18F-FDG PET/CT for the detection of large vessel vasculitis in patients with polymyalgia rheumatica | Revista Española de Medicina Nuclear e Imagen Molecular (English Edition)

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Grosso, B. Fattori, D. Volterrani, S. Chondrogiannis, G. Boni, A. Nacci, M.C. Marzola, D. Rubello" "autores" => array:8 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Grosso" ] 1 => array:2 [ "nombre" => "B." "apellidos" => "Fattori" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Volterrani" ] 3 => array:2 [ "nombre" => "S." "apellidos" => "Chondrogiannis" ] 4 => array:2 [ "nombre" => "G." "apellidos" => "Boni" ] 5 => array:2 [ "nombre" => "A." "apellidos" => "Nacci" ] 6 => array:2 [ "nombre" => "M.C." "apellidos" => "Marzola" ] 7 => array:2 [ "nombre" => "D." "apellidos" => "Rubello" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2253808915000804?idApp=UINPBA00004N" "url" => "/22538089/0000003400000005/v1_201508130058/S2253808915000804/v1_201508130058/en/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "Original Article" "titulo" => "18F-FDG PET/CT for the detection of large vessel vasculitis in patients with polymyalgia rheumatica" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "275" "paginaFinal" => "281" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "C. Lavado-Pérez, I. Martínez-Rodríguez, N. Martínez-Amador, I. Banzo, R. Quirce, J. Jiménez-Bonilla, M. De Arcocha-Torres, Z. Bravo-Ferrer, M. Jiménez-Alonso, J.L. López-Defilló, R. Blanco, M.A. González-Gay, J.M. Carril" "autores" => array:13 [ 0 => array:3 [ "nombre" => "C." "apellidos" => "Lavado-Pérez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "I." "apellidos" => "Martínez-Rodríguez" "email" => array:1 [ 0 => "mimartinez@humv.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "N." "apellidos" => "Martínez-Amador" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "I." "apellidos" => "Banzo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "R." "apellidos" => "Quirce" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "J." "apellidos" => "Jiménez-Bonilla" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "M." "apellidos" => "De Arcocha-Torres" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 7 => array:3 [ "nombre" => "Z." "apellidos" => "Bravo-Ferrer" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 8 => array:3 [ "nombre" => "M." "apellidos" => "Jiménez-Alonso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 9 => array:3 [ "nombre" => "J.L." "apellidos" => "López-Defilló" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] 10 => array:3 [ "nombre" => "R." "apellidos" => "Blanco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 11 => array:3 [ "nombre" => "M.A." "apellidos" => "González-Gay" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 12 => array:3 [ "nombre" => "J.M." "apellidos" => "Carril" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Nuclear Medicine, Molecular Imaging Group (IDIVAL), Marqués de Valdecilla University Hospital, University of Cantabria, Santander, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Rheumatology, Marqués de Valdecilla University Hospital, University of Cantabria, Santander, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "18F-FDG PET/TAC en pacientes con polimialgia reumática y sospecha de vasculitis de grandes vasos asociada" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1282 "Ancho" => 2168 "Tamanyo" => 104772 ] ] "descripcion" => array:1 [ "en" => "A 66-year-old woman with polymyalgia rheumatica in whom symptomatology worsened after steroid treatment was discontinued. Erythrocyte sedimentation rate was 72mm/h. Axial (A) and sagittal (B) 18F-FDG PET/CT views showed an intense and very well delineated uptake along the thoracic aorta wall confirming aortitis. A high dose steroid therapy was restarted and the patient showed a good clinical and biochemical response." ] ] ] "textoCompleto" => "IntroductionPolymyalgia rheumatica (PMR) is a relatively common inflammatory rheumatic disease characterized by aches and morning stiffness in the neck, shoulders and pelvic girdles affecting older people.PMR frequently occurs as an isolated condition, showing in general a rapid response to low-dose steroid therapy, but it may present concomitantly with large vessels vasculitis (LVV)<a class="elsevierStyleCrossRefs" href="#bib0155">1–5</a>. LVV is due to a leukocytic infiltration of the vessel walls in large arteries, especially the aorta and its main branches, and increases the risk of vascular complications such as aneurysms, stenosis, and stroke<a class="elsevierStyleCrossRefs" href="#bib0180">6–8</a>. An association between LVV and PMR has been previously described and several authors consider both processes as part of the same disease<a class="elsevierStyleCrossRefs" href="#bib0160">2,3,9,10</a>. Thus, a positive temporal biopsy for giant cell arteritis (GCA) was found in 20% of the patients with PMR and no symptoms of GCA<a class="elsevierStyleCrossRefs" href="#bib0205">11,12</a> and, on the other hand, a polymyalgic symptomatology has been found in 40–50% of the patients with GCA<a class="elsevierStyleCrossRefs" href="#bib0165">3,13,14</a>. The lack of improvement after steroid therapy, the presence of non-specific symptoms (fatigue, fever, weight loss, night sweats), and a prolonged increased C-reactive protein level or erythrocyte sedimentation rate raises the suspicion of an associated LVV which is often overlooked. In order to prevent irreversible tissue damage of the vessel walls, an early diagnosis and treatment and a close monitoring of these patients is mandatory. However, the diagnosis of an associated LVV remains a challenge. Temporal artery biopsy is frequently negative due to the segmental nature of this inflammation, the likelihood of exclusive extracraneal involvement or not sufficient sample for a reliable histopathological analysis. The major limitation of the structural imaging techniques (Doppler ultrasound, magnetic resonance imaging and computerized tomography) is the low sensitivity for the detection of the early inflammatory involvement as they only show the late anatomical changes such as stenosis and aneurysms<a class="elsevierStyleCrossRef" href="#bib0225">15</a>. In addition, they do not provide accurate information on the exact extent and intensity of the disease.Positron emission tomography (PET) is a powerful tool that provides highly sensitive functional imaging at a molecular level, revealing one of the important pathophysiological processes underlying inflammation<a class="elsevierStyleCrossRef" href="#bib0230">16</a>. Therefore, the advantage of 18F-FDG PET/CT imaging is that vessel wall inflammation can be detected early during the development of the disease before morphological changes are seen<a class="elsevierStyleCrossRef" href="#bib0235">17</a>. Additionally, it allows the evaluation of the whole body in a single examination and provides the anatomical information due to the CT component.In previous studies, 18F-FDG PET/CT has widely proved to be useful in the early diagnosis, the assessment of the extent of LVV and the monitoring of treatment response<a class="elsevierStyleCrossRefs" href="#bib0235">17–24</a>. However, there are only a few published work focused on the vascular inflammation using 18F-FDG PET/CT in patients with PMR, and none of them specifically involving therapy, which is a relevant issue. In this context, we have designed this study with the aim of assessing the impact of 18F-FDG PET/CT in the diagnosis and management of patients with LVV associated to PMR.Materials and methodsPatientsThis prospective study included 40 consecutive patients (27 women and 13 men, mean age: 68.10±10.27 years) with PMR and suspicion of associated LVV submitted for 18F-FDG PET/CT scan between May 2013 and January 2015. The suspicion of associated LVV rose from the clinical data in 33 out of the 40 patients (including abnormal temporal artery on physical examination, headache of recent onset, visual symptoms, constitutional syndrome, fever, intermittent claudication of the lower limbs, lack of treatment response) and/or biochemical data in 34 patients (based on increased erythrocyte sedimentation rate and/or C-reactive protein).The mean erythrocyte sedimentation rate (ESR) was 39.03±26.07mm/h (normal 1–20mm/h) and the mean plasma C-reactive protein (CRP) level was 1.39±1.54mg/dl (normal <0.5mg/dl).The final diagnosis was established by the combination of clinical and biochemical data, treatment response, 18F-FDG PET/CT initial findings and follow up, temporal artery biopsy, and conventional radiological imaging. According to these criteria, the patients were classified into two groups: patients with a diagnosis of LVV associated to PMR (26 out of the 40 patients, 65%) and patients without LVV (14 out of the 40, 35%). There were no significant differences between both groups of patients regarding sex, age, ESR or CRP (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The final diagnosis of the 14 patients without LVV was atypical PMR (5 patients), ankylosing spondylitis (2 patients), rheumatoid arthritis (2 patients), panarteritis nodosa (1 patient) and in 4 patients a definitive diagnosis has not been established.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Twenty-eight out of the 40 patients (70%) were on treatment during 18F-FDG PET/CT scan: 20 with a final diagnosis of LVV (19 were receiving steroids and 1 steroids plus methotrexate) and 8 without LVV (6 were receiving steroids and 2 steroids plus methotrexate).18F-FDG PET/CT acquisitionPatients fasted for at least 6h before the examination. 