Usefulness of imaging techniques in the management of giant cell arteritis

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Corte axial de una PET/TC realizada en una paciente con arteritis de células gigantes de nuevo diagnóstico que muestra captación lineal circunferencial del radiotrazador en la pared de la aorta ascendente –flecha en el panel C)– descendente –cabeza de flecha en el panel C)– y cayado aórtico –panel D)–. Imagen transversal de una angio-TC de un paciente con arteritis de células gigantes de nuevo diagnóstico que muestra engrosamiento parietal circunferencial de la aorta torácica descendente en fase arterial –flecha en panel E)–, con captación de contraste en fase venosa –flecha en panel F)–." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Sergio Prieto-González, Michelle Villarreal-Compagny, María C. Cid" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Sergio" "apellidos" => "Prieto-González" ] 1 => array:2 [ "nombre" => "Michelle" "apellidos" => "Villarreal-Compagny" ] 2 => array:2 [ "nombre" => "María C." 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Braga, Sergio Prieto-González, José Hernández-Rodríguez" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Beatriz P." "apellidos" => "Braga" ] 1 => array:2 [ "nombre" => "Sergio" "apellidos" => "Prieto-González" ] 2 => array:2 [ "nombre" => "José" "apellidos" => "Hernández-Rodríguez" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020619301779?idApp=UINPBA00004N" "url" => "/23870206/0000015200000012/v1_201906160657/S2387020619301779/v1_201906160657/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2387020619301950" "issn" => "23870206" "doi" => "10.1016/j.medcle.2019.02.023" "estado" => "S300" "fechaPublicacion" => "2019-06-21" "aid" => "4765" "copyright" => "Elsevier España, S.L.U." "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Med Clin. 2019;152:493-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "Editorial article" "titulo" => "Robotics in medicine" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "493" "paginaFinal" => "494" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La robótica en medicina" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Antonio Barrientos, Jaime del Cerro" "autores" => array:2 [ 0 => array:2 [ "nombre" => "Antonio" "apellidos" => "Barrientos" ] 1 => array:2 [ "nombre" => "Jaime" "apellidos" => "del Cerro" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0025775319301125" "doi" => "10.1016/j.medcli.2019.02.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0025775319301125?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020619301950?idApp=UINPBA00004N" "url" => "/23870206/0000015200000012/v1_201906160657/S2387020619301950/v1_201906160657/en/main.assets" ] "en" => array:21 [ "idiomaDefecto" => true "cabecera" => "Review" "titulo" => "Usefulness of imaging techniques in the management of giant cell arteritis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "495" "paginaFinal" => "501" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Sergio Prieto-González, Michelle Villarreal-Compagny, María C. Cid" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Sergio" "apellidos" => "Prieto-González" "email" => array:1 [ 0 => "sprieto@clinic.cat" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Michelle" "apellidos" => "Villarreal-Compagny" ] 2 => array:2 [ "nombre" => "María C." "apellidos" => "Cid" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Enfermedades Autoinmunes, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Utilidad de las técnicas de imagen en la valoración de la arteritis de células gigantes" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2774 "Ancho" => 2500 "Tamanyo" => 437271 ] ] "descripcion" => array:1 [ "en" => "Doppler ultrasound showing a hypoechoic ring (halo) in a cross-sectional view of the parietal branch of the temporal artery – panel A) – and the left primitive carotid artery – panel B) – in a patient with a recent diagnosis of giant cell arteritis. Axial section of a PET/CT performed in a patient with recently diagnosed giant cell arteritis that shows linear circumferential uptake of the radiotracer in the ascending aorta wall – arrow in panel C) – descending – arrowhead in panel C) – and aortic arch – panel D). Transversal image of a CT angiography of a patient with recently diagnosed giant cell arteritis showing circumferential parietal thickening of the descending thoracic aorta in the arterial phase – arrow in panel E) – with contrast uptake in the venous phase – arrow in panel F)." ] ] ] "textoCompleto" => "IntroductionGiant cell arteritis (GCA) is a granulomatous systemic vasculitis that predominantly affects large arteries.<a class="elsevierStyleCrossRefs" href="#bib0220">1,2</a> Diagnosis of this large vessel involvement is facilitated with imaging techniques, whose availability and quality have increased considerably in recent years, encouraging its systematic use.<a class="elsevierStyleCrossRef" href="#bib0230">3</a> In addition, the segmental character of the vascular lesions in GCA and its variable topography (the temporal artery is not always affected), added to the difficulty in obtaining biopsies in certain territories (aorta and main branches), has meant that radiology has become important in the diagnostic approach to GCA.<a class="elsevierStyleCrossRef" href="#bib0230">3</a> In addition, unlike what occurs with histological samples, imaging techniques allow an extensive vascular study and offer the possibility of sequential noninvasive evaluation.<a class="elsevierStyleCrossRef" href="#bib0230">3</a>The most commonly used radiological techniques in GCA are Doppler ultrasound; positron emission tomography (PET), usually combined with computed tomography (CT) (PET/CT); CT with angiography (CTA) and magnetic resonance angiography (MRA).<a class="elsevierStyleCrossRef" href="#bib0235">4</a> The utility of conventional arteriography in GCA is very limited and it is reduced to the endoluminal treatment of stenotic lesions.<a class="elsevierStyleCrossRefs" href="#bib0225">2,5</a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the radiological findings, as well as the advantages and limitations, of the different imaging techniques used in GCA.<a class="elsevierStyleCrossRefs" href="#bib0230">3,4</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The purpose of this review is to summarise the existing scientific evidence on the usefulness of imaging techniques for diagnosing and detecting structural vascular damage in GCA, as well as its potential use in the monitoring of disease activity and the prognostic value of its findings.DiagnosisIn the last decade, imaging techniques have become increasingly relevant in the diagnosis of GCA.<a class="elsevierStyleCrossRefs" href="#bib0230">3,4</a> The diagnosis of this disease has traditionally been based on histologic demonstration of inflammation in the temporal artery.<a class="elsevierStyleCrossRef" href="#bib0220">1</a> In centres where performing a temporal artery biopsy (TAB) in a timely manner is complicated, diagnosis is often carried out according to clinical criteria. This diagnostic approach entails major limitations because it typically implies using outdated American College of Rheumatology diagnostic qualifying criteria which were not designed for that purpose, and depends heavily on the professional's experience.<a class="elsevierStyleCrossRef" href="#bib0245">6</a> It is especially limiting in this scenario, where the use of imaging techniques has advanced the diagnosis of the disease. This is based on the observation of vascular disorder typical of GCA (involvement of the temporal artery and/or of the aorta and its branches) by detecting radiological signs suggestive of inflammation, either in the form of thickening/parietal oedema with Doppler ultrasound, CTA and MRA, or by uptake of radiotracer 18F-fluorodeoxyglucose (18FDG) with PET (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRefs" href="#bib0230">3,4</a>Doppler ultrasound is the radiological technique with most experience and scientific evidence to explore involvement of the temporal artery. It is used in most reference centres and multiple prospective case series carried out for diagnostic purposes, systematic reviews and up to four meta-analyses endorse its usefulness.<a class="elsevierStyleCrossRefs" href="#bib0235">4,7</a> The most characteristic and specific ultrasound finding is the presence of a hypoechoic ring around the vessel, which does not disappear with pressure, known as a ‘halo’ (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A).<a class="elsevierStyleCrossRefs" href="#bib0235">4,8,9</a> In the most recent meta-analysis published,<a class="elsevierStyleCrossRef" href="#bib0250">7</a> the presence of this radiological finding offers a sensitivity of 77% and a specificity of 96% for the diagnosis of GCA, compared to a clinical diagnosis, and 70% and 84%, respectively, compared with a histological diagnosis. Doppler ultrasound allows us to explore, in addition to the temporal artery, other vascular territories which, in the case of the epiaortic vessels, can affect more than 50% of patients with GCA.<a class="elsevierStyleCrossRef" href="#bib0230">3</a> Thus, a joint study of the temporal, axillary and carotid arteries can increase the diagnostic yield of the test, and its systematic evaluation is recommended when the ultrasound is used for diagnostic purposes (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>B).<a class="elsevierStyleCrossRefs" href="#bib0235">4,10</a><elsevierMultimedia ident="fig0005"></elsevierMultimedia>Doppler ultrasound has its limitations. Its ability to detect radiological signs suggestive of inflammation is clearly diminished in cases where the inflammatory involvement of the temporal artery is limited to the adventitial layer of the artery or collateral vessels of small calibre.<a class="elsevierStyleCrossRef" href="#bib0270">11</a> Furthermore, although one of the benefits of Doppler ultrasound is that we can chose the ideal artery to obtain a histological sample, a randomised prospective study did not show a greater number of positive biopsies in patients who underwent an ultrasound guided TAB, compared with a group of patients where the artery was chosen based on the symptoms and findings from an exploration.<a class="elsevierStyleCrossRef" href="#bib0275">12</a> Another important point worth mentioning is that the acquisition of the image and its interpretation depends on the training and expertise of the sonographer, unlike what occurs in other radiological techniques, where this is carried out in a protocolised and automated manner (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).Like ultrasound, high resolution MRA has shown a high diagnostic yield in detecting temporal artery involvement in patients with suspected GCA. A recent meta-analysis<a class="elsevierStyleCrossRef" href="#bib0250">7</a> found that its sensitivity and specificity was 73% and 88%, respectively, compared to clinical diagnoses, and 93% and 81%, respectively, when TAB positivity is used as a reference. In addition, MRA can detect additional findings that may be useful for diagnosis, such as the engagement of the deep temporal artery or oedema in the temporalis muscle, present in up to 20% and 40% of patients, respectively.