifestations are missing. Autologous hematopoietic stem cell transplantation could be one of the future innovative treatment of systemic sclerosis despite the occurrence of adverse events.

OP0031 AN INCREASE IN SERUM CALPROTECTIN LEVEL IN ANCA-ASSOCIATED VASCULITIDES PATIENTS DURING MAINTENANCE THERAPY IS ASSOCIATED WITH MORE RELAPSE AND ACCELERATED RENAL FUNCTION DECLINE

Background:

Calprotectin (S100A8/A9), a protein secreted by activated neutrophils and monocytes in inflammatory conditions, is upregulated in active ANCA-associated vasculitides. Serum calprotectin level variation during induction therapy is associated with disease relapse in PR3-ANCA-associated vasculitides (1). However, the place of this biomarker during maintenance therapy is unknown.

Objectives:

To demonstrate whether variation in serum calprotectin level during maintenance therapy could be used as a biomarker predicting subsequent relapse in ANCA-associated vasculitides.

Methods:

Patients with ANCA-associated vasculitides in complete remission (BVAS=0) after induction therapy with cyclophosphamide and included in the MAINRITSAN trial (2) were analyzed. Patients were randomized to receive rituximab or azathioprine as maintenance therapy. Relapse was defined as the re-occurrence or new onset of disease attributable to active vasculitis. Accelerated decline renal function (estimated Glomerular Filtration Rate (eGFR) assessed using the MDRD equation) was defined in concordance with NICE 2015 guideline (3) as “a decrease in eGFR of 25% or more and a change in GFR category or a sustained decrease in eGFR of 15 ml/min/1.73m2over 12 months”. Calprotectin was assessed in the serum at inclusion and 6 months by ELISA (IDK® Calprotectin ELISA kit, Immunodiagnostik). We defined an increase in serum levels of calprotectin as a positive variation of calprotectin level at M6 compared to baseline.

Results:

Of all, 96 patients (female 45.8%, mean age 55.3±13.5, 69.8% PR3+, 62.5% ANCA positive at inclusion) had at least a calprotectin dosage (86 at baseline, 86 at M6 and 76 patients at this 2 time-point). Calprotectin level at baseline or 6 months was not significantly different between relapsing patients and those without relapse after 18 months of follow-up, whereas the calprotectin variation at M6 compared to baseline was higher in relapsing patients (n=10) (mean (SD) 17991 (±28972) ng/ml) than in patients not experiencing any relapse (n=66) (9419 (±50002) ng/mL; p=0.03). An increase in serum calprotectin level at 6 months was significantly associated with an increased risk of relapse in PR3-ANCA patients (OR=5.6 (95%CI, 1.0-31.3; p=0,049) but not in the whole study group (OR=3.3 (95%CI, 0.8-14.1; p=0.1), and identified patients with accelerated renal function decline (all cohort: OR=10.6 (95%CI, 2.9-39.6; p=0.002; PR3+ patients: OR=5.909 (95%CI, 2.9-39.6; p=0.01)), whereas calprotectin level did not correlate with glomerular filtration rate (r = -0.07, p=0.35).

Conclusion:

An increase in serum calprotectin during the first 6 months of maintenance therapy in ANCA-associated vasculitides is a useful biomarker predicting vasculitis relapse and accelerated renal function deterioration in the following 12 months.

Increase calprotectin serum at 6 months identify relapser and accelerated decline renal function at 1 year.Kaplan-Meier survival curves of ANCA-associated vasculitis patients with an increase in serum calprotectin at 6 months (solid line) or not (dotted line) remaining total relapse-free or accelerated decline renal function-free. Gehan-Beslow-Wilcoxon test.

References:

[1]Pepper RJ et al. Arthritis Rheumatol. 2017;69(1):185-93.

[2]Guillevin L et al. N Engl J Med. 2014;371(19):1771-80.

[3]NIH. Chronic kidney disease 2014.

Acknowledgments:

Supported by a grant from the Programme Hospitalier de Recherche Clinique, French Ministry of Health (2008-002846-51).

