Use of imaging techniques in large vessel vasculitis and related conditions
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Abstract:
Giant cell arteritis (GCA) and Takayasu's arteritis (TA) are large vessel vasculitis (LVV) primarily affecting the aorta and its major branches, mainly differentiated by the onset age (>50 years GCA and <40 years TA). In addition, temporal artery involvement and polymyalgia rheumatica are typical features of GCA, but not TA. Imaging techniques are required to secure the diagnosis of large-vessel vasculitides, and to monitor the disease course. Both morphological and metabolic imaging are involved. Morphological imaging is represented mainly by computerized tomography (CT), CT angiography, magnetic resonance (MR), MR angiography, color-Doppler sonography (CDS) and high-resolution CDS. Metabolic aspects of inflammatory process in LVV can be well studied by positron emission tomography/computed tomography with [18F]deoxyglucose ([18F]FDG PET/CT). It has an important increasing role in diagnosis, extent assessment and disease activity and therapy response evaluation. In the near future the concomitant development of increasingly powerful PET/CT scanners, of new radiopharmaceuticals more specific for inflammation, and of new PET/MRI hybrid scanners probably will lead to a further new step forward in the diagnosis and clinical management of LVV.Keywords:
Polymyalgia rheumatica
Arteritis
Magnetic resonance angiography
Takayasu's arteritis
Giant cell arteritis (GCA) and Takayasu's arteritis (TA) are large vessel vasculitis (LVV) primarily affecting the aorta and its major branches, mainly differentiated by the onset age (>50 years GCA and <40 years TA). In addition, temporal artery involvement and polymyalgia rheumatica are typical features of GCA, but not TA. Imaging techniques are required to secure the diagnosis of large-vessel vasculitides, and to monitor the disease course. Both morphological and metabolic imaging are involved. Morphological imaging is represented mainly by computerized tomography (CT), CT angiography, magnetic resonance (MR), MR angiography, color-Doppler sonography (CDS) and high-resolution CDS. Metabolic aspects of inflammatory process in LVV can be well studied by positron emission tomography/computed tomography with [18F]deoxyglucose ([18F]FDG PET/CT). It has an important increasing role in diagnosis, extent assessment and disease activity and therapy response evaluation. In the near future the concomitant development of increasingly powerful PET/CT scanners, of new radiopharmaceuticals more specific for inflammation, and of new PET/MRI hybrid scanners probably will lead to a further new step forward in the diagnosis and clinical management of LVV.
Polymyalgia rheumatica
Arteritis
Magnetic resonance angiography
Takayasu's arteritis
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Polymyalgia rheumatica
Takayasu's arteritis
Arteritis
Takayasu Arteritis
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Polymyalgia rheumatica
Arteritis
Duplex ultrasonography
Tenosynovitis
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F-18 fluoro-2-deoxyglucose (F-18 FDG) positron emission tomography with computed tomography (PET/CT) is increasingly being used in the diagnosis of inflammatory disorders. We present a case of giant cell arteritis and polymyalgia rheumatica in a 64-year-old woman, identified on F-18 FDG PET/CT scanning during workup for an unknown primary tumor. This case highlights the importance of metabolic imaging in the assessment of extent and activity of large vessel vasculitis and related conditions.
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Arteritis
Aortitis
PET-CT
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Polymyalgia rheumatica
Takayasu's arteritis
Arteritis
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Polymyalgia rheumatica
Arteritis
Takayasu's arteritis
Constitutional symptoms
Aortitis
Anorexia
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Systemic vasculitis is a group of diseases with complex manifestations. The diagnose and disease activities evaluation is very difficult,especially in those without typical clinical signs. Positron emission tomographycomputed tomography could be used for early diagnosis of active large vessel vasculitis such as giant cell arteritispolymyalgia rheumatica and Takayasu arteritis,with a high sensitivity and specificity,and is more reliable than other imaging methods. It is also important that differential diagnosis should be performed for other vascular diseases. More studies are needed to assess the application of PETCT in disease activity evaluation of systemic vasculitis.