<a class="elsevierStyleCrossRef" href="#bib0280">13</a> The main limitation of the test is its limited availability and much higher cost compared to ultrasound.Using imaging techniques to study a potential large vessel inflammatory involvement can also be useful for the diagnosis of GCA. In this context, published studies are much more heterogeneous and there are a limited number of prospective studies. Some studies describe the casual diagnosis of the disease after radiological signs of large vessel vasculitis were detected in an imaging test requested for another reason.<a class="elsevierStyleCrossRef" href="#bib0285">14</a> Furthermore, PET/CT can detect large vessel vasculitis in 14% of patients with fever or inflammation of unknown origin.<a class="elsevierStyleCrossRef" href="#bib0290">15</a>Among the different radiological techniques, PET, with or without CT, is undoubtedly the most widely used to assess the presence of vasculitis in the aorta and its main branches (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>Cand D).<a class="elsevierStyleCrossRefs" href="#bib0230">3,4,16</a> In addition, when the conventional diagnostic process of a patient with suspected vasculitis is complemented with a PET, its findings influence clinical judgement and therapeutic decisions.<a class="elsevierStyleCrossRef" href="#bib0300">17</a> Multiple studies have explored the ability of PET to detect large vessel vasculitis in patients with GCA compared with controls.<a class="elsevierStyleCrossRef" href="#bib0295">16</a> Based on their results, three meta-analyses have been published that show a positron emission tomography sensitivity and specificity of around 80 and 89%, respectively, for the diagnosis of large vessel vasculitis in giant cell arteritis.<a class="elsevierStyleCrossRef" href="#bib0295">16</a>Despite this high sensitivity and specificity, it is noteworthy that among all published studies, only two prospectively explored the diagnostic yield of PET in the diagnosis of GCA.<a class="elsevierStyleCrossRef" href="#bib0250">7</a> In addition, many of the studies include patients with GCA and Takayasu arteritis (TAK), without analysing their findings separately and without considering the evolution of the disease in terms of time or the treatment being administered to the patient at the time the technique was carried out.<a class="elsevierStyleCrossRef" href="#bib0295">16</a> On the other hand, there is much heterogeneity in the criteria used to assume that the PET findings are compatible with vasculitis. Up to seven different criteria have been published to evaluate the vascular uptake of 18FDG (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). In addition, most published papers use a visual criterion of positivity, which makes their findings conditioned to high subjectivity and makes extrapolation difficult.<a class="elsevierStyleCrossRef" href="#bib0295">16</a> It is generally accepted that FDG uptake translates vasculitis when it is greater in the vascular wall than in the liver (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). However, vascular ageing and atherosclerosis, frequent in the same age range in which GCA occurs, increase the vascular uptake of FDG,<a class="elsevierStyleCrossRef" href="#bib0235">4</a> so the cut-off point from which uptake translates vasculitis is uncertain. In this regard, the semiquantitative assessment of vascular FDG uptake by the maximum standardised uptake value (SUVmax) may be useful, as it is more diagnostically sensitive than a qualitative visual scale.<a class="elsevierStyleCrossRef" href="#bib0305">18</a> With the purpose of obtaining cut-off points for FDG uptake that have diagnostic value, a prospective study with PET/CT analysed 20 controls and 32 patients with positive TAB treated for a maximum of three days.<a class="elsevierStyleCrossRef" href="#bib0310">19</a> SUVmax were obtained from the vascular regions of interest of four aortic segments and of the supra-aortic and iliofemoral territories and using receiver–operator characteristic curves, the cut-off points with the best sensitivity and specificity were calculated. The mean SUVmax in patients with GCA was significantly higher in all vascular territories compared to controls, and a mean SUVmax value of all vascular territories explored of 1.89 obtained a sensitivity of 80% and a specificity of 79% for a GCA diagnosis. Although there is a general agreement on the diagnostic value of PET, the validation of objective criteria of positivity, such as those provided in this study, is needed to standardise its use.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>18FDG-PET is not recommended for the evaluation of cranial arteries.<a class="elsevierStyleCrossRef" href="#bib0265">10</a> However, recent studies have demonstrated its ability to detect the inflammatory involvement of the temporal, maxillary and facial arteries.<a class="elsevierStyleCrossRef" href="#bib0315">20</a> It is too early to consider sensitivity and specificity in this context, but if its usefulness is confirmed in future studies, a single technique might be able to assess cranial and large vessels involvement.Doppler ultrasound versus temporal artery biopsy<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> compares the strengths and weaknesses of both techniques. In reference centres for patients with vasculitis, the sensitivity of both procedures is similar, although a recent study<a class="elsevierStyleCrossRef" href="#bib0320">21</a> has found that the sensitivity of ultrasound is greater when several arteries are explored. In contrast, specificity is higher in the case of TAB because it facilitates detecting other entities that can affect the temporal artery (amyloidosis, necrotising vasculitis, eosinophilia, infiltration due to haematological disease, etc.) and excludes the disease in cases of low clinical suspicion.<a class="elsevierStyleCrossRefs" href="#bib0320">21,22</a> As mentioned above, ultrasound can assess a much wider vascular territory than TAB, but it has limitations in detecting vascular inflammation of lower intensity and, in treated patients, its sensitivity drops much faster and more markedly than that of TAB.<a class="elsevierStyleCrossRef" href="#bib0330">23</a> Although both ultrasound and TAB depend on the experience of the radiologist and pathologist respectively,<a class="elsevierStyleCrossRef" href="#bib0320">21</a> ultrasound findings are subject to greater subjectivity.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Programming and receiving a histological result of a TAB in a timely manner is difficult, and in addition to the fact that the Doppler ultrasound is more available, has meant that the preference of many hospitals, especially European, is leaning towards that radiological technique.<a class="elsevierStyleCrossRef" href="#bib0265">10</a> However, in our opinion, a TAB should be considered for all patients who have suspected GCA, given that a histological diagnosis is still the technique of choice for patients with vasculitis as it provides a definitive diagnosis. It is in cases of high clinical suspicion and negative TAB, or in those with suspicion of large vessel involvement without cranial involvement, that imaging techniques become very useful.Prevalence and extension of large vessel involvementFor decades, evidence of inflammatory involvement of the aorta and its branches in GCA was limited to findings from sporadic autopsy or surgical studies.<a class="elsevierStyleCrossRef" href="#bib0225">2</a> Subsequently, large vessel inflammatory involvement began to be more often communicated with imaging techniques; however, most of these publications only included isolated cases or case series, studied retrospectively, with very heterogeneous patients and at different stages in the evolution of the disease.<a class="elsevierStyleCrossRef" href="#bib0225">2</a> Still today, prospective imaging studies designed to assess the prevalence and extent of large vessel involvement in GCA in unselected patients are very rare.In 2006, Blockmans et al.<a class="elsevierStyleCrossRef" href="#bib0335">24</a> published a prospective and consecutive study where they carried out a FDG-PET on 35 patients with recently diagnosed GCA (confirmed by TAB in 33 patients) before initiation of treatment. Signs of vasculitis were found on a visual scale (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) in 83% of the patients. The prevalence of aortic involvement was around 50% (54% in the abdominal portion and 51% in the thoracic), reaching 74% in the subclavian arteries. Carotid and axillary arteries involvement was 40% and involvement of the iliofemoral territory was 37%.In 2008, Agard et al.<a class="elsevierStyleCrossRef" href="#bib0340">25</a> published a prospective and consecutive study where they performed a contrast-enhanced CT on 22 patients with GCA (confirmed by TAB) during the first four weeks of treatment. The radiological sign compatible with vascular inflammation was the presence of a thickening of the aortic wall ≥2mm without an adjacent atheroma plaque. Aortitis was detected in the thoracic aorta in 45.4% of patients, and in the abdominal aorta in 22.7%. Other vascular territories were not assessed in this study.In 2012, our group published a prospective and consecutive study where we conducted an CTA on 40 patients with recently diagnosed GCA (all had a positive TAB) with a maximum of three days of treatment.<a class="elsevierStyleCrossRef" href="#bib0345">26</a> The radiological signs of vasculitis was the presence of a circumferential thickening of the vascular wall (≥2mm in the aorta and ≥1mm in its branches) without adjacent atheroma (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>E). 65% of the patients showed signs of vasculitis, and the vascular segments most affected were the aortic arch, the descending thoracic aorta and the supra-aortic vessels, with 57.5% prevalence in all three cases. This study included the evaluation of splanchnic and renal territory, involved in 22 and 7.5% of patients, respectively. It is the only published study that has systematically and prospectively explored prevalence in this territory.In addition to these three studies, another five prospective studies observed the prevalence and topography of the involvement of aorta branches detected with Doppler ultrasound.<a class="elsevierStyleCrossRef" href="#bib0230">3</a> Taken together, the involvement of different epiaortic arteries occurs in 15–30% of patients, and the prevalence of involvement in the iliofemoral territory is around 30%.