Background/Purpose
Colour Doppler ultrasonography (CDU) of the temporal (TA), axillary (AA) and common carotid arteries (CA) has excellent sensitivity and specificity for the diagnosis of GCA, typically showing halos (dark areas around the arterial walls) and stenoses or occlusions. The CDU pattern of patients with extra cranial and cranial GCA has been reported to substantially differ; visual impairment and age are inversely correlated to extra cranial GCA. In addition, involvement of the vertebral arteries (VA) is associated with vertebrobasilar stroke. The aim of this analysis was to evaluate the type and frequency of CDU abnormalities in the TA, AA, CA and VA and their relationship with clinical features amongst patients with a submitted diagnosis of GCA in the DCVAS study (a multinational observational study to develop diagnostic criteria and update classification criteria for primary vasculitis, using data from patients with vasculitis and comparators).
Methods
This analysis included data from all patients recruited into DCVAS through April 2014 who had complete 6 month follow-up data, a submitted diagnosis of GCA, and whose tests included a CDU of TA, AA, CA or VA. The presence of halo was considered diagnostic of GCA. Patients were defined as having cranial GCA if they underwent CDU of at least TA and AA but only had abnormities in TA; patients with extra-cranial GCA had involvement of the proximal arm arteries. CDU findings of each artery and cranial/extra cranial pattern were compared to clinical features using Chi-square or Mann-Whitney tests.
Results
GCA was diagnosed in 431 patients; 336 underwent TA biopsy (78%) and 133 (31%) underwent CDU of the following arterial territories: 107 TA, 72 CA, 42 AA and 21 VA. In 8 cases all 4 areas were evaluated; in 27 cases 3 areas; in 31 cases 2 areas; and in 67 cases 1 area. Halo occurred in 75% (TA), 16% (CA), 34% (AA), 41% (VA) of cases; stenosis was seen in 31% (TA), 11% (CA), 16% (AA) and 41% (VA); occlusion was present in 11% (TA), 0% (CA), 3% (AA) and 6% (VA); CDU was normal in 16% (TA), 73% (CA), 58% (AA) and 39% (VA). Table 1 shows that older people were more prone to having a positive TA CDU; headache was less frequent in extra-cranial GCA; PMR occurred in a higher number of patients with CA involvement; and an association between vascular examination and CDU was only found in AA (p<0.05). Moreover, no type of CDU involvement correlated to eye symptoms.
Conclusion
Despite the high sensitivity of CDU and its ability to evaluate several vessels, clinicians usually use TA biopsy for the diagnosis of GCA. Extra-cranial involvement is frequent in GCA and inversely correlated to history of headache. The presence of abnormal CDU findings in several arterial territories supports the use of more extensive imaging in GCA. No significant correlation between cranial GCA and eye symptoms was found, but the low number of patients with extra cranial CDU was a limitation in the analysis.
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Table 1: Relationship between the CDU findings and clinical features.