18F-FDG PET/CT scan was obtained 180′ after intravenous injection of 7MBq/kg of 18F-FDG. The serum glucose level was below 160mg/dl in all patients (mean value: 110.51±21.45mg/dl). Whole body scan including lower limbs was acquired using a Biograph LSO Pico 3D from Siemens Healthcare Molecular Imaging (Hoffman Estates, IL, USA). A low-dose CT scan (50mAs, 130kv) for attenuation correction and anatomic localization was first obtained. Then, a PET scan was acquired (250s/bed position). Iterative reconstruction was performed using the ordered subset expectation maximization (OSEM) algorithm applying two iterations and eight subsets.Analysis of 18F-FDG PET/CT imagesTwo experienced nuclear medicine specialists blinded to clinical, radiological and laboratory data performed a visual analysis of 18F-FDG PET/CT images by consensus.Five vascular regions were analyzed: supra-aortic trunks (SAT), thoracic aorta (TA), abdominal aorta (AA), iliac arteries (IA) and femoral/tibioperoneal arteries (FTA). The intensity of 18F-FDG uptake in each region was graded from 0 to 3 in comparison to the liver uptake (0: no uptake, 1: lower than liver uptake, 2: similar to liver uptake, and 3: higher than liver uptake). Vasculitis was reported when a lineal uptake along the vessel wall showing a grade 2 or 3 intensity in at least one vascular region.The CT images were used to anatomical localization and also to evaluate the presence of vessel calcification and to compare the regional distribution of calcification and FDG uptake.The results obtained for patients with and without a final diagnosis of LVV were compared. In addition, the therapeutic management after 18F-FDG PET/CT of the patients with a diagnosis of LVV was evaluated.Statistical analysisAll data are expressed as mean±standard deviation (SD). The p value was calculated using the Mann–Whitney U-test for nonparametric data and the chi-square using AnalystSoft Biostat Version 2009 for Windows (AnalystSoft Inc., Vancouver, Canada). Statistical significance was established at p values lower than 0.05.The study was approved by the hospital ethical committee and all patients signed a written informed consent.ResultsPatients with a final diagnosis of LVVAn overall approach to the results obtained in patients with a final diagnosis of LVV according to the intensity of 18F-FDG uptake for the different vascular regions is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>, while in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> a more detailed information for each patient is included.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>18F-FDG uptake was observed at the SAT in 16 patients (61.54%), and the intensity of uptake was grade 1 in 6 patients, grade 2 in 8 patients and grade 3 in 2 patients.With regard to the TA region, all 26 patients (100%) with a final diagnosis of LVV showed 18F-FDG uptake. The intensity of uptake was grade 3 in 10 patients (38.46%) and grade 2 in 14 patients (53.85%). In 2 patients (7.69%) the intensity of the TA uptake was grade 1. In these 2 patients (no. 25 and 26) the greater intensity of uptake, grade 2, was observed in the FTA.The AA showed 18F-FDG uptake grade 1 in 14 patients and grade 2 in 3 patients. The IA showed 18F-FDG uptake grade 1 in 5 patients and grade 2 in 1 patient. None of the patients showed a grade 3 uptake at the AA or IA.Finally, 14 patients showed 18F-FDG uptake at the FTA (grade 1 in 6 patients, grade 2 in 4 patients and grade 3 in 4 patients). Seven of these 14 patients had symptomatology in the lower extremities (3 patients had a 1 grade uptake, 2 patients a grade 2 and 2 patients a grade 3) and the other 7 presented no symptoms.The intensity of uptake at the FTA was lower than TA in 7 patients, equal in 3 and higher in 4 patients (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In 3 of these 4 patients with a higher uptake at the FTA compared to the TA the predominant symptomatology was in the lower limbs.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Three patients (no. 5, 9 and 20) showed 18F-FDG uptake in all vascular regions evaluated, the highest intensity of uptake being at the TA, the SAT and the FTA.Patients without LVVFour of the 14 patients without LVV (28.57%) showed no uptake in the 5 evaluated vascular regions.In the remaining 10 patients (71.43%) only a grade 1 uptake was observed in 1 or 2 vascular regions: in 9 patients the uptake was detected at the TA (lineal pattern in 7 and patchy in 2), in 3 at the SAT, in 3 at the AA and, finally, in 3 at the FTA. No patient showed vascular uptake grade 2 or 3 (<a class="elsevierStyleCrossRefs" href="#tbl0020">Tables 4 and 5</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia>Impact of 18F-FDG PET/CT in the management and follow-up of patients with a diagnosis of LVVTwenty out of the 26 patients with a diagnosis of LVV were on treatment at the time of PET/CT examination and six were not treated (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>18F-FDG PET/CT findings led to a change of therapy in 17 out of these 20 previously treated patients (85%). In 6 of them the steroid dose was increased and in 11 the steroid dose was increased and/or methotrexate or tocilizumab was added. In the other 3 patients (15%) no changes were made on the previously established steroid therapy. On the other hand, in all of the 6 no previously treated patients at the time of PET/CT a steroid and/or methotrexate therapy was started or reintroduced (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>With regard to outcome, 19 out of the 26 patients (73.08%) with LVV had a good clinical and laboratory response and in 8 of them a new PET/CT performed to monitor treatment response showed a decrease of 18F-FDG uptake. In 6 patients (23.08%) a poor response or worsening was observed despite treatment increase and the follow-up PET/CT showed an increase in the vascular uptake. Finally, 1 patient (3.84%) in whom the treatment was not changed suffered a worsening prompting increased treatment.DiscussionThe first time vascular 18F-FDG uptake in patients with PMR was reported in 1999. 18F-FDG uptake was observed in the thoracic vessels (4 out of the 5 patients) and the upper leg vessels (3 out of the 5 patients).<a class="elsevierStyleCrossRef" href="#bib0160">2</a> Since them, several authors have also reported vascular 18F-FDG uptake in patients with PMR. In a study including 25 patients, a vascular uptake was observed in 75% of the cases. The sensitivity for the TA was 56%, the specificity was 98% and the positive predictive value 93%. The uptake in the leg arteries was less specific (77%).<a class="elsevierStyleCrossRef" href="#bib0165">3</a>Moosig et al. studied 13 untreated patients with active PMR, using both a visual and a quantitative analysis. They described increased 18F-FDG uptake in the aorta and its main branches in 12 of these patients (92.3%), with a strong correlation with the inflammatory parameters and a significant decrease of uptake during the follow-up.<a class="elsevierStyleCrossRef" href="#bib0170">4</a>Vascular involvement, especially in the subclavian arteries, was reported in another article in 31% of the patients with isolated PMR and in whom the temporal artery biopsy was negative. The authors noted that the vascular uptake was less frequent and less intense in comparison with patients with GCA and decreased during follow-up in most patients.<a class="elsevierStyleCrossRef" href="#bib0245">19</a>In our study, 65% of the patients were diagnosed of LVV. The discrepancies between our results and the published articles according to the percentage of patients with PMR that showed vascular involvement can be explained by a combination of several factors such as the heterogeneity of the population regarding age, sex, inclusion criteria, treatment, etc. There are also some other technical aspects that should be taken into account such as the different acquisition protocols and criteria for interpretation of PET/CT images used. Thus, we use a more delayed acquisition in comparison to that applied for oncologic purposes as it has demonstrated a better visualization of the vessel wall uptake due to the decrease of the blood pool activity and the increase in the lesion/background ratio.<a class="elsevierStyleCrossRef" href="#bib0255">21</a> An increased 18F-FDG uptake time was also recommended by others.<a class="elsevierStyleCrossRef" href="#bib0275">25</a>Depending on the different vascular regions evaluated the incidence of vascular involvement was very different. It should be highlighted that the TA was the most frequently involved region and it also showed the most intense 18F-FDG uptake (grade 2 or 3 in more than 90% of the cases). This is in accordance with previous studies, both for GCA and PMR, who reported the TA as the most frequent and specific site of inflammation.<a class="elsevierStyleCrossRefs" href="#bib0160">2,4,21</a>The SAT was the second most frequently involved vascular region, and grade 2 the predominant intensity of uptake. The percentage of AA involvement was similar to the SAT, although in this case the intensity was much lower. The FTA showed 18F-FDG uptake in more than half of the patients. Finally, the IA were the less involved arteries and in almost all cases, the intensity of the uptake was mild and limited to its initial portion. Our results are not in accordance with those of a study published in 2012 including 14 untreated patients with active PMR and 17 controls. In the cited study, although a significantly higher vascular uptake was found in patients with PMR compared with controls, the intensity of uptake was very mild in most of the patients and only 2 showed intense 18F-FDG uptake in the aorta and subclavian arteries.