Diagnosing giant cell arteritis: a comprehensive practical guide for the practicing rheumatologist

Abstract

Giant cell arteritis (GCA) is the most common large vessel vasculitis in the elderly population. In recent years, advanced imaging has changed the way GCA can be diagnosed in many locations. The GCA fast-track clinic (FTC) approach combined with ultrasound (US) examination allows prompt treatment and diagnosis with high certainty. FTCs have been shown to improve prognosis while being cost effective. However, all diagnostic modalities are highly operator dependent, and in many locations expertise in advanced imaging may not be available. In this paper, we review the current evidence on GCA diagnostics and propose a simple algorithm for diagnosing GCA for use by rheumatologists not working in specialist centres.

Accuracy of Doppler ultrasound in the diagnosis of giant cell arteritis: a systematic review and meta-analysis

“…The precise diagnosis of GCA is essential in clinical practice since patients need long-term glucocorticoid therapy that bears a significant burden of adverse events. In patients presenting GCA manifestations, the diagnosis can be confirmed by temporal artery biopsy (TAB) or by imaging studies such as color Doppler ultrasound (CDU) of temporal and axillary arteries, by high-resolution magnetic resonance angiography (MRA) imaging of cranial arteries or by large-vessel imaging with positron emission tomography (PET) or computed tomography angiography (CTA) [4]. Although TAB has been considered the gold standard method for GCA diagnosis [5] and the American College of Rheumatology (ACR) guidelines for GCA recommend TAB as the first diagnostic test [6]; CDU has replaced TAB in some scenarios as this imaging modality can detect the halo sign, i.e., a dark area surrounding the vessel lumen, which is regarded as the most important sign of vasculitis in temporal arteries [7,8].…”

“…Large-vessel involvement in GCA has been shown to be associated with a higher relapse rate, increased mortality, higher levels of acute phase reactants, and an increased cumulative glucocorticoid dose compared to cranial GCA patients [18][19][20]. Therefore, it is essential to include large vessels such as the aorta and axillary arteries in the initial assessment of patients with suspected GCA [4].…”

Current developments in the diagnosis and treatment of giant cell arteritis

“…While large vessel involvement occurs in less than half of patients with any GCA, it is associated with increased mortality ( 15 , 16 ). The mixed phenotype includes features of both C-GCA and LV-GCA and may represent nearly 80% of GCA cases ( 17 ).…”

Diagnostik und Therapie der Großgefäßvaskulitiden – Wo stehen wir aktuell?

“…Bei zu kurzstreckigen Biopsaten verringert sich die Sensitivität, da häufig ein diskontinuierlicher Gefäßbefall vorliegt. Durch die immer weiter verbesserte Bildgebung, vor allem des US ist diese invasive Diagnostik aber nur noch dann indiziert, wenn Unsicherheit in der Bildgebung bezüglich der Diagnose besteht 15 16…”

“…Bei zu kurzstreckigen Biopsaten verringert sich die Sensitivität, da häufig ein diskontinuierlicher Gefäßbefall vorliegt. Durch die immer weiter verbesserte Bildgebung, vor allem des US ist diese invasive Diagnostik aber nur noch dann indiziert, wenn Unsicherheit in der Bildgebung bezüglich der Diagnose besteht [15][16] Medikamentöse Therapie Grundsätzlich gilt: bei alleinigem Verdacht auf eine GGV muss umgehend eine Therapie eingeleitet werden um ischämische Komplikationen zu verhindern [13,14].…”