What are the European League Against Rheumatism (EULAR) guidelines for giant cell arteritis imaging?

Updated: Sep 07, 2018
  • Author: Guruswami Giri, MD, FRCS; Chief Editor: Kyung J Cho, MD, FACR, FSIR  more...
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Answer

Answer

European League Against Rheumatism (EULAR) guidelines, published in 2018, include the following recommendations on imaging in giant cell arteritis (GCA) [17] :

  • In patients with suspected GCA, early imaging is recommended to complement the clinical diagnostic criteria, assuming high expertise and prompt availability of the imaging technique. Imaging should not delay initiation of treatment.
  • In patients in whom there is a high clinical suspicion of GCA and a positive imaging study, the diagnosis of GCA may be made without 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, additional efforts toward a diagnosis are necessary.
  • Temporal artery ultrasound (US), with or without axillary artery US, is recommended as the first imaging modality in patients with suspected GCA with predominantly cranial manifestations (eg, headache, visual symptoms, jaw claudication, temporal artery swelling and/or tenderness). A non-compressible ‘halo’ sign is the US finding most suggestive of GCA.
  • If US is not available or the results are inconclusive, high-resolution MRI of cranial arteries to investigate mural inflammation may be used as an alternative for diagnosis of GCA.
  • CT and PET are not recommended for the assessment of inflammation of cranial arteries.
  • US, PET, MRI, and/or CT may be used for detection of mural inflammation and/or luminal changes in extracranial arteries to support the diagnosis of large-vessel GCA. US is of limited value for assessment of aortitis.
  • Conventional angiography is not recommended for the diagnosis of GCA, as it has been superseded by the previously mentioned imaging modalities.
  • In patients with GCA in whom a flare is suspected, imaging might be helpful to confirm or exclude it. Imaging is not routinely recommended for patients in clinical and biochemical remission.
  • MRA, CTA, and/or US may be used for long-term monitoring of structural damage in patients with GCA, particularly to detect stenosis, occlusion, dilatation, and/or aneurysms. The frequency of screening as well as the imaging method applied should be decided on an individual basis.
  • Imaging examination should be done by a trained specialist using appropriate equipment, operational procedures, and settings. The reliability of imaging, which has often been a concern, can be improved by specific training.

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