Disclosure of Interests:

Xavier Romand Consultant of: Xavier ROMAND has received honorarium fees from Abbvie, Anais Courtier: None declared, Minh Vu Chuong Nguyen: None declared, Marie-Hélène Paclet: None declared, Philippe Gaudin Speakers bureau: Lilly, Loïc Guillevin: None declared, Benjamin Terrier: None declared, Athan Baillet Consultant of: Athan BAILLET has received honorarium fees from Abbvie for his participation as the coordinator of the systematic literature review

AB0467 REMISSION AND LOW DISEASE ACTIVITY STATE IN PATIENTS WITH GRANULOMATOSIS WITH POLYANGIITIS AND MICROSCOPIC POLYANGIITIS: PREVALENCE AND IMPACT ON DAMAGE ACCRUAL

Background:

Granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) require glucocorticoids (GCs) and immunosuppressants (IS) to induce and maintain remission. At the era of highly active drugs and treat-to-target strategies, defining the goal to achieve in terms of remission could be beneficial for the long-term management.

Objectives:

To assess the impact of prolonged remission or low disease activity state (LDAS) in GPA and MPA patients and its relationship with damage accrual.

Methods:

Patients diagnosed with GPA and MPA, according to ACR criteria and/or Chapel Hill definitions, seen in two vasculitis centers and followed-up for ≥5 years were included. Disease activity was assessed by BVAS, and damage accrual by the VDI. Three levels of remission were defined: complete remission (CR): BVAS=0 and negative ANCA in GCs-free and IS-free patients; clinical remission off therapy: no disease activity and positive ANCA in GCs-free and IS-free patients; clinical remission on therapy: no disease activity in patients with low dose GCs (≤5 mg/d) and/or IS. LDAS was defined as 0<BVAS≤3 without major organ activity, no new disease activity, low-dose GCs (≤7.5 mg/day) and well-tolerated IS. We defined remission or LDAS as prolonged when lasting ≥2 consecutive years. The effect of prolonged remission and LDAS on damage accrual was evaluated.

Table.

Prevalence of vasculitic affection of respective arteries in patients with giant cell arteritis and polymyalgia rheumatica and patients with giant cell arteritis only.

Affected arteryGroupPMR-GCA-group (n=27)GCA-group (n=18)UnilateralBilateralNoneUnilateralBilateralnoneAxillary artery9 (33%)12 (45%)6 (22%)5 (28%)7 (39%)6 (33%)Common superficial temporal artery3 (11%)21 (78%)3 (11%)5 (28%)13 (72%)0 (0%)Frontal branch6 (22%)17 (63%)4 (15%)3 (17%)11 (61%)4 (22%)Parietal branch5 (18%)21 (78%)1 (4%)3 (17%)13 (72%)2 (11%)Facial artery7 (26%)17 (63%)3 (11%)4 (22%)11 (61%)3 (17%)

PMR-GCA-group: patients with diagnosis of giant cell arteritis and consecutive polymyalgia rheumatica

GCA-group: patients with diagnosis of giant cell arteritis only

Results:

167 patients were included: 128 (76.6%) GPA, mean age 51.0±16.7 years. At 5-years, mean VDI was 2.7±2.0, mainly because of AAV-related items (2.0±1.7) rather than treatment-related items (0.7±1.0). During the 5-year follow-up, 10 (6.0%) patients achieved prolonged CR, 6 (3.6%) prolonged clinical remission off therapy, 89 (53.3%) prolonged clinical remission on therapy, 42 (25.1%) prolonged LDAS and 20 (12.0%) never achieved LDAS. Damage accrual at 5-years in patients with prolonged CR, clinical remission off therapy, clinical remission on therapy, LDAS or those never achieved LDAS was 1.6±1.1, 1.8±1.7, 2.3±1.9, 3.8±2.0 and 3.3±2.0, respectively (P<0.0001). Damage was comparable between patients in prolonged remission off therapy and those in remission on therapy (P=0.3). In contrast, patients in prolonged LDAS or those never in LDAS had significantly more damage accrual (P<0.0001 and P=0.01, respectively) than those in prolonged remission off therapy. Eighty-one patients (49%) reached a VDI ≥3 at 5-years. The inability to achieve prolonged remission was associated with a VDI ≥3 at 5-years (OR 5.07, 95% CI 2.53-9.84, P<0.0001), and considering only prolonged CR or clinical remission off therapy did not had any benefit on damage accrual. In contrast, achieving prolonged LDAS had no benefit compared to spending no time in LDAS (P>0.99). Compared to patients achieving prolonged remission, those not able to achieve prolonged remission were younger (46±16.0 vs. 53.5±16.6, P=0.001), had more frequent GPA (P=0.0003), had more PR3-ANCA (P=0.006), had more ENT and lung involvement (P<0.0001 and P=0.036, respectively).

