EULAR recommendations for the use of imaging in LVV in clinical practice
| Statement | LoE | LoA |
| 1. In patients with suspected GCA, an early imaging test is recommended to complement the clinical criteria for diagnosing GCA, assuming high expertise and prompt availability of the imaging technique. Imaging should not delay initiation of treatment. | 1 | 9.2 (2.1) 90% ≥8 |
| 2. In patients in whom there is a high clinical suspicion of GCA and a positive imaging test, 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, additional efforts towards a diagnosis are necessary. | 2 | 9.4 (1.0) 90% ≥8 |
| 3. Ultrasound of temporal±axillary arteries is recommended as the first imaging modality in patients with suspected predominantly cranial GCA*. A non-compressible ‘halo’ sign is the ultrasound finding most suggestive of GCA. | 1 | 9.7 (0.6) 100% ≥8 |
| 4. High resolution MRI† of cranial arteries‡ to investigate mural inflammation may be used as an alternative for GCA diagnosis if ultrasound is not available or inconclusive. | 2 | 9.2 (1.1) 90% >8 |
| 5. CT† and PET† are not recommended for the assessment of inflammation of cranial arteries. | 5 | 9.5 (1.2) 95% >8 |
| 6. Ultrasound, 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 LV-GCA. Ultrasound is of limited value for assessment of aortitis. | 3 (PET and CT) and 5 (MRI and ultrasound) | 9.8 (0.6) 100% ≥8 |
| 7. In patients with suspected TAK, MRI to investigate mural inflammation and/or luminal changes should be used as the first imaging test to make a diagnosis of TAK, assuming high expertise and prompt availability of the technique. | 3 | 9.1 (1.4) 90% >8 |
| 8. PET, CT and/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. | 3 (CT) and 5 (PET and ultrasound) | 9.4 (0.8) 100% ≥8 |
| 9. Conventional angiography is not recommended for the diagnosis of GCA or TAK as it has been superseded by the previously mentioned imaging modalities. | 5 | 9.8 (0.6) 100% ≥8 |
| 10. In patients with LVV (GCA or TAK) 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. | 5 | 9.4 (0.8) 100% ≥8 |
| 11. In patients with LVV (GCA or TAK), MRA, CTA and/or ultrasound may be used for long-term monitoring of structural damage, 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. | 5 | 9.3 (1.2) 95% ≥8 |
| 12. 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. Suggestions for technical and operational parameters are depicted in box 1. | 5 | 9.8 (0.6) 100% ≥8 |
Numbers in column ‘LoA’ indicate the mean and SD (in parentheses) of the LoA, as well as the percentage of task force members with an agreement ≥8.
*Cranial symptoms of GCA include headache, visual symptoms, jaw claudication, swelling and/or tenderness of temporal arteries.
†CT and MRI also refers to specific angiography techniques such as CT angiography (CTA) and MR angiography (MRA), and PET is commonly combined with CT or CTA.
‡Cranial arteries: superficial temporal, occipital and facial, usually all visible in one examination in MRI.
EULAR, European League Against Rheumatism; GCA, giant cell arteritis; LoA, level of agreement; LoE, level of evidence; LV-GCA, large vessel GCA; LVV, large vessel vasculitis; PET, positron emission tomography; TAK, Takayasu arteritis.