Acurácia da ultrassonografia doppler no diagnóstico da arterite de células gigantes: uma revisão sistemática e metanálise
Data
2022-03-21
Autores
Nakajima, Eliza [UNIFESP]
Orientadores
Iared, Wagner [UNIFESP]
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
A Arterite de Células Gigantes (ACG) é uma urgência médica. ACG é a vasculite sistêmica primária mais comum em pessoas com mais de 50 anos. O tratamento imediato com altas doses de corticoide em pacientes com suspeita de ACG é importante para prevenir a ocorrência de complicações isquêmicas, como cegueira e acidentes vasculares cerebrais. No entanto, a necessidade de um diagnóstico correto é essencial devido aos efeitos adversos que o tratamento pode causar. A biópsia de artéria temporal tem sido o padrão ouro, porém é invasiva e tem baixa sensibilidade. A ultrassonografia com pesquisa do sinal do halo, ou seja, uma área escura ao redor do lúmen do vaso é o sinal mais importante da vasculite. As recentes diretrizes recomendam a ultrassonografia de artérias temporais associada ou não à avaliação das artérias axilares como primeiros exames de imagem em pacientes com suspeita de ACG craniana. No entanto, o grupo recomenda examinar artérias axilares em pacientes em que o ultrassom de artérias temporais foi negativo ou inconclusivo. Historicamente antigos estudos e várias revisões sistemáticas concentravam-se no padrão da doença craniana. É importante reconhecer se o paciente com suspeita de ACG tem acometimento de artérias extracranianas, pois esses pacientes têm evolução clínica diferente. Recentes estudos com uso de aparelhos de alta resolução melhoraram a capacidade de identificar os sinais inflamatórios em artérias de pacientes com suspeita de ACG. Objetivo: determinar acurácia diagnóstica do Ultrassom Doppler color (UDC) na artéria temporal em pacientes com suspeita de ACG. Métodos: Revisão Sistemática seguindo protocolo do Handbook Cochrane. Foram pesquisadas as seguintes bases de dados: Pubmed, Embase, CENTRAL, CRDTAS, LILACS, clinicaltrials.gov, WHO – ICTRP e OpenGrey até setembro de 2021. Não houve restrição de idioma e data. Foram incluídos estudos que realizaram UDC de artérias temporais em pacientes com suspeita de ACG tendo como padrão referência o diagnóstico clínico realizado por especialistas. Dois pesquisadores selecionaram independentemente os títulos e resumos de todos os registros. A qualidade dos estudos foi avaliada usando a ferramenta Avaliação da Qualidade de Estudos de Acurácia Diagnóstica (QUADAS- 2). Utilizamos o programa R (versão 4.2) para análise dos dados. Resultados: Foram incluídos 17 estudos com 2017 participantes com suspeita de ACG que realizaram UDC de artéria temporal. Os resultados de análise primária demonstraram sensibilidade de 0.74 (IC 95% 0.66 – 0.81) e especificidade 0.90 (IC95% 0.86 – 0.93), quando o sinal do halo foi comparado com o diagnóstico clínico. A área sob a curva ROC foi 0.90 e a Odds Ratio Diagnóstic (DOR) foi 26.76 (IC 95% 13.08 – 54.69). Três estudos com 623 participantes estudaram o sinal do halo na artéria temporal como sinal da compressão resultando valores de sensibilidade de 0.86 (IC95% 0.74 – 0.92) e especificidade foi 0.98 (IC95% 0.94 – 0.99). Em três estudos com 266 participantes, o sinal do halo foi estudado em artérias temporais e axilares resultando sensibilidade de 0.82 (IC 95% 0.72 – 0.89) e a especificidade foi 0.93 (IC 95%: 0.86 – 0.95). Conclusão: A ultrassonografia do sinal do halo nas artérias temporais tem boa acurácia para diagnosticar ACG craniana.