Conclusion:

Sixty percent of GPA and MPA patients achieved prolonged remission, which was associated with a better outcome in terms of damage accrual. In contrast, prolonged LDAS was associated with increased damage and was not a sufficient target to achieve in GPA and MPA.

Disclosure of Interests: :

None declared

OP0030 GRANULOMATOSIS WITH POLYANGIITIS SUSTAINED REMISSION OFF-THERAPY: DATA FROM THE FRENCH VASCULITIS STUDY GROUP REGISTRY

Background:

Data on granulomatosis with polyangiitis (GPA) sustained remission off-therapy (SROT) are limited and it is unknown whether disease characteristics or treatment regimen may affect it.

Objectives:

This study aimed to assess SROT of GPA patients from the French Vasculitis Study Group registry, and identify factors associated with its occurrence and durability during follow-up.

Methods:

GPA had to satisfy the 1990 ACR classification criteria and/or revised Chapel Hill Nomenclature for study inclusion. SROT was defined as remission (BVAS=0) without glucocorticoids (GC) or immunosuppressants (IS), the latter for ≥6 months (ie 2 consecutive visits). SROT and its duration were extracted from the database. Data from patients with 3-, 5- and 10-year SROT were analyzed. Baseline characteristics of patients with 3-year GPA SROT were compared to those of registry GPA patients with available data at 3 years but not in SROT (controls), and 3-year SROT achieving 5-year SROT vs those who relapsed between 3 & 5 years. Patients with 3-year GPA SROT follow-up +7 years were analyzed according to maintained SROT or not.

Results:

Among 795 database patients with new-onset GPA, 259 achieved at least 1 SROT at some time during their disease, after a median [IQR] of 36 [28–63] months post-diagnosis. The first SROT lasted a median of 14 [I8-32] months. Among 202 of those patients who had follow-up, 73 (36%) remained in SROT for a median follow-up of 34 [14-45] months post-SROT. Among 434 (54%) patients followed for ≥3 years post-diagnosis, 82% had received GC and cyclophosphamide induction therapy. At 3 years post-diagnosis, 92 (21%) patients in SROT were compared to 342 (79%) controls who had relapsed or were still taking GC or IS. Patients achieving 3-year SROT vs controls, respectively, had more frequently received intravenous cyclophosphamide as induction therapy (89% vs 77%, P=0.01), with a higher median number of infusions (7.5 vs 6; P=0.05); no other clinical or biological baseline difference was found. Among those 92 3-year SROT patients, 74 had ≥2 years of additional follow-up: 46 (62%) attained 5-year SROT and 28 (38%) had relapsed after a mean follow-up of 13 months. Baseline clinical and biological characteristics of patients achieving 5-year SROT did not differ from those of 3-year SROT patients who relapsed. Among those 92 3-year SROT patients, 16 had ≥7 additional years of follow-up: 6 (38%) achieved 10-year SROT, ie 8% of 75 GPA with available data at 10 years, and 10 (63%) had relapsed a mean 35 ± 28 months after achieving 3-year SROT.

Conclusion:

Only 8% of GPA patients achieved 10-year SROT after conventional induction and maintenance therapies. No baseline clinical or biological characteristics helped distinguish patients achieving or maintaining SROT and those who relapsed. However, patients achieving 3-year SROT had received more intensive induction therapy than those who relapsed or were still on GC or IS at 3 years.

Disclosure of Interests:

None declared

Nevirapine Use Is Associated with Higher Bone Mineral Density in HIV-1 Positive Subjects on Long-Term Antiretroviral Therapy

We assessed bone mineral density (BMD) in a cohort of human immunodeficiency virus (HIV)-positive patients after a median of 11 years of combination antiretroviral therapy (cART) and evaluated the respective role of HIV infection and antiretroviral drugs (ARVs). A cross-sectional study of 162 participants (131 male) from the ANRS-C08 cohort was performed with bone dual-energy X-ray absorptiometry (DXA) scans and renal assessment. The window of exposure to ARVs was defined as an exposure of more than six cumulative months during the last 3 years before the DXA evaluation to account for a cumulative exposure that could affect bone remodeling. The association with low BMD (Z-score < -2) was assessed by a multiple logistic regression model. The study population was 50 years (median), hepatitis C virus (HCV) (18%), and hepatitis B virus (HBV) (8%) coinfection with HIV-RNA <50 c/mL in 89%, median CD4 of 619/mm³. Prevalence of low BMD was 18% in males and 6% in females. The factors associated with a Z-score < -2 in males were uric acid renal loss [adjusted odds ratio (aOR): 6.1; 95% confidence interval (CI): 1.2-31.5; p = .03], HCV coinfection (aOR: 4.0; 95% CI: 1.3-12.2; p = .02), and less frequent window of exposure to nevirapine (NVP) (aOR: 0.1; 95% CI: 0.02-0.6; p = .01). For the full study sample, there was a strong positive association between duration of exposure to NVP and lumbar spine Z-score (p = .004). HIV-positive patients exposed to long-term cART have a high incidence of low BMD. Tenofovir disoproxil fumarate and ritonavir-boosted protease inhibitors did not seem to be associated with increased risk of low BMD, whereas NVP exposure appeared to have an independent positive association.

