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(Stroke. 1996;27:2178-2182.)
© 1996 American Heart Association, Inc.

Articles

Ultrasonographic Study and Long-term Follow-up of Takayasu's Arteritis

Yu Sun, MD; Ping-Keung Yip, MD; Jiann-Shing Jeng, MD; Bao-Show Hwang, MT Win-Hwan Lin, MT

the Division of Neurovascular Disease, Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.

Correspondence to Ping-Keung Yip, MD, Department of Neurology, National Taiwan University Hospital, No. 7, Chung-Shan S Rd, Taipei 10016, Taiwan.

	Abstract

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Background and Purpose Takayasu's arteritis is an inflammatory vasculopathy involving the aorta and its major branches. Little information is available on the natural history and temporal profile of changes in the carotid vessels, the major vessels involved in Takayasu's arteritis. Duplex ultrasonography may provide a reliable and efficient tool for the characterization and follow-up of the brachiocephalic vascular changes in Takayasu's arteritis.

Methods Sixteen female patients fulfilling the clinical diagnostic criteria for Takayasu's arteritis were studied. Mean age at onset was 23.6 years (SD=6.0), and mean duration of follow-up was 17.1 years (SD=11.9). The clinical features were analyzed. Only one patient had had a stroke. They had undergone at least one duplex scanning examination to evaluate the brachiocephalic vessels, including the extracranial carotid, vertebral, and subclavian arteries. Six patients underwent sequential duplex examination and long-term clinical follow-up.

Results All the studied patients had subclavian artery involvement, and 11 (69%) had common carotid artery involvement. The percentage of bilateral concomitant involvement was 100% in the common carotid artery and 33% in the subclavian artery. Homogeneous circumferential intima-media thickening was commonly seen in stenotic common carotid arteries (89%). Four patients had internal carotid artery involvement (all on the left side). In the serial duplex follow-up study, 2 of 6 patients had progressive vascular stenosis with concentric thickening, rather than longitudinal spreading, in the bilateral common carotid arteries. Left-side lesions were more prominent. Most were clinically stationary, despite severe stenosis or occlusion of the common carotid arteries.

Conclusions The characteristic vascular lesions and progression changes in Takayasu's arteritis detected by duplex ultrasonography are quite different from those seen in ordinary atherosclerosis. Homogeneous circumferential intima-media thickening of the common carotid arteries is a highly specific ultrasonographic finding in patients with Takayasu's arteritis, particularly young women. Sequential duplex scanning showed vascular progression to be unpredictable and unrelated to medication in our patients. Further clinical investigations of vascular progression are warranted, and duplex scanning may provide a simple, safe, and accurate long-term means of follow-up.

Key Words: arteritis • carotid stenosis • Doppler • ultrasonics

	Introduction

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Takayasu's arteritis is an inflammatory arteriopathy of unknown cause, involving the aorta and its major branches (ie, the subclavian, carotid, and renal arteries). Arterial inflammation leads to stenosis or occlusion of the involved artery, aneurysm formation, or both.^{1 2} Previous studies of large series have shown a wide variation in clinical course and prognosis,^{3 4 5 6} but little is known about the natural history of the vascular pathology in this disease. The major factors governing presentation and outcome are extent and severity of vascular involvement, development of major complications, and disease activity.^{3 7} In the past, activity and progression of TA were monitored by following clinical symptoms, hematologic parameters, and angiographic findings.^{3 4 5 6 7} Recently, characteristic sonographic patterns have been reported to be related to TA,^{8 9 10 11} but few reports have described the temporal profile of such ultrasonic changes.¹² Because of the predilection of the vessels in the cervical and brachial regions,^{5 13 14} duplex ultrasonography may be an ideal substitute for angiography in long-term studies. We present 16 patients diagnosed with TA examined by duplex ultrasonography, six of them with long-term follow-up, to illustrate the possible natural history of the intravascular changes and the clinical relevance of ultrasonographic findings.

