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Journal ArticleDOI

Atherosclerosis as a potential pitfall in the diagnosis of giant cell arteritis.

01 Feb 2018-Rheumatology (Rheumatology (Oxford))-Vol. 57, Iss: 2, pp 318-321
TL;DR: A cut-off of TA IMT >0.34 mm in at least two branches is proposed to minimize false positives in a GCA diagnosis and might mimic the halo sign.
Abstract: Objectives To explore whether the increase in the intima-media thickness (IMT) in arteriosclerotic disease correlates with the increase in the IMT in temporal arteries (TAs) and if that could mimic the US GCA halo sign. Methods Consecutive patients ⩾50 years old with high vascular risk and without signs or symptoms of GCA were included. The carotid US IMT measurements were obtained using a standardized software radiofrequency-tracking technology. Colour Doppler US and grey-scale measurements of the IMT in the branches of both TAs were performed by a second sonographer using a 22 MHz probe. Results Forty patients were studied (28 men) with a mean age of 70.6 years. The carotid IMT exhibited significant correlation with the TA IMT. A carotid IMT >0.9 mm was associated with a temporal IMT >0.3 mm. Only one patient had an IMT >0.34 mm in two branches. Conclusions Atherosclerotic disease with a carotid IMT >0.9 mm increases the TA IMT and might mimic the halo sign. As atherosclerosis is common in this age group, we propose a cut-off of TA IMT >0.34 mm in at least two branches to minimize false positives in a GCA diagnosis.
Citations
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Journal ArticleDOI
TL;DR: Questions remain about the best treatment regimens and biomarkers to monitor disease activity and predict flare after discontinuation of treatment, including the tapering of treatment for giant cell arteritis and polymyalgia rheumatica.
Abstract: Giant cell arteritis (GCA) is the most common type of primary vasculitis in Western countries. Polymyalgia rheumatica (PMR) is the second most common inflammatory rheumatic disease of the elderly after rheumatoid arthritis. Glucocorticoids are the cornerstone of treatment for GCA and PMR, which are interrelated diseases. Glucocorticoids are effective, but adverse effects occur in a high proportion of patients. Careful use of glucocorticoids and the application of preventive strategies can minimize these adverse effects. Possible long-term complications of GCA include aneurysm and stenosis of vessels, even in patients with apparently clinically inactive disease; acute blindness is rare during glucocorticoid treatment. In PMR, whether subclinical chronic inflammation can lead to long-term damage is less clear. Management of both GCA and PMR is hampered by the lack of universally accepted definitions of remission and other disease states, such as low disease activity or vessel damage without active disease. In this Review, we outline current evidence on the monitoring and long-term management of patients with GCA and PMR, including the tapering of treatment.

44 citations

Journal ArticleDOI
TL;DR: The percentage of halo signs on the ultrasound of patients without GCA is low, but it does exist, and there are conditions that may also show the halo sign, and one must know these and always correlate the ultrasound findings with the patient's clinic records.
Abstract: Objectives To describe the frequency and causes for the presence of a halo sign on the ultrasound of patients without a diagnosis of GCA. Methods In total, 305 patients with temporal artery colour Doppler ultrasound showing the presence of halo sign (intima-media thickness ≥0.34 mm for temporal arteries [TAs] and ≥1 mm for axillary arteries) were included, and their medical records were reviewed. The clinical diagnosis based on the evolution of the patient over at least one year was established as the definitive diagnosis. Results Fourteen of the 305 (4.6%) patients included showed presence of the halo sign without final diagnosis of GCA: 12 patients in the TAs (86%), and two patients with isolated AAs involvement (14%). Their diagnoses were PMR (n = 4, 29%); atherosclerosis (n = 3, 21%); and non-Hodgkin lymphoma type T, osteomyelitis of the skull base, primary amyloidosis associated with multiple myeloma, granulomatosis with polyangiitis, neurosyphilis, urinary sepsis and narrow-angle glaucoma (n = 1 each, 7%). Conclusion The percentage of halo signs on the ultrasound of patients without GCA is low, but it does exist. There are conditions that may also show the halo sign (true positive halo sign), and we must know these and always correlate the ultrasound findings with the patient's clinic records.

