LB0009 EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice: 2023 update

Abstract

BackgroundImaging recommendations for primary large vessel vasculitis (LVV) were developed in 2018. Several new studies have emerged since then, and an update of the original statements was required.ObjectivesTo update the recommendations for the use of imaging in LVV.MethodsA systematic literature review update was performed to retrieve new evidence on ultrasound (US), magnetic resonance imaging (MRI), computed tomography (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.ResultsThree overarching principles and eight recommendations were agreed (Table 1). Compared to the 2018 version, US is now recommended as first line imaging test in all patients with suspected GCA, and axillary arteries should be included in the standard examination. As an alternative to US, cranial and extracranial arteries can be examined by FDG-PET or MRI. For Takayasu arteritis, MRI is the preferred imaging modality; CT or FDG-PET are alternatives. Although imaging is not routinely recommended for follow-up, US, 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. MRA, CTA or US may be used for long-term monitoring of structural damage, particularly at sites of preceding vascular inflammation.ConclusionThe 2023 recommendations provide up-to-date guidance for the role of imaging in the diagnosis and assessment of patients with (suspected) LVV.Table 1.Recommendations for the use of imaging in large vessel vasculitis in clinical practiceOverarching principlesA. In patients with suspected GCA, an early imaging test is recommended to support the clinical diagnosis of GCA, assuming high expertise and prompt availability of the imaging technique. Imaging should not delay initiation of treatment.B. Imaging examination should be done by a trained specialist using appropriate equipment, standardized operational procedures and settings.C. In patients in whom there is a high clinical suspicion of GCA and a positive imaging result, 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 (including the case of an inconclusive imaging result), additional efforts towards a diagnosis are necessary.Recommendations1. Ultrasound of temporal and axillary arteries should be considered as the first imaging modality to investigate mural inflammatory changes in patients with suspected GCA.2. High resolution MRI or FDG-PET can be used as alternatives to ultrasound for the assessment of cranial arteries in patients with suspected GCA.3. FDG-PET, alternatively MRI or CT, can be used for the detection of mural inflammation or luminal changes of extracranial arteries in patients with suspected GCA.4. In patients with suspected TAK, MRI to investigate mural inflammation or luminal changes should be used as the first imaging test to make a diagnosis of TAK.5. FDG-PET, CT or ultrasound may be used as alternative imaging modalities in patients with suspected TAK. Ultrasound is of limited value for assessment of the thoracic aorta.6. Conventional angiography is not recommended for the diagnosis of GCA or TAK as it has been superseded by the previously mentioned imaging modalities.7. In case of a suspected relapse of GCA or TAK, particularly when laboratory markers of disease activity are unreliable, ultrasound, FDG-PET or alternatively MRI may be considered for the assessment of vessel abnormalities. Imaging is not routinely recommended for patients in clinical and biochemical remission.8. In patients with GCA or TAK, MRA, CTA or ultrasound of extracranial vessels may be used for long-term monitoring of structural damage, particularly at sites of preceding vascular inflammation. The frequency of screening as well as the imaging method applied should be decided on an individual basis.ReferencesNIL.AcknowledgmentsFunding provided by EULAR (Project number: QoC13). We would like to thank Louise Falzon for her help with the literature search strategy. We also thank Lorna Neill, Luca Cimino and Fabrizio Gozzi for their help with the update of the PICO questions.Disclosure of InterestsChristian Dejaco Consultant of: AbbVie, Novartis, Janssen, Sanofi, Speakers bureau: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer, Roche, Galapagos and Sanofi, Grant/research support from: AbbVie, Sofia Ramiro Consultant of: AbbVie, Eli Lilly, Galapagos, MSD, Novartis, Pfizer, Sanofi, UCB, Speakers bureau: AbbVie, Eli Lilly, Galapagos, MSD, Novartis, Pfizer, Sanofi, UCB, Grant/research support from: AbbVie, Eli Lilly, Galapagos, MSD, Novartis, Pfizer, Sanofi, UCB, Milena Bond Consultant of: AbbVie, Philipp Bosch Speakers bureau: Janssen, Grant/research support from: Pfizer, Cristina Ponte Consultant of: AbbVie, Sanofi, Novartis, Vifor, AstraZeneca, GlaxoSmithKline, and Roche, Speakers bureau: Vifor, AstraZeneca, GlaxoSmithKline, and Roche, Sarah Mackie Consultant of: Roche/Chugai, Sanofi, AbbVie, AstraZeneca, Sanofi, GSK, Sparrow, Speakers bureau: Roche/Chugai, Vifor, Pfizer and Novartis, Torsten Bley Consultant of: BioTel Research, Chugai, Guerbet, Novartis, Roche and Siemens Healthineers, Speakers bureau: BioTel Research, Chugai, Guerbet, Novartis, Roche, Sanofi and Siemens Healthineers, Daniel Blockmans Consultant of: Roche and GSK, Sara Brolin Grant/research support from: Novartis, Ertugrul Cagri Bolek: None declared, Rebecca Cassie: None declared, Maria C. Cid Consultant of: GSK, SCL-Vifor, AbbVie, AstraZeneca and Janssen, Grant/research support from: Kiniksa Pharmaceuticals, Juan Molina Collada Consultant of: Abbvie, Lilly, Janssen, Novartis, Pfizer, UCB, MSD, Speakers bureau: Abbvie, Lilly, Janssen, Novartis, Pfizer, UCB, MSD, Bhaskar Dasgupta Consultant of: Novartis, Abbvie,Roche,Chugai,Sanofi, Grant/research support from: Novartis, Abbvie,Roche,Chugai,Sanofi, Berit Dalsgaard NIelsen Consultant of: Roche and Novartis, Speakers bureau: Roche and Novartis, Eugenio de Miguel Consultant of: Novartis, AbbVie, Pfizer, Janssen, Lilly, Speakers bureau: Abbvie, Novartis, Pfizer, Roche, Janssen, Lilly, MSD, BMS, UCB, Grunental and Sanofi, Grant/research support from: Novartis, AbbVie, Pfizer, Janssen, Lilly, Haner Direskeneli Consultant of: Abbvie and Novartis, Grant/research support from: Pfizer, Amgene, Celltrion, UCB and Roche, Christina Duftner Consultant of: Abbvie, AOP Orphan, Astra-Zeneca, Bristol-Myers-Squibb, Eli-Lilly, Janssen, Galapagos, Merck-Sharp-Dohme, Novartis, Pfizer, Roche, Sandoz, UCB, Vifor, Speakers bureau: Abbvie, AOP Orphan, Astra-Zeneca, Bristol-Myers-Squibb, Eli-Lilly, Janssen, Galapagos, Merck-Sharp-Dohme, Novartis, Pfizer, Roche, Sandoz, UCB, Vifor, Grant/research support from: Eli-Lilly, Pfizer, UCB, ALOJZIJA HOCEVAR: None declared, Anna Moltó Consultant of: AbbVie, BMS, Biogen, Eli Lilly, Galapagos, Janssen, MSD, Novartis, and UCB, Grant/research support from: AbbVie, BMS, Biogen, Eli Lilly, Galapagos, Janssen, MSD, Novartis, and UCB, Valentin Schäfer: None declared, Luca Seitz Grant/research support from: iQone and Sandoz, Riemer Slart Grant/research support from: Siemens Healtineers and Pfizer, Wolfgang Schmidt Consultant of: Abbvie, Chugai, GlaxoSmithKline, Medac, Novartis, Roche, and Sanofi, Speakers bureau: Abbvie, Chugai, GlaxoSmithKline, Medac, Novartis, Roche, and Sanofi.