	Subjects and Methods

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Patient Selection
Patients were selected from two sources: (1) Ten patients diagnosed with TA were first identified retrospectively from 9000 consecutive extracranial carotid duplex sonographic examinations conducted in our neurovascular laboratory between October 1987 and June 1995. One of these patients, in whom the lesion was restricted to the descending aorta, was excluded from the present study, and the remaining constitute patients 1 to 9. (2) Another 24 patients were identified by a review of in-patient records covering the past three decades (code 446.7, International Classification of Diseases, 9th Revision). Of these, seven patients (patients 10 to 16) underwent clinical and ultrasonographic follow-up. All patients met the criteria proposed by Ishikawa¹³ in 1988. All patients underwent angiography except one (patient 8), who was diagnosed by clinical history and ultrasonography.

Ultrasonographic Studies
Conventional extracranial duplex ultrasonography was performed with a Diasonics DRF 400 duplex system, consisting of a 10-MHz real-time B-mode transducer and a 4.5-MHz pulsed Doppler transducer. Two different color Doppler duplex scanners (Aloka SSD-3000 system and Diasonic Gateway Series Color Doppler system) were used for follow-up studies. A complete duplex sonographic study was composed of insonation of both CCAs, ICAs, ECAs, proximal or mid portion of SAs, and proximal VAs from C6 to C3. The morphology of the arterial walls, flow direction, peak systolic and end-diastolic velocities, resistivity index, and flow volume were investigated in each artery examined. Special attention was paid to the measurement of the intima-media complex thickness of the CCA. The mean duration between the initial ultrasonographic study and presumed disease onset was 15.4 years (SD=13.3). All patients underwent at least one duplex examination, and the findings are shown in the Table. Six patients (patients 2, 3, 5, 6, 7, and 9) underwent multiple serial clinical and ultrasonographic examinations. The average duplex follow-up period was 52.7 months (SD=28.5), with a range of 11 to 81 months.

View this table: [in this window] [in a new window]   Table 1. Initial Duplex Ultrasonography in 16 Patients With TA

	Results

Top Abstract Introduction Subjects and Methods Results Discussion References

 
All 16 patients were women, with a mean age at disease onset of 23.6 years (SD=6.0) and a mean age at diagnosis of 34.0 years (SD=11.7). The mean follow-up period from onset was 17.1 years (SD=11.9). The most frequent clinical presentation was asymmetrical bilateral blood pressure (difference >20 mm Hg), found in 12 patients (75%), and absence of detectable pulses in both arms, found in 2. Most patients presented incidentally during prenatal pregnancy examination or during admission for other diseases. Hypertension was found in 4 patients. Dizziness was the major neurological complaint (56%), and some of the patients had previously experienced blurred vision (31%) or syncope (19%). During the course of follow-up, 1 patient suffered a cerebral infarction with residual contralateral hemiparesis (patient 16).

Initial Duplex Results (Table)
Of the 16 patients, 11 showed abnormal findings in the CCA, all bilateral: stenoses in 9, right-side stenosis and left-side occlusion in 1, and bilateral occlusions in 1. The CCA involvement was more severe on the left side in 5 patients, more severe on the right side in 1 patient, and equally severe in 5 patients. Four patients had ICA involvement. In 17 of the 19 stenotic CCAs (89%), longitudinal section of B-mode images showed long-segmental, homogeneous thickening, with isoechogenicity or hyperechogenicity, of the intima-media complex (Fig 1A), and the transverse section showed concentric thickening (Fig 1B). This thickening was localized in the proximal half or two thirds of the CCA and had a clear-cut margin. The distal part to bulb areas of the CCA were essentially free of involvement. Only 1 patient (patient 9) displayed focal plaques in both bulbs, presumed to be atherosclerosis.

View larger version (205K): [in this window] [in a new window]   Figure 1. Duplex sonograms of the CCA in TA. A, Longitudinal view shows long-segmental, homogeneous intima-media complex thickening (arrow) with clear-cut margin at the CCA and spared bulb and ICA. B, Transverse view shows concentric intima-media complex thickening ("macaroni sign"). IJV indicates internal jugular vein.