<a class="elsevierStyleCrossRef" href="#bib0230">3</a>Although it has not been studied prospectively and systematically, medium-vessel involvement in GCA has also been found in imaging techniques. Isolated cases or retrospective series of patients with involvement of the vertebral artery branches, the carotid siphon or the ophthalmic artery have been described, associated with an increased risk of developing ischaemic events.<a class="elsevierStyleCrossRefs" href="#bib0225">2,4,5</a>In addition to the GCA, large vessel involvement is present in other vasculitis, such as TAK, Behçet's disease, ANCA-associated vasculitis and chronic periaortitis. It can also be seen in other entities, such as IgG4-related disease, sarcoidosis, rheumatoid arthritis, systemic lupus erythematosus or spondyloarthropathies.<a class="elsevierStyleCrossRef" href="#bib0350">27</a> Although the distribution of the lesions is similar in patients with GCA and TAK, involvement of the left carotid artery and the mesenteric artery is more frequent in TAK, while involvement of the axillary arteries is more frequent in GCA.<a class="elsevierStyleCrossRefs" href="#bib0225">2,28</a> Likewise, the topography and the mural extension of the involvement can be useful for differential diagnosis. For example, involvement of the supra-aortic trunks is typical of GCA and TAK and is uncommon in other entities. Conversely, periaortic tissue involvement is rare in GCA and TAK, and more typical of IgG4-related disease, chronic periaortitis or granulomatosis with polyangiitis.<a class="elsevierStyleCrossRef" href="#bib0350">27</a> Furthermore, in a patient with noninfectious histological inflammation detected in an eventual intervention for an aortic aneurysm, studying the extent of vascular involvement and its characteristics may help differentiate an isolated form of aortitis, either primary or associated with other processes, the existence of a large vessel systemic vasculitis or a suspicion of other diseases such as an IgG4-related disease.<a class="elsevierStyleCrossRefs" href="#bib0225">2,4</a>Structural vascular damageIn systematic prospective studies, the prevalence of aortic dilatation at the time of diagnosis of GCA is approximately 15%, and may exceed 30% after long-term follow-up, with maximum incidence between the four and eight years of the disease's evolution.<a class="elsevierStyleCrossRefs" href="#bib0340">25,26,29,30</a> It occurs almost exclusively in the thoracic aorta, with a clear predilection for its ascending segment.<a class="elsevierStyleCrossRefs" href="#bib0365">30,31</a> It is important that it is detected, since up to 50% of patients with aortic dilatation fulfil radiological criteria for surgical intervention,<a class="elsevierStyleCrossRef" href="#bib0365">30</a> and its presence, according to a recent population study, is related to a lower survival rate.<a class="elsevierStyleCrossRef" href="#bib0375">32</a>Although it is not the only factor involved,<a class="elsevierStyleCrossRefs" href="#bib0345">26,31</a> its initial inflammation causes damage and vascular remodelling that probably leads to a chronic lesion of the vessel in the form of stenosis, dilation and aneurysm. Blockmans et al.<a class="elsevierStyleCrossRef" href="#bib0380">33</a> performed a CT after a mean follow-up of 46 months (range 1–110 months) with 46 patients who had a PET at the time of diagnosis. The authors observed that the diameters of the thoracic aorta on the CT were significantly higher in patients with FDG uptake in PET. Although the few published studies that were carried out were not designed to prospectively study this potential relationship, it is likely that the presence and degree of initial vascular inflammation play an important role in the development of structural vascular damage.A CTA is the ideal technique for the diagnosis and evolutionary control of structural vascular damage. Even without the administration of contrast, a CT has an excellent spatial resolution that accurately measures the diameter of the vessel (surgical criteria) and detection of mural calcifications.<a class="elsevierStyleCrossRefs" href="#bib0230">3,34</a> In addition, CTA facilitates measuring the contrast thickness and uptake in the venous phase in the vascular wall (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>E and F) which can help differentiate, from the radiological perspective, between inflammatory activity and vascular remodelling,<a class="elsevierStyleCrossRef" href="#bib0390">35</a> as well as diagnose other vascular alterations such as mural haematomas.<a class="elsevierStyleCrossRef" href="#bib0385">34</a> MRA is also an excellent technique for assessing vascular structural damage. Compared with CTA, it has the advantage that it does not expose the patient to radiation, allows a better study of the soft tissues and can detect the presence of oedema without the administration of contrast with the T2 sequences.<a class="elsevierStyleCrossRefs" href="#bib0230">3,34</a> However, its cost and acquisition times are significantly higher, and the availability of the technique and its spatial resolution are lower (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).Effect of treatmentThe high doses of glucocorticoids used for the induction of remission of GCA impact on macrophage activation and the presence of tissue oedema,<a class="elsevierStyleCrossRef" href="#bib0395">36</a> which in turn inevitably influences the ability of imaging techniques to detect signs of vasculitis.<a class="elsevierStyleCrossRef" href="#bib0235">4</a> This is significant when the image is used for diagnostic purposes.In prospective studies, the halo in the temporal artery usually disappears after two-three weeks of glucocorticoid treatment, although its resolution has been described after only two days;<a class="elsevierStyleCrossRef" href="#bib0255">8</a> however, there are studies that describe its persistence after many weeks or even months of treatment.<a class="elsevierStyleCrossRef" href="#bib0255">8</a> After four days of treatment, the thickness of the halo decreases significantly, and the diagnostic sensitivity of ultrasound can fall from 87% to 50%.<a class="elsevierStyleCrossRef" href="#bib0255">8</a> Moreover, a significant decrease in its diagnostic yield after four-six days of treatment has been observed with an MRA of the temporal artery.<a class="elsevierStyleCrossRef" href="#bib0400">37</a>Short periods of treatment influence the detection of radiological signs of large vessel vasculitis in PET and CTA. In the case of PET, three days of treatment, despite decreasing the degree of FDG uptake, does not seem to influence its diagnostic capacity.<a class="elsevierStyleCrossRefs" href="#bib0310">19,38</a> Conversely, a period of 10 or more days can significantly affect its detection capacity.<a class="elsevierStyleCrossRefs" href="#bib0335">24,38,39</a> Moreover, the initiation of treatment increases the hepatic uptake of FDG, which influences the quantitative assessment of the vessel uptake when compared to its avidity by the liver.<a class="elsevierStyleCrossRef" href="#bib0305">18</a> Likewise, with CTA, a maximum of three days of treatment can significantly reduce the prevalence of large vessel vasculitis.<a class="elsevierStyleCrossRef" href="#bib0345">26</a>Monitoring and prognostic valueTo date, assessment of the activity of GCA is based almost exclusively on the patient's clinical symptoms and on the variation of the inflammatory reactants.<a class="elsevierStyleCrossRef" href="#bib0220">1</a> As mentioned above, treatment reduces the diagnostic yield of imaging techniques<a class="elsevierStyleCrossRefs" href="#bib0310">19,26,38</a>; however, this means the image can play a role in the assessment of activity and response to treatment during follow-up. Given the functional component of the radiological findings of PET (the FDG uptake reflects glucose consumption and, therefore, metabolic activity), they may be especially useful in follow-up, in comparison with other tests that mainly detect morphological changes.<a class="elsevierStyleCrossRefs" href="#bib0230">3,40</a> In addition, certain studies associate FDG uptake to serum levels of inflammatory reactants.<a class="elsevierStyleCrossRef" href="#bib0235">4</a> In the case of CTA and MRA, contrast uptake can also help to differentiate between activity and vascular fibrosis/remodelling.<a class="elsevierStyleCrossRefs" href="#bib0235">4,35</a>After a significant decrease in the prevalence of signs of vasculitis during the first few weeks of treatment, its persistence during follow-up is frequent.<a class="elsevierStyleCrossRefs" href="#bib0335">24,35,41</a> However, most patients are in clinical and analytical remission, so their meaning and clinical value is unclear. A recent prospective longitudinal study with PET associated a greater FDG uptake in the aorta and its branches in patients with large vessel vasculitis (GCA and TA analysed together) in clinical remission, with an increased risk of resurgence during follow-up.<a class="elsevierStyleCrossRef" href="#bib0420">41</a> Moreover, the presence of large vessel inflammation detected by imaging techniques at the time of diagnosis has also been associated with an unfavourable evolution in terms of refractoriness in certain studies,<a class="elsevierStyleCrossRefs" href="#bib0425">42,43</a> but not in others.<a class="elsevierStyleCrossRef" href="#bib0330">23</a> It should be noted that none of these studies was designed to specifically and prospectively evaluate the relationship between radiological signs of vasculitis and refractoriness, so their relationship is uncertain.ConclusionsImaging techniques have become an essential tool in the assessment of GCA. They play a very important role in the diagnosis of GCA and in the detection and assessment of the extent of structural damage, and have a potential utility in the monitoring and prognosis of the disease. Apart from Doppler ultrasound of the temporal artery, most of the published studies show promising – but not robust – results, so their findings should be validated in prospective studies that use a greater number of patients and international, multicentre collaborations.FundingSubsidised by the Marató TV3 2104/201507 and Ministry of Economy, Industry and Competitiveness (SAF 2017-88275-R) grants.Conflict of interestThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:16 [ 0 => array:3 [ "identificador" => "xres1207523" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1124526" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1207524" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1124525" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Diagnosis" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Doppler ultrasound versus temporal artery biopsy" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Prevalence and extension of large vessel involvement" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Structural vascular damage" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Effect of treatment" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Monitoring and prognostic value" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conclusions" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Funding" ] 13 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of interest" ] 14 => array:2 [ "identificador" => "xack412516" "titulo" => "Acknowledgements" ] 15 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-08-20" "fechaAceptado" => "2018-10-16" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1124526" "palabras" => array:7 [ 0 => "Giant cell arteritis" 1 => "Imaging" 2 => "Vasculitis" 3 => "Aortic aneurysm" 4 => "Positron emission tomography" 5 => "Computed tomography angiography" 6 => "Magnetic resonance imaging" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1124525" "palabras" => array:7 [ 0 => "Arteritis de células gigantes" 1 => "Técnicas de imagen" 2 => "Vasculitis" 3 => "Aneurisma aórtico" 4 => "Tomografía por emisión de positrones" 5 => "Tomografía computarizada con angiografía" 6 => "Resonancia magnética con angiografía" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Imaging has become an essential tool in the management of patients with giant cell arteritis. Cranial involvement detected by Doppler ultrasonography is an unquestionable diagnostic finding. Imaging of the aorta and its branches with positron emission tomography, computed tomography angiography or magnetic resonance imaging may also have a role in diagnosis and in the assessment of disease activity and response to treatment, but standardisation and validation are still needed before their widespread use as an outcome measure. Aortic structural damage is associated with increased mortality in giant cell arteritis; therefore, periodic screening is recommended." