European League Against Rheumatisms Recommendations for the Use of Imaging in Large Vessel Vasculitis in Clinical Practice

Christian Dejaco¹, Sofia Ramiro², Christina Duftner³, Florent L. Besson⁴, Thorsten Bley⁵, Daniel Blockmans⁶, Elisabeth Brouwer⁷, Marco A. Cimmino⁸, Eric Clark⁹, Bhaskar Dasgupta¹⁰, Andreas P Diamantopoulos¹¹, Haner Direskeneli¹², Annamaria Iagnocco¹³, Thorsten Klink⁵, Lorna Neill¹⁴, Cristina Ponte¹⁵, Carlo Salvarani¹⁶, Riemer Slart¹⁷, Madeline Whitlock¹⁸ and Wolfgang A. Schmidt¹⁹, ¹Rheumatology, Hospital of Bruneck, Bruneck, Italy, ²Rheumatology, Department of Rheumatology, LUMC, Leiden, Netherlands, Leiden, Netherlands, ³Department of Internal Medicine, Clinical Division of Internal Medicine II, Medical University Innsbruck, Innsbruck, Austria, ⁴Department of Nuclear Medicine, CHU Bicêtre, AP-HP, Université Paris-Sud, Paris, France, ⁵University of Würzburg, Würzburg, Germany, ⁶General Internal Medicine, University Hospital Gasthuisberg, Leuven, Belgium, ⁷Rheumatology and Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands, ⁸Research Laboratory and Academic Unit of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy, ⁹PMRGCAuk, London, United Kingdom, ¹⁰Rheumatology, Southend University Hospital NHS Foundation Trust, Southend, UK, Westcliff-on-Sea, United Kingdom, ¹¹Rheumatology, Martina Hansens Hospital, Bærum, Oslo, Norway, ¹²Departement of İnternal Medicine, Division of Rheumatology, Marmara University, Istanbul, Turkey, ¹³Academic Rheumatology Unit, Università degli Studi di Torino, Torino, Italy, ¹⁴PMRGCAuk, Dundee, United Kingdom, ¹⁵Instituto de Medicina Molecular (IMM), Rheumatology Research Unit, Lisbon, Portugal, ¹⁶Rheumatology Unit, Arcispedale Santa Maria Nuova - IRCCS; Università di Modena e Reggio Emilia, Reggio-Emilia, Italy, ¹⁷University of Groningen, Enschede, Netherlands, ¹⁸Southend University Hospital, Southend, United Kingdom, ¹⁹Medical Center for Rheumatology and Clinical Immunology Berlin-Buch, Immanuel Krankenhaus Berlin, Berlin, Germany

Meeting: 2017 ACR/ARHP Annual Meeting

Date of first publication: September 18, 2017

Keywords: Computed tomography (CT), giant cell arteritis, Magnetic resonance imaging (MRI), positron emission tomography (PET) and ultrasound

Session Information

Date: Sunday, November 5, 2017

Title: Vasculitis Poster I: Large Vessel Vasculitis

Session Type: ACR Poster Session A

Session Time: 9:00AM-11:00AM

Background/Purpose: Modern imaging modalities including ultrasound, magnetic resonance imaging (MRI), computed tomography (CT) and ¹⁸F-FDG positron emission tomography (PET/CT) have been increasingly used in primary large vessel vasculitis (LVV) including giant cell arteritis (GCA) and Takayasu arteritis (TAK). However, there is still significant controversy and uncertainty about when to use which imaging technique, and whether imaging might be helpful during follow-up to assess disease activity and damage. We aimed to develop EULAR recommendations for the use of imaging modalities in LVV in clinical practice.

Methods: The EULAR Standardised Operating Procedures have been followed. A systematic literature review was conducted to retrieve data on the role of imaging in LVV. Based on evidence and expert opinion, the task force consisting of 20 experts (physicians, a health care professional and patients) from 12 EULAR countries developed recommendations, with consensus obtained through informal voting. The final level of agreement was voted anonymously.

Results: A total of 12 recommendations have been formulated (Table). The task force recommends an early imaging test in patients with suspected LVV, assuming high expertise and prompt availability of the imaging technique. Ultrasound has been suggested as the first choice imaging modality in GCA, because of a good performance of the test, easy access, absence of radiation and other procedural risks, and low resource use. MRI, and in case of predominant large vessel (LV)-GCA, PET and CT, might be alternatives to ultrasound. For TAK, MRI is the preferred imaging modality, because of the absence of radiation exposure and the possibility to assess simultaneously the vessel wall and luminal changes of the aorta and its proximal branches. PET, CT and ultrasound can be used as alternatives.

In patients with a suspected flare of LVV, imaging might be helpful to assess disease activity. The frequency and choice of imaging modalities for long-term monitoring of structural damage remains an individual based decision. All imaging should be performed by a trained specialist using appropriate equipment, operational procedures and settings.

Conclusion: These are the first EULAR recommendations providing up-to-date guidance on the role of imaging in the diagnosis and monitoring of patients with (suspected) LVV.