Fifteen patients underwent duplex scanning of the SA and VA. Abnormal SA Doppler signals, consisting of monophasic waveforms with loss of the diastolic reverse flow, were found in 11 patients. These were bilateral in 3 patients, left-sided in 6, and right-sided in 2. Five patients showed a reversed vertebral flow direction, accompanied by ipsilateral proximal stenosis of the SA consistent with subclavian steal. They all occurred on the left side. Compared with angiography, duplex scanning underestimated SA lesions in 5 patients (4 right-sided and 1 bilateral), but it provided better visualization of lesions in the CCA. No evidence of involvement of the ECA or VA was seen in any case. The percentage of bilateral concomitant involvement was higher in the CCA (11/11, 100%) than in the SA (5/15, 33%). Ten patients (67%) had unilateral SA involvement (5 patients solely on the right side and 5 patients solely on the left side).

Follow-up Study
Six patients underwent repeated duplex ultrasonography to follow the course of vasculopathy. The mean length of follow-up was 52.7 months (SD=28.5), with a range of 11 to 81 months, and the number of examinations ranged from 2 to 10. Of these 6 patients, 2 (patients 5 and 6) were found to have progressive narrowing of both CCAs. In patient 5, initial duplex ultrasonography revealed moderate stenosis with long-segmental intima-media complex thickening of both proximal CCAs, more severe on the left side. Patient 5 also had evidence of subclavian steal syndrome. Despite treatment with prednisolone (60 mg/d) and aspirin (100 mg/d), progression of bilateral CCA stenoses to occlusions was observed. Patient 5 then underwent bilateral aortocarotid bypass and left aortosubclavian bypass. Her condition was stationary after the operation. In patient 6, serial duplex ultrasonography showed bilateral proximal CCA stenoses (Fig 2A), which progressively worsened to occlusion (Fig 2B), with reversed flow of the ECA through the carotid bulb into the patent ICA (Fig 2C). Both SAs showed abnormal monophasic Doppler signals. Patient 6 had previously received antiplatelet treatment (aspirin 650 mg/d), but her carotid stenosis still progressed. The left VA flow increased gradually to more than 1000 mL/min (the normal average flow of bilateral VAs is 147 mL/min [SD=58] in our laboratory). This patient did not have any specific neurological symptoms or signs during regular follow-up. The other 4 patients (patients 2, 3, 7, and 9) were clinically stable, and duplex scanning showed nonprogression. These 4 patients had only received steroids for a few days after the diagnosis and received no antiplatelet agents or cytotoxic drugs. No specific cerebral ischemic events or focal signs were noted.

View larger version (217K): [in this window] [in a new window]   Figure 2. Color-coded sonograms of CCA progression in patient 6. A, Mild stenosis in the proximal CCA. B, Total occlusion without color flow in the lumen of the previous CCA during follow-up study. C, Reversed flow from the ECA (blue) to the ICA (red).

Carotid Involvement and Clinical Relevance
Eleven of 16 patients had carotid involvement (69%). Most of the patients (7/11, 64%) with stenotic or occluded CCAs had patent ICAs and ECAs. In these 11 patients, possible neurological manifestations included ischemic stroke in 1, monocular blurred vision in 5, dizziness in 3, neck pain in 2, and syncope in 1. The duration from disease onset to duplex study was 2 months to 43 years. According to the duplex evaluation in the 32 CCAs of the 16 patients, the incidence of CCA occlusion was 22% (7/32; 4 of 16 patients). Of the 4 patients with CCA occlusion, 2 (patients 3 and 5) had monocular progressive blurred vision, while 2 (patients 6 and 11) had no ischemic symptoms. Patient 3 had become totally blind in the left eye 7 years before coming to our hospital. Patient 5 showed dramatic improvement after carotid bypass surgery. Of the 16 patients, except the aforementioned 2 patients with progressive vision symptoms and 1 with stroke, none suffered progressive or fixed cerebral ischemic symptoms, despite severe carotid stenosis or occlusion.

