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Comparative analysis of arterial involvement in predominant cranial and isolated extracranial phenotypes of giant cell arteritis using 18F-FDG PET-CT

Arthritis Research & Therapy volume 26, Article number: 230 (2024) Cite this article

Abstract

Objective

To investigate differences in arterial involvement patterns on 18F-FDG PET-CT between predominant cranial and isolated extracranial phenotypes of giant cell arteritis (GCA).

Methods

A retrospective review of 18F-FDG PET-CT findings was conducted on 140 patients with confirmed GCA. The patients were divided into two groups: the cranial group, which presented craniofacial ischemic symptoms either at diagnosis or during follow-up, and the isolated extracranial group which never exhibited such manifestations.

Results

Of the 140 patients (90 women), 99 (71%) were considered to have a predominantly cranial phenotype, while 41 (29%) had isolated extracranial GCA. Patients with the extracranial phenotype were younger (p = 0.001), had lower TAB positivity (25%), and experienced longer diagnostic delays (p = 0.004). Polymyalgia rheumatica was more common in the extracranial group (p = 0.029), which also showed fewer constitutional symptoms, milder increases in acute phase reactants, and more frequent limb claudication and aortic complications, although these differences were not statistically significant. When comparing arterial involvement on 18F-FDG PET-CT, we observed statistically significant differences. The extracranial phenotype showed greater involvement across all segments of the thoracic aorta (p = 0.001), as well as in the abdominal aorta (p = 0.005), subclavian (p = 0.021), iliac (p = 0.004), and femoral arteries (p = 0.025). In contrast, the cranial phenotype exhibited a higher frequency of vertebral artery involvement (p < 0.001).

Conclusion

Significant differences in arterial involvement patterns on 18F-FDG PET-CT were observed between phenotypes. These findings may explain atypical symptoms such as inflammatory lower back pain or limb claudication and the increased risk of aortic complications in extracranial GCA.

Introduction

Recent evidence suggests that giant cell arteritis (GCA) is not solely a cranial disease but encompasses a broader and more diverse clinical spectrum than previously recognized. While GCA traditionally presents with classic cranial ischemic symptoms, it can also manifest through non-specific clinical signs associated with a general inflammatory state (such as occult systemic GCA presenting as fever of unknown origin and/or constitutional symptoms) or through involvement of extracranial large vessels (LV), including the aorta, supra-aortic trunks, and large peripheral arteries [1,2,3,4]. There is increasing recognition of GCA cases that lack typical cranial symptoms [1,2,3,4,5,6,7] and its close relationship and overlap with polymyalgia rheumatica (PMR), which can sometimes be the only clinical manifestation of vasculitis (PMR as the presenting manifestation of “occult” extracranial GCA) [8, 9]. This has led to a new perspective that these conditions are interconnected, now often referred to collectively as GCA–PMR spectrum disease (GPSD) [10], and the growing acceptance that GCA can present in two often overlapping patterns: cranial and extracranial [1,2,3,4,5,6,7,8,9,10,11,12].

Although cranial and extracranial manifestations of GCA often coexist in the same patients, we also frequently encounter individuals with isolated extracranial presentations. Unlike those with the classic predominantly cranial presentation, these patients tend to be younger and initially present with nonspecific clinical manifestations, lacking the classic cranial symptoms [2, 4,5,6, 10,11,12,13,14]. Their predominant clinical feature is often a girdle syndrome, which typically presents at an earlier age and can be associated with constitutional symptoms such as fever, asthenia, and weight loss. Additionally, they may experience atypical symptoms such as inflammatory lower back pain or limb claudication. Some studies have shown that this phenotype generally carries a lower risk of developing cranial ischemic complications [2,5–7,11−14]. Biopsy or colour Doppler ultrasound (CDUS) of the temporal arteries are often negative, which consequently hinders and delays diagnosis. This delay can lead to serious complications, including the development of aneurysms, stenosis, and aortic dissection [2,5–7,11−14]. A recent review highlighted that patients with LV-GCA are 3.6 times more likely to develop an aortic aneurysm, with 12% of deaths in this group directly attributable to large vessel complication [6, 13]. Moreover, these patients appear to have a higher risk of relapse during follow-up [13, 14].