Positron Emission Computed Tomography Spectrum of Large Vessel Vasculitis in a Tertiary Center: Differences in 18F-fluorodeoxyglucose Uptake between Large Vessel Vasculitis with Predominant Cranial and Extracranial Giant Cell Arteritis Phenotypes

“…This should be carried out by experts in imaging diagnosis soon after a diagnosis of GCA is suspected. They considered that a temporal artery biopsy may be an adequate option, in particular when imaging is not readily available or expertise with imaging in GCA is insufficient [11]. However, as previously reported [12,13], the frequency of positive temporal artery biopsy is low in patients with predominantly extracranial pattern of the disease, in particular in those who do not show the classic cranial ischemic manifestation of this vasculitis.…”

“…PET scanning was reported to have high sensitivity and specificity for the diagnosis of GCA, and at the same time, the negative predictive value of a PET scan for GCA was also very high [10]. With respect to this, the EULAR recommendations for the use of imaging modalities in primary LVV have recently been updated [11]. These recommendations were made by a group of physicians highly experienced in the diagnosis and treatment of LVV.…”

“…However, as previously reported [12,13], the frequency of positive temporal artery biopsy is low in patients with predominantly extracranial pattern of the disease, in particular in those who do not show the classic cranial ischemic manifestation of this vasculitis. EULAR task force experts also pointed out that ultrasound of temporal and axillary arteries should be considered the first imaging technique to be used to assess mural inflammatory changes in patients with suspected GCA [11]. They also said that highresolution magnetic resonance imaging (MRI) or FDG-PET can be used as alternatives to ultrasound for the assessment of cranial arteries in patients with suspected GCA [11].…”

“…EULAR task force experts also pointed out that ultrasound of temporal and axillary arteries should be considered the first imaging technique to be used to assess mural inflammatory changes in patients with suspected GCA [11]. They also said that highresolution magnetic resonance imaging (MRI) or FDG-PET can be used as alternatives to ultrasound for the assessment of cranial arteries in patients with suspected GCA [11]. Moreover, they emphasized that FDG-PET should be considered the first imaging alternative to ultrasound of extracranial vessels [11].…”

“…In this sense, patients with predominantly cranial characteristics were older at the time of diagnosis of the disease (mean ± SD: 75.5 ± 7.6 years vs. 68.1 ± 9.9 years, p = 0.017). In contrast, patients with extracranial LVV-GCA had a longer delay in diagnosis from symptom onset compared to those with the classic cranial GCA phenotype (median [IQR]: 12 [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] vs. 4 [3][4][5][6][7][8]; p = 0.006). All patients with the predominant cranial phenotype had a diagnosis confirmed by a positive biopsy and/or ultrasound of the temporal artery, while none of the 22 with extracranial LVV-GCA in whom one of these tests was performed had positive results.…”