<a class="elsevierStyleCrossRef" href="#bib0280">26</a> However, it should be considered that the two populations evaluated are very different (patients with PMR and a high suspicion of LVV based on clinical and laboratory data in the present study vs. asymptomatic patients for arteritis) regarding the pretest probability of vascular inflammation.An important aspect is the association between the PET/CT findings and symptomatology. Thus, regarding the involvement of the leg arteries and, as we already noted, more than a half of the patients (14 out of 26) with a diagnosis of LVV showed 18F-FDG uptake at the FTA. The intensity of the uptake was predominantly grade 2 or 3. Interestingly, only half of these 14 patients had symptomatology in the lower extremities complaining of pain and intermittent claudication. The other 7 patients were asymptomatic for the legs, in spite of a high intensity of 18F-FDG uptake (grade 3) in some cases. In 4 patients the uptake at the FTA was more intense than in the TA, in 3 of them the predominant symptoms involved the lower extremities. In summary, the vascular uptake in the lower extremities explained the symptomatology in some patients although an intense 18F-FDG uptake in the FTA was not always accompanied by specific symptoms.Another interesting issue that deserves a detailed analysis is the result obtained in the group of patients without LVV. Thus, a grade 1 uptake was seen in more than 70% of these patients within a maximum of 1 or 2 vascular regions, more frequently at the TA, followed by the SAT, the AA and the FTA. Most authors agree that a mild vascular 18F-FDG uptake is seen in controls and is not indicative of vascular inflammatory involvement<a class="elsevierStyleCrossRefs" href="#bib0160">2,27</a> although this could be closely related with the time of acquisition and, in this sense, semiquantitative analysis could help to a more objective interpretation.<a class="elsevierStyleCrossRef" href="#bib0285">27</a> A mild 18F-FDG uptake in the leg arteries has been described in more than 26% of the controls.<a class="elsevierStyleCrossRef" href="#bib0160">2</a> This uptake is considered less specific for vasculitis and has been attributed to atherosclerosis, especially when a patchy pattern was observed. In this sense, the morphological information provided by the CT component of the PET/CT is important establishing the presence of calcifications within the arterial wall.As in most of the published work, a high percentage of our patients were under therapy with steroids or other immunosuppressive drugs at the moment of the PET/CT scan. It has been reported that a previous therapy causes a decrease in the intensity of the vessel wall uptake that should be taken into account when interpreting the PET/CT findings.<a class="elsevierStyleCrossRef" href="#bib0250">20</a> However, despite a previous treatment in these patients, the technique proved to be useful for the patients’ management. A study published in 2008 reported that 3 out of 8 patients (37.5%) with PMR and low-dosage steroid-resistant were diagnosed of LVV by PET.<a class="elsevierStyleCrossRef" href="#bib0290">28</a>The reports on the impact of 18F-FDG PET/CT on the clinical management of patients with LVV are scarce. Thus, Fuchs et al. published an interesting study performed in patients with and without immunosuppressive therapy and suspicion of LVV, also using a visual analysis of the vascular uptake in comparison to the liver uptake. The addition of 18F-FDG PET/CT changed the treatment recommendation in more than 20% of patients both with and without immunosuppressive therapy.<a class="elsevierStyleCrossRef" href="#bib0295">29</a> However, to the best of our knowledge, there are no published studies specifically addressed to evaluate the impact in the management of patients with PMR and suspicion of LVV. Our results prove the strong influence of 18F-FDG PET/CT findings in the therapeutic approach of the patients with vascular inflammation as it prompted an intensification in the treatment in a high percentage of the cases. During the outcome, a good clinical and laboratory response and a decrease on 18F-FDG uptake was noted in more than 70% of these patients. However, a small number of patients showed a clinical worsening and increased 18F-FDG uptake despite treatment intensification. It should be emphasize that we have not found significant differences between patients with a good or a poor response to treatment according to symptomatology, ESR, CRP level or PET/CT findings. Therefore, PET/CT was not able to predict the treatment response in these patients. In this sense, it as has been previously reported both in patients with GCA and PMR that 18F-FDG PET/CT is not a good predictor of relapse and is not able to identify those patients who will require a longer steroid therapy.<a class="elsevierStyleCrossRefs" href="#bib0245">19,30</a>The main limitations of this study, as it happens in most of these kinds of studies, are related to the absence of a gold standard for the diagnosis of LVV and the lack of a histological confirmation. Also, the use of the PET/CT itself as a criterion for the diagnosis and for the therapeutic decision obviously may introduce a bias.In conclusion, our results confirmed that 18F-FDG PET/CT was a useful tool in identifying patients with LVV associated to PMR, providing valuable information on the extent and intensity of the vascular involvement and allowing a reliable follow-up of the patients. The detection of vascular inflammation by 18F-FDG PET/CT had an important impact and led to a change of treatment in a high percentage of the patients with a diagnosis of LVV.Conflict of interestThe authors declare that they have no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres540820" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 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" => "xpalclavsec560289" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres540819" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec560288" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patients" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "F-FDG PET/CT acquisition" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Analysis of F-FDG PET/CT images" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Patients with a final diagnosis of LVV" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Patients without LVV" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Impact of F-FDG PET/CT in the management and follow-up of patients with a diagnosis of LVV" ] ] ] 7 => array:2 [ "identificador" => "sec0055" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Conflict of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-04-23" "fechaAceptado" => "2015-05-27" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec560289" "palabras" => array:6 [ 0 => "Polymyalgia rheumatica" 1 => "Large vessel vasculitis" 2 => "Aortitis" 3 => "Giant cell arteritis" 4 => "18F-FDG PET/CT" 5 => "Positron emission tomography" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec560288" "palabras" => array:6 [ 0 => "Polimialgia reumática" 1 => "Vasculitis de grandes vasos" 2 => "Aortitis" 3 => "Arteritis de células gigantes" 4 => "18F-FDG PET/TAC" 5 => "Tomografía por emisión de positrones" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "PurposePolymyalgia rheumatica (PMR) may present together with large vessel vasculitis (LVV), and frequently requires a more intensive therapy. The aim of the study was to evaluate the impact of 18F-FDG PET/CT in the diagnosis and management of LVV associated to PMR. Material and methodsThis prospective study included 40 consecutive patients (27 women/13 men, 68.10±10.27 years) with PMR and suspicion of associated LVV submitted for 18F-FDG PET/CT. A PET/CT scan was obtained 180min after 18F-FDG intravenous injection. A visual analysis was performed on the images. Five vascular regions were evaluated: supra-aortic trunks (SAT), thoracic aorta (TA), abdominal aorta (AA), iliac arteries (IA), and femoral/tibioperoneal arteries (FTA). The intensity of uptake was graded from 0 to 3. A final diagnosis of LVV was established in 26/40 patients (65%). ResultsIn the 26 patients with a diagnosis of LVV, the highest intensity of 18F-FDG uptake was observed in the TA, SAT, and FTA. All of these patients showed uptake at the TA, with grade 2 and 3 in most cases. In 4 of the 14 patients without LVV, no uptake was observed in any vascular region, and in the other 10 patients only a grade 1 uptake was observed in 1 or to 2 territories. Out of the 20 treated LVV patients, 18F-FDG PET/CT led to a therapeutic change in 17 (85%). Conclusion18F-FDG PET/CT was useful in identifying patients with LVV associated to PMR. The detection of vascular inflammation had an important impact, and led to a change of treatment in a high percentage of patients with LVV." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 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" => "ObjetivoLa polimialgia reumática (PMR) puede presentarse asociada a vasculitis de grandes vasos (VGV), necesitando frecuentemente una intensificación del tratamiento. Nuestro objetivo fue evaluar el impacto de la 18F-FDG PET/TAC en el diagnóstico y tratamiento de VGV asociada a PMR. Material y métodosEste estudio prospectivo incluyó 40 pacientes consecutivos (27 mujeres/13 hombres, 68,10±10,27 años) con PMR y sospecha de VGV asociada evaluados con 18F-FDG PET/TAC. Los estudios PET/TAC fueron obtenidos 180 minutos después de la inyección intravenosa de 18F-FDG. Se realizó un análisis visual de la intensidad de captación (0–3) en troncos supraaórticos (TSA), aorta torácica (AT), aorta abdominal (AA), arterias ilíacas (AI) y arterias femoro/tibioperoneales (AFT). Se estableció un diagnóstico final de VGV en 26/40 pacientes (65%). ResultadosEn los 26 pacientes con diagnóstico de VGV la mayor intensidad de captación de 18F-FDG se objetivó en AT, TSA y AFT. En todos ellos se observó captación en la AT, principalmente grado 2 y 3. En 4 de los 14 sin VGV no se visualizó captación en ninguna región vascular y en los otros 10 solo se observó captación grado 1 en uno o 2 territorios. De los 20 pacientes con VGV previamente tratados, la 18F-FDG PET/TC motivó un cambio terapéutico en 17 (85%). ConclusionesLa 18F-FDG PET/TAC fue una herramienta útil para identificar pacientes con VGV asociada a PMR. La detección de inflamación vascular tuvo un importante impacto, motivando un cambio de tratamiento en un alto porcentaje de los pacientes con VGV." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "multimedia" => array:8 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1985 "Ancho" => 2258 "Tamanyo" => 214632 ] ] "descripcion" => array:1 [ "en" => "A 78-year-old man with polymyalgia rheumatica for 3 years, poor treatment response and clinical and biochemical worsening after stopping steroid treatment. Sagittal (A) and axial (B) 18F-FDG PET/CT views showed a grade 2 uptake at the thoracic aorta. The maximum intensity projection image (C) showed a more intense uptake at the lower extremities arteries." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1325 "Ancho" => 2259 "Tamanyo" => 167053 ] ] "descripcion" => array:1 [ "en" => "Therapeutic management in the 26 patients with polymyalgia rheumatica and a final diagnosis of large vessel vasculitis (LVV: large vessel vasculitis, MTX: methotrexate, TCZ: tocilizumab)." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1282 "Ancho" => 2168 "Tamanyo" => 104772 ] ] "descripcion" => array:1 [ "en" => "A 66-year-old woman with polymyalgia rheumatica in whom symptomatology worsened after steroid treatment was discontinued. Erythrocyte sedimentation rate was 72mm/h. Axial (A) and sagittal (B) 18F-FDG PET/CT views showed an intense and very well delineated uptake along the thoracic aorta wall confirming aortitis. A high dose steroid therapy was restarted and the patient showed a good clinical and biochemical response." ] ] 3 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "F: female; M: male; ESR: erythrocyte sedimentation rate; CRP: C-reactive protein." "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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Group of patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex (F/M) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age (years) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ESR (mm/h) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">CRP (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">All patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27/13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68.10±10.27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41.58±26.76 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.38±1.55 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Vasculitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18/8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">68.46±8.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.50±28.02 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.28±1.38 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">No vasculitis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">9/5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67.43±13.06 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39.86±25.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.57±1.85 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Vasculitis vs. no vasculitis (p value) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.7525 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7876 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.8205 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.9322 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab868436.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Patient characteristics." ] ] 4 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "STA: supra-aortic trunks; TA: thoracic aorta; AA: abdominal aorta: IA: iliac arteries, FTA: femoral/tibioperoneal arteries." "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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grade of 18F-FDG uptake \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SAT \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">AA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FTA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">29 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab868440.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Intensity of 18F-FDG uptake and vascular regions in the 26 patients with large vessel vasculitis." ] ] 5 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "STA: supra-aortic trunks; TA: thoracic aorta; AA: abdominal aorta: IA: iliac arteries, FTA: femoral/tibioperoneal arteries." "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="table-head " align="left" valign="top" scope="col">No. patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="5" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Intensity of 18F-FDG uptake</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SAT \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">AA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FTA \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">17 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">19 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">21 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">22 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">23 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">25 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab868437.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Patchy uptake." ] ] ] "descripcion" => array:1 [ "en" => "18F-FDG uptake in each of the 26 patients with large vessel vasculitis according to the different vascular regions evaluated." ] ] 6 => array:7 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "STA: supra-aortic trunks; TA: thoracic aorta; AA: abdominal aorta: IA: iliac arteries, FTA: femoral/tibioperoneal arteries." "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="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grade of 18F-FDG uptake \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SAT \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">AA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FTA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">– \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab868438.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Intensity of 18F-FDG uptake and vascular regions in the 14 patients with a final diagnosis of no large vessel vasculitis." ] ] 7 => array:7 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "STA: supra-aortic trunks; TA: thoracic aorta; AA: abdominal aorta: IA: iliac arteries, FTA: femoral/tibioperoneal arteries." "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="table-head " align="left" valign="top" scope="col">No. patient \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="5" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Intensity of 18F-FDG uptake</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SAT \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">AA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IA \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FTA \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">12 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="char" valign="top">14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab868439.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "Patchy uptake." ] ] ] "descripcion" => array:1 [ "en" => "18F-FDG uptake in each of the 14 patients with a final diagnosis of no large vessel vasculitis according to the different vascular regions evaluated." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0155" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The spectrum of polymyalgia reumática in northwestern Spain: incidence and analysis of variables associated with relapse in a 10 year study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M.A. González-Gay" 1 => "C. 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Original Article

18F-FDG PET/CT for the detection of large vessel vasculitis in patients with polymyalgia rheumatica

18F-FDG PET/TAC en pacientes con polimialgia reumática y sospecha de vasculitis de grandes vasos asociada

C. Lavado-Péreza, I. Martínez-Rodrígueza,

Corresponding author

mimartinez@humv.es

Corresponding author.