40 citations

Journal ArticleDOI
TL;DR: This is a report on the performance of ultrasound (US), magnetic resonance imaging (MRI), computed tomography (CT), 18F-fluorodeoxyglucose positron emission tomographic (18-FDG-PET), and other emerging imaging techniques in diagnosis, outcome prediction, and monitoring of disease activity.
Abstract: To discuss and summarize the latest evidence on imaging techniques in giant cell arteritis (GCA) and Takayasu arteritis (TAK). This is a report on the performance of ultrasound (US), magnetic resonance imaging (MRI), computed tomography (CT), 18F-fluorodeoxyglucose positron emission tomography (18-FDG-PET), and other emerging imaging techniques in diagnosis, outcome prediction, and monitoring of disease activity. Imaging techniques have gained an important role for diagnosis of large vessel vasculitides (LVV). As signs of vasculitis, US, MRI, and CT show a homogeneous arterial wall thickening, which is mostly concentric. PET displays increased FDG uptake in inflamed artery walls. US is recommended as the initial imaging modality in GCA. MRI and PET/CT may also detect vasculitis of temporal arteries. For TAK, MRI is recommended as the first imaging modality as it provides a good overview without radiation. Extracranial LVV can be confirmed by all four modalities. In addition, MRI and PET/CT provide consistent examination of the aorta and its branches. New techniques such as contrast-enhanced ultrasound, PET/MRI, and auxiliary methods such as “computer-assisted quantitative analysis” have emerged and need to be further validated. Imaging has partly replaced histology for confirming LVV. Provided experience and adequate training, US, MRI, CT, or PET provide excellent diagnostic accuracy. Imaging results need to complement history and clinical examination. Ongoing studies are evaluating the role of imaging for monitoring and outcome measurement.

37 citations

Journal ArticleDOI
TL;DR: The involvement of a large array of arteries is easily and commonly detected by CDS and provides a high diagnostic yield in patients with suspected GCA, and proposed IMT cut-off values might further improve the diagnostic utility of CDS in these patients.
Abstract: Objectives Colour Doppler sonography (CDS) is becoming ever more important in the diagnosis of GCA. Data on cut-off values for intima-media complex thickness (IMT) that can be used in clinical practice to distinguish between normal and inflamed arteries are limited. We aimed to derive potential cut-off values for IMT of seven preselected arteries by comparing IMT between GCA patients and a control group. Methods We performed CDS of the preselected temporal, facial, occipital, carotid, vertebral, subclavian and axillary arteries in consecutive newly diagnosed GCA patients between October 2013 and September 2019. A 'halo' with positive compression sign was considered a positive finding. We measured the maximum IMT in the preselected arteries and compared it with the maximum IMT of the control group. Results We were able to demonstrate a halo sign in at least one of the examined arteries of 244/248 (98.4%) GCA patients. Temporal arteries were the most commonly affected vessels, involved in 192 (77.4%) patients. We found extracranial large vessel involvement in 87 (35.1%) patients. The following cut-off values showed high levels of diagnostic accuracy: ≥0.4 mm for temporal, facial and occipital arteries, ≥0.7 mm for vertebral arteries, and ≥1 mm for carotid, subclavian and axillary arteries. Conclusion The involvement of a large array of arteries is easily and commonly detected by CDS and provides a high diagnostic yield in patients with suspected GCA. Proposed IMT cut-off values might further improve the diagnostic utility of CDS in these patients.

30 citations

Journal ArticleDOI
TL;DR: Giant cell arteritis is a more heterogeneous condition than previously thought and awareness of all the potential clinical manifestations and judicious use of diagnostic tests may be an aid to avoid delayed detection and consequently ominous complications.
Abstract: Giant cell arteritis is a vasculitis of large and middle-sized arteries that affects patients aged over 50 years. It can show a typical clinical picture consisting of cranial manifestations but sometimes nonspecific symptoms and large-vessel involvement prevail. Prompt diagnosis and treatment is essential to avoid irreversible damage. There has been an increasing knowledge on the occurrence of the disease without the typical cranial symptoms and its close relationship and overlap with polymyalgia rheumatica, and this may contribute to reduce the number of underdiagnosed patients. Although temporal artery biopsy is still the gold-standard and temporal artery ultrasonography is being widely used, newer imaging techniques (FDG-PET/TAC, MRI, CT) can be of valuable help to identify giant cell arteritis, in particular in those cases with a predominance of extracranial large-vessel manifestations. Giant cell arteritis is a more heterogeneous condition than previously thought. Awareness of all the potential clinical manifestations and judicious use of diagnostic tests may be an aid to avoid delayed detection and consequently ominous complications.

30 citations

References
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Journal ArticleDOI
TL;DR: This updated consensus document delineates further criteria to distinguish early atherosclerotic plaque formation from thickening of IMT and recommends against serial monitoring in individual patients.
Abstract: Intima-media thickness (IMT) provides a surrogate end point of cardiovascular outcomes in clinical trials evaluating the efficacy of cardiovascular risk factor modification. Carotid artery plaque further adds to the cardiovascular risk assessment. It is defined as a focal structure that encroaches into the arterial lumen of at least 0.5 mm or 50% of the surrounding IMT value or demonstrates a thickness >1.5 mm as measured from the media-adventitia interface to the intima-lumen interface. The scientific basis for use of IMT in clinical trials and practice includes ultrasound physics, technical and disease-related principles as well as best practice on the performance, interpretation and documentation of study results. Comparison of IMT results obtained from epidemiological and interventional studies around the world relies on harmonization on approaches to carotid image acquisition and analysis. This updated consensus document delineates further criteria to distinguish early atherosclerotic plaque formation from thickening of IMT. Standardized methods will foster homogenous data collection and analysis, improve the power of randomized clinical trials incorporating IMT and plaque measurements and facilitate the merging of large databases for meta-analyses. IMT results are applied to individual patients as an integrated assessment of cardiovascular risk factors. However, this document recommends against serial monitoring in individual patients.