Statement	LoE	LoA
1. In patients with suspected GCA, an early imaging test is recommended to complement the clinical criteria for diagnosing GCA, assuming high expertise and prompt availability of the imaging technique. Imaging should not delay initiation of treatment.	1	9.2 (2.1) 90% ≥8
2. In patients in whom there is a high clinical suspicion of GCA and a positive imaging test, the diagnosis of GCA may be made without an additional test (biopsy or further imaging). In patients with a low clinical probability and a negative imaging result, the diagnosis of GCA can be considered unlikely. In all other situations, additional efforts towards a diagnosis are necessary.	2	9.4 (1.0) 90% ≥8
3. US of temporal ± axillary arteries is recommended as the first imaging modality in patients with suspected predominantly cranial GCA*. A non-compressible ’halo’ sign is the US finding most suggestive of GCA.	1	9.7 (0.6) 100% ≥8
4. High resolution MRI of cranial arteriesǂ to investigate mural inflammation may be used as an alternative for GCA diagnosis if US is not available or inconclusive.	2	9.2 (1.1) 90% ≥8
5. CT and PET are not recommended for the assessment of inflammation of cranial arteries.	5	9.5 (1.2) 95% ≥8
6. US, PET, MRI and/or CT may be used for detection of mural inflammation and/or luminal changes in extracranial arteries to support the diagnosis of LV-GCA. US is of limited value for assessment of aortitis.	3 (PET, CT) -5 (US, MRI)	9.8 (0.6) 100% ≥8
7. In patients with suspected TAK, MRI to investigate mural inflammation and/or luminal changes should be used as the first imaging test to make a diagnosis of TAK, assuming high expertise and prompt availability of the technique.	3	9.1 (1.4) 90% ≥8
8. PET, CT and/or US may be used as alternative imaging modalities in patients with suspected TAK. US is of limited value for assessment of the thoracic aorta.	3 (CT) – 5 (PET, US)	9.4 (0.8) 100% ≥8
9. Conventional angiography is not recommended for the diagnosis of GCA or TAK as it has been superseded by the previously mentioned imaging modalities.	5	9.8 (0.6) 100% ≥8
10. In patients with LVV (GCA or TAK) in whom a flare is suspected, imaging might be helpful to confirm or exclude it. Imaging is not routinely recommended for patients in clinical and biochemical remission.	5	9.4 (0.8) 100% ≥8
11. In patients with LVV (GCA or TAK), MRA, CTA and/or US may be used for long-term monitoring of structural damage, particularly to detect stenosis, occlusion, dilatation and/or aneurysms. The frequency of screening as well as the imaging method applied should be decided on an individual basis.	5	9.3 (1.2) 95% ≥8
12. Imaging examination should be done by a trained specialist using appropriate equipment, operational procedures and settings. The reliability of imaging, which has often been a concern, can be improved by specific training. Suggestions for technical and operational parameters are depicted in Box 1.	5	9.8 (0.6) 100% ≥8

LoA, level of agreement; CT, computed tomography; GCA, giant cell arteritis; LV-GCA, large vessel GCA; LoE, Level of evidence according to the Oxford Centre for Evidence Based Medicine; LVV, large vessel vasculitis; MRI, magnetic resonance imaging; PET, 18F-FDG positron emission tomography; TAK, Takayasu arteritis; US, ultrasound

*cranial symptoms of GCA include headache, visual symptoms, jaw claudication, swelling and/or tenderness of temporal arteries; ǂcranial arteries: superficial temporal, occipital and facial, usually all visible in one examination in MRI.

Disclosure: C. Dejaco, None; S. Ramiro, None; C. Duftner, None; F. L. Besson, None; T. Bley, None; D. Blockmans, None; E. Brouwer, None; M. A. Cimmino, None; E. Clark, None; B. Dasgupta, None; A. P. Diamantopoulos, Roche Pharmaceuticals, 8,Bristol-Myers Squibb, 8; H. Direskeneli, None; A. Iagnocco, None; T. Klink, None; L. Neill, None; C. Ponte, None; C. Salvarani, None; R. Slart, None; M. Whitlock, None; W. A. Schmidt, None.

To cite this abstract in AMA style:

Dejaco C, Ramiro S, Duftner C, Besson FL, Bley T, Blockmans D, Brouwer E, Cimmino MA, Clark E, Dasgupta B, Diamantopoulos AP, Direskeneli H, Iagnocco A, Klink T, Neill L, Ponte C, Salvarani C, Slart R, Whitlock M, Schmidt WA. European League Against Rheumatisms Recommendations for the Use of Imaging in Large Vessel Vasculitis in Clinical Practice [abstract]. Arthritis Rheumatol. 2017; 69 (suppl 10). https://acrabstracts.org/abstract/european-league-against-rheumatisms-recommendations-for-the-use-of-imaging-in-large-vessel-vasculitis-in-clinical-practice/. Accessed .

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