	Discussion

Top Abstract Introduction Subjects and Methods Results Discussion References

 
The incidence of clinical manifestations in the present series is similar to that reported in series from other countries, ie, Lupi-Herrera et al⁵ from Mexico, Ishikawa⁶ from Japan, and Kerr et al¹⁴ from the United States. Several aspects of the cross-sectional and longitudinal follow-up study by carotid duplex ultrasonography and clinical evaluations deserve special discussion: (1) distribution, location, and character of vessel involvement—probable ultrasonographic criteria for the diagnosis of TA; (2) comparison of ultrasonography and angiography in the detection of TA pathology in the cervical vessels; and (3) benefits of the duplex findings for determination of treatment.

Distribution, Location, and Character of Vessel Involvement—Probable Ultrasonographic Criteria for the Diagnosis of TA
In the past, two large series of TA studies in which angiography was used have shown that 91% to 93% of patients have SA involvement and 58% to 60% CCA involvement.^{13 14} Our present study revealed that the subclavian system was also more commonly involved (15/15, 100%) (either side in 67%, both sides in 33%) than the carotid system (11/16, 69%) (both sides in 100%). Four patients had only SA involvement without concomitant carotid involvement. The frequency of SA involvement on either side was the same (67%). Despite the fact that simultaneous bilateral involvement of the CCA was 100% (11/11), the CCA lesion was more severe on the left side than the right side (5:1). During the serial follow-up, the progression of vascular lesions was faster on the left side.

The carotid lesion in TA can be seen clearly by B-mode ultrasonography. The long-segmental arterial wall thickening of the proximal CCA is a characteristic finding in TA (Fig 1A). In transverse section, the circumferentially thickened intima-media complex is termed the "macaroni sign" by Maeda et al⁹ (Fig 1B). This was seen in 17 of our 19 stenotic CCAs (89%), while atherosclerotic plaques were seen in only 2. The carotid lesion in TA can be clearly distinguished from atherosclerotic plaques by B-mode ultrasonography. In TA, the vascular lesions are often homogeneous in density, long-segmental involvement, and concentric or circumferential thickening and are located in the proximal to middle segment of the CCA. The ICA is not commonly involved. In atherosclerosis, the plaques are either homogeneous or heterogeneous in density (depending on the stage and severity of development), shortened and irregular in shape, and often eccentrically located in the posterior wall with a predilection for the bulb-bifurcation areas and proximal ICA.^{15 16 17} In addition, all of our TA patients showed a clear-cut boundary between involved and noninvolved areas in the middle third of the CCA, while in atherosclerotic plaques, the margin usually forms a convex protrusion.^{15 16 17}

In the follow-up study, we found that the extension of vascular lesion in 2 patients with progression occurred in a segmentally circumferential, centripetal direction rather than by longitudinal progression. This differs from the usual atherosclerotic progressive process, which generally starts eccentrically from the posterior wall of the bulb-bifurcation area, progressing to the proximal CCA and ICA.^{15 16}

According to the aforementioned findings, we tentatively propose certain ultrasonographic criteria for de novo diagnosis of TA: (1) distribution of lesion: (a) isolated SA involvement or (b) one- or two-sided SA and bilateral CCA involvement; (2) location of lesion: proximal to mid SA and/or proximal to mid CCA, relative sparing of the carotid bulb and the proximal ICA; (3) morphology: B-mode image of the CCA lesion: (a) longitudinal section: homogeneous long-segmental arterial wall thickening; (b) transverse section: "macaroni" sign; and (c) homogeneous density and clear-cut margin. If these ultrasonographic findings are seen in a young female, a diagnosis of TA should be considered.