Giant Cell Arteritis (GCA) is a medical urgency and the most common primary systemic vasculitis in people 50 years of age and over. Prompt high doses of corticosteroids treatment in patients in suspicion of GCA is mandatory to prevent the occurrence of ischemic complications, such as blindness and/or stroke. However, a correct diagnosis is essential due to the adverse effects of this treatment. Temporal artery biopsy has been the gold standard, but it is an invasive procedure, and its sensitivity is low. Ultrasonography of the halo sign, is a dark area around the blood vessel’s lumen, is the most important sign for vasculitis. Recent guidelines propose the ultrasound of temporal arteries associated or not to the evaluation of the axillary arteries as the first imaging test in patients with suspicion of cranial GCA. However, the group recommends examining axillary arteries in patients whose temporal artery ultrasound had negative or inconclusive results. Historically, previous studies and systematic reviews focused on the standard of cranial disease, but it is important to recognize whether there is extracranial artery involvement in the patient with suspected GCA, as these patients have a different clinical course and development. Recent studies using high-resolution ultrasound devices have improved the capability to identify signs of arterial inflammation in GCA suspicion patients. Objective: Determine the diagnostic accuracy of halo sign on temporal artery with color Doppler ultrasound (UDC) in people with suspected GCA. Methods: A systematic review following Cochrane’s handbook protocol. The database sources were: Pubmed, Embase, CENTRAL, CRDTAS, LILACS, clinicaltrials.gov, WHO and OpenGrey up to September 2021. No date and language restrictions were applied. UDC papers/studies with patients with temporal arteries GCA suspicion in a standard reference of clinical diagnosis were included. Paper titles and abstracts were selected by two investigators on an independent basis from all available records. The quality of the study was assessed using the Quality of Diagnostic Accuracy Studies tool (QUADAS-2) with R program (version 4.2) data analysis. Results: Seventeen studies were included with 2017 participants with GCA suspicion who underwent temporal artery UDC. The primary analysis results showed a sensitivity of 0.74 (95% CI 0.66 – 0.81) and specificity of 0.90 (95% CI 0.86 – 0.93) when the halo sign was compared with only clinical diagnosis. The area under the ROC curve was 0.90 and the Diagnostic Odds Ratio (DOR) was 26.76 (95% CI 13.08 – 54.69). The sensitivity values of 0.86 (95%CI 0.74 – 0.92) and specificity of 0.98 (95%CI 0.94 – 0.99) was found in three studies involving 623 participants with the sign of compression on the temporal artery where the halo sign was studied. A sensitivity of 0.82 (95% CI 0.72 – 0.89) and specificity of 0.92 (95% CI: 0.86 – 0.95) was found in three studies with 266 participants where the halo sign was studied on temporal and axillary arteries. Conclusion: Ultrasonography detecting the halo sign in the temporal arteries has a good performance for diagnose cranial GCA.
Giant Cell Arteritis (GCA) is a medical urgency and the most common primary systemic vasculitis in people 50 years of age and over. Prompt high doses of corticosteroids treatment in patients in suspicion of GCA is mandatory to prevent the occurrence of ischemic complications, such as blindness and/or stroke. However, a correct diagnosis is essential due to the adverse effects of this treatment. Temporal artery biopsy has been the gold standard, but it is an invasive procedure, and its sensitivity is low. Ultrasonography of the halo sign, is a dark area around the blood vessel’s lumen, is the most important sign for vasculitis. Recent guidelines propose the ultrasound of temporal arteries associated or not to the evaluation of the axillary arteries as the first imaging test in patients with suspicion of cranial GCA. However, the group recommends examining axillary arteries in patients whose temporal artery ultrasound had negative or inconclusive results. Historically, previous studies and systematic reviews focused on the standard of cranial disease, but it is important to recognize whether there is extracranial artery involvement in the patient with suspected GCA, as these patients have a different clinical course and development. Recent studies using high-resolution ultrasound devices have improved the capability to identify signs of arterial inflammation in GCA suspicion patients. Objective: Determine the diagnostic accuracy of halo sign on temporal artery with color Doppler ultrasound (UDC) in people with suspected GCA. Methods: A systematic review following Cochrane’s handbook protocol. The database sources were: Pubmed, Embase, CENTRAL, CRDTAS, LILACS, clinicaltrials.gov, WHO and OpenGrey up to September 2021. No date and language restrictions were applied. UDC papers/studies with patients with temporal arteries GCA suspicion in a standard reference of clinical diagnosis were included. Paper titles and abstracts were selected by two investigators on an independent basis from all available records. The quality of the study was assessed using the Quality of Diagnostic Accuracy Studies tool (QUADAS-2) with R program (version 4.2) data analysis. Results: Seventeen studies were included with 2017 participants with GCA suspicion who underwent temporal artery UDC. The primary analysis results showed a sensitivity of 0.74 (95% CI 0.66 – 0.81) and specificity of 0.90 (95% CI 0.86 – 0.93) when the halo sign was compared with only clinical diagnosis. The area under the ROC curve was 0.90 and the Diagnostic Odds Ratio (DOR) was 26.76 (95% CI 13.08 – 54.69). The sensitivity values of 0.86 (95%CI 0.74 – 0.92) and specificity of 0.98 (95%CI 0.94 – 0.99) was found in three studies involving 623 participants with the sign of compression on the temporal artery where the halo sign was studied. A sensitivity of 0.82 (95% CI 0.72 – 0.89) and specificity of 0.92 (95% CI: 0.86 – 0.95) was found in three studies with 266 participants where the halo sign was studied on temporal and axillary arteries. Conclusion: Ultrasonography detecting the halo sign in the temporal arteries has a good performance for diagnose cranial GCA.
Descrição
Citação
NAKAJIMA, Eliza. Acurácia da ultrassonografia doppler no diagnóstico da arterite de células gigantes: uma revisão sistemática e metanálise. São Paulo, 2022. 169 f. Tese (doutorado em Saúde Baseada em Evidências) – Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, 2022