CAN WE REPLACE TEMPORAL ARTERY BIOPSY WITH CRANIAL ULTRASOUND FOR THE DIAGNOSIS OF GIANT CELL ARTERITIS?

Transcription

1 CAN WE REPLACE TEMPORAL ARTERY BIOPSY WITH CRANIAL ULTRASOUND FOR THE DIAGNOSIS OF GIANT CELL ARTERITIS? Adam P. Croft (ST3 Rheumatology) Susan Mollan, Paresh Jobunputra Speaker has no disclosures

2

3 TAB versus TUS TAB remains gold standard for GCA Reported sensitivity 7-44% diagnosis False negative rate 13-19% Rarely informs clinical decision making Complication rate 0.5-1% Prognostic significance?

4 TABUL Temporal artery biopsy versus ultrasound in diagnosis of giant cell arteritis

5 Retrospective study of clinical utility of cranial USS for diagnosis of GCA All patients referred to radiology at UHB for temporal artery USS for suspected GCA from Follow-up for 3 months Diagnosis confirmed by rheumatologist clinically at 3 months diagnostic gold standard Clinical data was obtained from electronic records and primary care providers

6 Baseline Characteristics of patients undergoing temporal artery ultrasound GCA (n=36) Non-GCA (n=51) P-value Age (yrs) 75 (SD 10) 71 (SD 8) Female ESR mm/h mean CRP (mg/dl, median) Platelets Temporal headache Temporal tenderness 26 4 <0.001 Jaw claudication 13 3 <0.001 Visual Distrubance PMR symptoms Weight loss Thickened temporal A 18 2 <0.001

7 Rheumatology 64% Acute Medicine 19% GP 11% Ophthalmology 4% Other 2% Temporal Artery Ultrasound n=87 Time from steroids to scan Median 5 days (range 1-9) Halo Sign Present (n=30, 34%) Halo Sign Absent (n=57, 66%) Biopsy n=13, 43% No Biopsy n=17, 57% Biopsy n=11, 19% No Biopsy n=46, 81% Biopsy positive n=7, 54% Biopsy positive n=1, 9% False Negative Biopsy negative n=6, 46% False Positives? 20% Biopsy negative N=10, 91%

8 Sensitivity and Specificity of TUS compared to TAB for clinically suspected GCA (at 3m FU) GCA+ GCA- Total TAU TAU Total GCA+ GCA- Total TAB TAB Total 17 7 Sensitivity 81% Specificity 98% LR LR PPV 97% NPV 88% Sensitivity 53% Specificity 100% LR LR- 0.2 PPV 100% NPV 47% Temporal artery ultrasound Temporal artery biopsy

9 Sensitivity and Specificity of TUS compared to TAB proven GCA or clinically suspected GCA (at 3m FU) GCA+ GCA- Total TAU TAU Total TAU versus Clinical Diagnosis Sensitivity 81% Specificity 98% LR LR PPV 97% NPV 88% GCA+ GCA- Total TAU TAU Total 8 14 TAU versus Biopsy Proven GCA Sensitivity 88% Specificity 63% LR LR- 0.2 PPV 54% NPV 91%

10 TAU compared to ACR Criteria as predictors of decision to treat at 3 months

11 Post-test clinical probabilities based on TUS result and the presence of symptoms/signs of GCA Clinical Features of GCA Pre-test probability Post test Probability Overall 42 TUS+ TUS- Temporal headache only Headache and ESR> Headache, ESR >50 and scalp tenderness Headache, ESR >50, temporal artery abnormalities Headache, ESR >50, jaw claudication

12 Discontinuation of steroids following a negative TUS compared to a negative TAB

13 Conclusions US result was the strongest predictor for a clinical diagnosis of GCA Greater sensitivity than clinical evaluation Comparable results with previous reports (Sensitivity 81%, Specificity 98%) Non-invasive test with high PPV TAU sensitivity 50% >4 days post Rx Investigator dependent test Directional biopsy in unilateral halos

14 Right temporal artery CDU features before (A) and after (B) 2 days of steroid treatment. Steroids induced early disappearance of the halo sign, leading to normalization of CDU. High-resolution MRI of the superficial temporal arteries: enlargement of contrast enhanced T1 weighted Santoro L et al. Rheumatology 2013;52:622