Combined pulmonary fibrosis and emphysema in systemic sclerosis: A syndrome associated with heavy morbidity and mortality

BACKGROUND

The syndrome of combined pulmonary fibrosis and emphysema (CPFE) primarily due to tobacco smoking has been reported in connective tissue disease, but little is known about its characteristics in systemic sclerosis (SSc).

METHODS

In this retrospective multi-center case-control study, we identified 36 SSc patients with CPFE, and compared them with 72 SSc controls with interstitial lung disease (ILD) without emphysema.

RESULTS

Rate of CPFE in SSc patients with CT scan was 3.6%, and 7.6% among SSc patients with ILD. CPFE-SSc patients were more likely to be male (75 % vs 18%, p < 0.0001), smokers (83 % vs 33%, p < 0.0001), and to have limited cutaneous SSc (53 % vs 24% p < 0.01) than ILD-SSc controls. No specific autoantibody was significantly associated with CPFE. At diagnosis, CPFE-SSc patients had a greater decrease in carbon monoxide diffusing capacity (DLCO 39 ± 13 % vs 51 ± 12% of predicted value, p < 0.0001) when compared to SSc-ILD controls, whereas lung volumes (total lung capacity and forced vital capacity) were similar. During follow-up, CPFE-SSc patients more frequently developed precapillary pulmonary hypertension (PH) (44 % vs 11%, p < 10^-4), experienced more frequent unscheduled hospitalizations (50 % vs 25%, p < 0.01), and had decreased survival (p < 0.02 by Kaplan-Meier survival analysis) as compared to ILD-SSc controls.

CONCLUSIONS

The CPFE syndrome is a distinct pulmonary manifestation in SSc, with higher morbidity and mortality. Early diagnosis of CPFE by chest CT in SSc patients (especially smokers) may result in earlier smoking cessation, screening for PH, and appropriate management.

IgG Binding to Endothelial Cells in Systemic Lupus Erythematosus

Endothelial-asSociated IgG were determined in 20 patients with systemic lupus erythematosis (SLE) - 8 of whom had a lupus anticoagulant (LA) and 6 a history of thrombosis. The binding of IgG present in patient plasma to cultured human endothelial cells was detected using radiolabeled staphylococcal protein A. Thirteen samples gave positive results and a significant association between endothelial-associated IgG and lupus anticoagulant was found (p <0.05). No statistically significant relationship with a previous history of thrombosis was found. These results suggest that the lupus anticoagulant may be directly involved in immune vascular injury induced by either antibodies or immune complexes in SLE.

Pharmacokinetics of Paracetamol, Diclofenac and Vidarabine during Plasma Exchange

In order to establish guidelines for prescribing drugs in patients treated with plasma exchange (PE), we studied the pharmacokinetics of paracetamol (5 patients), diclofenac (4 patients) and vidarabine (3 patients) during one or several PE. Results were compared with those obtained without PE. Diclofenac and paracetamol were choosen because they presented different volume distribution and protein binding characteristics. Vidarabine was studied because we use it for the treatment of patients with polyarteritis nodosa related to hepatitis B virus.

Diclofenac (100 mg) and paracetamol (1000 mg) were given 1 hour before PE. Samples were obtained 60 and 30 min before PE, every 15 min during PE and hourly for 2 hours after the end of PE. Vidarabine was given in continuous infusion, 15 mg/kg/d during the first week of treatment and 7.5 mg/kg/d during subsequent weeks. Samples were obtained before PE, 3 times during PE and every 30 min for 4 hours after the end of PE. Paracetamol, diclofenac, vidarabine and hypoxanthine arabinoside were assayed by high performance liquid chromatography. During each PE 60 ml/kg were removed and replaced by albumin.

We found that 17% of diclofenac, 4.3% of paracetamol and 4.9% of vidarabine were removed during each session. Plasmapheresis clearance was 51% of plasma clearance for diclofenac, 15% for paracetamol and 10% for vidarabine.