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|
CDU findings (n) |
Female sex n (%) |
Mean age (±SD) |
Eye Sympt. 1 n (%) |
PMR n (%) |
Jaw claudic. n (%) |
Headache n (%) |
Stroke / TIA n (%) |
Mean ESR (±SD) |
TAB positive 2 n (%) |
Vasc. examination abnormality 3 n (%) |
|
TA + (70 patients) |
40 (57%) |
74±9 |
29 (41%) |
16 (23%) |
25 (36%) |
49 (70%) |
3 (4%) |
73±31 |
45 (83%) |
39 (59%) |
|
TA – (15 patients) |
12 (80%) |
70±7 |
5 (33%) |
5 (33%) |
4 (27%) |
12 (80%) |
1 (7%) |
66±31 |
6 (60%) |
8 (53%) |
|
p value |
0.09 |
0.03
|
0.56 |
0.39 |
0.50
|
0.44 |
0.69 |
0.35 |
0.09 |
0.68 |
|
VA + (7 patients) |
4 (57%) |
78±5 |
5 (71%) |
0 (0%) |
3 (43%) |
6 (86%) |
1 (14%) |
83±15 |
7 (100%) |
– |
|
VA – (7 patients) |
4 (57%) |
70±7 |
2 (29%) |
2 (29%) |
2 (29%) |
7 (100%) |
0 (0%) |
88±43 |
3 (50%) |
– |
|
p value |
1.00 |
0.03
|
0.11 |
0.13 |
0.58 |
0.30 |
0.30 |
0.39 |
0.03
|
–
|
|
CA + (10 patients) |
7 (70%) |
72±8 |
3 (30%) |
5 (50%) |
1 (10%) |
1 (10%) |
0 (0%) |
77±17 |
3 (100%) |
0 (0%) |
|
CA – (45 patients) |
31 (69%) |
73±8 |
22 (49%) |
7 (16%) |
11 (24%) |
32 (71%) |
2 (4%) |
71±30 |
27 (79%) |
3 (8%) |
|
p value |
0.95 |
0.81 |
0.28 |
0.02
|
0.32 |
0.001
|
0.50 |
0.59 |
0.38 |
0.37 |
|
AA + (13 patients) |
11 (85%) |
73±8 |
6 (46%) |
1 (8%) |
4 (31%) |
7 (54%) |
0 (0%) |
70±26 |
7 (78%) |
5 (50%) |
|
AA – (22 patients) |
13 (59%) |
74±5 |
6 (27%) |
2 (9%) |
6 (27%) |
15 (68%) |
1 (5%) |
79±30 |
15 (75%) |
0 (0%) |
|
p value |
0.15 |
0.59 |
0.26 |
0.87 |
0.83 |
0.40 |
0.44 |
0.29 |
0.87 |
0.002
|
|
Cranial GCA (19 patients) |
13 (68%) |
74±8 |
5 (26%) |
2 (11%) |
5 (26%) |
15 (79%) |
1 (5%) |
76±31 |
13 (77%) |
– |
|
Extra cranial GCA (17 patients) |
15 (88%) |
74±6 |
8 (47%) |
3 (18%) |
5 (29%) |
8 (47%) |
0 (0%) |
74±24 |
8 (73%) |
– |
|
p value |
0.15 |
0.79 |
0.20 |
0.54 |
0.84 |
0.04
|
0.34 |
0.94 |
0.63 |
|
|
(+) Positive findings for GCA; (-) Negative findings for GCA; AA – Axillary artery; CA – Carotid artery; CDU – Colour Doppler ultrasonography, ESR – Erythrocyte Sedimentation Rate; GCA – Giant Cell Arteritis; PMR – Polymyalgia Rheumatica; SD – Standard deviation; TA – Temporal artery; TAB – Temporal artery biopsy; TIA – Transient Ischaemic Attack; VA – Vertebral artery. 1 Eye symptoms were considered when “amaurosis fugax”, “sudden visual loss”, “blurred vision in either eye”, “diplopia” or “optic neuritis” was recorded. 2 TAB was defined has positive when “definitive vasculitis” or “consistent with vasculitis but not definitive” was recorded. 3 The presence of a diminished/absent pulse, tenderness, hard ‘cord like’ or/and bruit in the area scanned.
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Disclosure:
C. Ponte,
None;
R. Geraldes,
None;
A. Craven,
None;
A. Judge,
None;
P. C. Grayson,
None;
R. Suppiah,
None;
J. Robson,
None;
R. A. Watts,
None;
P. A. Merkel,
Genentech and Biogen IDEC Inc.,
2,
Bristol-Myers Squibb,
2,
GlaxoSmithKline,
2,
Actelion Pharmaceuticals US,
2,
Actelion Pharmaceuticals US,
5,
Sanofi-Aventis Pharmaceutical,
5,
Chemocentryx,
5;
R. Luqmani,
None.
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