In this study, we investigate whether there are differences in the patterns of arterial involvement on 18F-fluorodeoxyglucose positron emission tomography PET/CT (18F-FDG PET-CT) between predominant cranial and isolated extracranial phenotypes that could potentially explain the observed clinical and prognostic differences.

Methods

Study cohort

The study was carried out under routine clinical practice conditions. We retrospectively reviewed our hospital databases to identify all patients with a new proven diagnosis of GCA who underwent an 18F-FDG PET-CT scan between January 2005 and March 2023. In the absence of formal diagnostic criteria for GCA, the diagnosis was made in all cases based on the following six criteria:

  1. 1)

    Age at disease onset ≥ 50 years.

  2. 2)

    The presence of compatible clinical symptoms including craniofacial ischemic symptoms (headache, scalp tenderness, abnormal temporal artery examination, jaw claudication, visual symptoms), PMR, constitutional symptoms or fever, and manifestations related to extracranial LV involvement (such as arm/leg claudication, pulse discrepancies, bruits of extracranial arteries unrelated to atherosclerosis, tenderness on palpation or reduced pulsation, and inflammatory lower back pain).

  3. 3)

    Elevated acute-phase reactants, defined as an erythrocyte sedimentation rate (ESR) > 30 mm/hour by the Westergren method or C-reactive protein (CRP) > 5 mg/L.

  4. 4)

    Objective evidence of vasculitis based on temporal artery biopsy (TAB) findings indicative of GCA, the presence of a non-compressible “halo” sign on a CDUS of the temporal and/or axillary arteries, or evidence of LV vasculitis on 18F-FDG PET-CT.

  5. 5)

    A prompt and sustained response to glucocorticoid (GC) therapy.

  6. 6)

    No change in diagnosis during a follow-up period of at least 1 year.

After a detailed review of the medical records, patients were categorized into two groups: the cranial group, which presented craniofacial ischemic symptoms either at diagnosis or during follow-up (including headache, scalp tenderness, temporal artery abnormalities, jaw claudication, visual symptoms, and strokes), and the isolated extracranial group which never exhibited such manifestations.

Information regarding the dose and duration of corticosteroid treatment prior to the18F-FDG PET-CT, along with detailed clinical, laboratory, and topographic evaluations of arterial involvement, was extracted from the clinical records using a specifically designed protocol. The endpoint of patient follow-up was defined as the date of the last clinic visit.

Due to the retrospective nature of the study, we received an exemption from the ethics committee regarding the need for informed consent. Patient data was pseudonymized before analysis.

18F-FDG PET/CT imaging technique and protocol

PET/CT studies were performed in a Discovery ST scanner (GE Healthcare, Milwaukee, USA) following procedural guidelines recommended by the European Association of Nuclear Medicine (EANM), the Cardiovascular Council of the Society of Nuclear Medicine and Molecular Imaging (SNMMI), and the PET Interest Group (PIG), with endorsement from the American Society of Nuclear Cardiology (ASNC) [15].

Patients were required to fast for at least 6 h and maintain blood glucose levels below 11 mmol/L before the intravenous injection of FDG (185–370 MBq). Initially, imaging was performed 60 min after radiotracer administration; however, when evidence suggested that delayed image acquisition beyond 60 min enhances FDG-PET sensitivity for detecting vasculitis [16], the imaging start time was extended to 90 min.

Scans were conducted with patients in a supine position, covering the area from the skull base to the proximal thigh; the scan region was extended if distal involvement was clinically suspected. PET images were obtained at 3 min per bed position in a 3-dimensional mode, using a matrix size of 128 × 128, with a pixel size of 5.4 mm and a spatial resolution of 5.2 mm. A low-dose CT (140 kV and 80 mA) was acquired before the PET emission scan for attenuation correction and anatomical localization. CT images were used to correct the attenuation of the PET emission data, utilizing the OSEM (ordered subset expectation maximization) image reconstruction algorithm.

