MR imaging of atlantoaxial joint in early rheumatoid arthritis

Purpose

This study was done to assess the involvement of the atlantoaxial joint in patients with early rheumatoid arthritis and evaluate the role of magnetic resonance (MR) imaging in depicting this early joint involvement.

Materials and methods

Twenty patients (16 women and four men, mean age 55.0±12.9 years) with clinical and laboratory evidence of early rheumatoid arthritis (mean disease duration <12 months) were included in our study. MR imaging of the atlantoaxial joint was performed in all patients within 3 months from diagnosis. The MR features were correlated with clinical and biochemical variables.

Results

Five (25.0%) of the 20 patients exhibited enhancement of the periodontoid synovial spaces after gadolinium administration due to inflammatory synovitis. Compared with patients without cervical involvement, these five patients showed significantly higher values of erythrocyte sedimentation rate [median 77.0 mm/h (range 25th and 75th percentile 69.0–86.0) vs median 33.0 mm/h (range 25th and 75th percentile: 9.2–52) (p=0.007)]; significantly higher C-reactive protein values [median 53.6 mg/l (range 25th and 75th percentile 21.9–81.9) vs median 14.0 mg/l (range 25th and 75th percentile 0.8–20) (p=0.03)]; higher disease activity score [median 4.2 (range 25th and 75th percentile 3.9–5.4) vs median 3.2 (range 25th and 75th percentile 2.8–3.8) (p=0.03)]. Four (80%) of these five patients presented anti-citrulline antibodies (anti-CCP) and rheumatoid factor at laboratory testing. The latter was positive in 12 of the 20 patients (66%), and anti-CCP were positive in 15 (83%).

Conclusions

MR imaging showed an atlantoaxial inflammatory synovitis in 25% of patients with early rheumatoid arthritis. Our results indicate that patients with higher disease activity are likely to be at higher risk of presenting early involvement of the atlantoaxial joint. MR imaging of the cervical spine is an excellent tool for assessing the early manifestations of rheumatoid arthritis before any destructive changes occur. Therefore, MR imaging should be included in the diagnostic workup in order to provide reliable guidance for treatment choices.     

Juvenile rheumatoid arthritis: assessment with MR imaging

Thirty-three joints of the appendicular skeleton in 15 children with juvenile rheumatoid arthritis were examined with magnetic resonance (MR) imaging to determine if it could demonstrate synovial hypertrophy and status of the articular cartilage. Presumed synovial hypertrophy was seen in 13 joints as masses of varying sizes of low to intermediate signal intensity on T1- and T2-weighted images; sometimes foci of increased signal intensity, most likely due to fluid or inflammation, were seen on T2-weighted images. Probable abnormal articular cartilage was detected in ten joints, and MR imaging also demonstrated epiphyseal overgrowth, bone erosions, joint effusions, and joint space narrowing. Because MR imaging appears to provide an objective method of evaluating both synovial hypertrophy and status of articular cartilage, it may prove to be useful in monitoring progression of juvenile rheumatoid arthritis and response to therapy.     

MR imaging assessment of clinical problems in rheumatoid arthritis

Although MR imaging has been increasingly recognized as a useful tool in the diagnosis of early rheumatoid arthritis (RA) and in the assessment of disease activity, these applications have not yet been usually included in the routine management of this condition. Our goal is to review the current role of MRI in the everyday clinical management of patients with RA. The usefulness of MRI in the evaluation of articular and para-articular changes in specific locations, mainly the craniocervical region and the temporomandibular joint, are reviewed. Clinical problems derived from local extra-articular involvement, such as tenosynovitis, "rice-bodies" bursitis, and Baker's cyst rupture, are also described. Finally, we also review the value of MRI in evaluation of some complications of RA such as tendinous rupture, osteonecrosis, stress fracture, and septic arthritis/osteomyelitis.     

