Brief report
Doppler ultrasonography of superficial temporal artery in a cohort of patients with strong clinical suspicion of giant cell arteritis
Ecografía Doppler de arterias temporales superficiales en la arteritis de células gigantes en una cohorte con alta sospecha clínica
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artery in a cohort of patients with strong clinical suspicion of giant cell arteritis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "151" "paginaFinal" => "153" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Paula Estrada Alarcón, Dèlia Reina, Vanessa Navarro Ángeles, Dacia Cerdà, Daniel Roig-Vilaseca, Hèctor Corominas" "autores" => array:6 [ 0 => array:3 [ "nombre" => "Paula" "apellidos" => "Estrada Alarcón" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 1 => array:3 [ "nombre" => "Dèlia" "apellidos" => "Reina" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => 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] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servei de Reumatologia, Hospital Moisès Broggi, Consorci Sanitari Integral (CSI), Sant Joan Despí (Barcelona), Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servei de Reumatologia, Hospital General de L’Hospitalet, Consorci Sanitari Integral (CSI), L’Hospitalet (Barcelona), Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Ecografía Doppler de arterias temporales superficiales en la arteritis de células gigantes en una cohorte con alta sospecha clínica" ] ] "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" => 553 "Ancho" => 1667 "Tamanyo" => 121533 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Image of superficial temporal artery oedema in longitudinal (a) and transverse (b) in patient with positive biopsy. Worth noting is the existence of an anechoic zone (asterisk) of >0.30<span class="elsevierStyleHsp" style=""></span>mm that corresponds to inflammatory oedema and translates a vasculitis base (GCA).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Giant cell arteritis (GCA) is the most common systemic vasculitis in adults. Delays in diagnosis due to its clinical heterogeneity or a lack of early treatment after diagnosis can cause serious complications, such as irreversible sudden blindness.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Clinical diagnosis is not simple and is based on ACR (American College of Rheumatology) classification criteria, which are not always sufficient: diagnosis can only be confirmed when there is a histological sample of the artery affected with indisputable signs of vascular inflammation.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Currently, biopsy of the superficial temporal artery is the gold standard for a definitive diagnosis: the presence of multinucleated giant cells, macrophages and CD4 (+) lymphocytes is the most frequently objective finding. Even so, there is variability of histological patterns and they can lead to confusion. A negative result due to segmental involvement of the disease, the stage of the disease or technical difficulty, greatly complicates the clinical diagnosis and treatment processes.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> In a remarkable part of the patients, diagnosis according to clinical criteria obliges them to continue treatment with oral glucocorticoids even when the biopsy is negative, as the possibility of irreversible serious complications exists. From the initial studies evaluating USTA in GCA<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1,5,6</span></a> until today, and with the substantial improvement of high-end ultrasound scanners grey scale and Doppler colour software, there are promising data showing that this non-invasive tool offers a growing evidence basis that can support the diagnosis of GCA using imaging techniques. Thus, recently, the usefulness of USTA to evaluate inflammation of the vascular wall has been demonstrated.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> On this basis and evidence, and in the absence of validated diagnostic criteria, the present study proposes an ultrasound evaluation in consecutive patients of a cohort with clinical suspicion, in order to reinforce the role of USTA in the final diagnosis of GCA and to assess its possible inclusion in the classification criteria in its next and necessary revision.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">During the 2015–2016 period, an observational and descriptive cohort study was conducted in which 120 USTA performed on 60 patients with clinical suspicion of GCA were evaluated. The derivations of the USTA carried out were sourced from Rheumatology services, Internal Medicine, Neurology, Ophthalmology and general practitioners. The patients provided their informed consent to obtain and use their data. For this review, patients with diagnostic suspicion based on classic ACR criteria were considered and separated into the following groups according to their clinical presentation: (1) exclusive cephalic symptoms (recent onset of headaches, mandibular claudication or visual disturbances); (2) polymyalgia rheumatica, according to EULAR/ACR 2012 criteria<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a>; (3) non-specific toxic or febrile syndrome, once infectious causes were ruled out and with screening for negative neoplasms, and (4) stroke in vertebrobasilar territory, without relevant cardiovascular antecedents or findings of atherogenic or embolic aetiology after directed study. Demographic data were collected: age, sex, time of evolution of the disease, cumulative dose of oral glucocorticoids at the time of performing the ultrasound, clinical signs and symptoms associated with the acute episode and serological values. Likewise, a follow-up was carried out after the initial episode to note the definitive diagnosis and the clinical or histological confirmation of GCA. Blind ultrasound (Esaote MyLAB 70 XVG), 5–15<span class="elsevierStyleHsp" style=""></span>MHz probe for grey scale and Doppler colour (gain of 60% and PRF of 1500<span class="elsevierStyleHsp" style=""></span>kHz) was carried out in the examination room by rheumatology specialists with a long history and experience in musculoskeletal ultrasound and, specifically, in the vascular evaluation (Doppler) of temporal arteries. After an exploratory grey scale evaluation, the temporal arteries were evaluated bilaterally by Doppler colour, in their frontoorbital and parietal branches, making longitudinal and transverse cuts in all patients. Of the nonspecific findings described to date as suggestive of GCA through Doppler (vascular stenoses, arterial occlusion and halo sign) only the ‘halo sign’ specificity was considered positive (>0.30<span class="elsevierStyleHsp" style=""></span>mm).