Skip to main content

PET/CT uncovers cranial giant cell arteritis



Giant cell arteritis (GCA) is an inflammation of large and medium sized vessels, mainly affecting people over 50 years of age. Diagnosis needs to be made quickly to prevent complications. Steroids treatment should be started once diagnosis is made.

Case presentation

Here we reported a case of cranial GCA in a 82-year-old man. [18F]FDG PET/CT imaging demonstrated higher FDG uptake in medium sized and cranial vessels. Glucocorticoid treatment was started, followed by a rapid and marked improvement of symptoms and inflammatory markers.


This case report supports the role of PET/CT hybrid imaging as a useful noninvasive tool in the evaluation of cranial GCA.


Giant cell arteritis, also known as temporal arteritis is categorized as a vasculitis of large and medium-sized vessels because it can involve the aorta and great vessels. Systemic symptoms are common in GCA and vascular involvement can be widespread. It is the most common idiopathic systemic vasculitis and affects mainly older adults, peak incidence between ages 70 and 79. Symptoms onset tends to be subacute and nonspecific. Treatment with glucocorticoids should be promptly once the diagnosis is made, to prevent visual loss. The diagnosis of GCA is usually based on histopathology or imaging exams. Histopathologic evidence of GCA is most often acquired by invasive temporal artery biopsy (TAB), histopathologic evidence of GCA is most often acquired by invasive temporal artery biopsy (TAB), it has been reported that false-negative results (10–61%) may occur, due to the patchy involvement of the artery—“skip lesions” (Ashton-Key and Gallagher 1992; Gonzalez-Gay et al. 2001; Oh et al. 2018). Ultrasound with Doppler is another diagnostic tool, but there is the absence of extensive experience. Other temporal artery imaging such as MRI angiography has poor sensitivity. Another diagnostic tool, as will be detailed in this case study, is PET/CT.

Case presentation

A 82-year-old man with a medical history of Dyslipidemia, Hypertension, and glaucoma, presented with a 3-week history of fever of unknown origin and a rash. Physical examination was notable for erythematous papular rash over his trunk, fatigue and weight loss was recorded. Laboratory studies showed hemoglobin levels of 7.6 g/dL (reference range 14–17 g/dL) and thrombocytosis of 600·103/µL (reference range 150–450 103/µL). Ferritin levels of 1300 ng/milliliter (reference range 22–277 ng/ml) and ESR level of 120 mm/h (reference range < 20 mm/h). Serological tests for infectious agents as well as rheumatoid panels were all non-diagnostic. To support the diagnosis of FUO; PET/CT was done; the patient was prepared according to known recommendations (Slart et al. 2018). PET/CT showed involvement of cranial and extra-cranial vessels including superficial temporal, maxillary, vertebral and occipital arteries, as well as medium size vessels such as subclavian, brachial, femoral, and tibial arteries (Fig. 1). Despite the high physiologic FDG uptake in the brain, we noted that temporal artery and bilateral upper and lower extremity arteries had higher uptake than the surrounding tissue, a grade 2, and higher uptake than the liver’s, meaning grade III. SUVmax was 4.1 left temporal artery, 4.3 in axillary and brachial arteries, and 7.5 in femoral, popliteal and tibial arteries. Thoracic aorta was not significantly involved, SUVmax 3.5 (Nielsen et al. 2019; Stellingwerff et al. 2015; Slart et al. 2018; Nienhuis et al. 2020); Thus, a GCA diagnosis was presumed. Despite the abscess of jaw claudication and headaches, an ultrasound was done due to confirm the diagnosis however US and cytological findings of the temporal arteries were non-remarkable of the presumption of skips lesions. Based on the widespread distribution and typical pattern on PET/CT, a diagnosis of giant cell arteritis was made. Glucocorticoid treatment was started, followed by a rapid and marked improvement of symptoms and inflammatory markers.

Fig. 1

Total body [18F]FDG PET/CT was performed; coronal maximal intensity projection (MIP) image (a) showed increased FDG uptake of moderate-intensity along medium-sized extra-cranial (maxillary, and superficial temporal arteries), and cranial vessels; corresponding axial contrast-enhanced CT and [18F]FDG-PET (b, c) showed involvement of the left temporal artery with pathological tracer uptake (arrow), indicating active disease


The European League Against Rheumatism (EULAR) recommended diagnosing large vessel vasculitis (LVV) on clinical grounds and on diagnostic imaging (Dejaco et al. 2018). 83% sensitivity and 75% specificity was reveled by visual analysis while a 79% sensitivity and a 92% specificity were found when measuring SUVmax in the cranial arteries (Nienhuis et al. 2020). Thus [18F]FDG PET/CT hybrid imaging proved to be a useful and noninvasive tool in diagnostic evaluation of inflammatory conditions such as GCA. However additional randomized studies are needed to support this.