MR imaging appearance of rheumatoid arthritis in the foot

Although conventional radiographs remain the initial mainstay for imaging of the foot in patients with rheumatoid arthritis (RA), magnetic resonance (MR) imaging has afforded the ability to detect early signs of the disease (i.e., synovitis, tenosynovitis, bone lesions, and bursitis), especially at the forefoot. In addition, the relatively symmetric distribution of the imaging abnormalities depicted in the metatarsophalangeal joints and the frequent involvement of the retro-calcaneal bursitis are almost specific for RA. In more advanced stages of the disease, MR imaging is well suited to evaluation of the hindfoot joints and tendons as well as the musculoskeletal complications of RA (e.g., tendon disruption, rheumatoid nodules, sinus tarsi syndrome).     

MR imaging for evaluation of early rheumatoid arthritis

In rheumatoid arthritis (RA), due to its superior contrast resolution and tomographic nature, magnetic resonance (MR) imaging can depict soft tissue and joint involvement better than plain radiography. Active synovitis and pannus are shown by a wide variety of contrast on T1- and T2-weighted images. They are markedly enhanced by intravenous gadolinium-chelate injection. Fat-suppressed T1-weighted imaging with gadolinium enhancement is the most sensitive technique to demonstrate these tissues. Compared with plain radiography, MR imaging is more sensitive and equally specific in the diagnosis of early RA compared with plain radiography. MR imaging is useful in the diagnosis and treatment of patients who are suspected of having early RA.     

MR imaging of the cervical spine in rheumatoid arthritis

The cervical spine was examined with MR imaging and conventional radiography in 23 patients with severe rheumatoid arthritis. All patients had neck pain and 17 also had neurologic symptoms. MR provided detailed information about soft-tissue lesions, vertebral dislocation, and narrowing of the spinal canal. Pannus surrounding the odontoid process was revealed in 14 patients, all with horizontal atlantoaxial subluxation. Compression of the medulla and/or spinal cord, caused by dislocated vertebrae and/or the soft-tissue mass around the odontoid process, was seen in 15 patients. When there was more than one dislocation the most important level could be determined. Posterior occipitocervical fusion had been performed in six of the patients, and in only two of these was adequate analysis of the upper cervical spine impossible because of artifacts from metal (stainless steel wires and pins). Sagittal MR in the neutral position combined with conventional radiography, including lateral views in flexion and extension, provided all the information necessary for further clinical management of rheumatoid arthritis of the cervical spine.     

Knee in early juvenile rheumatoid arthritis: MR imaging findings

PURPOSE: To determine the magnetic resonance (MR) imaging findings in the knee in early juvenile rheumatoid arthritis. MATERIALS AND METHODS: MR imaging (1.5 T) was performed in the more symptomatic knee in 30 children with juvenile rheumatoid arthritis with a symptom duration 1 year or less. Conventional, fast spin-echo, three-dimensional gradient-echo, and gadolinium-enhanced T1-weighted images were assessed. Two radiologists independently read the images, and a third resolved disagreements. These images were compared with knee radiographs in 27 children. RESULTS: Mean maximal synovial thickness was 4.8 mm +/- 2.4 (SD). Mean synovial volume was 15.4 mL +/- 10.8. Suprapatellar joint effusions were seen in 26 (87%) of 30 knees, meniscal hypoplasia in 11 (37%) of 30 knees, and abnormal epiphyseal marrow in eight (27%) of 30 knees. Three knees had articular cartilage contour irregularity, fissures, and/or thinning. One knee had a bone erosion. Knee radiographs showed suprapatellar fullness in 78% of the knees, joint space narrowing in one knee, and no bone abnormalities. CONCLUSION: Synovial hypertrophy and joint effusions are the most frequent MR imaging findings of knees in early juvenile rheumatoid arthritis. Early in the disease, radiographically occult cartilage and bone erosions are uncommonly seen at MR imaging. The potential relationship of synovitis to cartilage abnormalities deserves further study.     

Quantitative cerebral MR in rheumatoid arthritis.

