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Imaging of vasculitis: State of the art

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Abstract

The increasing availability and improvement of imaging techniques are making a profound impact in the evaluation and management of patients with vasculitis, particularly for those with large vessel vasculitis, and will most likely play an ever more important role in the future. Deep, large vessels can be examined by CT or MRI, while ultrasound is the method of choice for the evaluation of superficial vessels (such as temporal, carotid, and axillary arteries). PET is very sensitive in detecting large vessel inflammation, but it does not delineate the vessel wall. Imaging studies can also be used to monitor the disease course and the development of late vascular complication. This review will focus on the role of imaging studies in diagnosing and monitoring LVV, but will also mention their principal applications in medium and small-sized vessel vasculitis. Indications and limitations of the available imaging modalities will be discussed as well.

Introduction

Primary systemic vasculitides are classified by the diameter of the vessels that are predominantly involved. The increasing availability and improvement of imaging techniques are making a profound impact in the evaluation of patients with vasculitis, particularly for those with large vessel vasculitis (LVV), that include giant cell arteritis (GCA), Takayasu arteritis (TAK) and with primary central nervous system vasculitis (PCNSV). Available imaging techniques are ultrasound, computed tomography (CT) and computed tomography angiography (CTA), magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA), and 18F-Fluorodeoxyglucose (FDG) positron emission tomography (PET), often co-registered with computerized tomography (PET/CT) ∗[1], [2], [3]. Except for the detection of the characteristic microaneurysms alternating with stenoses in medium-sized vessel vasculitis, digital subtraction angiography (DSA) has become a therapeutic procedure for endovascular intervention in LVV rather than a diagnostic method ∗[1], [3]. Finally, in small vessel vasculitis imaging modalities are usually required to document internal organs involvement [3]. This review will focus on the role of imaging studies in diagnosing and monitoring LVV, but will also mention their principal applications in medium and small-sized vessel vasculitis. Indications and limitations of the available imaging modalities will be discussed as well.

Section snippets

Giant cell arteritis

Ultrasound depicts inflammatory artery wall thickening in LVV similar to MRI and CT. The wall thickening is most commonly concentric in axial views. It appears hypoechoic (darker) compared to the surrounding tissue. However, echogenicity is higher than the anechoic (black) artery lumen. A normal intima-media complex is a homogenous, hypo- or anechoic echostructure delineated by two parallel hyperechoic margins. In case of vasculitis thickened hypoechoic tissue with echogenicity similar to

Large vessel vasculitis

Computed tomography (CT) and CT angiography (CTA) are well suited to detect inflammatory changes in large, deep arteries because of their good spacial resolution and convenient scanning time. CT can measure aortic diameter and detect mural calcifications. CTA can evaluate both the vessel wall and the lumen of the large vessels, but cannot visualize relatively small vessels [1].

CTA has a role in diagnosing early and advanced large vessel vasculitis (LVV). In early LVV, CT may show arterial wall

Large vessel vasculitis

Similarly to CT, magnetic resonance imaging (MRI) is particularly indicated to examine the aorta and the other deep, large vessels without the use of ionizing radiation or ionidated contrast. Increased vessel wall thickness (usually with a diffuse circumferential pattern), associated with vessel wall edema on T2 and fat-suppressed sequences, and mural contrast enhancement on T1 sequences are early signs of vascular inflammation. Post-contrast T1 images are superior to T2 or fat-suppressed

Conventional angiography

Digital subtraction angiography (DSA) clearly depicts vessel luminal changes in LVV [1]. The commonest angiographic findings are long, smooth vascular stenoses, and sometimes occlusions and aneurysm [74]. Panangiography is required to determined the extent of disease involvement. However, DSA cannot demonstrate earlier vasculitic changes such as thickening of the vessel wall and mural enhancement, and is thus not useful for early diagnosis [1]. Disadvantages of DSA include its invasive nature

Positron emission tomography

18F-Fluorodeoxyglucose (FDG) positron emission tomography (PET) is a nuclear medicine technique, currently often co-registered with computerized tomography (CT; PET/CT), which assesses the extent and amount of vascular uptake of the radiolabeled glucose analog FDG by metabolically active cells in infections, malignancies, and inflammation [1]. In active large-vessel vasculitis (LVV), there is increased FDG uptake by the vessel wall, typically with a smooth linear pattern [77]; it is unknown

Summary

Imaging studies are useful to document temporal artery inflammation in GCA and essential to show large vessel inflammation in early LVV, when vascular lesions have often not yet developed and clinical examination may thus be unrevealing. However, early imaging findings can be affected by previous immunosuppressive treatment. On the other hand, in established LVV imaging studies are useful to document the development of late vascular complications, such as stenosis, occlusion and/or dilatation.

Funding

None.

Conflict of interest statement

Wolfgang A. Schmidt: Roche (advisory board, speakers bureau), GlaxoSmithKline (advisory board, trial participation).

All the other authors declare no conflict of interest.

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