This case report supports the role of PET/CT hybrid imaging as a useful noninvasive tool in the evaluation of cranial GCA.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.



Giant cell arteritis


Cranial giant cell arteritis


Large vessel vasculitis


Temporal artery biopsy


Positron emission tomography


Computed tomography


Maximum intensity projection


18 Fluroide-Fulorodeoxyglucose


Maximum standardized uptake value


  1. Ashton-Key MR, Gallagher PJ (1992) False-negative temporal artery biopsy. Am J Surg Pathol 16(6):634–635.

    CAS  Article  PubMed  Google Scholar 

  2. Dejaco C, Ramiro S, Duftner C et al (2018) EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice. Ann Rheum Dis 77(5):636–643.

    Article  PubMed  Google Scholar 

  3. Gonzalez-Gay MA, Garcia-Porrua C, Llorca J et al (2001) Biopsy-negative giant cell arteritis: clinical spectrum and predictive factors for positive temporal artery biopsy. Semin Arthritis Rheum 30(4):249–256.

    CAS  Article  PubMed  Google Scholar 

  4. Hommada M, Mekinian A, Brillet PY, Abad S, Larroche C, Dhôte R, Fain O, Soussan M (2017) Aortitis in giant cell arteritis: diagnosis with FDG PET/CT and agreement with CT angiography. Autoimmun Rev 16(11):1131–1137.

    Article  PubMed  Google Scholar 

  5. Nielsen BD, Hansen IT, Kramer S, Haraldsen A, Hjorthaug K, Bogsrud TV, Ejlersen JA, Stolle LB, Keller KK, Therkildsen P, Hauge EM, Gormsen LC (2019) Simple dichotomous assessment of cranial artery inflammation by conventional 18F-FDG PET/CT shows high accuracy for the diagnosis of giant cell arteritis: a case-control study. Eur J Nucl Med Mol Imaging 46(1):184–193.

    CAS  Article  PubMed  Google Scholar 

  6. Nienhuis PH, Sandovici M, Glaudemans AW, Slart RH, Brouwer E (2020) Visual and semiquantitative assessment of cranial artery inflammation with FDG-PET/CT in giant cell arteritis. Semin Arthritis Rheum 50(4):616–623.

    CAS  Article  PubMed  Google Scholar 

  7. Oh LJ, Wong E, Gill AJ, McCluskey P, Smith JEH (2018) Value of temporal artery biopsy length in diagnosing giant cell arteritis. ANZ J Surg 88(3):191–195.

    Article  PubMed  Google Scholar 

  8. Slart RHJA, Writing group, Reviewer group, Members of EANM Cardiovascular, Members of EANM Infection & Inflammation, Members of Committees, SNMMI Cardiovascular, Members of Council, PET Interest Group, Members of ASNC, EANM Committee Coordinator (2018) FDG-PET/CT(A) imaging in large vessel vasculitis and polymyalgia rheumatica: joint procedural recommendation of the EANM, SNMMI, and the PET Interest Group (PIG), and endorsed by the ASNC. Eur J Nucl Med Mol Imaging 45(7):1250–1269.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Soussan M, Nicolas P, Schramm C, Katsahian S, Pop G, Fain O, Mekinian A (2015) Management of large-vessel vasculitis with FDG-PET: a systematic literature review and meta-analysis. Medicine (baltimore) 94(14):e622.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Stellingwerff MD, Brouwer E, Lensen KDF et al (2015) Different scoring methods of FDG PET/CT in giant cell arteritis: need for standardization. Medicine (baltimore) 94(37):e1542.

    Article  Google Scholar 

Download references


Not applicable.


No funding was received for this study.

Author information




All authors read and approved the final manuscript.

Corresponding author

Correspondence to Tamer Anati.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare they have no conflicts of interest or competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Anati, T., Hoffman Ben Shabat, M. PET/CT uncovers cranial giant cell arteritis. European J Hybrid Imaging 5, 20 (2021).

Download citation


  • [18F]FDG PET/CT
  • Giant cell arteritis
  • Temporal
  • cGCA