PURPOSETo determine the presence of hyperintense white matter lesions and atrophy reflecting cerebral vasculitis in rheumatoid arthritis.METHODSThirty-three patients with rheumatoid arthritis and 48 control subjects were examined with MR. Mean age was 45.1 years (range, 26 to 55 years) for the patients and 42.2 years (range, 25 to 55 years) in the control group. To determine atrophy we measured the area of corpus callosum, the cerebrum, and the cerebellum on midline sagittal sections. On transverse images, the ventricle-to-brain ratio, the bifrontal ratio, and the bicaudate ratio were selected as atrophy parameters. Area and signal intensity were measured for the biggest and the smallest lesions in both groups.RESULTSNine patients (27%) had hyperintense lesions compared with 15 (31%) of the control subjects. Mean numbers of hyperintense lesions were 1.3 in patients and 2.1 in control subjects. Mean area of the largest lesion in each patient was 27.4 mm2 for the patients and 29.8 mm2 in the control group. In patients with long disease duration (> 15 years) the mean ventricle-to-brain ratio was 0.09 compared with 0.08 in the control subjects. The midsagittal area of the cerebellum was 1349.8 mm2 in the patients with long disease duration and 1573.3 mm2 in the control group. No difference in number of hyperintense white matter lesions was detected between patients with long disease duration and the control subjects. Comparing the total group of patients with the control subjects, no significant differences in atrophy parameters or hyperintense white matter lesions were found. Also, there were no significant differences in relative signal intensity of the hyperintense lesions and corpus callosum between the two groups. We were not able to detect differences between treated versus untreated patients.CONCLUSIONThis study indicates a tendency of more cerebral and cerebellar atrophy in patients with severe rheumatoid arthritis. The number and size of the white matter lesions were not significantly different in the two groups and do not support a higher frequency of even clinically silent infarcts caused by vasculitis in the patients with rheumatoid arthritis compared with control subjects.     

Ultra low field MR imaging of cervical spine involvement in rheumatoid arthritis.

In a study of 30 patients with longstanding rheumatoid arthritis the diagnostic usefulness of ultra low field MR equipment was analyzed in assessing lesions of the craniocervical junction. It was found that at 0.04 T all the examinations were diagnostic and that in combination with plain radiography the diagnostic information obtained was valuable in further planning of the treatment strategies. The neurologic findings were related to the degree and severity of atlantoaxial luxation, either horizontal or vertical, and to the periodontoid pannus formation. The correlation between the degree of cord compression shown with MR imaging and the clinical symptoms, especially long tract symptoms, was poor. The only correlating factor was the duration of the disease.     

Pre- and postoperative MR imaging of the craniocervical junction in rheumatoid arthritis

Ten patients with severe chronic rheumatoid arthritis with atlantoaxial subluxation were examined with conventional radiography and MR imaging of the cervical spine before and at an average of 6 months after posterior occipitocervical fusion. Periodontoid pannus formation was revealed by MR preoperatively in nine patients, all with mobile horizontal atlantoaxial subluxation. Compression of the medulla and/or upper cervical cord, due to subluxation and periodontoid pannus bulging into the spinal canal, was seen in seven patients. After the stabilizing surgery the periodontoid pannus had decreased in size in all patients with preoperative pannus. This reduction in the pannus seems to be the result of the atlantoaxial immobility achieved by the posterior fusion. Postoperatively, three patients had some remaining compression of the medulla and/or cord secondary to immobile subluxation, while the pannus posterior to the odontoid process had disappeared. Artifacts from the surgical stainless steel fixation material were confined to the posterior part of the neck on short TR/short TE MR images and did not interfere with the evaluation of the periodontoid region and the anterior part of the medulla/cervical cord. We found that flexion and extension lateral radiographs, combined with sagittal short TR/short TE MR images in the neutral position, enable preoperative evaluation of patients with rheumatoid arthritis in the cervical spine. Postoperative MR should be performed only if there are residual or new symptoms.     

