Diagnostic Approaches for Large Vessel Vasculitides

Abstract

The large vessel vasculitides comprise giant cell arteritis (GCA), Takayasu arteritis (TAK), and chronic periaortitis. The diagnostic approach to these conditions involves the correct use and interpretation of clinical criteria, imaging techniques, and, in case of GCA, temporal artery biopsy. Ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT) reveal a homogeneous, concentric, thickening of the arterial wall. MRI and CT may also reveal aneurysms and stenoses. 18F-Fluorodeoxyglucose (FDG)-PET shows increased FDG uptake of inflamed artery walls delineating increased metabolic activity. Ultrasound, FDG-PET, and MRI are the recommended imaging techniques in GCA and TAK. In patients with a high suspicion of GCA who present with visual disturbances, initiation of high-dose intravenous corticosteroids should not be delayed by imaging. Extracranial large vessel vasculitis may be confirmed by all three modalities, particularly by FDG-PET in case of atypical clinical pictures. In this article, we review the role of the GCA and TAK ACR classification criteria, temporal artery biopsy, conventional angiography, ultrasound, MRI, magnetic resonance angiography (MRA), CT angiography (CTA), and FDG-PET in the diagnostic approach of large vessel vasculitis.

Diagnostik und Therapie der Großgefäßvaskulitiden – Wo stehen wir aktuell?

“…Da sich vor allem die Bildgebung seither massiv verbessert hat, kommen diese heute eigentlich nicht mehr zur Anwendung; allerdings gibt es bis heute auch noch keine Aktualisierung. Die Diagnosestellung erfolgt anhand verschiedener Parameter wie der Anamnese, körperlicher Untersuchung, Laborparametern, bildgebender Verfahren und bedarfsweiser Hinzunahme einer Histopathologie 5 12 .…”

“…Eine Diagnose einer (bisher unbehandelten) Großgefäßvaskulitis ohne Nachweis hoher Entzündungszeichen (in der Regel BSG>50 mm/h) ist sehr unwahrscheinlich. Auch Leukopenien oder Thrombopenien sind untypisch 12 13 . Allerdings ist unter bestimmten Medikamenten, wie Tocilizumab, die Wertigkeit zur Beurteilung der Krankheitsaktivität von BSG/CRP stark vermindert und auch Leukopenien finden sich relativ häufig.…”

Vascular Imaging Techniques to Diagnose and Monitor Patients with Takayasu Arteritis: A Review of the Literature

“…2.5.1. Diagnosis 18F-Fluorodeoxyglucose (FDG)-PET has been used for the diagnosis and assessment of TA (Figure 4a,b) [44]. FDG-PET is often used in conjunction with CT.…”

“…The transport of FDG in capillaries correlates with glucose uptake. Because activated white blood cells have increased glucose metabolism, FDG-PET is frequently used in infectious and noninfectious inflammatory diseases [44]. It provides functional information on the metabolic activity of organs and tissues.…”

“…DUS is considered useful for both diagnosis and monitoring because it is highly accessible, inexpensive, noninvasive, and radiation-free; notably, however, it is more subjective than other tests [42]. FDG-PET may be particularly useful as a monitoring method [32,44], but it has low accessibility and involves radiation exposure. OCT is used to obtain tomographic images based on the coherence of light.…”