, N. Martínez-Amadora, I. Banzoa, R. Quircea, J. Jiménez-Bonillaa, M. De Arcocha-Torresa, Z. Bravo-Ferrera, M. Jiménez-Alonsoa, J.L. López-Defillóa, R. Blancob, M.A. González-Gayb, J.M. Carrila

a Department of Nuclear Medicine, Molecular Imaging Group (IDIVAL), Marqués de Valdecilla University Hospital, University of Cantabria, Santander, Spain

b Department of Rheumatology, Marqués de Valdecilla University Hospital, University of Cantabria, Santander, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Polymyalgia rheumatica &#40;PMR&#41; is a relatively common inflammatory rheumatic disease characterized by aches and morning stiffness in the neck&#44; shoulders and pelvic girdles affecting older people&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">PMR frequently occurs as an isolated condition&#44; showing in general a rapid response to low-dose steroid therapy&#44; but it may present concomitantly with large vessels vasculitis &#40;LVV&#41;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">1&#8211;5</span></a>&#46; LVV is due to a leukocytic infiltration of the vessel walls in large arteries&#44; especially the aorta and its main branches&#44; and increases the risk of vascular complications such as aneurysms&#44; stenosis&#44; and stroke<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">6&#8211;8</span></a>&#46; An association between LVV and PMR has been previously described and several authors consider both processes as part of the same disease<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">2&#44;3&#44;9&#44;10</span></a>&#46; Thus&#44; a positive temporal biopsy for giant cell arteritis &#40;GCA&#41; was found in 20&#37; of the patients with PMR and no symptoms of GCA<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">11&#44;12</span></a> and&#44; on the other hand&#44; a polymyalgic symptomatology has been found in 40&#8211;50&#37; of the patients with GCA<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">3&#44;13&#44;14</span></a>&#46; The lack of improvement after steroid therapy&#44; the presence of non-specific symptoms &#40;fatigue&#44; fever&#44; weight loss&#44; night sweats&#41;&#44; and a prolonged increased C-reactive protein level or erythrocyte sedimentation rate raises the suspicion of an associated LVV which is often overlooked&#46; In order to prevent irreversible tissue damage of the vessel walls&#44; an early diagnosis and treatment and a close monitoring of these patients is mandatory&#46; However&#44; the diagnosis of an associated LVV remains a challenge&#46; Temporal artery biopsy is frequently negative due to the segmental nature of this inflammation&#44; the likelihood of exclusive extracraneal involvement or not sufficient sample for a reliable histopathological analysis&#46; The major limitation of the structural imaging techniques &#40;Doppler ultrasound&#44; magnetic resonance imaging and computerized tomography&#41; is the low sensitivity for the detection of the early inflammatory involvement as they only show the late anatomical changes such as stenosis and aneurysms<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">15</span></a>&#46; In addition&#44; they do not provide accurate information on the exact extent and intensity of the disease&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Positron emission tomography &#40;PET&#41; is a powerful tool that provides highly sensitive functional imaging at a molecular level&#44; revealing one of the important pathophysiological processes underlying inflammation<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">16</span></a>&#46; Therefore&#44; the advantage of <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT imaging is that vessel wall inflammation can be detected early during the development of the disease before morphological changes are seen<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">17</span></a>&#46; Additionally&#44; it allows the evaluation of the whole body in a single examination and provides the anatomical information due to the CT component&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In previous studies&#44; <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT has widely proved to be useful in the early diagnosis&#44; the assessment of the extent of LVV and the monitoring of treatment response<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">17&#8211;24</span></a>&#46; However&#44; there are only a few published work focused on the vascular inflammation using <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT in patients with PMR&#44; and none of them specifically involving therapy&#44; which is a relevant issue&#46; In this context&#44; we have designed this study with the aim of assessing the impact of <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT in the diagnosis and management of patients with LVV associated to PMR&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0025" class="elsevierStylePara elsevierViewall">This prospective study included 40 consecutive patients &#40;27 women and 13 men&#44; mean age&#58; 68&#46;10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;27 years&#41; with PMR and suspicion of associated LVV submitted for <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT scan between May 2013 and January 2015&#46; The suspicion of associated LVV rose from the clinical data in 33 out of the 40 patients &#40;including abnormal temporal artery on physical examination&#44; headache of recent onset&#44; visual symptoms&#44; constitutional syndrome&#44; fever&#44; intermittent claudication of the lower limbs&#44; lack of treatment response&#41; and&#47;or biochemical data in 34 patients &#40;based on increased erythrocyte sedimentation rate and&#47;or C-reactive protein&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The mean erythrocyte sedimentation rate &#40;ESR&#41; was 39&#46;03<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>26&#46;07<span class="elsevierStyleHsp" style=""></span>mm&#47;h &#40;normal 1&#8211;20<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#41; and the mean plasma C-reactive protein &#40;CRP&#41; level was 1&#46;39<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;54<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;normal &#60;0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The final diagnosis was established by the combination of clinical and biochemical data&#44; treatment response&#44; <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT initial findings and follow up&#44; temporal artery biopsy&#44; and conventional radiological imaging&#46; According to these criteria&#44; the patients were classified into two groups&#58; patients with a diagnosis of LVV associated to PMR &#40;26 out of the 40 patients&#44; 65&#37;&#41; and patients without LVV &#40;14 out of the 40&#44; 35&#37;&#41;&#46; There were no significant differences between both groups of patients regarding sex&#44; age&#44; ESR or CRP &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The final diagnosis of the 14 patients without LVV was atypical PMR &#40;5 patients&#41;&#44; ankylosing spondylitis &#40;2 patients&#41;&#44; rheumatoid arthritis &#40;2 patients&#41;&#44; panarteritis nodosa &#40;1 patient&#41; and in 4 patients a definitive diagnosis has not been established&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">Twenty-eight out of the 40 patients &#40;70&#37;&#41; were on treatment during <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT scan&#58; 20 with a final diagnosis of LVV &#40;19 were receiving steroids and 1 steroids plus methotrexate&#41; and 8 without LVV &#40;6 were receiving steroids and 2 steroids plus methotrexate&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080"><span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT acquisition</span><p id="par0045" class="elsevierStylePara elsevierViewall">Patients fasted for at least 6<span class="elsevierStyleHsp" style=""></span>h before the examination&#46; <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT scan was obtained 180&#8242; after intravenous injection of 7<span class="elsevierStyleHsp" style=""></span>MBq&#47;kg of <span class="elsevierStyleSup">18</span>F-FDG&#46; The serum glucose level was below 160<span class="elsevierStyleHsp" style=""></span>mg&#47;dl in all patients &#40;mean value&#58; 110&#46;51<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21&#46;45<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#46; Whole body scan including lower limbs was acquired using a Biograph LSO Pico 3D from Siemens Healthcare Molecular Imaging &#40;Hoffman Estates&#44; IL&#44; USA&#41;&#46; A low-dose CT scan &#40;50<span class="elsevierStyleHsp" style=""></span>mAs&#44; 130<span class="elsevierStyleHsp" style=""></span>kv&#41; for attenuation correction and anatomic localization was first obtained&#46; Then&#44; a PET scan was acquired &#40;250<span class="elsevierStyleHsp" style=""></span>s&#47;bed position&#41;&#46; Iterative reconstruction was performed using the ordered subset expectation maximization &#40;OSEM&#41; algorithm applying two iterations and eight subsets&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Analysis of <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT images</span><p id="par0050" class="elsevierStylePara elsevierViewall">Two experienced nuclear medicine specialists blinded to clinical&#44; radiological and laboratory data performed a visual analysis of <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT images by consensus&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Five vascular regions were analyzed&#58; supra-aortic trunks &#40;SAT&#41;&#44; thoracic aorta &#40;TA&#41;&#44; abdominal aorta &#40;AA&#41;&#44; iliac arteries &#40;IA&#41; and femoral&#47;tibioperoneal arteries &#40;FTA&#41;&#46; The intensity of <span class="elsevierStyleSup">18</span>F-FDG uptake in each region was graded from 0 to 3 in comparison to the liver uptake &#40;0&#58; no uptake&#44; 1&#58; lower than liver uptake&#44; 2&#58; similar to liver uptake&#44; and 3&#58; higher than liver uptake&#41;&#46; Vasculitis was reported when a lineal uptake along the vessel wall showing a grade 2 or 3 intensity in at least one vascular region&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The CT images were used to anatomical localization and also to evaluate the presence of vessel calcification and to compare the regional distribution of calcification and FDG uptake&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The results obtained for patients with and without a final diagnosis of LVV were compared&#46; In addition&#44; the therapeutic management after <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT of the patients with a diagnosis of LVV was