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Las técnicas de imagen se han convertido en una herramienta esencial en la valoración de los pacientes con arteritis de células gigantes. La detección del compromiso del territorio craneal con la ecografía Doppler tiene una utilidad diagnóstica indudable. La afectación de la aorta y sus ramas detectada mediante la tomografía por emisión de positrones, la tomografía computarizada con angiografía o la resonancia magnética con angiografía puede ayudar también en el diagnóstico y en la valoración de la actividad de la enfermedad y la respuesta al tratamiento, pero es necesaria la estandarización y validación de su uso. El desarrollo de daño vascular aórtico puede influir en la supervivencia de los pacientes con arteritis de células gigantes por lo que se recomienda su cribado periódico." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Prieto-González S, Villarreal-Compagny M, Cid MC. Utilidad de las técnicas de imagen en la valoración de la arteritis de células gigantes. Med Clin (Barc). 2019;152:495–501." ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2774 "Ancho" => 2500 "Tamanyo" => 437271 ] ] "descripcion" => array:1 [ "en" => "Doppler ultrasound showing a hypoechoic ring (halo) in a cross-sectional view of the parietal branch of the temporal artery – panel A) – and the left primitive carotid artery – panel B) – in a patient with a recent diagnosis of giant cell arteritis. Axial section of a PET/CT performed in a patient with recently diagnosed giant cell arteritis that shows linear circumferential uptake of the radiotracer in the ascending aorta wall – arrow in panel C) – descending – arrowhead in panel C) – and aortic arch – panel D). Transversal image of a CT angiography of a patient with recently diagnosed giant cell arteritis showing circumferential parietal thickening of the descending thoracic aorta in the arterial phase – arrow in panel E) – with contrast uptake in the venous phase – arrow in panel F)." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "FDG: fluorodeoxyglucose; PET: positron emission tomography; MR/MRA: magnetic resonance/with angiography; CTA: computed tomography with angiography.Source: Prieto Gonzalez et al.<a class="elsevierStyleCrossRef" href="#bib0230">3</a> and Prieto Gonzalez et al.<a class="elsevierStyleCrossRef" href="#bib0235">4</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Modality \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Findings \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Advantages \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Disadvantages \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CTA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vascular light/diameterParietal thickeningContrast uptake \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low costFast acquisition of imagesExtensive body assessmentMinimally invasiveReproducible \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RadiationContraindicated if there is allergy to contrastContraindicated if there is severe renal failureLimited resolution for small calibre vesselsRequires venepuncture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">MR/MRA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vascular light/diameterParietal thickeningOedema (without contrast)Contrast uptake \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No radiationExtensive body assessmentMinimally invasiveReproducible \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">High costGadolinium contraindicated if there is severe renal failureClaustrophobiaCannot be used with certain metallic body devicesLimited resolution for medium/small calibre vesselsLong acquisition times in extensive body assessmentRequires venepuncture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PET/PET-CT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Metabolic activity (FDG uptake) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Extensive body assessmentMinimally invasiveReproducible \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RadiationHigh costLong scan timesAbsence of an established positivity criterionNot available in all centresUnable to assess vascular lightLimited resolution for medium/small calibre vesselsRequires venepuncture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Doppler ultrasound \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vascular light/diameterPerivascular hypoechoic ring (halo) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Low costNo radiationDoes not require venepunctureReproducibleGood resolution for medium-calibre arteries \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Long exploration times in extensive body assessmentInterobserver variationDoes not allow assessment of structures in which air or bone is interposed (thoracic aorta) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Angiography \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vascular light/diameter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Extensive body assessmentReproducibleVery good resolution for small calibre arteriesTherapeutic intervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">RadiationInvasiveContraindicated if there is allergy to contrastContraindicated if there is moderate-severe renal failure \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2061135.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Imaging techniques used for the detection of vascular inflammation/remodelling in giant cell arteritis." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "FDG: fluorodeoxyglucose; PET: positron emission tomography; SUV: standard uptake value.Source: Slart et al.<a class="elsevierStyleCrossRef" href="#bib0295">16</a> and Puppo et al.<a class="elsevierStyleCrossRef" href="#bib0305">18</a>" "tablatextoimagen" => array:2 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Visual analysis \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Presence/absence of FDG uptake±uptake pattern (linear or patched) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Scale in relation to liver uptake \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 – absence of uptake \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 – mild uptake less than liver \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 – moderate uptake similar to liver \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 – intense uptake higher than liver \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Total vascular score: number of vascular segments affected multiplied by the visual scale score in relation to liver uptake \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2061133.png" ] ] 1 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Semiquantitative analysis \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Absolute value of maximum SUV in vascular wall \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ratio between maximum SUV in vascular wall and the liver \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ratio between maximum SUV in vascular wall and the lung \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ratio between maximum SUV in vascular wall and venous blood (in vena cava) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2061132.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Criteria used to evaluate the vascular uptake of the FDG radiotracer with PET in giant cell arteritis." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Biopsy \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ultrasound \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sensitivity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">40–90% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">54–95%<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Specificity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">81–90% \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Relationship with histology \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Identifies a histological pattern \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Limitation in the detection of incipient lesions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other diagnoses \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diagnostic yield under treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Does not change in <8 weeks \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">May decrease in a few days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vascular segment explored \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Small (fragment of the temporal artery) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Broad (several arteries) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dependence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pathologist \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sonographer \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2061134.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "Sensitivity increases when other cranial arteries are explored in addition to the temporal artery. 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Usefulness of imaging techniques in the management of giant cell arteritis

Utilidad de las técnicas de imagen en la valoración de la arteritis de células gigantes

Sergio Prieto-González

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sprieto@clinic.cat

Corresponding author.