18F-FDG PET/CT imaging interpretation

Positron emission tomography/CT image scans were independently reviewed by nuclear medicine physicians with at least 8 years of experience in PET/CT. Each scan was classified as either active or inactive vasculitis based on the reader’s overall subjective assessment, with strong inter-reader reliability (κ = 0.92). In cases of uncertainty, a joint re-review of the PET/CT images was conducted in a clinical session to reach a consensus.

PET images were evaluated both visually and semi-quantitatively. The degree of FDG uptake in the arteries was assessed using a visual 0-to-3 vascular to liver 18F-FDG uptake grading scale: 0 = no uptake (≤ mediastinum); 1 = low-grade but not negligible FDG diffuse homogeneous uptake (< liver); 2 = intermediate-grade uptake (= liver); and 3 = high-grade uptake (> liver), with grade 2 considered potentially indicative and grade 3 considered positive for active vasculitis [15, 17,18,19]. In addition to the uptake intensity, the uptake pattern was also taken into account when establishing the diagnosis of vasculitis, being indicative of wall inflammation those cases with a circumferential uptake and smooth linear or long segmental pattern, without wall microcalcifications [15,17.19].

For semi-quantitative analysis, automatic volumes of interest were placed and adjusted over the selected arterial region to determine the maximum standardized uptake value (SUVmax).

Statistical analysis

Results are expressed as the mean with standard deviation or as the median with interquartile range (IQR) [25th-75th percentile] for continuous data, as appropriate. Categorical variables are presented as the number of cases and percentages. The Student’s t-test or the Mann–Whitney U test was used to compare numerical variables based on normality assumptions. The chi-squared test or Fisher’s exact test was used for categorical variables. Statistical significance was defined as P < 0.05.

Results

Study population

A total of 140 patients were included in the study. Table 1 provides a summary of their main clinical features, laboratory data, diagnostic methods, and treatments received. Ninety-nine patients (70.7%) had cranial ischemic manifestations of GCA either at diagnosis or during follow-up, while 41 (29.3%) were considered to have an isolated extracranial phenotype.

Table 1 Main clinical features, laboratory data, diagnostic methods and treatments received by of the study cohort
Full size table

TAB was performed in 93 cases, with 57% (53/93) yielding positive results. CDUS of the temporal arteries was conducted in 66 patients, with 27.3% (18/66) being positive. 18F-FDG PET-CT was performed in all cases, showing positive LV involvement in 82.1% (115/140), including the aorta, supra-aortic trunks (carotid, subclavian, and vertebral arteries, and the brachiocephalic trunk), and/or large peripheral arteries (iliac, femoral, axillary, and the proximal third of the brachial arteries). The median time from diagnosis to the performance of the PET-CT scan was 5 days (IQR 25–75 th: 1–56).

Ninety patients (64.2%) received GC treatment prior to undergoing PET-CT. Despite this treatment, 18F-FDG PET-CT revealed varying degrees of vascular uptake involving LV in a significant number of cases: grade 3 uptake was observed in 17.7% of cases (16/90), grade 2 uptake in 27.8% (25/90), and a grade 1 circumferential uptake, with a smooth linear or long segmental pattern without wall microcalcifications, in 32.2% (29/90). Consequently, PET positivity (defined as grade 2 or 3 FDG uptake) was detected in 45.5% of patients (41/90), maintaining a remarkable diagnostic value.

It is important to note that scans showing a grade 1 circumferential uptake with these characteristics raises the possibility of an “apparently inactive” vasculitis due to prior GC treatment, potentially representing a residual footprint of previously active GCA. This is particularly relevant in cases where typical PMR joint uptake patterns are also present (observed in 22 of the 29 cases). Consequently, if we also consider these grade 1 uptake cases with such features as positive, the 18F-FDG PET-CT positivity rate increases to 77.7% (70/90).