evaluated&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0070" class="elsevierStylePara elsevierViewall">All data are expressed as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>standard deviation &#40;SD&#41;&#46; The <span class="elsevierStyleItalic">p</span> value was calculated using the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span>-test for nonparametric data and the chi-square using AnalystSoft Biostat Version 2009 for Windows &#40;AnalystSoft Inc&#46;&#44; Vancouver&#44; Canada&#41;&#46; Statistical significance was established at <span class="elsevierStyleItalic">p</span> values lower than 0&#46;05&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The study was approved by the hospital ethical committee and all patients signed a written informed consent&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Patients with a final diagnosis of LVV</span><p id="par0080" class="elsevierStylePara elsevierViewall">An overall approach to the results obtained in patients with a final diagnosis of LVV according to the intensity of <span class="elsevierStyleSup">18</span>F-FDG uptake for the different vascular regions is shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#44; while in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> a more detailed information for each patient is included&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleSup">18</span>F-FDG uptake was observed at the SAT in 16 patients &#40;61&#46;54&#37;&#41;&#44; and the intensity of uptake was grade 1 in 6 patients&#44; grade 2 in 8 patients and grade 3 in 2 patients&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">With regard to the TA region&#44; all 26 patients &#40;100&#37;&#41; with a final diagnosis of LVV showed <span class="elsevierStyleSup">18</span>F-FDG uptake&#46; The intensity of uptake was grade 3 in 10 patients &#40;38&#46;46&#37;&#41; and grade 2 in 14 patients &#40;53&#46;85&#37;&#41;&#46; In 2 patients &#40;7&#46;69&#37;&#41; the intensity of the TA uptake was grade 1&#46; In these 2 patients &#40;no&#46; 25 and 26&#41; the greater intensity of uptake&#44; grade 2&#44; was observed in the FTA&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">The AA showed <span class="elsevierStyleSup">18</span>F-FDG uptake grade 1 in 14 patients and grade 2 in 3 patients&#46; The IA showed <span class="elsevierStyleSup">18</span>F-FDG uptake grade 1 in 5 patients and grade 2 in 1 patient&#46; None of the patients showed a grade 3 uptake at the AA or IA&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Finally&#44; 14 patients showed <span class="elsevierStyleSup">18</span>F-FDG uptake at the FTA &#40;grade 1 in 6 patients&#44; grade 2 in 4 patients and grade 3 in 4 patients&#41;&#46; Seven of these 14 patients had symptomatology in the lower extremities &#40;3 patients had a 1 grade uptake&#44; 2 patients a grade 2 and 2 patients a grade 3&#41; and the other 7 presented no symptoms&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The intensity of uptake at the FTA was lower than TA in 7 patients&#44; equal in 3 and higher in 4 patients &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In 3 of these 4 patients with a higher uptake at the FTA compared to the TA the predominant symptomatology was in the lower limbs&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">Three patients &#40;no&#46; 5&#44; 9 and 20&#41; showed <span class="elsevierStyleSup">18</span>F-FDG uptake in all vascular regions evaluated&#44; the highest intensity of uptake being at the TA&#44; the SAT and the FTA&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Patients without LVV</span><p id="par0115" class="elsevierStylePara elsevierViewall">Four of the 14 patients without LVV &#40;28&#46;57&#37;&#41; showed no uptake in the 5 evaluated vascular regions&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">In the remaining 10 patients &#40;71&#46;43&#37;&#41; only a grade 1 uptake was observed in 1 or 2 vascular regions&#58; in 9 patients the uptake was detected at the TA &#40;lineal pattern in 7 and patchy in 2&#41;&#44; in 3 at the SAT&#44; in 3 at the AA and&#44; finally&#44; in 3 at the FTA&#46; No patient showed vascular uptake grade 2 or 3 &#40;<a class="elsevierStyleCrossRefs" href="#tbl0020">Tables 4 and 5</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Impact of <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT in the management and follow-up of patients with a diagnosis of LVV</span><p id="par0125" class="elsevierStylePara elsevierViewall">Twenty out of the 26 patients with a diagnosis of LVV were on treatment at the time of PET&#47;CT examination and six were not treated &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT findings led to a change of therapy in 17 out of these 20 previously treated patients &#40;85&#37;&#41;&#46; In 6 of them the steroid dose was increased and in 11 the steroid dose was increased and&#47;or methotrexate or tocilizumab was added&#46; In the other 3 patients &#40;15&#37;&#41; no changes were made on the previously established steroid therapy&#46; On the other hand&#44; in all of the 6 no previously treated patients at the time of PET&#47;CT a steroid and&#47;or methotrexate therapy was started or reintroduced &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">With regard to outcome&#44; 19 out of the 26 patients &#40;73&#46;08&#37;&#41; with LVV had a good clinical and laboratory response and in 8 of them a new PET&#47;CT performed to monitor treatment response showed a decrease of <span class="elsevierStyleSup">18</span>F-FDG uptake&#46; In 6 patients &#40;23&#46;08&#37;&#41; a poor response or worsening was observed despite treatment increase and the follow-up PET&#47;CT showed an increase in the vascular uptake&#46; Finally&#44; 1 patient &#40;3&#46;84&#37;&#41; in whom the treatment was not changed suffered a worsening prompting increased treatment&#46;</p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">The first time vascular <span class="elsevierStyleSup">18</span>F-FDG uptake in patients with PMR was reported in 1999&#46; <span class="elsevierStyleSup">18</span>F-FDG uptake was observed in the thoracic vessels &#40;4 out of the 5 patients&#41; and the upper leg vessels &#40;3 out of the 5 patients&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> Since them&#44; several authors have also reported vascular <span class="elsevierStyleSup">18</span>F-FDG uptake in patients with PMR&#46; In a study including 25 patients&#44; a vascular uptake was observed in 75&#37; of the cases&#46; The sensitivity for the TA was 56&#37;&#44; the specificity was 98&#37; and the positive predictive value 93&#37;&#46; The uptake in the leg arteries was less specific &#40;77&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">3</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Moosig et al&#46; studied 13 untreated patients with active PMR&#44; using both a visual and a quantitative analysis&#46; They described increased <span class="elsevierStyleSup">18</span>F-FDG uptake in the aorta and its main branches in 12 of these patients &#40;92&#46;3&#37;&#41;&#44; with a strong correlation with the inflammatory parameters and a significant decrease of uptake during the follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">4</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Vascular involvement&#44; especially in the subclavian arteries&#44; was reported in another article in 31&#37; of the patients with isolated PMR and in whom the temporal artery biopsy was negative&#46; The authors noted that the vascular uptake was less frequent and less intense in comparison with patients with GCA and decreased during follow-up in most patients&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">19</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">In our study&#44; 65&#37; of the patients were diagnosed of LVV&#46; The discrepancies between our results and the published articles according to the percentage of patients with PMR that showed vascular involvement can be explained by a combination of several factors such as the heterogeneity of the population regarding age&#44; sex&#44; inclusion criteria&#44; treatment&#44; etc&#46; There are also some other technical aspects that should be taken into account such as the different acquisition protocols and criteria for interpretation of PET&#47;CT images used&#46; Thus&#44; we use a more delayed acquisition in comparison to that applied for oncologic purposes as it has demonstrated a better visualization of the vessel wall uptake due to the decrease of the blood pool activity and the increase in the lesion&#47;background ratio&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">21</span></a> An increased <span class="elsevierStyleSup">18</span>F-FDG uptake time was also recommended by others&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">25</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Depending on the different vascular regions evaluated the incidence of vascular involvement was very different&#46; It should be highlighted that the TA was the most frequently involved region and it also showed the most intense <span class="elsevierStyleSup">18</span>F-FDG uptake &#40;grade 2 or 3 in more than 90&#37; of the cases&#41;&#46; This is in accordance with previous studies&#44; both for GCA and PMR&#44; who reported the TA as the most frequent and specific site of inflammation&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">2&#44;4&#44;21</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">The SAT was the second most frequently involved vascular region&#44; and grade 2 the predominant intensity of uptake&#46; The percentage of AA involvement was similar to the SAT&#44; although in this case the intensity was much lower&#46; The FTA showed <span class="elsevierStyleSup">18</span>F-FDG uptake in more than half of the patients&#46; Finally&#44; the IA were the less involved arteries and in almost all cases&#44; the intensity of the uptake was mild and limited to its initial portion&#46; Our results are not in accordance with those of a study published in 2012 including 14 untreated patients with active PMR and 17 controls&#46; In the cited study&#44; although a significantly higher vascular uptake was found in patients with PMR compared with controls&#44; the intensity of uptake was very mild in most of the patients and only 2 showed intense <span class="elsevierStyleSup">18</span>F-FDG uptake in the aorta and subclavian arteries&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">26</span></a> However&#44; it should be considered that the two populations evaluated are very different &#40;patients with PMR and a high suspicion of LVV based on clinical and laboratory data in the present study vs&#46; asymptomatic patients