‘It’s going to be imaging’: MRI, ultrasound to streamline giant cell arteritis diagnosis
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SAN DIEGO — Imaging techniques are poised to streamline the diagnosis of giant cell arteritis in the United States, after gaining traction elsewhere, according to a speaker at the 2024 Congress of Clinical Rheumatology West.
“I can tell you that molecular biomarkers, serum biomarkers, are not going to be it,” Paul A. Monach, MD, PhD, associate professor of medicine at Harvard Medical School, told attendees. “It’s going to be imaging, and it’s already on the way.”
Commonly, when rheumatologists are called upon to diagnose suspected GCA, the strategy resembles “something in the middle,” according to Monach. For example, a negative biopsy with elevated erythrocyte sedimentation rate and C-reactive protein.
“This is where we need something else, and that something else is imaging,” he said.
However, implementing such techniques requires training.
“Your typical ultrasonographer in the radiology department can’t do it,” Monach said. “It does require training regardless of what background you come from. The training is getting there in the United States. Some of the big centers have it.”
Imaging techniques for GCA are already “widely used in Europe,” according to Monach. In most European centers — and, he noted, at Brigham and Women’s Hospital, in Boston — positive ultrasound findings can support a confident GCA diagnosis, though a biopsy will still be ordered if there is remaining suspicion with negative findings.
Monach also highlighted MRI techniques he said are used in Canada.
“They like to use a negative MRI to rule out GCA, and then if the MRI is positive, they’re not sure they believe it,” he said. “They still biopsy it.”
The comparative findings of imaging vs. biopsy are important because MRI and ultrasound lose sensitivity at a faster rate than a biopsy, according to Monach.
“If you get a biopsy within 7 days, you’re not losing much sensitivity,” he said, adding that with ultrasound and MRI, sensitivity is lost “a lot of times within a couple days.”
Monach explained the MRI strategies used in his group at the VA Boston Healthcare System.
“If we have a low clinical suspicion, but I really feel like I can support ruling it out — it’s not zero, 10% — it can wait 5 days,” he said. “I don’t want to give the patient steroids which would throw off the MRI. Don’t treat them in the meantime, but get it done. And if its negative, don’t treat. On the other hand, if it ends up being positive, I’m going to treat. If it’s equivocal, then I will say, ‘OK, I’m going to treat them,’ but I’m still going to do a biopsy.”
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Monach PA. Vasculitis Update. Presented at The Congress of Clinical Rheumatology West; Sept. 26-29, 2024. (hybrid meeting).
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