18F-FDG PET-CT results according to the GCA phenotype in patients with and without prior GC treatment are shown in Table 2. Among those with cranial GCA, 73.7% (73/99) had already received GC treatment, compared to 41.5% (17/41) of patients with an isolated extracranial phenotype LVV. The median duration of treatment before PET-CT in patients with the cranial phenotype initially treated with intravenous methylprednisolone boluses (at doses ranging from 125 mg to 1 g per day for three days) was 5 days [IQR 25-75%: 3–7], and 10 days [IQR 25-75%: 10–386] in those treated with high-dose oral GC. This group included patients initially diagnosed with isolated or “pure” PMR who subsequently experienced an arteritic relapse with the development of classic cranial ischemic symptoms. The median duration of treatment before the PET-CT in patients with an isolated extracranial phenotype was 320 days [IQR 25-75%: 71–497].

Table 2 18F-FDG PET-CT results in patients with and without prior glucocorticoid treatment
Full size table

Comparative analysis: predominantly cranial vs. isolated extracranial GCA phenotypes

Results of the comparative study between both groups of patients are shown in Table 3.

Table 3 Comparative study between patients with predominantly cranial and exclusive extracranial GCA
Full size table

Patients with the isolated extracranial phenotype were notably younger, with an average age of 71.1 ± 6.9 years compared to 76.4 ± 7.8 years in the cranial group (p = 0.0001). Additionally, these patients experienced a significantly longer delay in diagnosis, averaging 243 ± 688 days versus 43 ± 51 days for the cranial group (p = 0.004).

Regarding diagnostic utility, TAB was more effective for detecting the cranial phenotype, yielding positive results in 62.3% of these cases compared to only 25% in those with isolated extracranial involvement (p = 0.0001). In contrast, 18F-FDG PET/CT scans were particularly effective for diagnosing the extracranial phenotype, with all such patients showing positive results, compared to 74.7% of the cranial group (p = 0.0001).

Clinically, aside from differences in craniofacial ischemic symptoms, PMR was more prevalent in patients with isolated extracranial GCA (58.5% vs. 38.4%; p = 0.029). Additionally, these patients generally exhibited fewer constitutional symptoms, had a less pronounced increase in acute phase reactants, and more frequently experienced limb claudication and the development of aortic aneurysm or dilation, although these differences were not statistically significant.

In terms of treatment, intravenous methylprednisolone was administered more frequently to patients in the cranial group (30.3% vs. 0%; p = 0.001). The usage rates of tocilizumab and methotrexate were comparable between the two groups.

Topography of arterial involvement

The topographical distribution of arterial involvement in the two groups is summarized in Table 4. To minimize the influence of prior GC treatment, we included patients with grade 3 or 2 uptake, and with circumferential grade 1 uptake characterized by a smooth linear or long segmental pattern without wall microcalcifications (a footprint of treated active GCA).

Table 4 Topography of vessel involvement in patients with positive 18F-FDG PET-CT
Full size table

Increased vascular FDG uptake was observed in 82.1% (115/140) of the total sample, with 74.7% (74/99) positivity among patients with predominantly cranial GCA and 100% (41/41) positivity among cases with exclusive extracranial GCA.

The study revealed significant differences between the 2 groups. Patients with an isolated extracranial phenotype exhibited markedly higher thoracic aortic involvement, with 92.7% affected compared to 58.6% in the cranial group (p = 0.001). These differences were observed in all segments: ascending, arch, and descending. Similarly, abdominal aorta involvement was significantly greater in the extracranial group, affecting 61% of patients compared to 35.4% in the cranial group (p = 0.005). There was also a notable trend towards increased involvement of the supra-aortic trunks in the extracranial group, with significantly higher involvement of the subclavian arteries (65% vs. 43.4%; p = 0.021). In contrast, the cranial phenotype showed a significantly higher incidence of vertebral artery involvement (39.4% vs. 10%; p = 0.001).

Lower-extremity arteries were more frequently involved in the extracranial phenotype as well. The iliac arteries were affected in 56.1% of extracranial patients compared to 30.3% of cranial patients (p = 0.004), and the femoral arteries in 53.7% versus 33.3% (p = 0.025).

Discusion

The clinical presentation of GCA is variable. Although cranial and extracranial manifestations of GCA often occur in the same individuals, we frequently encounter patients with isolated extracranial involvement. This has led to the widespread acceptance of two different clinical presentations or phenotypes of GCA that often overlap: cranial and predominantly or isolated extracranial, which constitute a continuum in the clinical spectrum of the disease.