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Background
Giant cell arteritis (GCA) is a large vessel vasculitis with a predisposition for the cranial branches of the external carotid artery. However, aorta and/or its main branches may also be involved.Objectives
In a series of patients with GCA who presented extracranial vessel involvement, our aim was to assess a) the vascular territories most frequently affected and b) correlation of a major extension of extracranial vascular involvement with a more severe clinical and analytical features.Methods
Multicenter study of 68 patients with GCA who presented a compromise of extracranial vessels confirmed by PET/CT. Visual analysis of vascular uptake was performed on supra-aortic trunks (SAT), aortic arch (AA), thoracic aorta (TA), abdominal aorta (AbA), iliac arteries (IA), lower limb arteries (LLA), and upper limb arteries (ULA).Results
We evaluated 68 patients with GCA (51w/17m) with a mean age of 68.0±8.3 years. The vascular territories affected were: TA (n=58, 85.29%), SAT (n=38, 55.88%), AbA (n=28, 41.18%), AA (n=18, 26.47%), LLA (n=17, 25%), IA (n=13, 19.12%) and ULA (n=6, 8.82%). We considered 3 groups according to the number of vascular territories affected: a) 1 or 2 territories, b) 3 or 4 territories and c) 5 or more territories and made a comparative study between this groups. In patients with ≥5 vascular territories affected, we observed a higher baseline ESR, and the most frequent systemic manifestations were polymyalgia rheumatica and constitutional symptoms with statistical significance (TABLE). Distribution of categorical variables was compared by the Pearson Chi-squared test. Quantitative variables were analyzed using the ANOVA test.Conclusion
In patients with GCA the involvement of TA is very frequent, followed by the SAT and the AbA. Regarding the laboratory findings, patients with higher levels of ESR presented a major extension of extracranial vascular involvement, as well as presenting PMR and/or constitutional symptoms was also related to more affection of extracranial territories.References
[1] Loricera J, Blanco R, Hernaández JL, et al. Use of positron emission tomography (PET) for the diagnosis of large-vessel vasculitis. Rev Esp Med Nucl Imagen Mol. 2015; 34: 372-377. [2] Loricera J, Blanco R, Hernaández JL, et al. Non-infectious aortitis: a report of 32 cases from a single tertiary centre in a 4-year period and literature review. Clin Exp Rheumatol. 2015; 33: S19-31.Disclosure of Interests
Monica Calderón-Goercke: None declared, J. Loricera: None declared, D. Prieto-Peña: None declared, J. Narváez Consultant for: Bristol-Myers Squibb, Santos Castañeda Consultant for: Amgen, BMS, Pfizer, Lilly, MSD, Roche, Sanofi, UCB, Elena Aurrecoechea: None declared, Ignacio Villa-Blanco: None declared, Catalina Gomez-Arango: None declared, Eva Perez-Pampín: None declared, Vicente Aldasoro: None declared, Noelia Alvarez-Rivas: None declared, Nagore Fernández-Llanio: None declared, María Álvarez del Buergo: None declared, Luisa Marena Rojas: None declared, Francisca Sivera: None declared, Eva Galindez: None declared, Roser Solans-Laqué: None declared, Susana Romero-Yuste: None declared, Norberto Ortego: None declared, Marcelino Revenga: None declared, Rafael Melero: None declared, Eva Salgado-Pérez: None declared, Sabela Fernández: None declared, Vanesa Calvo-Río: None declared, Natalia Palmou-Fontana: None declared, Jose Ignacio Banzo: None declared, Isabel Martínez-Rodríguez: None declared, Carmen González-Vela: None declared, Raquel Dos-Santos: None declared, J. Luis Hernández: None declared, Miguel A González-Gay Grant/research support from: Prof. MA Gonzalez-Gay received grants/research supports from Abbvie, MSD, Jansen and Roche., Speakers bureau: Consultation fees/participation in company sponsored speaker's bureau from Pfizer, Lilly, Sobi, Celgene, Novartis, Roche and Sanofi., Ricardo Blanco Grant/research support from: Abbvie, MSD, and Roche, Consultant for: Abbvie, Pfizer, Roche, Bristol-Myers, Janssen, Speakers bureau: Abbvie, Pfizer, Roche, Bristol-Myers, JanssenArteritis
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To determine whether giant cell (temporal) arteritis (GCA) can be differentiated from Takayasu's arteritis on the basis of clinical findings.A comparative study contrasting 217 patients with GCA to 63 patients with Takayasu's arteritis was conducted, using the prospectively gathered large multicenter data set of the American College of Rheumatology Vasculitis Criteria Databank. Logistic regression and recursive partitioning were used to assess the capability of a variety of variables to separate these 2 vasculitic disorders.Age of 40 years at onset of disease was the most discriminatory single variable. Excluding age at onset, ethnic background and a combination of clinical signs indicating upper limb vascular impairment, shoulder stiffness, and tender scalp led to correct classifications of 95% in both GCA and Takayasu's arteritis. Vascular insufficiency of the upper extremities, a key feature of Takayasu's arteritis, was noted in 15% of patients with GCA, although to a lesser degree.Although similar in many respects, GCA and Takayasu's arteritis were easily definable and separable disorders, even when the typical age barrier of 40 years at onset of disease was excluded. These findings strengthen the concept that they are distinct disease entities.
