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Meta-Analysis: Test Performance of Ultrasonography for Giant-Cell Arteritis

Fotini B. Karassa, MD; Miltiadis I. Matsagas, MD; Wolfgang A. Schmidt, MD; and John P.A. Ioannidis, MD
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From University of Ioannina School of Medicine and Foundation for Research and Technology—Hellas, Ioannina, Greece; Medical Center for Rheumatology Berlin—Buch, Berlin, Germany; and Tufts-New England Medical Center, Tufts University School of Medicine, Boston, Massachusetts.

Acknowledgments: The authors thank Xavier Puéchal, MD; Matthias Reinhard, MD; and Helen Murgatroyd, MD, for providing clarifications or additional data on their studies and for reviewing the final draft. They also thank Efi Souli, MA; Evangelos Douitsis, MD; and Dionysis Spyridakos, MD, for reviewing German, Italian, and Japanese articles, respectively.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: John P.A. Ioannidis, MD, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, 45110 Ioannina, Greece; e-mail, jioannid@cc.uoi.gr.

Current Author Addresses: Drs. Karassa and Ioannidis: Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, 45110 Ioannina, Greece.

Dr. Matsagas: Department of Surgery—Vascular Surgery Unit, University of Ioannina School of Medicine, 45110 Ioannina, Greece.

Dr. Schmidt: Medical Center for Rheumatology Berlin—Buch, Karower Strasse 11, 13125 Berlin, Germany.

Ann Intern Med. 2005;142(5):359-369. doi:10.7326/0003-4819-142-5-200503010-00011
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Background: Giant-cell arteritis is a diagnostic challenge.

Purpose: To determine the diagnostic performance of ultrasonography for giant-cell arteritis.

Data Sources: Studies published up to April 2004 in the MEDLINE, EMBASE, and Cochrane databases; reference lists; and direct contact with investigators.

Study Selection: Studies in any language that examined temporal artery ultrasonography for diagnosis of giant-cell arteritis, enrolled at least 5 patients, and used biopsy or the American College of Rheumatology (ACR) criteria as the reference standard.

Data Extraction: Two reviewers independently graded methodologic quality and abstracted data on sensitivity and specificity of ultrasonography for giant-cell arteritis. Diagnostic performance was determined for the halo sign, stenosis, or occlusion and for any of these ultrasonographic abnormalities.

Data Synthesis: Weighted sensitivity and specificity estimates and summary receiver-operating characteristic (ROC) curve analysis were used. Twenty-three studies, involving a total of 2036 patients, met the inclusion criteria. The weighted sensitivity and specificity of the halo sign were 69% (95% CI, 57% to 79%) and 82% (CI, 75% to 87%), respectively, compared with biopsy and 55% (CI, 36% to 73%) and 94% (CI, 82% to 98%), respectively, compared with ACR criteria. Stenosis or occlusion was an almost equally sensitive marker compared with either biopsy (sensitivity, 68% [CI, 49% to 82%]) or ACR criteria (sensitivity, 66% [CI, 32% to 89%]). Consideration of any vessel abnormality nonsignificantly improved diagnostic performance compared with ACR criteria. Between-study heterogeneity was significant, but summary ROC curves were consistent with weighted estimates. When the pretest probability of giant-cell arteritis is 10%, negative results on ultrasonography practically exclude the disease (post-test probability, 2% to 5% for various analyses).

Limitations: The primary studies were small and of modest quality and had considerable heterogeneity.

Conclusion: Ultrasonography may be helpful in diagnosing giant-cell arteritis, but cautious interpretation of the test results based on clinical presentation and pretest probability of the disease is imperative.


Grahic Jump Location
Summary receiver-operating characteristic (ROC) curves for the ultrasonographic evidence of various types of vessel abnormality versus biopsy or the American College of Rheumatology (ACR) criteria for the diagnosis of giant-cell arteritis.

Each ellipse corresponds to a study estimate of sensitivity and specificity; the area of each ellipse is proportional to study size. Dotted lines indicate unweighted analyses; black lines indicate weighted analyses. Shaded rectangles mark the 95% CIs of the pooled sensitivity and pooled specificity by random-effects calculations. Exact estimates are indicated by “X”. A. Halo sign vs. biopsy. B. Stenosis or occlusion vs. biopsy. C. Halo, stenosis, or occlusion vs. biopsy. D. Halo sign vs. ACR criteria. E. Stenosis or occlusion vs. ACR criteria. F. Individual study estimates (circle) and pooled estimates (squares) of sensitivity and specificity of halo, stenosis, or occlusion vs. ACR criteria (random-effects model). For each study, solid lines represent 95% CIs. Summary ROC curves are meaningless for this comparison because all 3 studies had very similar estimates of sensitivity and specificity.

Grahic Jump Location
Grahic Jump Location
Appendix Figure.
Reports evaluated for inclusion in the meta-analysis.

GCA = giant-cell arteritis; US = ultrasonography.

Grahic Jump Location




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Summary for Patients

Ultrasonography To Diagnose Giant-Cell Arteritis

The summary below is from the full report titled “Meta-Analysis: Test Performance of Ultrasonography for Giant-Cell Arteritis.” It is in the 1 March 2005 issue of Annals of Internal Medicine (volume 142, pages 359-369). The authors are F.B. Karassa, M.I. Matsagas, W.A. Schmidt, and J.P.A. Ioannidis.


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