In our study, we confirm that patients with an isolated extracranial phenotype appear to form a distinct subset of GCA. As previously described [2, 5,6,7, 11,12,13,14], these patients were generally younger at diagnosis compared to those with predominantly cranial GCA and more frequently presented with PMR. They also experienced a longer delay to diagnosis and had lower rates of positive TAB.

Additionally, they generally presented with a lower frequency of constitutional symptoms, exhibited a less pronounced increase in acute phase reactants, and more frequently experienced limb claudication and the development of aortic aneurysm or dilation, although these differences were not statistically significant. Potential complications of aortic involvement include aneurysm, dissection, and rupture. Although these are well-recognized complications, studies reporting prevalence in extracranial GCA show conflicting results [20,21,22]. Data from a review and meta-analysis on this topic found that patients with LV involvement were 3.6 times more likely to develop an aortic aneurysm [6].

In general terms, we observed that the increase in acute phase reactant levels tends to be less pronounced in patients with the isolated extracranial phenotype compared to the classic cranial form, a finding also reported in two other Spanish studies [23, 24]. While some studies have also reported a lower frequency of constitutional symptoms in patients with the extracranial phenotype [11], the aforementioned meta-analysis found no significant difference in rates of fever (OR: 1.15; 95% CI: 0.7, 1.88), suggesting that fever cannot be used to reliably differentiate cranial from LV disease [6].

Any degree of increased vascular FDG uptake was observed in 82.1% of our total sample, consistent with other studies that have systematically investigated the presence of LV involvement using 18F-FDG PET-CT [25]. A recent meta-analysis examining the prevalence of extracranial LVV using PET/CT reported an overall pooled prevalence of 60% in patients with a previous diagnosis of GCA [26].

Analyzing our subgroups separately, we found that 74.7% of patients with predominantly cranial GCA and 100% of patients with exclusive extracranial GCA had positive findings on PET-CT. Although PET-CT is not generally used for patients with suspected GCA presenting with evident cranial manifestations, recent studies indicate that it may also be useful for diagnosing GCA in these cases, showing positivity rates ranging from 71.4 to 77.2% [27, 28].

In this sense, our group has successfully implemented a dual diagnostic strategy that combines PET-CT with a cranial test (either TAB or CDUS) for patients with suspected GCA [4, 16, 17]. This approach has enhanced diagnostic accuracy and facilitated the detection of LV involvement, particularly in areas like the aorta and brachiocephalic trunk, which cannot be adequately visualized by ultrasound. We believe that screening for LV involvement is important, as it can lead to complications such as aortic aneurysm and dissection, aortic arch syndrome, and limb arterial stenosis [6, 7]. The 2021 ACR/Vasculitis Foundation guidelines for the management of GCA conditionally recommend that patients with newly diagnosed GCA undergo non-invasive vascular imaging to assess LV involvement and aid in the long-term monitoring of potential disease sequelae [29], although it remains to be demonstrated that such screening programs improve outcomes.

In patients with isolated extracranial GCA, the thoracic aorta is the most commonly affected artery, followed by the abdominal aorta and supra-aortic trunks with comparable frequency, and finally the large peripheral arteries of the limbs. Table 5 summarizes the topography of vessel involvement in the main series of predominantly extracranial or LVV GCA that have been recently published [7, 24, 30,31,32]. Although the percentages of involvement for each territory vary across studies, the hierarchical order of territory involvement remains consistent.

Table 5 Topography of vessel involvement in previously published series of patients with isolated-predominantly extracranial GCA or LVV GCA
Full size table

Given the clinical differences between patients with predominantly cranial and isolated extracranial patterns of the disease, we aimed to investigate whether these differences could be explained by distinct patterns of arterial involvement. The study revealed significant differences between the two groups. A notably higher proportion of aortic involvement, including all segments of the thoracic aorta and the abdominal aorta, was observed in the isolated extracranial phenotype. This group also showed significantly greater involvement of the subclavian and lower-extremity arteries (iliac and femoral). In contrast, the cranial phenotype exhibited a significantly higher frequency of vertebral artery involvement.