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Background: Angiography is essential to detect vascular disease in patients with large-vessel vasculitis (LVV). Guidelines differ on the role of periodic angiography to monitor patients with LVV, in part because there is limited prospective data characterizing the natural history of angiographic disease. Development of new areas of arterial damage, even in periods of apparent clinical remission, has been reported in LVV; however, whether this is a common or rare phenomenon is unknown. Objectives: To characterize angiographic progression of disease over time in Takayasu’s arteritis (TAK) compared to giant cell arteritis (GCA). Methods: Patients with GCA or TAK were recruited into a prospective, observational cohort. Patients fulfilled the 1990 American College of Rheumatology (ACR) Classification Criteria for TAK or modified 1990 ACR Criteria for GCA. All patients underwent baseline magnetic resonance angiography (MRA) and a follow-up MRA at least one year after baseline per a standardized imaging protocol. The presence of angiographic lesions, defined as stenosis, occlusion, or aneurysm, was evaluated by visual inspection by a single reader who was blinded to clinical status. Angiographic lesions were evaluated in 4 segments of the aorta and in 13 branch arteries. On follow up angiography, the development of new lesions was recorded, and existing lesions were characterized as improved, worsened, or unchanged. Results: 782 arterial territories were evaluated from 46 patients with LVV (TAK=28; GCA=18). Baseline characteristics were as follows: Age [TAK=24.8 years (18.6-34.9), GCA=64.8 years (57.8-73.9)], Female gender [TAK=21 patients (78%), GCA=16 patients (84%)], Disease duration [TAK=2.3 years (0.6-4.9), GCA 1.2 years (0.4-2.9)], Active clinical disease [TAK=12 patients (44%), GCA 12 patients (63%)]. The median time from initial MRA to follow up MRA was 2.4 years (1.5-3.1) for GCA and 1.6 years (1.3-3.3) for TAK. There were 159 territories affected at the baseline visit in 41 patients [TAK: 108 territories in 26 patients, GCA: 51 territories in 15 patients]. The development of new territory involvement was infrequent and only occurred in patients with TAK (8 new lesions out of 352 baseline unaffected territories (2.3%) in 5 patients). At follow up, existing arterial lesions improved in 25 (15.7%) territories, worsened in 6 (3.8%) territories, and stayed the same in 128 (80.5%) territories. There were no significant differences in angiographic progression of disease between the two diseases: improved - TAK 19 (17.6%), GCA 6 (11.8%); worsened - TAK 5 (4.6%), GCA 1 (1.9%); unchanged - TAK 84 (77.8%), GCA 44 (86.3%). Change in the branch arteries was more dynamic than change in the aorta (Figure). Improvement in angiographic disease was observed in 8 (17%) patients (TAK=6, GCA=2). Worsening of disease was seen in 3 (7%) patients (TAK=2, GCA=1). In 5 (11%) patients (TAK=5, GCA=0), there were areas of improvement and other areas of worsening disease within the same patient. Conclusion: Dynamic change in arterial lesions is observed in patients with TAK and GCA. Improvement and worsening of arterial lesions can be observed over time, even within the same patient. This observation suggests that both local factors at the level of the artery and systemic factors (e.g. treatment response) are likely associated with angiographic progression. The development of new angiographic lesions was infrequent, and only occurred in patients with TAK. These data may inform future guideline recommendations for angiographic monitoring in LVV. References: N/A Figure. Disclosure of Interests: None declared
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Polymyalgia rheumatica
Magnetic resonance angiography
Takayasu's arteritis
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