Drugs which are mainly removed during PE are those which are bound to proteins with a small distribution volume. Those drugs, such as diclofenac, must be administered after the end of each PE session. Drugs which present a large distribution volume and low protein binding can be given before the session. Vidarabine can be administered during PE without loss of effectiveness due to drug removal.

Treatment of Progressive Systemic Sclerosis by Plasma Exchange: Long-term Results in 40 Patients

The efficacy of plasma exchanges (PE) during the course of scleroderma has only been investigated for short periods. The aim of this study was to follow patients over a long enough period to observe the course of the clinical and paraclinical symptoms in the short, medium, and long term. Forty patients, 24 women and 16 men, were treated by PE and observed for 1–3, 3–12 and over 12 months. Immunological, biological and clinical course and any undesirable side effects were evaluated using a detailed questionnaire. Concomitant therapies were reported and most frequently consisted of corticosteroids, colchicine, factor XIII or vasodilators (nifedipine, captopril). The therapeutic effectiveness of PE was assessed on the basis of improvements in cutaneous, digestive, joint, muscular, lung, cardiovascular and renal lesions. Our findings confirmed the effectiveness of short-term PE on scleroderma (52% of the patients improved during the first 3 months). However, this improvement was transient (5% improvement between 3 and 12 months and only 2.5% over 12 months) and limited to the cutaneous and muscular lesions. Thus, PE cannot be recommended for the treatment of progressive systemic sclerosis.

Treatment of Progressive Systemic Sclerosis with Plasma Exchange. Seven Cases

Seven patients, 4 women and 3 men afflicted with severe progressive systemic sclerosis (PSS) were treated with Plasma Exchange after failure of different other treatment. All patients presented Raynaud phenomenon and arthritis, 6 patients presented extensive skin lesions, 5 of them digestive manifestations, 3 pulmonary fibrosis. In one case PSS was associated with polymyositis, one patient presented bilateral recurrent cornea ulcerations, (Sjögren Syndrom) and one patient numerous skin ulcerations. In 5 patients adjuvant corticosteroid therapy was given during the course of PE.

In 3 patients PE must be stopped after one or two sessions because of insufficient venous access.

Among the 4 other patients 8 to 20 PE were performed: the patient with cornea ulcerations became blind during the treatment, skin ulcerations and severe Raynaud phenomenon did not improved in two other patients. Benefit of PE was noted in only one patient with regressive myositis, and improvement of articular and cutaneous symptoms.

Therefore, PE are not useful in most patients afflicted with PSS, they are difficult to realize in numerous patients and did not improve clinical symptoms in most cases.

Concordance of Time-of-Flight MRA and Digital Subtraction Angiography in Adult Primary Central Nervous System Vasculitis

BACKGROUND AND PURPOSE

3D-TOF-MRA and DSA are 2 available tools to demonstrate neurovascular involvement in primary central nervous system vasculitis. We aimed to compare the diagnostic concordance of vessel imaging using 3D-TOF-MRA and DSA in patients with primary central nervous system vasculitis.

MATERIALS AND METHODS

We retrospectively identified all patients included in the French primary central nervous system vasculitis cohort of 85 patients who underwent, at baseline, both intracranial 3D-TOF-MRA and DSA in an interval of no more than 2 weeks and before treatment initiation. Two neuroradiologists independently reviewed all 3D-TOF-MRA and DSA imaging. Brain vasculature was divided into 25 arterial segments. Concordance between 3D-TOF-MRA and DSA for the identification of arterial stenosis was assessed by the Cohen κ Index.

RESULTS

Thirty-one patients met the inclusion criteria, including 20 imaged with a 1.5T MR unit and 11 with a 3T MR unit. Among the 25 patients (81%) with abnormal DSA findings, 24 demonstrated abnormal 3D-TOF-MRA findings, whereas all 6 remaining patients with normal DSA findings had normal 3D-TOF-MRA findings. In the per-segment analysis, concordance between 1.5T 3D-TOF-MRA and DSA was 0.82 (95% CI, 0.75-0.93), and between 3T 3D-TOF-MRA and DSA, it was 0.87 (95% CI, 0.78-0.91).

CONCLUSIONS

3D-TOF-MRA shows a high concordance with DSA in diagnostic performance when analyzing brain vasculature in patients with primary central nervous system vasculitis. In patients with negative 3T 3D-TOF-MRA findings, the added diagnostic value of DSA is limited.