Giant Cell Arteritis Imaging
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Giant cell arteritis is a systemic obliterative vasculitis mainly involving the arteries that originate from the arch of the aorta. However, any vessel in the body can be affected. The inflammation is a necrotizing obliterative vasculitis of large and medium-sized vessels. [1] The superficial temporal, vertebral, ophthalmic, and posterior ciliary arteries are more commonly affected than the internal and external carotid arteries. Intracranial arteries other than those involving the orbits are less commonly affected. Cases involving the proximal distal aorta and the subclavian and abdominal arteries have been reported. The inflammation is segmental, and therefore, skip lesions are seen. [2]
Giant cell arteritis is a disease of elderly persons, the incidence of which increases with increasing age. The mean age of onset is 70 years.
Color Doppler ultrasonography is a method of assessing blood flow qualitatively and quantitatively. In the presence of arteritis, the sonograms show a hypoechoic halo due to edema of the arterial wall. [3] A systematic review and meta-analysis found that, compared with a clinical diagnosis of giant cell arteritis, the ‘halo’ sign at temporal arteries (8 studies, 605 patients) had a pooled sensitivity of 77% (95% CI, 62% to 87%) and specificity of 96% (95% CI, 62% to 87%). [4]
The presence of a halo sign is a criterion used to diagnose giant cell arteritis with color Doppler ultrasonography. However, the sign is not seen in all patients, and it may also be seen in healthy persons. The halo has also been reported in polyarteritis nodosa. Therefore, the criterion standard is the temporal artery biopsy.
The advantages of color Doppler ultrasound are that it is simple, it is noninvasive, and it can be used to examine several vessels, superficial and deep. Another advantage of this technique is that follow-up scans can be obtained to assess the response to steroids. The hypoechoic shadow becomes mid-echoic in about 2 weeks. With fibrosis, the shadow becomes hyperechoic. [5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15]
Other nonradiologic investigations include a determination of the blood sedimentation rate and temporal artery biopsy (see the images below). [16]
CT and MRI are not useful in diagnosing giant cell arteritis; however, they may be used to diagnose complications due to giant cell arteritis, such as stroke.
For patient education information, see Temporal Arteritis.
European League Against Rheumatism (EULAR) guidelines, published in 2018, include the following recommendations on imaging in giant cell arteritis (GCA) [17] :
Overview
What is giant cell arteritis (GCA)?
What is the preferred imaging evaluation for giant cell arteritis (GCA) imaging?
What are the European League Against Rheumatism (EULAR) guidelines for giant cell arteritis imaging?
Devauchelle-Pensec V, Jousse S, Destombe C, Saraux A. Epidemiology, imaging, and treatment of giant cell arteritis. Joint Bone Spine. 2008 Feb 21. [Medline].
Albert DM, Jacobiec FA. Principles and Practice of Ophthalmology. Vol 5. Philadelphia: WB Saunders Co. 2000: 4570-6.
Francois M, Koussa D, Declerck D. [Periarterial temporal halo in the ultrasonographic image of polyarteritis nodosa]. Presse Med. 1999 Jan 23. 28(3):133. [Medline].
Duftner C, Dejaco C, Sepriano A, Falzon L, Schmidt WA, Ramiro S. Imaging in diagnosis, outcome prediction and monitoring of large vessel vasculitis: a systematic literature review and meta-analysis informing the EULAR recommendations. RMD Open. 2018. 4 (1):e000612. [Medline]. [Full Text].
Aloisi D. [Doppler color ultrasonography in the assessment of epiaortic vessels in giant-cell arteritis]. Minerva Cardioangiol. 1999 Dec. 47(12):645-6. [Medline].
Ghanchi FD, Williamson TH, Lim CS, et al. Colour Doppler imaging in giant cell (temporal) arteritis: serial examination and comparison with non-arteritic anterior ischaemic optic neuropathy. Eye. 1996. 10 (Pt 4):459-64. [Medline].
Kraft HE, Moller DE, Volker L, Schmidt WA. [Color Doppler ultrasound of the temporal arteries–a new method for diagnosing temporal arteritis]. Klin Monatsbl Augenheilkd. 1996 Feb. 208(2):93-5. [Medline].
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Schmidt WA, Kraft HE, Borkowski A, Gromnica-Ihle EJ. Color duplex ultrasonography in large-vessel giant cell arteritis. Scand J Rheumatol. 1999. 28(6):374-6. [Medline].
Schmidt WA. Doppler ultrasonography in the diagnosis of giant cell arteritis. Clin Exp Rheumatol. 2000 Jul-Aug. 18(4 Suppl 20):S40-2. [Medline].