, Michelle Villarreal-Compagny, María C. Cid

Servicio de Enfermedades Autoinmunes, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain

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    "titulo" => "Usefulness of imaging techniques in the management of giant cell arteritis"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Doppler ultrasound showing a hypoechoic ring &#40;halo&#41; in a cross-sectional view of the parietal branch of the temporal artery &#8211; panel A&#41; &#8211; and the left primitive carotid artery &#8211; panel B&#41; &#8211; in a patient with a recent diagnosis of giant cell arteritis&#46; Axial section of a PET&#47;CT performed in a patient with recently diagnosed giant cell arteritis that shows linear circumferential uptake of the radiotracer in the ascending aorta wall &#8211; arrow in panel C&#41; &#8211; descending &#8211; arrowhead in panel C&#41; &#8211; and aortic arch &#8211; panel D&#41;&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transversal image of a CT angiography of a patient with recently diagnosed giant cell arteritis showing circumferential parietal thickening of the descending thoracic aorta in the arterial phase &#8211; arrow in panel E&#41; &#8211; with contrast uptake in the venous phase &#8211; arrow in panel F&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Giant cell arteritis &#40;GCA&#41; is a granulomatous systemic vasculitis that predominantly affects large arteries&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">1&#44;2</span></a> Diagnosis of this large vessel involvement is facilitated with imaging techniques&#44; whose availability and quality have increased considerably in recent years&#44; encouraging its systematic use&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">3</span></a> In addition&#44; the segmental character of the vascular lesions in GCA and its variable topography &#40;the temporal artery is not always affected&#41;&#44; added to the difficulty in obtaining biopsies in certain territories &#40;aorta and main branches&#41;&#44; has meant that radiology has become important in the diagnostic approach to GCA&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">3</span></a> In addition&#44; unlike what occurs with histological samples&#44; imaging techniques allow an extensive vascular study and offer the possibility of sequential noninvasive evaluation&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The most commonly used radiological techniques in GCA are Doppler ultrasound&#59; positron emission tomography &#40;PET&#41;&#44; usually combined with computed tomography &#40;CT&#41; &#40;PET&#47;CT&#41;&#59; CT with angiography &#40;CTA&#41; and magnetic resonance angiography &#40;MRA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">4</span></a> The utility of conventional arteriography in GCA is very limited and it is reduced to the endoluminal treatment of stenotic lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">2&#44;5</span></a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the radiological findings&#44; as well as the advantages and limitations&#44; of the different imaging techniques used in GCA&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">3&#44;4</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The purpose of this review is to summarise the existing scientific evidence on the usefulness of imaging techniques for diagnosing and detecting structural vascular damage in GCA&#44; as well as its potential use in the monitoring of disease activity and the prognostic value of its findings&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Diagnosis</span><p id="par0020" class="elsevierStylePara elsevierViewall">In the last decade&#44; imaging techniques have become increasingly relevant in the diagnosis of GCA&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">3&#44;4</span></a> The diagnosis of this disease has traditionally been based on histologic demonstration of inflammation in the temporal artery&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">1</span></a> In centres where performing a temporal artery biopsy &#40;TAB&#41; in a timely manner is complicated&#44; diagnosis is often carried out according to clinical criteria&#46; This diagnostic approach entails major limitations because it typically implies using outdated <span class="elsevierStyleItalic">American College of Rheumatology</span> diagnostic qualifying criteria which were not designed for that purpose&#44; and depends heavily on the professional&#39;s experience&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">6</span></a> It is especially limiting in this scenario&#44; where the use of imaging techniques has advanced the diagnosis of the disease&#46; This is based on the observation of vascular disorder typical of GCA &#40;involvement of the temporal artery and&#47;or of the aorta and its branches&#41; by detecting radiological signs suggestive of inflammation&#44; either in the form of thickening&#47;parietal oedema with Doppler ultrasound&#44; CTA and MRA&#44; or by uptake of radiotracer <span class="elsevierStyleSup">18</span>F-fluorodeoxyglucose &#40;<span class="elsevierStyleSup">18</span>FDG&#41; with PET &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">3&#44;4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Doppler ultrasound is the radiological technique with most experience and scientific evidence to explore involvement of the temporal artery&#46; It is used in most reference centres and multiple prospective case series carried out for diagnostic purposes&#44; systematic reviews and up to four meta-analyses endorse its usefulness&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">4&#44;7</span></a> The most characteristic and specific ultrasound finding is the presence of a hypoechoic ring around the vessel&#44; which does not disappear with pressure&#44; known as a &#8216;halo&#8217; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">4&#44;8&#44;9</span></a> In the most recent meta-analysis published&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">7</span></a> the presence of this radiological finding offers a sensitivity of 77&#37; and a specificity of 96&#37; for the diagnosis of GCA&#44; compared to a clinical diagnosis&#44; and 70&#37; and 84&#37;&#44; respectively&#44; compared with a histological diagnosis&#46; Doppler ultrasound allows us to explore&#44; in addition to the temporal artery&#44; other vascular territories which&#44; in the case of the epiaortic vessels&#44; can affect more than 50&#37; of patients with GCA&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">3</span></a> Thus&#44; a joint study of the temporal&#44; axillary and carotid arteries can increase the diagnostic yield of the test&#44; and its systematic evaluation is recommended when the ultrasound is used for diagnostic purposes &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">4&#44;10</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Doppler ultrasound has its limitations&#46; Its ability to detect radiological signs suggestive of inflammation is clearly diminished in cases where the inflammatory involvement of the temporal artery is limited to the adventitial layer of the artery or collateral vessels of small calibre&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">11</span></a> Furthermore&#44; although one of the benefits of Doppler ultrasound is that we can chose the ideal artery to obtain a histological sample&#44; a randomised prospective study did not show a greater number of positive biopsies in patients who underwent an ultrasound guided TAB&#44; compared with a group of patients where the artery was chosen based on the symptoms and findings from an exploration&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">12</span></a> Another important point worth mentioning is that the acquisition of the image and its interpretation depends on the training and expertise of the sonographer&#44; unlike what occurs in other radiological techniques&#44; where this is carried out in a protocolised and automated manner &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Like ultrasound&#44; high resolution MRA has shown a high diagnostic yield in detecting temporal artery involvement in patients with suspected GCA&#46; A recent meta-analysis<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">7</span></a> found that its sensitivity and specificity was 73&#37; and 88&#37;&#44; respectively&#44; compared to clinical diagnoses&#44; and 93&#37; and 81&#37;&#44; respectively&#44; when TAB positivity is used as a reference&#46; In addition&#44; MRA can detect additional findings that may be useful for diagnosis&#44; such as the engagement of the deep temporal artery or oedema in the temporalis muscle&#44; present in up to 20&#37; and 40&#37; of patients&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">13</span></a> The main limitation of the test is its limited availability and much higher cost compared to ultrasound&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Using imaging techniques to study a potential large vessel inflammatory involvement can also be useful for the diagnosis of GCA&#46; In this context&#44; published studies are much more heterogeneous and there are a limited number of prospective studies&#46; Some studies describe the casual diagnosis of the disease after radiological signs of large vessel vasculitis were detected in an imaging test requested for another reason&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">14</span></a> Furthermore&#44; PET&#47;CT can detect large vessel vasculitis in 14&#37; of patients with fever or inflammation of unknown origin&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">15</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Among the different radiological techniques&#44; PET&#44; with or without CT&#44; is undoubtedly the most widely used to assess the presence of vasculitis in the aorta and its main branches &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a><span class="elsevierStyleSmallCaps">C</span>and D&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">3&#44;4&#44;16</span></a> In addition&#44; when the conventional diagnostic process of a patient with suspected vasculitis is complemented with a PET&#44; its findings influence clinical judgement and therapeutic decisions&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">17</span></a> Multiple studies have explored the ability of PET to detect large vessel vasculitis in patients with GCA compared with controls&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">16</span></a> Based on their results&#44; three meta-analyses have been published that show a positron emission tomography sensitivity and specificity of around 80 and 89&#37;&#44; respectively&#44; for the diagnosis of large vessel vasculitis in giant cell arteritis&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">16</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Despite this high sensitivity and specificity&#44; it is noteworthy that among all published studies&#44; only two prospectively explored the diagnostic yield of PET in the diagnosis of GCA&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">7</span></a> In addition&#44; many of the studies include patients with GCA and Takayasu arteritis &#40;TAK&#41;&#44; without analysing their findings separately and without considering the evolution of the disease in terms of time or the treatment being administered to the patient at the time the technique was carried out&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">16</span></a> On the other hand&#44; there is much heterogeneity in the criteria used to assume that the PET findings are compatible with vasculitis&#46; Up to seven different criteria have been published to evaluate the vascular uptake of <span class="elsevierStyleSup">18</span>FDG &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; In