Several studies have previously compared the distribution patterns of arterial involvement between GCA phenotypes. Bull Haaversen et al. [32] studied 133 patients with new-onset GCA using an extended ultrasound examination. Consistent with our results, they found that patients with isolated extracranial GCA had significantly higher involvement of the thoracic and abdominal aorta compared to those with mixed GCA. They also observed that the carotid and subclavian arteries were more frequently affected in the extracranial forms. Conversely, they found a significantly higher incidence of vertebral artery involvement in mixed forms compared to isolated extracranial forms (30-34.7% vs. 4.7%). In another study conducted in Madrid by Heras-Recuero et al. [24], no statistically significant differences were observed between the two disease patterns. However, patients with extracranial LVV-GCA exhibited a higher frequency of vasculitic involvement in the lower-extremity arteries (iliac and femoral), whereas subclavian and brachiocephalic involvement was slightly more prevalent in those with predominantly cranial features.

Several potential limitations should be considered when interpreting the study results. These include: (1) the observational and retrospective nature of the study; (2) selection bias, as all patients were diagnosed based on histology or imaging at a tertiary center, with PET indications likely influenced by specific clinical features suggesting a high pre-test probability for the condition; (3) the challenge of “circular testing,” where the imaging method being investigated was part of the diagnostic criteria for GCA; and (4) the fact that physicians were aware of PET results when confirming the diagnosis. These factors may contribute to an overestimation of the diagnostic accuracy of PET-CT.

Another limitation concerns the prior administration of GC in 64.2% of patients before undergoing 18F-FDG PET-CT, with differences between groups (73.7% in the cranial phenotype and 41.5%), which may have influenced the imaging results. GC treatment can reduce vascular wall uptake of 18F-FDG while increasing FDG uptake in the liver, potentially leading to an underestimation of vasculitis. To minimize this effect, it is recommended that 18F-FDG PET-CT be performed as soon as possible, ideally within the first 3 to 10 days after initiating high-dose steroid treatment [15]. However, if this is not feasible, recent studies conducted under routine clinical conditions suggest that despite the potential reduction in 18F-FDG uptake due to GC therapy, PET-CT remains a valuable tool for detecting musculoskeletal and LVV involvement in GCA [33,34,35,36,37]. Narváez et al. [33] showed that its diagnostic value remains significant in a considerable proportion of patients with new-onset GCA within the first 6 weeks of treatment, except when IV boluses of MP doses greater than 125 mg are used. Supporting this finding, a prospective study revealed that PET-CT identified LV disease in the majority (71.4%) of GCA patients, even after the start of GC therapy, with comparable uptake [34]. Similarly, a study by Hay et al. [35] found that corticosteroid therapy did not significantly impact diagnostic performance, though there was a trend toward reduced sensitivity in patients who received corticosteroids for more than 3 days. More recently, Aldasoro V et al. [37] have demonstrated the usefulness of delayed imaging protocols to improve diagnostic accuracy in patients on GC therapy. They have shown that performing imaging at 180 min could be useful for patients who have been on GCs for more than 3 days, as well as for those with highly suspected GCA but negative findings in baseline PET scans at 60 min.

Conclusion

In conclusion, by classifying patients with GCA into two phenotypes through a simple dichotomous assessment based on the presence or absence of classic craniofacial ischemic manifestations at any point during the disease course, we confirm that patients with an isolated extracranial presentation constitute a distinct subset of GCA.

In addition to the known clinical differences, we observed significant differences in the arterial involvement distribution patterns on 18F-FDG PET-CT. Patients with an isolated extracranial phenotype exhibited a higher incidence of vasculitis in the aorta (thoracic and abdominal), subclavian, and lower-extremity arteries. These differences may account for atypical symptoms such as inflammatory lower back pain or limb claudication and align with the reported increased risk of aortic dilatation or aneurysm.

Despite some experts being reluctant to accept the existence of two phenotypes, real clinical practice demonstrates the presence of two distinct groups of patients: those presenting with classic cranial signs (with or without large vessel involvement; mixed GCA or predominantly cranial GCA, respectively) and those presenting exclusively with extracranial manifestations. Current evidence suggests that both phenotypes are different clinical expressions of the same disease, as there are no well-established differences in genetic predisposition to GCA regardless of the predominant phenotype [2, 38,39,40].

