EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice: 2023 update

Abstract

ObjectivesTo update the EULAR recommendations for the use of imaging modalities in primary large vessel vasculitis (LVV).MethodsA systematic literature review update was performed to retrieve new evidence on ultrasound, MRI, CT and [18F]-fluorodeoxyglucose positron emission tomography (FDG-PET) for diagnosis, monitoring and outcome prediction in LVV. The task force consisted of 24 physicians, health professionals and patients from 14 countries. The recommendations were updated based on evidence and expert opinion, iterating until voting indicated consensus. The level of agreement was determined by anonymous votes.ResultsThree overarching principles and eight recommendations were agreed. Compared to the 2018 version, ultrasound is now recommended as first-line imaging test in all patients with suspected giant cell arteritis, and axillary arteries should be included in the standard examination. As an alternative to ultrasound, cranial and extracranial arteries can be examined by FDG-PET or MRI. For Takayasu arteritis, MRI is the preferred imaging modality; FDG-PET, CT or ultrasound are alternatives. Although imaging is not routinely recommended for follow-up, ultrasound, FDG-PET or MRI may be used for assessing vessel abnormalities in LVV patients with suspected relapse, particularly when laboratory markers of inflammation are unreliable. MR-angiography, CT-angiography or ultrasound may be used for long-term monitoring of structural damage, particularly at sites of preceding vascular inflammation.ConclusionsThe 2023 EULAR recommendations provide up-to-date guidance for the role of imaging in the diagnosis and assessment of patients with LVV.

Large‐vessel vasculitis induced by pegfilgrastim and immune checkpoint inhibitor in a patient with small‐cell lung cancer

“…4 Drug-induced vasculitis is diagnosed using ultrasound, CT, magnetic resonance imaging (MRI), and [18F]-fluorodeoxyglucose positron emission tomography (FDG-PET). 5 Ultrasound may be used for temporal and axillary arteries and abdominal aorta and limited value for thoracic aorta. High-resolution MRI or FDG-PET can be used as alternatives to ultrasound for the assessment of cranial arteries.…”

Bildgebung bei Großgefäßvaskulitiden

“…Im Wettbewerb mit allen anderen in diesem Übersichtsartikel vorgestellten Bildgebungsmodalitäten bei Großgefäßvaskulitiden hat die konventionelle Angiografie mittlerweile ihren Stellenwert verloren. Die gerade augenblicklich überarbeiteten europäischen Empfehlungen zur Bildgebungsanwendung in der klinischen Praxis empfehlen keinerlei diagnostischen Einsatz der Angiografie mehr in der Diagnostik von Großgefäßvaskulitiden [17].…”

Riesenzellarteriitis

“…Wird in der Bildgebung (Farb-Duplex-Sonografie, Magnetresonanztomografie [MRT], Positronenemissionstomografie mit Computertomografie [PET-CT]) sicher eine Riesenzellarteriitis nachgewiesen, ist keine Biopsie mehr notwendig. Diese sollte nur dann erfolgen, wenn die Bildgebung nicht eindeutig ist [38].…”

“…Die Farb-Duplex-Sonografie stellt die wichtigste Methode für die Bildgebung bei der Riesenzellarteriitis dar. Sie ist nicht invasiv, kostengünstig, liefert ein schnelles Ergebnis und erlaubt eine Visualisierung der entzündeten Gefäße [38]. Als Zeichen der Riesenzellarteriitis in der Farb-Duplex-Untersuchung findet sich das Halo-Zeichen, eine echoarme, nicht komprimierbare, in der Regel zirkuläre Wandverdickung der Arterie aufgrund eines Wandödems (▶ Abb.…”

“…If giant cell arteritis is reliably detected on imaging (color duplex ultrasound, magnetic resonance imaging [MRI], positron emission tomography with computed tomography [PET-CT]), a biopsy is no longer necessary. Biopsies should only be performed if the imaging is unclear [38].…”