addition&#44; most published papers use a visual criterion of positivity&#44; which makes their findings conditioned to high subjectivity and makes extrapolation difficult&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">16</span></a> It is generally accepted that FDG uptake translates vasculitis when it is greater in the vascular wall than in the liver &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; However&#44; vascular ageing and atherosclerosis&#44; frequent in the same age range in which GCA occurs&#44; increase the vascular uptake of FDG&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">4</span></a> so the cut-off point from which uptake translates vasculitis is uncertain&#46; In this regard&#44; the semiquantitative assessment of vascular FDG uptake by the maximum standardised uptake value &#40;SUVmax&#41; may be useful&#44; as it is more diagnostically sensitive than a qualitative visual scale&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">18</span></a> With the purpose of obtaining cut-off points for FDG uptake that have diagnostic value&#44; a prospective study with PET&#47;CT analysed 20 controls and 32 patients with positive TAB treated for a maximum of three days&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">19</span></a> SUVmax were obtained from the vascular regions of interest of four aortic segments and of the supra-aortic and iliofemoral territories and using receiver&#8211;operator characteristic curves&#44; the cut-off points with the best sensitivity and specificity were calculated&#46; The mean SUVmax in patients with GCA was significantly higher in all vascular territories compared to controls&#44; and a mean SUVmax value of all vascular territories explored of 1&#46;89 obtained a sensitivity of 80&#37; and a specificity of 79&#37; for a GCA diagnosis&#46; Although there is a general agreement on the diagnostic value of PET&#44; the validation of objective criteria of positivity&#44; such as those provided in this study&#44; is needed to standardise its use&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleSup">18</span>FDG-PET is not recommended for the evaluation of cranial arteries&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">10</span></a> However&#44; recent studies have demonstrated its ability to detect the inflammatory involvement of the temporal&#44; maxillary and facial arteries&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">20</span></a> It is too early to consider sensitivity and specificity in this context&#44; but if its usefulness is confirmed in future studies&#44; a single technique might be able to assess cranial and large vessels involvement&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Doppler ultrasound versus temporal artery biopsy</span><p id="par0060" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> compares the strengths and weaknesses of both techniques&#46; In reference centres for patients with vasculitis&#44; the sensitivity of both procedures is similar&#44; although a recent study<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">21</span></a> has found that the sensitivity of ultrasound is greater when several arteries are explored&#46; In contrast&#44; specificity is higher in the case of TAB because it facilitates detecting other entities that can affect the temporal artery &#40;amyloidosis&#44; necrotising vasculitis&#44; eosinophilia&#44; infiltration due to haematological disease&#44; etc&#46;&#41; and excludes the disease in cases of low clinical suspicion&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">21&#44;22</span></a> As mentioned above&#44; ultrasound can assess a much wider vascular territory than TAB&#44; but it has limitations in detecting vascular inflammation of lower intensity and&#44; in treated patients&#44; its sensitivity drops much faster and more markedly than that of TAB&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">23</span></a> Although both ultrasound and TAB depend on the experience of the radiologist and pathologist respectively&#44;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">21</span></a> ultrasound findings are subject to greater subjectivity&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Programming and receiving a histological result of a TAB in a timely manner is difficult&#44; and in addition to the fact that the Doppler ultrasound is more available&#44; has meant that the preference of many hospitals&#44; especially European&#44; is leaning towards that radiological technique&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">10</span></a> However&#44; in our opinion&#44; a TAB should be considered for all patients who have suspected GCA&#44; given that a histological diagnosis is still the technique of choice for patients with vasculitis as it provides a definitive diagnosis&#46; It is in cases of high clinical suspicion and negative TAB&#44; or in those with suspicion of large vessel involvement without cranial involvement&#44; that imaging techniques become very useful&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Prevalence and extension of large vessel involvement</span><p id="par0070" class="elsevierStylePara elsevierViewall">For decades&#44; evidence of inflammatory involvement of the aorta and its branches in GCA was limited to findings from sporadic autopsy or surgical studies&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">2</span></a> Subsequently&#44; large vessel inflammatory involvement began to be more often communicated with imaging techniques&#59; however&#44; most of these publications only included isolated cases or case series&#44; studied retrospectively&#44; with very heterogeneous patients and at different stages in the evolution of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">2</span></a> Still today&#44; prospective imaging studies designed to assess the prevalence and extent of large vessel involvement in GCA in unselected patients are very rare&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In 2006&#44; Blockmans et al&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">24</span></a> published a prospective and consecutive study where they carried out a FDG-PET on 35 patients with recently diagnosed GCA &#40;confirmed by TAB in 33 patients&#41; before initiation of treatment&#46; Signs of vasculitis were found on a visual scale &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; in 83&#37; of the patients&#46; The prevalence of aortic involvement was around 50&#37; &#40;54&#37; in the abdominal portion and 51&#37; in the thoracic&#41;&#44; reaching 74&#37; in the subclavian arteries&#46; Carotid and axillary arteries involvement was 40&#37; and involvement of the iliofemoral territory was 37&#37;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">In 2008&#44; Agard et al&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">25</span></a> published a prospective and consecutive study where they performed a contrast-enhanced CT on 22 patients with GCA &#40;confirmed by TAB&#41; during the first four weeks of treatment&#46; The radiological sign compatible with vascular inflammation was the presence of a thickening of the aortic wall &#8805;2<span class="elsevierStyleHsp" style=""></span>mm without an adjacent atheroma plaque&#46; Aortitis was detected in the thoracic aorta in 45&#46;4&#37; of patients&#44; and in the abdominal aorta in 22&#46;7&#37;&#46; Other vascular territories were not assessed in this study&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In 2012&#44; our group published a prospective and consecutive study where we conducted an CTA on 40 patients with recently diagnosed GCA &#40;all had a positive TAB&#41; with a maximum of three days of treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">26</span></a> The radiological signs of vasculitis was the presence of a circumferential thickening of the vascular wall &#40;&#8805;2<span class="elsevierStyleHsp" style=""></span>mm in the aorta and &#8805;1<span class="elsevierStyleHsp" style=""></span>mm in its branches&#41; without adjacent atheroma &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>E&#41;&#46; 65&#37; of the patients showed signs of vasculitis&#44; and the vascular segments most affected were the aortic arch&#44; the descending thoracic aorta and the supra-aortic vessels&#44; with 57&#46;5&#37; prevalence in all three cases&#46; This study included the evaluation of splanchnic and renal territory&#44; involved in 22 and 7&#46;5&#37; of patients&#44; respectively&#46; It is the only published study that has systematically and prospectively explored prevalence in this territory&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In addition to these three studies&#44; another five prospective studies observed the prevalence and topography of the involvement of aorta branches detected with Doppler ultrasound&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">3</span></a> Taken together&#44; the involvement of different epiaortic arteries occurs in 15&#8211;30&#37; of patients&#44; and the prevalence of involvement in the iliofemoral territory is around 30&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">3</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">Although it has not been studied prospectively and systematically&#44; medium-vessel involvement in GCA has also been found in imaging techniques&#46; Isolated cases or retrospective series of patients with involvement of the vertebral artery branches&#44; the carotid siphon or the ophthalmic artery have been described&#44; associated with an increased risk of developing ischaemic events&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">2&#44;4&#44;5</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In addition to the GCA&#44; large vessel involvement is present in other vasculitis&#44; such as TAK&#44; Beh&#231;et&#39;s disease&#44; ANCA-associated vasculitis and chronic periaortitis&#46; It can also be seen in other entities&#44; such as IgG4-related disease&#44; sarcoidosis&#44; rheumatoid arthritis&#44; systemic lupus erythematosus or spondyloarthropathies&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">27</span></a> Although the distribution of the lesions is similar in patients with GCA and TAK&#44; involvement of the left carotid artery and the mesenteric artery is more frequent in TAK&#44; while involvement of the axillary arteries is more frequent in GCA&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">2&#44;28</span></a> Likewise&#44; the topography and the mural extension of the involvement can be useful for differential diagnosis&#46; For example&#44; involvement of the supra-aortic trunks is typical of GCA and TAK and is uncommon in other entities&#46; Conversely&#44; periaortic tissue involvement is rare in GCA and TAK&#44; and more typical of IgG4-related disease&#44; chronic periaortitis or granulomatosis with polyangiitis&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">27</span></a> Furthermore&#44; in a patient with noninfectious histological inflammation detected in an eventual intervention for an aortic aneurysm&#44; studying the extent of vascular involvement and its characteristics may help differentiate an isolated form of aortitis&#44; either primary or associated with other processes&#44; the existence of a large vessel systemic vasculitis or a suspicion of other diseases such as an IgG4-related disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">2&#44;4</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Structural vascular damage</span><p id="par0105" class="elsevierStylePara elsevierViewall">In systematic prospective studies&#44; the prevalence of aortic dilatation at the time of diagnosis of GCA is approximately 15&#37;&#44; and may exceed 30&#37; after long-term follow-up&#44; with maximum incidence between the four and eight years of the disease&#39;s evolution&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">25&#44;26&#44;29&#44;30</span></a> It