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> In those cases in which a hypoechoic image of >0.30<span class="elsevierStyleHsp" style=""></span>mm was observed around at least one of the evaluated vessels, the test was considered as suggestive of GCA (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). To avoid errors in the measurement, technical adjustments were made such as correcting the inclination of the Doppler colour box, confirming the halo in grey scale and objectifying the findings in both planes. At the discretion of the requesting physician, some patients underwent biopsy or positron emission tomography<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>computed tomography (PET-CT).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0015" class="elsevierStylePara elsevierViewall">The cohort's general characteristics are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. We excluded eight patients for not meeting ACR clinical criteria for GCA. Given the suspicion of a GCA and considering the fact that some patients belonged to one or more groups, according to their clinical presentation, they were distributed as follows: exclusively cranial symptoms (17.3%), accompanied by PMR (11.5%)), with febrile/toxic syndrome (11.5%), onset with VB stroke (5.8%). In 53.8% of the chaos groups overlapped.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">After the USTA, a biopsy was performed in 25 patients (48.1%), which was positive in 64% (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Seven patients were studied by PET-CT to search for large vessel vasculitis, which was normal in all cases. Of this subgroup, all but one were treated with glucocorticoids, mainly, methylprednisolone boluses, with an average cumulative dose of 4.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.7<span class="elsevierStyleHsp" style=""></span>g (mean daily dose 68.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>62.3). 42.9% presented a final diagnosis of GCA, which was correlated with a positive halo sign in 100% of the cases.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">A total of 12 patients (48%) presented a final diagnosis of GCA by classic criteria of ACR, positive USTA and positive biopsy. We decided, using different clinical criteria, to not perform a temporal artery biopsy and treatment was scheduled according to the clinical diagnosis of GCA, with favourable evolution, in only two (3.8%) cases with positive USTA. In three cases (5.8%) of patients with negative ultrasound examination, without suspicion in the USTA, we decided, according to clinical suspicion, to perform a biopsy, which was positive. The sensitivity and specificity of the ultrasound in our cohort of patients were 81.8 and 93.3%, respectively, with a positive predictive value (PPV) of 90.1% and a negative predictive value (NPV) of 87.5%.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Since Smith et al.’s initial study,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> USTA has evolved over time parallel to the improvement of scanning probes and software to analyse the vascular image of the inflamed artery. Ultrasound has proven to be a reliable tool in identifying signs suggestive of vasculitis, such as oedema of the vascular wall, which is represented by a hypo- or anechoic halo. It has proven to be useful in diagnosis, provided that it is carried out according to a standardised methodology, and with such validity that some authors consider that it could be part of the decision-making process for the clinical-ecographic diagnosis of GCA.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8,9</span></a> In our cohort, we observed that the ultrasound performed in patients with clinical suspicion of GCA had a sensitivity of 81.8% and a specificity of 93.3%, together with a PPV of 90% and a NPV of 87.5%, which initially contrasts with the ACR classification criteria (sensitivity of 65.37%, specificity of 62.89%) with a PPV of 70% and a NPV of 57.82%. A halo sign, especially if it is bilateral, is a consistent value predictor of GCA, with a strength level that allows this technique to be recommended in clinical practice.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> We concur with these authors and believe that it should be included in the new GCA classification criteria framework.</p><p id="par0035" class="elsevierStylePara elsevierViewall">This study has a series of limitations. The first is that, although we have performed the ultrasound evaluation in the two temporal arteries of patients, which has increased sensitivity, we do not evaluate other locations such as occipital or axillary arteries. Another important technical limitation is found in a recent publication, which evaluated whether the increase in intima-media thickness in arteriosclerotic disease correlates with the increase in said thickness of the temporal arteries, and whether this could be a confounding factor in the diagnosis of GCA by giving a greater number of false positives.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">As a summary, the results support bilateral temporal artery ultrasound as a useful, painless, rapid, accessible and highly diagnostic technique in patients with suspected GCA. The proposal to include USTA for diagnosis is more consistent if there is a positive bilateral halo sign: a temporal biopsy could be done instead of the arterial one, without losing sensibility and, above all, improving specificity. The interpretation of the result will be based mainly on the “pre-test” probability of presenting the disease, on the explorer's experience and on the accessibility to high-end devices.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1231355" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1144047" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1231354" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Fundamento y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1144048" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 9 => array:2 [ "identificador" => "xack421439" "titulo" => "Acknowledgements" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-12-01" "fechaAceptado" => "2018-04-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1144047" "palabras" => array:3 [ 0 => "Temporal artery" 1 => "Ultrasound" 2 => "Giant cell arteritis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1144048" "palabras" => array:3 [ 0 => "Arteria temporal" 1 => "Ecografía" 2 => "Arteritis de células gigantes" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background and objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Giant cell arteritis (GCA) is the most frequent systemic vasculitis in adults. In recent years, the usefulness of temporal artery ultrasound (TAUS) as a diagnostic tool to assess the underlying inflammation of the vascular wall during the inflammatory process has been under clinical investigation.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Observational and descriptive cohort study of 120 TAUS in 60 patients with clinical suspicions of GCA, according to the ACR (American College of Rheumatology) classification criteria.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Among all patients who underwent ultrasound, 42.3% met clinical criteria for GCA according to ACR. Sensitivity and specificity of TAUS in our cohort with clinical suspicion was 81.8% and 93.3%, respectively. A PPV of 90.1% and a VPN of 87.5% were observed.