Comparison of Ultrasonography and Angiography in the Detection of TA
In the detection of TA, ultrasonography has certain advantages over angiography. First, homogeneous intima-media thickening of the CCA, the early characteristic TA finding, can be easily seen by ultrasonography. Angiography cannot depict the pathological changes of the arterial wall and may miss mild stenosis of the CCA. Second, duplex ultrasonography can detect hemodynamic change. Isolated CCA occlusion with reversed ECA flow to the patent ICA is not infrequent in TA (Fig 2C). Such findings were seen in our 3 patients, including 2 with a progressive course. Duplex ultrasonography, coded with color-flow imaging, is superior to angiography in the detection of the patent ICA and ECA as well as the flow direction change in CCA occlusion.¹⁸ Third, duplex ultrasonography is a noninvasive, efficient, and reliable method for patients and is suitable for long-term repeated follow-up.

However, false-negatives were seen in 5 patients in detecting SA vasculopathy by duplex scan (6 of 30 studied SAs). Some drawbacks of duplex ultrasonography may contribute to this result: (1) the proximal part of the SA is difficult to approach by the B-mode imaging technique because of its deep intrathoracic portion, located behind the sternoclavicular joints; (2) SA stenosis and occlusion may be bypassed through collateral pathways formed from its major branches, such as the thyrocervical trunk and the internal mammary and subscapular arteries, which may result in rather normal flow in the distal or mid portion of SA detected by the Doppler probe; and (3) the stenosis must be severe enough to produce a change in the Doppler flow pattern. It is well documented that a 50% reduction in diameter is required to modify the triphasic Doppler signal in the peripheral arterial tree.^{19 20} However, abnormal monophasic waveforms in the axillary and brachial arteries may be of use as an indirect sign indicating distal SA stenosis. From this viewpoint, we suggest that evaluation of the peripheral arteries of the extremities, in addition to the cephalic branches, is required in examining any suspected TA patients.

Benefits of Duplex Findings for Treatment Consideration
TA shows a large variation in clinical course. In the past, the clinical course was classified on the basis of patient history into four patterns: plateau, decrescendo, decrescendo-plateau-crescendo, and plateau-crescendo.⁶ In both our study and others,^{6 7 14} progression and response to therapy in TA were heterogeneous and unpredictable. Both medical and surgical treatments, including aspirin, steroids, cytotoxic agents, angioplasty, reconstruction, and bypass graft surgery,^{14 21 22 23 24 25 26 27} have been applied to TA patients. Recent reports have shown that steroids, with or without cytotoxic agents, have an effect on clinical remission¹⁴ and on regression in angiographic follow-up studies.²⁷ A few case reports have also shown regression of vascular stenosis after management, as detected by CT, MRI, or duplex.^{12 28 29} However, failure to respond to therapy or restenosis is not uncommon.¹⁴ In our study, 2 patients who received steroids and aspirin still had progressive vasculopathy, progressing from bilateral CCA stenosis to total occlusion during duplex follow-up, while most patients remained stable almost without treatment. Clinical presentation and current laboratory markers, such as erythrocyte sedimentation rate, are not consistently reliable markers of disease activity since clinically inactive patients have shown histologically active disease¹⁴ and progressive stenosis during duplex follow-up in our patients (patients 5 and 6). What would be the ideal guideline for treatment? Whether the patient is in progression or nonprogression, although unpredictable, is a key factor in choice of treatment. Quantitative study by duplex follow-up, together with monitoring of clinical manifestations, in TA patients with carotid involvement is a safe, sensitive, and efficient means of detecting the presence of progression or plateau of the course of TA. Surgical intervention or aggressive medical treatment is necessary in patients with progression of vascular lesions.^{21 22 23 24 25 26 27} Therefore, we suggest that duplex sonography should be included in the diagnosis and follow-up of every patient with TA.

	Selected Abbreviations and Acronyms

 

CCA = common carotid artery ECA = external carotid artery ICA = internal carotid artery SA = subclavian artery TA = Takayasu's arteritis VA = vertebral artery

Received March 1, 1996; revision received August 23, 1996; accepted August 23, 1996.

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