occurs almost exclusively in the thoracic aorta&#44; with a clear predilection for its ascending segment&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">30&#44;31</span></a> It is important that it is detected&#44; since up to 50&#37; of patients with aortic dilatation fulfil radiological criteria for surgical intervention&#44;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">30</span></a> and its presence&#44; according to a recent population study&#44; is related to a lower survival rate&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">32</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Although it is not the only factor involved&#44;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">26&#44;31</span></a> its initial inflammation causes damage and vascular remodelling that probably leads to a chronic lesion of the vessel in the form of stenosis&#44; dilation and aneurysm&#46; Blockmans et al&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">33</span></a> performed a CT after a mean follow-up of 46 months &#40;range 1&#8211;110 months&#41; with 46 patients who had a PET at the time of diagnosis&#46; The authors observed that the diameters of the thoracic aorta on the CT were significantly higher in patients with FDG uptake in PET&#46; Although the few published studies that were carried out were not designed to prospectively study this potential relationship&#44; it is likely that the presence and degree of initial vascular inflammation play an important role in the development of structural vascular damage&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">A CTA is the ideal technique for the diagnosis and evolutionary control of structural vascular damage&#46; Even without the administration of contrast&#44; a CT has an excellent spatial resolution that accurately measures the diameter of the vessel &#40;surgical criteria&#41; and detection of mural calcifications&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">3&#44;34</span></a> In addition&#44; CTA facilitates measuring the contrast thickness and uptake in the venous phase in the vascular wall &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>E and F&#41; which can help differentiate&#44; from the radiological perspective&#44; between inflammatory activity and vascular remodelling&#44;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">35</span></a> as well as diagnose other vascular alterations such as mural haematomas&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">34</span></a> MRA is also an excellent technique for assessing vascular structural damage&#46; Compared with CTA&#44; it has the advantage that it does not expose the patient to radiation&#44; allows a better study of the soft tissues and can detect the presence of oedema without the administration of contrast with the T2 sequences&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">3&#44;34</span></a> However&#44; its cost and acquisition times are significantly higher&#44; and the availability of the technique and its spatial resolution are lower &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Effect of treatment</span><p id="par0120" class="elsevierStylePara elsevierViewall">The high doses of glucocorticoids used for the induction of remission of GCA impact on macrophage activation and the presence of tissue oedema&#44;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">36</span></a> which in turn inevitably influences the ability of imaging techniques to detect signs of vasculitis&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">4</span></a> This is significant when the image is used for diagnostic purposes&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In prospective studies&#44; the halo in the temporal artery usually disappears after two-three weeks of glucocorticoid treatment&#44; although its resolution has been described after only two days&#59;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">8</span></a> however&#44; there are studies that describe its persistence after many weeks or even months of treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">8</span></a> After four days of treatment&#44; the thickness of the halo decreases significantly&#44; and the diagnostic sensitivity of ultrasound can fall from 87&#37; to 50&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">8</span></a> Moreover&#44; a significant decrease in its diagnostic yield after four-six days of treatment has been observed with an MRA of the temporal artery&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">37</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">Short periods of treatment influence the detection of radiological signs of large vessel vasculitis in PET and CTA&#46; In the case of PET&#44; three days of treatment&#44; despite decreasing the degree of FDG uptake&#44; does not seem to influence its diagnostic capacity&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">19&#44;38</span></a> Conversely&#44; a period of 10 or more days can significantly affect its detection capacity&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">24&#44;38&#44;39</span></a> Moreover&#44; the initiation of treatment increases the hepatic uptake of FDG&#44; which influences the quantitative assessment of the vessel uptake when compared to its avidity by the liver&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">18</span></a> Likewise&#44; with CTA&#44; a maximum of three days of treatment can significantly reduce the prevalence of large vessel vasculitis&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">26</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Monitoring and prognostic value</span><p id="par0135" class="elsevierStylePara elsevierViewall">To date&#44; assessment of the activity of GCA is based almost exclusively on the patient&#39;s clinical symptoms and on the variation of the inflammatory reactants&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">1</span></a> As mentioned above&#44; treatment reduces the diagnostic yield of imaging techniques<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">19&#44;26&#44;38</span></a>&#59; however&#44; this means the image can play a role in the assessment of activity and response to treatment during follow-up&#46; Given the functional component of the radiological findings of PET &#40;the FDG uptake reflects glucose consumption and&#44; therefore&#44; metabolic activity&#41;&#44; they may be especially useful in follow-up&#44; in comparison with other tests that mainly detect morphological changes&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">3&#44;40</span></a> In addition&#44; certain studies associate FDG uptake to serum levels of inflammatory reactants&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">4</span></a> In the case of CTA and MRA&#44; contrast uptake can also help to differentiate between activity and vascular fibrosis&#47;remodelling&#46;<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">4&#44;35</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">After a significant decrease in the prevalence of signs of vasculitis during the first few weeks of treatment&#44; its persistence during follow-up is frequent&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">24&#44;35&#44;41</span></a> However&#44; most patients are in clinical and analytical remission&#44; so their meaning and clinical value is unclear&#46; A recent prospective longitudinal study with PET associated a greater FDG uptake in the aorta and its branches in patients with large vessel vasculitis &#40;GCA and TA analysed together&#41; in clinical remission&#44; with an increased risk of resurgence during follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">41</span></a> Moreover&#44; the presence of large vessel inflammation detected by imaging techniques at the time of diagnosis has also been associated with an unfavourable evolution in terms of refractoriness in certain studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">42&#44;43</span></a> but not in others&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">23</span></a> It should be noted that none of these studies was designed to specifically and prospectively evaluate the relationship between radiological signs of vasculitis and refractoriness&#44; so their relationship is uncertain&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conclusions</span><p id="par0145" class="elsevierStylePara elsevierViewall">Imaging techniques have become an essential tool in the assessment of GCA&#46; They play a very important role in the diagnosis of GCA and in the detection and assessment of the extent of structural damage&#44; and have a potential utility in the monitoring and prognosis of the disease&#46; Apart from Doppler ultrasound of the temporal artery&#44; most of the published studies show promising &#8211; but not robust &#8211; results&#44; so their findings should be validated in prospective studies that use a greater number of patients and international&#44; multicentre collaborations&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Funding</span><p id="par0150" class="elsevierStylePara elsevierViewall">Subsidised by the Marat&#243; TV3 2104&#47;201507 and Ministry of Economy&#44; Industry and Competitiveness &#40;SAF 2017-88275-R&#41; grants&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interest</span><p id="par0155" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "titulo" => "Doppler ultrasound versus temporal artery biopsy"
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          "identificador" => "sec0020"
          "titulo" => "Prevalence and extension of large vessel involvement"
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          "titulo" => "Structural vascular damage"
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          "titulo" => "Monitoring and prognostic value"
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          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2018-08-20"
    "fechaAceptado" => "2018-10-16"
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          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1124526"
          "palabras" => array:7 [
            0 => "Giant cell arteritis"
            1 => "Imaging"
            2 => "Vasculitis"
            3 => "Aortic aneurysm"
            4 => "Positron emission tomography"
            5 => "Computed tomography angiography"
            6 => "Magnetic resonance imaging"
          ]
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      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1124525"
          "palabras" => array:7 [
            0 => "Arteritis de c&#233;lulas gigantes"
            1 => "T&#233;cnicas de imagen"
            2 => "Vasculitis"
            3 => "Aneurisma a&#243;rtico"
            4 => "Tomograf&#237;a por emisi&#243;n de positrones"
            5 => "Tomograf&#237;a computarizada con angiograf&#237;a"
