EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practise.

The European League Against Rheumatism, EULAR, has published a set of recommendations in journal, The Annals of Rheumatic Diseases which look at the use of imaging modalities in primary large vessel vasculitis, including giant cell arteritis and Takayasu arteritis.

The recommendations are intended to advise physicians on the use of imaging modalities (including ultrasound, magnetic resonance imaging, MRI, computed tomography, CT, and positron emission tomography, PET) when making a clinical diagnosis of large vessel vasculitis (LVV), and when to apply imaging for monitoring of disease activity and damage. CT and MRI also refer to specific angiography techniques such as CT-angiography (CTA) and MR-angiography (MRA), and PET is commonly used in conjunction with CT or CTA. These recommendations are not intended to cover all aspects of diagnosis and management of LVV, and particularly do not discuss in full the role of temporal artery biopsy (TAB) for giant cell arteritis (GCA) diagnosis.

The targeted users of these recommendations are secondary and tertiary care physicians including rheumatologists, ophthalmologists, neurologists, radiologists, nuclear medicine specialists, vascular surgeons, angiologists, geriatricians and other specialists in general (internal) medicine. The target population is patients with suspected or established primary LVV, specifically GCA or Takayasu arteritis (TAK). These recommendations may also inform patients participating in shared decision-making, primary care physicians and health care providers organising care of LVV patients.

Based on evidence and expert opinion, the EULAR task force consisting of 20 experts from 10 EULAR countries developed the recommendations, with consensus obtained through informal voting. The final level of agreement was voted anonymously. The aim was to develop evidence-based recommendations for the use of imaging modalities in primary LVV including giant cell arteritis GCA and TAK.
When formulating the recommendations, EULAR Standardised Operating Procedures were followed. A systematic literature review was conducted to retrieve data on the role of imaging modalities including ultrasound, MRI, computed tomography CT and [18F]-fluorodeoxyglucose positron emission tomography in LVV.

The task force recommends an early imaging test in patients with suspected LVV, with ultrasound and MRI being the first choices in GCA and TAK, respectively. CT or PET may be used alternatively. In case the diagnosis is still in question after clinical examination and imaging, additional investigations including and/or additional imaging are required. In patients with a suspected flare, imaging might help to better assess disease activity.

The frequency and choice of imaging modalities for long-term monitoring of structural damage remains an individual decision, close monitoring for aortic aneurysms should be conducted in patients at risk for this complication. All imaging should be performed by a trained specialist using appropriate operational procedures and settings. These are the first EULAR recommendations providing up-to-date guidance for the role of imaging in the diagnosis and monitoring of patients with (suspected) LVV.

Useful Links
EULAR Journal, Annals of Rheumatic Diseases: https://www.eular.org/EULAR_journal.cfm
EULAR Recommendation reference: annrheumdis-2017-212649: Recommendation 'Recommendation'
EULAR Recommendations: https://www.eular.org/recommendations_home.cfm