Further investigations in other populations are needed to validate our findings. Therefore, there is a need for biomarkers to help identify these patients, particularly those with occult extracranial LV-GCA presenting as apparent pure PMR. A comprehensive analysis of genomic and epigenomic results could potentially help to better understand the entire spectrum of GCA [2].

Data availability

No datasets were generated or analysed during the current study.

Abbreviations

ASCN:

American Society of Nuclear Cardiology

CDUS:

Color doppler ultrasound

CI:

Confidence interval

CRP:

C reactive protein

EANM:

European Association of Nuclear Medicine

18F-FDG PET-CT:

18 F-fluorodeoxyglucose positron emission tomography/computed tomography

ESR:

Erythrocyte sedimentation rate

GC:

Glucocorticoid

GCA:

Giant cell arteritis

GPSD:

GCA–PMR spectrum disease

LV:

Large vessel

LVV:

Large vessel vasculitis

PIG:

PET Interest Group

PMR:

Polymyalgia rheumatica

RCTs:

Randomized controlled trials

SD:

Standard deviation

SNMMI:

Society of Nuclear Medicine and Molecular Imaging

TAB:

Temporal artery biopsy

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Acknowledgements

The authors thank to the CERCA Programme of the Generalitat de Cataluña and the Bellvitge Biomedical Research Institute (IDIBELL) for their valuable institutional support.

Funding

None. This study is not a part of corporate-sponsored research effort.

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Authors and Affiliations

  1. Department of Rheumatology, Hospital Universitario de Bellvitge. Bellvitge Biomedical Research Institute (IDIBELL), Barcelona, Spain

    Javier Narvaez, Paola Vidal-Montal, Judith Palacios-Olid, Pol Maymó-Paituvi & Joan Miquel Nolla

  2. Nuclear Medicine Department-PET (IDI), Hospital Universitario de Bellvitge, Barcelona, Spain

    Iván Sánchez-Rodríguez, Aida Sabaté-Llobera & Montserrat Cortés-Romera

  3. Department of Rheumatology (Planta 10-2), Hospital Universitario de Bellvitge, Feixa Llarga, s/n, Hospitalet de Llobregat, Barcelona, 08907, Spain

    Javier Narvaez

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Contributions

All authors had access to the data and it meets the Uniform Requirements for Manuscripts Submitted to Biomedical Journals Criteria for authorship. 1a. Substantial contributions to study conception and design. 1b. Substantial contributions to acquisition of data. 1c. Substantial contributions to analysis and interpretation of data. 2. Drafting the article or revising it critically for important intellectual content. 3. Final approval of the version of the article to be published. JN: 1a, 1b, 1c, 2 and 3. PVM: 1a, 1b, 1c, 2 and 3. ISR: 1c, 2, 3. ASLL: 1c, 2, 3. MC: 1c, 2, 3. JPO: 2 and 3. PM: 2 and 3. JMN: 2 and 3.

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Correspondence to Javier Narvaez.

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Ethics approval

The study has bee approved by of our institutional ethics committee (Clinical Research Ethics Committee of Bellvitge University Hospital-IDIBELL). The local ethics committee confirm that the findings in this report were based on normal clinical practice and were therefore suitable for dissemination. Since our study was performed retrospectively, we were relieved by the ethics committee of our hospital from obtaining informed consent. Informed consent was not obtained from the patients, but their clinical records and information were anonymized prior to analysis. This study was conducted inaccordance with the principles of the Declaration of Helsinki and the International Conference for Harmonization.

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Narvaez, J., Vidal-Montal, P., Sánchez-Rodríguez, I. et al. Comparative analysis of arterial involvement in predominant cranial and isolated extracranial phenotypes of giant cell arteritis using 18F-FDG PET-CT. Arthritis Res Ther 26, 230 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13075-024-03464-w

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Keywords

Arthritis Research & Therapy

ISSN: 1478-6362

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