            6 => "Resonancia magn&#233;tica con angiograf&#237;a"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Imaging has become an essential tool in the management of patients with giant cell arteritis&#46; Cranial involvement detected by Doppler ultrasonography is an unquestionable diagnostic finding&#46; Imaging of the aorta and its branches with positron emission tomography&#44; computed tomography angiography or magnetic resonance imaging may also have a role in diagnosis and in the assessment of disease activity and response to treatment&#44; but standardisation and validation are still needed before their widespread use as an outcome measure&#46; Aortic structural damage is associated with increased mortality in giant cell arteritis&#59; therefore&#44; periodic screening is recommended&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Las t&#233;cnicas de imagen se han convertido en una herramienta esencial en la valoraci&#243;n de los pacientes con arteritis de c&#233;lulas gigantes&#46; La detecci&#243;n del compromiso del territorio craneal con la ecograf&#237;a Doppler tiene una utilidad diagn&#243;stica indudable&#46; La afectaci&#243;n de la aorta y sus ramas detectada mediante la tomograf&#237;a por emisi&#243;n de positrones&#44; la tomograf&#237;a computarizada con angiograf&#237;a o la resonancia magn&#233;tica con angiograf&#237;a puede ayudar tambi&#233;n en el diagn&#243;stico y en la valoraci&#243;n de la actividad de la enfermedad y la respuesta al tratamiento&#44; pero es necesaria la estandarizaci&#243;n y validaci&#243;n de su uso&#46; El desarrollo de da&#241;o vascular a&#243;rtico puede influir en la supervivencia de los pacientes con arteritis de c&#233;lulas gigantes por lo que se recomienda su cribado peri&#243;dico&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as&#58; Prieto-Gonz&#225;lez S&#44; Villarreal-Compagny M&#44; Cid MC&#46; Utilidad de las t&#233;cnicas de imagen en la valoraci&#243;n de la arteritis de c&#233;lulas gigantes&#46; Med Clin &#40;Barc&#41;&#46; 2019&#59;152&#58;495&#8211;501&#46;</p>"
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        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Doppler ultrasound showing a hypoechoic ring &#40;halo&#41; in a cross-sectional view of the parietal branch of the temporal artery &#8211; panel A&#41; &#8211; and the left primitive carotid artery &#8211; panel B&#41; &#8211; in a patient with a recent diagnosis of giant cell arteritis&#46; Axial section of a PET&#47;CT performed in a patient with recently diagnosed giant cell arteritis that shows linear circumferential uptake of the radiotracer in the ascending aorta wall &#8211; arrow in panel C&#41; &#8211; descending &#8211; arrowhead in panel C&#41; &#8211; and aortic arch &#8211; panel D&#41;&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transversal image of a CT angiography of a patient with recently diagnosed giant cell arteritis showing circumferential parietal thickening of the descending thoracic aorta in the arterial phase &#8211; arrow in panel E&#41; &#8211; with contrast uptake in the venous phase &#8211; arrow in panel F&#41;&#46;</p>"
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        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">FDG&#58; fluorodeoxyglucose&#59; PET&#58; positron emission tomography&#59; MR&#47;MRA&#58; magnetic resonance&#47;with angiography&#59; CTA&#58; computed tomography with angiography&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Prieto Gonzalez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">3</span></a> and Prieto Gonzalez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">4</span></a></p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Modality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Findings&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Advantages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Disadvantages&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CTA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vascular light&#47;diameterParietal thickeningContrast uptake&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Low costFast acquisition of imagesExtensive body assessmentMinimally invasiveReproducible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RadiationContraindicated if there is allergy to contrastContraindicated if there is severe renal failureLimited resolution for small calibre vesselsRequires venepuncture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MR&#47;MRA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vascular light&#47;diameterParietal thickeningOedema &#40;without contrast&#41;Contrast uptake&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No radiationExtensive body assessmentMinimally invasiveReproducible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">High costGadolinium contraindicated if there is severe renal failureClaustrophobiaCannot be used with certain metallic body devicesLimited resolution for medium&#47;small calibre vesselsLong acquisition times in extensive body assessmentRequires venepuncture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">PET&#47;PET-CT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Metabolic activity &#40;FDG uptake&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Extensive body assessmentMinimally invasiveReproducible&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RadiationHigh costLong scan timesAbsence of an established positivity criterionNot available in all centresUnable to assess vascular lightLimited resolution for medium&#47;small calibre vesselsRequires venepuncture&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Doppler ultrasound&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vascular light&#47;diameterPerivascular hypoechoic ring &#40;halo&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Low costNo radiationDoes not require venepunctureReproducibleGood resolution for medium-calibre arteries&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Long exploration times in extensive body assessmentInterobserver variationDoes not allow assessment of structures in which air or bone is interposed &#40;thoracic aorta&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Angiography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vascular light&#47;diameter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Extensive body assessmentReproducibleVery good resolution for small calibre arteriesTherapeutic intervention&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">RadiationInvasiveContraindicated if there is allergy to contrastContraindicated if there is moderate-severe renal failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2061135.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Imaging techniques used for the detection of vascular inflammation&#47;remodelling in giant cell arteritis&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at2"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">FDG&#58; fluorodeoxyglucose&#59; PET&#58; positron emission tomography&#59; SUV&#58; standard uptake value&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>&#58; Slart et al&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">16</span></a> and Puppo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">18</span></a></p>"
          "tablatextoimagen" => array:2 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Visual analysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Presence&#47;absence of FDG uptake<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>uptake pattern &#40;linear or patched&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Scale in relation to liver uptake&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#8211; absence of uptake&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#8211; mild uptake less than liver&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#8211; moderate uptake similar to liver&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#8211; intense uptake higher than liver&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Total vascular score&#58; number of vascular segments affected multiplied by the visual scale score in relation to liver uptake&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2061133.png"
              ]
            ]
            1 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Semiquantitative analysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Absolute value of maximum SUV in vascular wall&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ratio between maximum SUV in vascular wall and the liver&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ratio between maximum SUV in vascular wall and the lung&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Ratio between maximum SUV in vascular wall and venous blood &#40;in vena cava&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2061132.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Criteria used to evaluate the vascular uptake of the FDG radiotracer with PET in giant cell arteritis&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Biopsy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ultrasound&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sensitivity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">40&#8211;90&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">54&#8211;95&#37;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Specificity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">81&#8211;90&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Relationship with histology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Identifies a histological pattern&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Limitation in the detection of incipient lesions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Other diagnoses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diagnostic yield under treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Does not change in <span class="elsevierStyleMonospace">&#60;</span>8 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">May decrease in a few days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Vascular segment explored&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Small &#40;fragment of the temporal artery&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Broad &#40;several arteries&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dependence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Pathologist&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Sonographer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2061134.png"
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "&#42;"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Sensitivity increases when other cranial arteries are explored in addition to the temporal artery&#46;</p> <p class="elsevierStyleNotepara" id="npar0010"><span class="elsevierStyleItalic">Source</span>&#58; Refs&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">3&#44;4&#44;10&#44;21&#8211;23</span></a></p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Comparison of the advantages and disadvantages of biopsy with regard to Doppler ultrasound of the temporal artery for the diagnosis of giant cell arteritis&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:43 [
            0 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical features of polymyalgia rheumatica and giant cell arteritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "C&#46; Salvarani"
                            1 => "N&#46; Pipitone"
                            2 => "A&#46; Versari"
                            3 => "G&#46;G&#46; Hunder"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1038/nrrheum.2012.97"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nat Rev Rheumatol"
                        "fecha" => "2012"
                        "volumen" => "8"
                        "paginaInicial" => "509"
                        "paginaFinal" => "521"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22825731"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The spectrum of vascular involvement in giant-cell arteritis&#58; clinical consequences of detrimental vascular remodelling at different sites"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46;C&#46; Cid"
                            1 => "S&#46; Prieto-Gonzalez"
                            2 => "P&#46; Arguis"
                            3 => "G&#46; Espigol-Frigole"
                            4 => "M&#46; Butjosa"
                            5 => "J&#46; Hernandez-Rodriguez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "APMIS Suppl"
                        "fecha" => "2009"
                        "paginaInicial" => "10"
                        "paginaFinal" => "20"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
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