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  • Title: Diagnosing vasculitis with ultrasound: findings and pitfalls.
    Author: Schmidt WA, Schäfer VS.
    Journal: Ther Adv Musculoskelet Dis; 2024; 16():1759720X241251742. PubMed ID: 38846756.
    Abstract:
    Rheumatologists are increasingly utilizing ultrasound for suspected giant cell arteritis (GCA) or Takayasu arteritis (TAK). This enables direct confirmation of a suspected diagnosis within the examination room without further referrals. Rheumatologists can ask additional questions and explain findings to their patients while performing ultrasound, preferably in fast-track clinics to prevent vision loss. Vascular ultrasound for suspected vasculitis was recently integrated into rheumatology training in Germany. New European Alliance of Associations for Rheumatology recommendations prioritize ultrasound as the first imaging tool for suspected GCA and recommend it as an imaging option for suspected TAK alongside magnetic resonance imaging, positron emission tomography and computed tomography. Ultrasound is integral to the new classification criteria for GCA and TAK. Diagnosis is based on consistent clinical and ultrasound findings. Inconclusive cases require histology or additional imaging tests. Robust evidence establishes high sensitivities and specificities for ultrasound. Reliability is good among experts. Ultrasound reveals a characteristic non-compressible 'halo sign' indicating intima-media thickening (IMT) and, in acute disease, artery wall oedema. Ultrasound can further identify stenoses, occlusions and aneurysms, and IMT can be measured. In suspected GCA, ultrasound should include at least the temporal and axillary arteries bilaterally. Nearly all other arteries are accessible except the descending thoracic aorta. TAK mostly involves the common carotid and subclavian arteries. Ultrasound detects subclinical GCA in over 20% of polymyalgia rheumatica (PMR) patients without GCA symptoms. Patients with silent GCA should be treated as GCA because they experience more relapses and require higher glucocorticoid doses than PMR patients without GCA. Scores based on intima-thickness (IMT) of temporal and axillary arteries aid follow-up of GCA, particularly in trials. The IMT decreases more rapidly in temporal than in axillary arteries. Ascending aorta ultrasound helps monitor patients with extracranial GCA for the development of aneurysms. Experienced sonologists can easily identify pitfalls, which will be addressed in this article. Diagnosing vasculitis with ultrasound Rheumatologists use ultrasound to diagnose two types of blood vessel inflammation: giant cell arteritis (GCA) or Takayasu arteritis (TAK). They can do this right in their office during the examination, without sending patients elsewhere. During the ultrasound, rheumatologists can talk with patients about what they see. This is especially helpful in fast-track clinics to prevent vision loss. In Germany, doctors training to become rheumatologists learn how to use ultrasound to check for problems like these. An organization called ‘European Alliance of Associations for Rheumatology (EULAR)’ recommends using ultrasound as the main way to look for GCA and, if needed, for TAK. Ultrasound is also an important part of the new classification criteria for GCA and TAK. However, doctors do not rely on ultrasound alone. They also look what patients are feeling and do other medical tests. If ultrasound is not clear enough, doctors might need to do more tests like taking a small piece of tissue (biopsy) or using other kinds of imaging like MRI or CT scans. Ultrasound can show some characteristic signs of blood vessel inflammation, like a ‘halo sign,’ which tells doctors that the blood vessel walls are thicker than normal. It can also spot other problems like blockages or bulges in the blood vessels. When doctors suspect GCA, they should at least examine the arteries at the forehead and at the armpit. Most of the time, these areas are easy to see with ultrasound, but some areas might be harder to reach. Sometimes, people can have blood vessel inflammation without feeling any typical symptoms. Ultrasound can still find this silent inflammation in more than 20% of people with a condition called polymyalgia rheumatica (PMR). Even though these patients do not have typical symptoms of GCA, it is important to treat them the same way as those with GCA. Otherwise, they may have more flare-ups and need higher doses of glucocorticoids. Doctors may measure the thickness of the artery walls over time in research studies. This helps them to see if treatments are working well. The wall thickness decreases faster in arteries of the head than in larger arteries outside the head. Ultrasound of the aorta close to heart helps to find out if a widening of the aorta develops. This can be dangerous because of rupture.
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