Is performing a diagnostic cerebral angiogram in a patient with systemic vasculitis (inflammation of blood vessels) considered dangerous?

From the Guidelines

Performing a diagnostic cerebral angiogram in a patient with systemic vasculitis is not recommended due to the increased risks of triggering vasculitic flares or causing vascular complications, and alternative imaging modalities such as MR angiography or CT angiography should be considered first. The procedure carries increased risks in these patients, particularly the possibility of triggering vasculitic flares or causing vascular complications in already inflamed blood vessels. Patients with active vasculitis have fragile vessel walls that may be more susceptible to dissection, rupture, or thromboembolic events during catheter manipulation. According to the most recent study 1, conventional angiography is not recommended for the diagnosis of GCA or TAK as it has been superseded by other imaging modalities.

Key Considerations

• The risks associated with cerebral angiography in patients with systemic vasculitis include stroke, death, and vascular complications 1.
• Alternative imaging modalities such as MR angiography or CT angiography have lower risk profiles and should be considered first unless there is a specific diagnostic question that only conventional angiography can answer 1.
• If cerebral angiography is deemed necessary, the procedure should be performed by an experienced neurointerventionalist with careful attention to technique, minimal contrast use, and close monitoring for complications both during and after the procedure.
• Patients should be informed about the increased risks and provide informed consent before proceeding.

Management Approach

• Before proceeding with cerebral angiography, the vasculitis should ideally be well-controlled with appropriate immunosuppressive therapy, which might include corticosteroids, cyclophosphamide, rituximab, or other disease-modifying agents depending on the specific type of vasculitis.
• The use of alternative imaging modalities such as MR angiography or CT angiography can help reduce the risks associated with cerebral angiography and provide valuable diagnostic information.
• Close monitoring for complications and careful attention to technique are crucial when performing cerebral angiography in patients with systemic vasculitis.

From the Research

Diagnostic Cerebral Angiogram in Systemic Vasculitis

• The utility of diagnostic cerebral angiography in the management of suspected central nervous system vasculitis has been assessed in various studies 2, 3, 4.
• Cerebral angiography is considered the radiological gold standard for diagnosis in patients with compatible clinical findings, but advances in noninvasive neuroimaging techniques may obviate the need for invasive catheter angiography 2.
• The use of noninvasive imaging modalities such as computed tomographic angiography, magnetic resonance angiography, color Doppler ultrasound, and positron emission tomography/computed tomography is commonly used for both diagnosis and follow-up of systemic vasculitis 5, 6.
• Invasive catheter-based angiography may be of limited benefit in the diagnosis and management of primary central nervous system vasculitis (PCNSV) when considered in the context of clinical and laboratory findings and MRA or CTA results 2.
• A multidisciplinary approach among rheumatologists, vascular cardiologists, radiologists, and vascular interventionalists can be used to raise diagnostic certainty in cases with large- and/or medium-vessel involvement 5.

Risks and Challenges

• The diagnosis of cerebral vasculitis can be challenging due to the broad differential diagnosis and generally nonspecific initial clinical manifestations 3, 4.
• Exclusion of more frequent differential diagnoses is a key element of diagnostic work-up to protect patients from 'blind' immunosuppressive therapy in unrecognized non-inflammatory differential diagnosis 3.
• The use of targeted therapies is limited, and glucocorticoids and cyclophosphamide remain the mainstays of therapy in primary angiitis of the CNS (PACNS) 4.

Imaging Modalities

• Various imaging modalities are emerging as important aids to the diagnosis, staging, evaluation of disease activity, and response to treatment in systemic vasculitis 6.
• Refinement and increasing accuracy of imaging modalities are providing useful information in the evaluation of medium-vessel and small-vessel vasculitis 6.
• Conventional angiography can give important details regarding luminal anatomy and pressure gradients in medium- and large-vessel vasculitis, but noninvasive imaging modalities are commonly used for both diagnosis and follow-up 5.