MR imaging of the wrist in rheumatoid arthritis using gadobenate dimeglumine

Objective. To determine the dosage of gadobenate dimeglumine (Gd-BOPTA) necessary for MRI of rheumatoid arthritis of the wrist. Design and patients. Seven wrists inflamed with rheumatoid arthritis were imaged using a dedicated 0.2-T MR unit. Four cumulative dosages of 0.0125, 0.025, 0.05 and 0.1 mmol/kg body weight (BW) Gd-BOPTA were tested. Three-dimensional T1-weighted gradient-recalled echo sequences (GRE; TR: 100 ms, TE: 18 ms, flip angle 90°, 4:55 min) were acquired prior to an intravenous injection and after each additional dosage of Gd-BOPTA. Relative enhancement, signal-difference-to-noise ratios (SDNRs) and the size of the inflamed tissue were quantified. Three radiologists independently evaluated the image quality, the size and the contrast of the enhancing tissue. Results. The readers agreed on a dose of 0.05 mmol/kg BW as satisfactory for the evaluation of the size of the inflammatory tissue and for determination of bone involvement (κ=0.9, P<0.001). Highly inflammatory pannus was depicted with adequate image contrast using 0.025 mmol/kg BW Gd-BOPTA. According to the SDNR and relative enhancement findings, a dose of 0.05 mmol/kg BW suffices for both off-center and centered regions of tissue inflammation (t-test, P<0.05). Conclusion. Gadolinium-BOPTA is an alternative contrast agent for MRI of rheumatoid disease. This study shows that a dose of 0.05 mmol/kg BW suffices at low field strength. Received: 7 June 2000 Revision requested: 22 August 2000 Revision received: 8 September 2000 Accepted: 21 September 2000     

Advanced imaging in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic and progressive inflammatory disorder primarily affecting the synovium. We now recognise that conventional radiographic images show changes of rhuematoid arthritis late after irreversible joint damage has occured. With the advent of powerful disease-modifying drugs there is a need for early demonstration of rheumatoid arthritis and to monitor progress of the disease and response to therapy. Advanced imaging techniques such as ultrasound and MRI have focussed on the demonstration and quanitification of synovitis and erosions and allow early diagnosis of RA. The technology to quantify synovitis and erosions is developing rapidly and now allows change in disease activity to be assessed. However, problems undoubtedly exist in quantification techniques and this review serves to highlight them. Much of the literature on advanced imaging in RA appears in rheumatological journals and may not be familiar to radiologists. This review article aims to increase the awareness of radiologists to this field and to encourage them to participate and contribute to the ongoing development of these modalities. Without this collaboration it is unlikely that these modalities will reach their full potential in the field of rheumatological imaging. This review is in two parts. This first part addresses synovitis imaging. The second part will look at advanced imaging of erosions in RA. Part 1 of this article (Synovitis) can be found at: . In our previous article we described issues surrounding the advanced imaging of synovitis. This article addresses erosions in a similar manner.     

Advanced imaging in rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic and progressive inflammatory disorder primarily affecting the synovium. We now recognise that conventional radiographic images show changes of rheumatoid arthritis long after irreversible joint damage has occured. With the advent of powerful disease-modifying drugs, there is a need for early demonstration of rheumatoid arthritis and a need to monitor progress of the disease and response to therapy. Advanced imaging techniques such as ultrasound and MRI have focussed on the demonstration and quantification of synovitis and erosions and allow early diagnosis of RA. The technology to quantify synovitis and erosions is developing rapidly and now allows change in disease activity to be assessed. However, problems undoubtedly exist in quantification techniques, and this review serves to highlight them. Much of the literature on advanced imaging in RA appears in rheumatological journals and may not be familiar to radiologists. This review article aims to increase the awareness of radiologists about this field and to encourage them to participate and contribute to the ongoing development of these modalities. Without this collaboration, it is unlikely that these modalities will reach their full potential in the field of rheumatological imaging. This review is in two parts. The first part addresses synovitis imaging. The second part will look at advanced imaging of erosions in RA. Part 2 of this article (Erosions) can be found at .     