Steigerwalt RD Jr, Cesarone MR, Laurora G, et al. Doppler ultrasonography in giant cell arteritis. Int Angiol. 1994 Dec. 13(4):286-9. [Medline].
Ghinoi A, Pipitone N, Nicolini A, Boiardi L, Silingardi M, Germanò G, et al. Large-vessel involvement in recent-onset giant cell arteritis: a case-control colour-Doppler sonography study. Rheumatology (Oxford). 2012 Apr. 51(4):730-4. [Medline].
Diamantopoulos AP, Haugeberg G, Hetland H, Soldal DM, Bie R, Myklebust G. The diagnostic value of color Doppler ultrasonography of temporal arteries and large vessels in giant cell arteritis: A consecutive case series. Arthritis Care Res (Hoboken). 2013 Sep 19. [Medline].
Croft AP, Thompson N, Duddy MJ, Barton C, Khattak F, Mollan SP, et al. Cranial ultrasound for the diagnosis of giant cell arteritis. A retrospective cohort study. J R Coll Physicians Edinb. 2015 Dec. 45 (4):268-72. [Medline].
Germanò G, Macchioni P, Possemato N, Boiardi L, Nicolini A, Massimiliano Casali, et al. Contrast-enhanced ultrasound of the carotid artery in patients with large vessel vasculitis: Correlation with positron emission tomography findings. Arthritis Care Res (Hoboken). 2016 Apr 5. [Medline].
Muratore F, Boiardi L, Cavazza A, Aldigeri R, Pipitone N, Restuccia G, et al. Correlations between histopathological findings and clinical manifestations in biopsy-proven giant cell arteritis. J Autoimmun. 2016 May. 69:94-101. [Medline].
[Guideline] Dejaco C, Ramiro S, Duftner C, Besson FL, Bley TA, Blockmans D, et al. EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice. Ann Rheum Dis. 2018 May. 77 (5):636-643. [Medline]. [Full Text].
Martins N, Polido-Pereira J, Rodrigues AM, Soares F, Batista P, Pereira da Silva JA. The use of the color Doppler ultrasonography in the diagnosis and monitoring of an atypical case of giant-cell arteritis. Acta Reumatol Port. 2015 Nov 16. [Medline].
Luqmani R, Lee E, Singh S, Gillett M, Schmidt WA, Bradburn M, et al. The Role of Ultrasound Compared to Biopsy of Temporal Arteries in the Diagnosis and Treatment of Giant Cell Arteritis (TABUL): a diagnostic accuracy and cost-effectiveness study. Health Technol Assess. 2016 Nov. 20 (90):1-238. [Medline]. [Full Text].
Guruswami Giri, MD, FRCS Vitreo-Retinal Surgeon, Sacramento, CA
Guruswami Giri, MD, FRCS is a member of the following medical societies: American Academy of Ophthalmology, Royal College of Surgeons of Edinburgh, Royal College of Ophthalmologists
Disclosure: Nothing to disclose.
Shanthi Giri, MD Rheumatologist, Kaiser Permanente
Disclosure: Nothing to disclose.
VP Sukumar, MBBS, MD, FRCR Specialist Registrar, Department of Radiology, Oxford Radcliffe Hospitals NHS Trust, UK
VP Sukumar, MBBS, MD, FRCR is a member of the following medical societies: British Institute of Radiology, Royal College of Radiologists
Disclosure: Nothing to disclose.
Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.
Douglas M Coldwell, MD, PhD Professor of Radiology, Director, Division of Vascular and Interventional Radiology, University of Louisville School of Medicine
Douglas M Coldwell, MD, PhD is a member of the following medical societies: American Association for Cancer Research, American Heart Association, SWOG, Special Operations Medical Association, Society of Interventional Radiology, American Physical Society, American College of Radiology, American Roentgen Ray Society
Disclosure: Received consulting fee from Sirtex, Inc. for speaking and teaching; Received honoraria from DFINE, Inc. for consulting.
Kyung J Cho, MD, FACR, FSIR William Martel Emeritus Professor of Radiology (Interventional Radiology), Frankel Cardiovascular Center, University of Michigan Health System
Kyung J Cho, MD, FACR, FSIR is a member of the following medical societies: American College of Radiology, American Heart Association, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America
Disclosure: Nothing to disclose.
Anthony Watkinson, MD Professor of Interventional Radiology, The Peninsula Medical School; Consultant and Senior Lecturer, Department of Radiology, The Royal Devon and Exeter Hospital, UK
Anthony Watkinson, MD is a member of the following medical societies: Radiological Society of North America, Royal College of Radiologists, Royal College of Surgeons of England
Disclosure: Nothing to disclose.
Giant Cell Arteritis Imaging
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