for arteritis&#41; regarding the pretest probability of vascular inflammation&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">An important aspect is the association between the PET&#47;CT findings and symptomatology&#46; Thus&#44; regarding the involvement of the leg arteries and&#44; as we already noted&#44; more than a half of the patients &#40;14 out of 26&#41; with a diagnosis of LVV showed <span class="elsevierStyleSup">18</span>F-FDG uptake at the FTA&#46; The intensity of the uptake was predominantly grade 2 or 3&#46; Interestingly&#44; only half of these 14 patients had symptomatology in the lower extremities complaining of pain and intermittent claudication&#46; The other 7 patients were asymptomatic for the legs&#44; in spite of a high intensity of <span class="elsevierStyleSup">18</span>F-FDG uptake &#40;grade 3&#41; in some cases&#46; In 4 patients the uptake at the FTA was more intense than in the TA&#44; in 3 of them the predominant symptoms involved the lower extremities&#46; In summary&#44; the vascular uptake in the lower extremities explained the symptomatology in some patients although an intense <span class="elsevierStyleSup">18</span>F-FDG uptake in the FTA was not always accompanied by specific symptoms&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Another interesting issue that deserves a detailed analysis is the result obtained in the group of patients without LVV&#46; Thus&#44; a grade 1 uptake was seen in more than 70&#37; of these patients within a maximum of 1 or 2 vascular regions&#44; more frequently at the TA&#44; followed by the SAT&#44; the AA and the FTA&#46; Most authors agree that a mild vascular <span class="elsevierStyleSup">18</span>F-FDG uptake is seen in controls and is not indicative of vascular inflammatory involvement<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">2&#44;27</span></a> although this could be closely related with the time of acquisition and&#44; in this sense&#44; semiquantitative analysis could help to a more objective interpretation&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">27</span></a> A mild <span class="elsevierStyleSup">18</span>F-FDG uptake in the leg arteries has been described in more than 26&#37; of the controls&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">2</span></a> This uptake is considered less specific for vasculitis and has been attributed to atherosclerosis&#44; especially when a patchy pattern was observed&#46; In this sense&#44; the morphological information provided by the CT component of the PET&#47;CT is important establishing the presence of calcifications within the arterial wall&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">As in most of the published work&#44; a high percentage of our patients were under therapy with steroids or other immunosuppressive drugs at the moment of the PET&#47;CT scan&#46; It has been reported that a previous therapy causes a decrease in the intensity of the vessel wall uptake that should be taken into account when interpreting the PET&#47;CT findings&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">20</span></a> However&#44; despite a previous treatment in these patients&#44; the technique proved to be useful for the patients&#8217; management&#46; A study published in 2008 reported that 3 out of 8 patients &#40;37&#46;5&#37;&#41; with PMR and low-dosage steroid-resistant were diagnosed of LVV by PET&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">28</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">The reports on the impact of <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT on the clinical management of patients with LVV are scarce&#46; Thus&#44; Fuchs et al&#46; published an interesting study performed in patients with and without immunosuppressive therapy and suspicion of LVV&#44; also using a visual analysis of the vascular uptake in comparison to the liver uptake&#46; The addition of <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT changed the treatment recommendation in more than 20&#37; of patients both with and without immunosuppressive therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">29</span></a> However&#44; to the best of our knowledge&#44; there are no published studies specifically addressed to evaluate the impact in the management of patients with PMR and suspicion of LVV&#46; Our results prove the strong influence of <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT findings in the therapeutic approach of the patients with vascular inflammation as it prompted an intensification in the treatment in a high percentage of the cases&#46; During the outcome&#44; a good clinical and laboratory response and a decrease on <span class="elsevierStyleSup">18</span>F-FDG uptake was noted in more than 70&#37; of these patients&#46; However&#44; a small number of patients showed a clinical worsening and increased <span class="elsevierStyleSup">18</span>F-FDG uptake despite treatment intensification&#46; It should be emphasize that we have not found significant differences between patients with a good or a poor response to treatment according to symptomatology&#44; ESR&#44; CRP level or PET&#47;CT findings&#46; Therefore&#44; PET&#47;CT was not able to predict the treatment response in these patients&#46; In this sense&#44; it as has been previously reported both in patients with GCA and PMR that <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT is not a good predictor of relapse and is not able to identify those patients who will require a longer steroid therapy&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">19&#44;30</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">The main limitations of this study&#44; as it happens in most of these kinds of studies&#44; are related to the absence of a gold standard for the diagnosis of LVV and the lack of a histological confirmation&#46; Also&#44; the use of the PET&#47;CT itself as a criterion for the diagnosis and for the therapeutic decision obviously may introduce a bias&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">In conclusion&#44; our results confirmed that <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT was a useful tool in identifying patients with LVV associated to PMR&#44; providing valuable information on the extent and intensity of the vascular involvement and allowing a reliable follow-up of the patients&#46; The detection of vascular inflammation by <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT had an important impact and led to a change of treatment in a high percentage of the patients with a diagnosis of LVV&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Conflict of interest</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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          "identificador" => "xres540820"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
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          "titulo" => "Materials and methods"
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            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Patients"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "F-FDG PET&#47;CT acquisition"
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            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Analysis of F-FDG PET&#47;CT images"
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              "titulo" => "Statistical analysis"
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          "titulo" => "Results"
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              "identificador" => "sec0040"
              "titulo" => "Patients with a final diagnosis of LVV"
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              "identificador" => "sec0045"
              "titulo" => "Patients without LVV"
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              "identificador" => "sec0050"
              "titulo" => "Impact of F-FDG PET&#47;CT in the management and follow-up of patients with a diagnosis of LVV"
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          "titulo" => "Discussion"
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    "fechaRecibido" => "2015-04-23"
    "fechaAceptado" => "2015-05-27"
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            0 => "Polymyalgia rheumatica"
            1 => "Large vessel vasculitis"
            2 => "Aortitis"
            3 => "Giant cell arteritis"
            4 => "<span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT"
            5 => "Positron emission tomography"
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            0 => "Polimialgia reum&#225;tica"
            1 => "Vasculitis de grandes vasos"
            2 => "Aortitis"
            3 => "Arteritis de c&#233;lulas gigantes"
            4 => "<span class="elsevierStyleSup">18</span>F-FDG PET&#47;TAC"
            5 => "Tomograf&#237;a por emisi&#243;n de positrones"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Purpose</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Polymyalgia rheumatica &#40;PMR&#41; may present together with large vessel vasculitis &#40;LVV&#41;&#44; and frequently requires a more intensive therapy&#46; The aim of the study was to evaluate the impact of <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT in the diagnosis and management of LVV associated to PMR&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This prospective study included 40 consecutive patients &#40;27 women&#47;13 men&#44; 68&#46;10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;27 years&#41; with PMR and suspicion of associated LVV submitted for <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT&#46; A PET&#47;CT scan was obtained 180<span class="elsevierStyleHsp" style=""></span>min after <span class="elsevierStyleSup">18</span>F-FDG intravenous injection&#46; A visual analysis was performed on the images&#46; Five vascular regions were evaluated&#58; supra-aortic trunks &#40;SAT&#41;&#44; thoracic aorta &#40;TA&#41;&#44; abdominal aorta &#40;AA&#41;&#44; iliac arteries &#40;IA&#41;&#44; and femoral&#47;tibioperoneal arteries &#40;FTA&#41;&#46; The intensity of uptake was graded from 0 to 3&#46; A final diagnosis of LVV was established in 26&#47;40 patients &#40;65&#37;&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In the 26 patients with a diagnosis of LVV&#44; the highest intensity of <span class="elsevierStyleSup">18</span>F-FDG uptake was observed in the TA&#44; SAT&#44; and FTA&#46; All of these patients showed uptake at the TA&#44; with grade 2 and 3 in most cases&#46; In 4 of the 14 patients without LVV&#44; no uptake was observed in any vascular region&#44; and in the other 10 patients only a grade 1 uptake was observed in 1 or to 2 territories&#46; Out of the 20 treated LVV patients&#44; <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT led to a therapeutic change in 17 &#40;85&#37;&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT was useful in identifying patients with LVV associated to PMR&#46; The detection of vascular inflammation had an important impact&#44; and led to a change of treatment in a high percentage of patients with LVV&#46;</p></span>"