The temporomandibular joint in rheumatoid arthritis

The temporomandibular joint (TMJ) was investigated clinically and by orthopantomography in 110 patients with rheumatoid arthritis (RA) and in 73 control subjects. Clinical symptoms in the TMJ were established in 34 per cent of the RA patients and in 18 per cent of the controls. Radiographic abnormalities were found in 60 per cent of the RA patients compared with 15 per cent in the controls. No single radiographic abnormality was characteristic of joint involvement by RA. The most common radiologic features in RA patients were changes in the morphology of the condylar head and articular eminentia, marginal irregularities, reduced mobility, and an anterior position of the condylar head. No abnormalities were encountered in the early stage of the disease, which at least in part could be attributed to the inherent limitations of orthopantomography. The incidence of joint lesions increased with duration of the RA.     

Ultrasound patterns of rheumatoid and psoriatic arthritis in finger joints

PURPOSE: Rheumatoid and psoriasic arthritis involve proximal joints symmetrically and distal joints asymmetrically, respectively, the differential diagnosis between these two types of arthritis is not easy. Therefore we investigated which US signs could help the diagnosis and/or treatment of these conditions and compared them with radiographic patterns and articular and physical symptoms. MATERIAL AND METHODS: Fifty-one patients, 30 women and 21 men aged 19-42 years were enrolled in this study. Thirty patients had rheumatoid and 21 psoriasic arthritis. US of the skin and joints of the fingers was performed with a GE Sonora Logic 500 MD unit with 7.5 and 10 MHz scanheads. We studied the shape of articular bone heads, the intra-articular space distance and the thickness of extensor tendon and of the dermis and hypodermis covering it. These findings show the extent of damage in articular bone heads and intra-articular space and they indicate cutaneous and articular inflammation. US patterns were also compared with radiographic findings in all patients. RESULTS: US showed bone and joint and/or inflammatory damage in both types of arthritis. Articular bone heads had a bodkin-like appearance in proximal phalanges in rheumatoid arthritis, versus a hook-like appearance in distal phalanges in psoriasic arthritis. Inflammatory damage was indicated by intra-articular space thinning and by tendon, dermis and hypodermis thickening. These signs, confirmed radiographically, account for finger deformation and functional impairment, swelling and pain. CONCLUSION: US signs can help the diagnosis of rheumatoid and psoriasic arthritis. US can show inflammatory damage and the disease evolution.     

累及掌指关节的类风湿性关节炎:软骨钆对比剂延迟增强MRI的可行性研究

目的评估类风湿性关节炎(RA)病人掌指关节软骨的钆对比剂延迟增强MRI的可行性,并与对照组比较。材料与方法本研究经过机构审查委员会的批准及受试者     

MR imaging of the knee in acute rheumatoid arthritis: synovial uptake of gadolinium-DOTA

In patients with rheumatoid arthritis, the presence of acute synovial inflammation is an indication of the activity of the disease. It is an important finding because it often influences therapeutic decisions. However, acute synovitis may be difficult to detect by clinical examination, especially if a joint effusion also is present. As gadolinium tetra-azacyclododecane tetraacetic acid (Gd-DOTA) can be expected to accumulate in areas of acute inflammation, we studied the value of Gd-DOTA-enhanced MR to determine the presence of acute synovitis. Nine patients with current knee symptoms underwent MR examination of the knee. Short and long TR/TE MR images were obtained with a 0.3-T magnet before and immediately after IV administration of Gd-DOTA. A 15-min delayed short TR/TE image also was obtained. Of eight patients with moderate to severe clinical evidence of acute synovitis, six had marked increase and two had moderate increase in signal intensity from synovial tissue on the short TR/TE image obtained immediately after administration of contrast material. In the ninth patient, who had minimal synovitis clinically, the signal from the synovium did not change after administration of contrast material. No difference was seen between the enhancement pattern on the immediate and the 15-min delayed images. These results suggest that Gd-DOTA is taken up by inflamed synovium and that Gd-DOTA-enhanced MR scans may be useful in detecting acute synovitis in patients with rheumatoid arthritis.