1,257 citations

Journal ArticleDOI
TL;DR: In patients with typical clinical signs and a halo on ultrasonography, it may be possible to make a diagnosis of temporal arteritis and begin treatment without performing a temporal-artery biopsy.
Abstract: Background The diagnosis of temporal arteritis usually requires a biopsy of the temporal artery. We examined the usefulness of color duplex ultrasonography in patients suspected of having temporal arteritis. Methods In this prospective study, all patients seen in the departments of rheumatology and ophthalmology from January 1994 to October 1996 who had clinically suspected active temporal arteritis or polymyalgia rheumatica were examined by duplex ultrasonography. The final diagnoses, made according to standard criteria, were temporal arteritis in 30 patients, 21 with biopsy-confirmed disease; polymyalgia rheumatica in 37; and negative histologic findings and a diagnosis other than temporal arteritis or polymyalgia rheumatica in 15. We also studied 30 control patients matched for age and sex to the patients with arteritis. Two ultrasound studies were performed and read before the biopsies; one ultrasonographer was unaware of the clinical information. Results In 22 (73 percent) of the 30 patients with tem...

630 citations

Journal ArticleDOI
TL;DR: The European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) as discussed by the authors were developed by the Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts).
Abstract: European Guidelines on cardiovascular disease prevention in clinical practice (version 2012) : the Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts)

486 citations

Journal ArticleDOI
TL;DR: A comprehensive meta-analysis of available evidence on the diagnostic performance of ultrasonography for giant-cell arteritis found several studies showed that a dark halo around the temporal artery lumen (a sign of arterial wall edema) was specific for giants- cell arteritis.
Abstract: This meta-analysis shows a sensitivity and specificity of 86% when the halo sign or occlusion or stenosis is present. The post-test probability is low if none of these findings are present and the ...

370 citations

Journal ArticleDOI
01 Feb 2012-Heart
TL;DR: In this article, a systematic review of the available evidence on the added predictive performance of imaging markers in terms of discrimination, calibration and (re)classification was conducted, and 25 studies were selected that provided information on added predictive value of FMD, CIMT, carotid plaques, and/or CAC.
Abstract: Context Imaging for subclinical atherosclerosis on top of conventional risk factor assessment may improve risk prediction for the occurrence of cardiovascular disease events in asymptomatic individuals. Objective To systematically review the available evidence on this issue. Data Sources PubMed MEDLINE was systematically searched on 7 September 2011. Study selection Studies were included that evaluated the added value of flow mediated dilation (FMD), carotid intima-media thickness (CIMT), carotid plaques and/or coronary artery calcification (CAC) scoring in the prediction of risk for developing fatal or non-fatal cardiovascular events. Data extraction Data on general study characteristics and the added predictive performance of imaging markers in terms of discrimination, calibration and (re)classification were extracted. Results 25 studies were selected that provided information on added predictive value of FMD (n=2), CIMT (n=12), carotid plaques (n=6) and/or CAC (n=9). Heterogeneity existed across studies in the conventional risk models that were used and in the measurements of the imaging marker. The added predictive value, quantified by the difference in c-index, of FMD, CIMT, carotid plaques or CAC ranged from 0.00 to 0.01 for FMD, from 0.00 to 0.03 for CIMT, from 0.01 to 0.05 for carotid plaque and from 0.05 to 0.13 for CAC. The reported net reclassification improvement (NRI) by the imaging markers ranged from −1.4% to 12% for CIMT, 8% to 11% for carotid plaques, 14% to 25% for CAC and 29% for FMD). Although the definition of intermediate cardiovascular risk varied across studies, the NRI was the highest in those at intermediate cardiovascular risk. Conclusions Published evidence on the added value of atherosclerosis imaging varies across the different markers, with limited evidence for FMD and considerable evidence for CIMT, carotid plaque and CAC. The added predictive value of additional screening may be primarily found in asymptomatic individuals at intermediate cardiovascular risk. Additional research in asymptomatic individuals is needed to quantify the cost effectiveness and impact of imaging for subclinical atherosclerosis on cardiovascular risk factor management and patient outcomes.

350 citations

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