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            "titulo" => "Material and methods"
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            "titulo" => "Results"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La polimialgia reum&#225;tica &#40;PMR&#41; puede presentarse asociada a vasculitis de grandes vasos &#40;VGV&#41;&#44; necesitando frecuentemente una intensificaci&#243;n del tratamiento&#46; Nuestro objetivo fue evaluar el impacto de la <span class="elsevierStyleSup">18</span>F-FDG PET&#47;TAC en el diagn&#243;stico y tratamiento de VGV asociada a PMR&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Este estudio prospectivo incluy&#243; 40 pacientes consecutivos &#40;27 mujeres&#47;13 hombres&#44; 68&#44;10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#44;27 a&#241;os&#41; con PMR y sospecha de VGV asociada evaluados con <span class="elsevierStyleSup">18</span>F-FDG PET&#47;TAC&#46; Los estudios PET&#47;TAC fueron obtenidos 180 minutos despu&#233;s de la inyecci&#243;n intravenosa de <span class="elsevierStyleSup">18</span>F-FDG&#46; Se realiz&#243; un an&#225;lisis visual de la intensidad de captaci&#243;n &#40;0&#8211;3&#41; en troncos supraa&#243;rticos &#40;TSA&#41;&#44; aorta tor&#225;cica &#40;AT&#41;&#44; aorta abdominal &#40;AA&#41;&#44; arterias il&#237;acas &#40;AI&#41; y arterias femoro&#47;tibioperoneales &#40;AFT&#41;&#46; Se estableci&#243; un diagn&#243;stico final de VGV en 26&#47;40 pacientes &#40;65&#37;&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">En los 26 pacientes con diagn&#243;stico de VGV la mayor intensidad de captaci&#243;n de <span class="elsevierStyleSup">18</span>F-FDG se objetiv&#243; en AT&#44; TSA y AFT&#46; En todos ellos se observ&#243; captaci&#243;n en la AT&#44; principalmente grado 2 y 3&#46; En 4 de los 14 sin VGV no se visualiz&#243; captaci&#243;n en ninguna regi&#243;n vascular y en los otros 10 solo se observ&#243; captaci&#243;n grado 1 en uno o 2 territorios&#46; De los 20 pacientes con VGV previamente tratados&#44; la <span class="elsevierStyleSup">18</span>F-FDG PET&#47;TC motiv&#243; un cambio terap&#233;utico en 17 &#40;85&#37;&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La <span class="elsevierStyleSup">18</span>F-FDG PET&#47;TAC fue una herramienta &#250;til para identificar pacientes con VGV asociada a PMR&#46; La detecci&#243;n de inflamaci&#243;n vascular tuvo un importante impacto&#44; motivando un cambio de tratamiento en un alto porcentaje de los pacientes con VGV&#46;</p></span>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">A 78-year-old man with polymyalgia rheumatica for 3 years&#44; poor treatment response and clinical and biochemical worsening after stopping steroid treatment&#46; Sagittal &#40;A&#41; and axial &#40;B&#41; <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT views showed a grade 2 uptake at the thoracic aorta&#46; The maximum intensity projection image &#40;C&#41; showed a more intense uptake at the lower extremities arteries&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Therapeutic management in the 26 patients with polymyalgia rheumatica and a final diagnosis of large vessel vasculitis &#40;LVV&#58; large vessel vasculitis&#44; MTX&#58; methotrexate&#44; TCZ&#58; tocilizumab&#41;&#46;</p>"
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">A 66-year-old woman with polymyalgia rheumatica in whom symptomatology worsened after steroid treatment was discontinued&#46; Erythrocyte sedimentation rate was 72<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#46; Axial &#40;A&#41; and sagittal &#40;B&#41; <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT views showed an intense and very well delineated uptake along the thoracic aorta wall confirming aortitis&#46; A high dose steroid therapy was restarted and the patient showed a good clinical and biochemical response&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">F&#58; female&#59; M&#58; male&#59; ESR&#58; erythrocyte sedimentation rate&#59; CRP&#58; C-reactive protein&#46;</p>"
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex &#40;F&#47;M&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">ESR &#40;mm&#47;h&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">All patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#47;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#46;10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>10&#46;27&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&#46;58<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>26&#46;76&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;38<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;55&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Vasculitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">18&#47;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">68&#46;46<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8&#46;69&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#46;50<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>28&#46;02&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;28<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;38&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">No vasculitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9&#47;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67&#46;43<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>13&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&#46;86<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>25&#46;18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;57<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Vasculitis vs&#46; no vasculitis &#40;<span class="elsevierStyleItalic">p</span> value&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;9322&nbsp;\t\t\t\t\t\t\n
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      4 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">STA&#58; supra-aortic trunks&#59; TA&#58; thoracic aorta&#59; AA&#58; abdominal aorta&#58; IA&#58; iliac arteries&#44; FTA&#58; femoral&#47;tibioperoneal arteries&#46;</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="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grade of <span class="elsevierStyleSup">18</span>F-FDG uptake&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SAT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">AA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FTA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab868440.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Intensity of <span class="elsevierStyleSup">18</span>F-FDG uptake and vascular regions in the 26 patients with large vessel vasculitis&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:3 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">STA&#58; supra-aortic trunks&#59; TA&#58; thoracic aorta&#59; AA&#58; abdominal aorta&#58; IA&#58; iliac arteries&#44; FTA&#58; femoral&#47;tibioperoneal arteries&#46;</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="table-head  " align="left" valign="top" scope="col">No&#46; patient&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="5" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Intensity of <span class="elsevierStyleSup">18</span>F-FDG uptake</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SAT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">AA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FTA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top"><span class="elsevierStyleItalic">0</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">18</span>F-FDG uptake in each of the 26 patients with large vessel vasculitis according to the different vascular regions evaluated&#46;</p>"
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">STA&#58; supra-aortic trunks&#59; TA&#58; thoracic aorta&#59; AA&#58; abdominal aorta&#58; IA&#58; iliac arteries&#44; FTA&#58; femoral&#47;tibioperoneal arteries&#46;</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="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grade of <span class="elsevierStyleSup">18</span>F-FDG uptake&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SAT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">TA&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">IA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">FTA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Total&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">STA&#58; supra-aortic trunks&#59; TA&#58; thoracic aorta&#59; AA&#58; abdominal aorta&#58; IA&#58; iliac arteries&#44; FTA&#58; femoral&#47;tibioperoneal arteries&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col">No&#46; patient&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 22538089
Original language: English

DOI:10.1016/j.remnie.2015.07.005

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 October	0	5	5
2024 September	0	11	11
2024 August	0	10	10
2024 July	0	8	8
2024 June	0	6	6
2024 May	0	3	3
2024 April	0	3	3
2024 March	0	2	2
2024 February	0	5	5
2024 January	0	7	7
2023 December	0	1	1
2023 November	0	4	4
2023 October	0	1	1
2023 September	4	4	8
2023 August	0	3	3
2023 July	0	13	13
2023 June	0	5	5
2023 April	0	5	5
2023 March	2	2	4
2023 February	0	1	1
2022 December	0	5	5
2022 November	0	4	4
2022 September	0	1	1
2022 August	0	2	2
2022 July	0	1	1
2022 June	0	1	1
2022 May	0	1	1
2022 March	0	3	3
2022 January	1	2	3
2021 November	0	1	1
2021 October	0	4	4
2021 August	0	3	3
2021 July	0	1	1
2021 May	0	3	3
2021 April	0	5	5
2021 March	0	16	16
2021 February	0	1	1
2021 January	0	7	7
2020 December	0	2	2
2020 November	0	5	5
2020 October	0	4	4
2020 September	1	3	4
2020 August	0	6	6
2020 June	0	1	1
2020 May	0	14	14
2020 April	1	3	4
2020 March	0	8	8
2020 February	0	12	12
2020 January	0	11	11
2019 December	0	8	8
2019 November	0	10	10
2019 October	0	5	5
2019 September	0	11	11
2019 August	0	11	11
2019 July	0	9	9
2019 June	0	11	11
2019 May	0	13	13
2019 April	0	29	29
2019 March	0	3	3
2019 February	0	5	5
2019 January	0	3	3
2018 December	0	4	4
2018 October	0	2	2
2018 February	3	0	3
2018 January	10	0	10
2017 December	3	1	4
2017 November	5	2	7
2017 October	6	1	7
2017 September	9	3	12
2016 December	0	1	1
2016 October	0	6	6
2016 September	0	1	1
2016 July	0	1	1
2016 April	0	21	21
2016 March	0	1	1
2016 February	0	3	3
2016 January	0	2	2

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