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Our results showed that TAUS as a useful, indolent, fast, and accessible tool with high diagnostic specificity and diagnostic value.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Background and objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Fundamento y objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La arteritis de células gigantes (ACG) es la vasculitis sistémica más frecuente en adultos. En los últimos años, existe un interés creciente en evaluar la utilidad de la ecografía de arterias temporales superficiales (EATS), que permite valorar la inflamación de la pared vascular.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y métodos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio de cohorte observacional y descriptivo de 120 EATS a 60 pacientes con sospecha clínica de ACG según criterios clásicos de ACR (American College of Rheumatology).</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">De todos los pacientes a quienes se les realizó la EATS, el 42,3% presentó diagnóstico de ACG según los criterios de clasificación ACR. La sensibilidad y la especificidad de la ecografía en nuestra cohorte de pacientes con alta sospecha clínica fueron de 81,8 y 93,3%, respectivamente, con un VPP de 90,1% y un VPN de 87,5%.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Los resultados avalan la ecografía de arteria temporal bilateral como una técnica útil, indolora, rápida, accesible, de alta especificidad y amplia validez diagnóstica.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Fundamento y objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Estrada Alarcón P, Reina D, Navarro Ángeles V, Cerdà D, Roig-Vilaseca D, Corominas H. Ecografía Doppler de arterias temporales superficiales en la arteritis de células gigantes en una cohorte con alta sospecha clínica. Med Clin (Barc). 2019;153:151–153.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 553 "Ancho" => 1667 "Tamanyo" => 121533 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Image of superficial temporal artery oedema in longitudinal (a) and transverse (b) in patient with positive biopsy. Worth noting is the existence of an anechoic zone (asterisk) of >0.30<span class="elsevierStyleHsp" style=""></span>mm that corresponds to inflammatory oedema and translates a vasculitis base (GCA).</p>" ] ] 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" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">GCA: giant cell arteritis; TA: temporal artery; PCR: C-reactive protein; ESR: erythrocyte sedimentation rate.</p>" "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">Data at the time of ultrasound (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>52) \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"><span class="elsevierStyleItalic">n</span> (%) \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">Sex, male \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">30 (57) \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">Age >50 \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">51 (98) \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">Typical headache GCA \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">27 (52.8) \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">TA 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">17 (32.6) \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">ESR >50<span class="elsevierStyleHsp" style=""></span>mm/h \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">47 (90.4) \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">Mean ESR mm/h \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">82.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>43.4 \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">CRP, mg/L \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">80.7<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>83.9 \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">Haemoglobin, g/L \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">11.6<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>2.1 \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">Leukocytes, ×10<span class="elsevierStyleSup">9</span>/L \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">10.5<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>3.6 \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">Platelets, ×10<span class="elsevierStyleSup">9</span>/L \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">304.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>129.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2103632.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Patients’ general characteristics.</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="spar0065" class="elsevierStyleSimplePara elsevierViewall">GCA: giant cell arteritis; TA: temporal artery; USTA: ultrasound of the superficial temporal artery.</p>" "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">USTA halo sign (+) <span class="elsevierStyleItalic">n</span>, (%) \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">USTA halo sign (−) <span class="elsevierStyleItalic">n</span>, (%) \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">Total (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>52) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18 (34.6) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">29 (55.7) \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">Final diagnosis of GCA (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>22) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (72.7) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (27.3) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (6.67) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 (93.3) \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">TA biopsies (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>25) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16 (64) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 (36) \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">GCA positive biopsies (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>16) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 (81.3) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (18.6) \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">Negative biopsies of GCA (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>9) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (33.3) \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="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 (66.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2103633.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">USTA results.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "What is the best approach to diagnosing large vessel vasculitis?" 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