Scoring inflammatory activity of the spine by magnetic resonance imaging in ankylosing spondylitis: a multireader experiment

OBJECTIVE: Magnetic resonance imaging (MRI) of the spine is increasingly important in the assessment of inflammatory activity in clinical trials with patients with ankylosing spondylitis (AS). We investigated feasibility, inter-reader reliability, sensitivity to change, and discriminatory ability of 3 different scoring methods for MRI activity and change in activity of the spine in patients with AS. METHODS: Thirty sets of spinal MRI at baseline and after 24 weeks of followup, derived from a randomized clinical trial comparing a tumor necrosis factor (TNF)-blocking drug (n = 20) with placebo (n = 10) and selected to cover a wide range of activity at baseline and change in activity, were presented electronically in a partial latin-square design to 9 experienced readers from different countries (Europe, Canada). Readers scored each set of MRI 3 times, using 3 different methods including the Ankylosing Spondylitis spine Magnetic Resonance Imaging-activity [ASspiMRI-a, grading activity (0-6) per vertebral unit in 23 units]; the Berlin modification of the ASspiMRI-a; and the Spondyloarthritis Research Consortium of Canada (SPARCC) scoring system, which scores the 6 vertebral units considered by the reader as the most abnormal, with additional scores for "depth" and "intensity." Both the order of the methods used by each reader and the timepoints (before/after treatment) were randomized. Feasibility of each scoring system was evaluated by measuring the mean time needed to score each set of MRI, and inter-reader reliability was evaluated by smallest detectable change (SDC) and by intraclass correlation coefficients (ICC) for all readers together and for all possible reader pairs separately. Sensitivity to change was investigated by calculating Guyatt's effect size on change scores. Discriminatory ability was assessed using Z-scores (Mann-Whitney test) comparing change in score between patients treated with TNF-blocking drug and placebo. RESULTS: The mean time to score one set of MRI was shortest for the Berlin method. SDC was lowest for the Berlin method and highest for SPARCC. Overall inter-reader ICC per method were between 0.49 and 0.77 for scoring activity status, and between 0.46 and 0.72 for scoring activity change. ICC for all possible reader pairs showed much more fluctuation per method, with lowest observed values of about 0.05 (very low agreement) and highest observed values over 0.90 (excellent agreement). In general, ICC for SPARCC were consistently higher than for other systems. Sensitivity to change differed per reader, and was more consistent with SPARCC than with the other methods, but was in general excellent for all 3 methods. Discrimination between groups (TNF-blocker vs placebo) assessed by Z-scores was good and comparable among methods. CONCLUSION: This experiment demonstrates the feasibility of multiple-reader MRI scoring exercises for method comparison, provides evidence for the feasibility, reliability, sensitivity to change, and discriminatory capacity of all 3 tested scoring systems to be used in assessing spinal activity on MRI in patients with AS in clinical trials. On the basis of these results it is not possible to prioritize one of the 3 methods.     

Assessment of structural lesions in sacroiliac joints enhances diagnostic utility of magnetic resonance imaging in early spondylarthritis

Objective

To compare the diagnostic utility of T1‐weighted and STIR magnetic resonance imaging (MRI) sequences in early spondylarthritis (SpA) using a standardized approach to the evaluation of sacroiliac (SI) joints, and to test whether systematic calibration of readers directed at recognition of abnormalities on T1‐weighted MRI would enhance diagnostic utility.

Methods

Six readers independently assessed T1‐weighted and STIR MRI scans of the SI joints from 187 subjects: 75 ankylosing spondylitis (AS) and 27 preradiographic inflammatory back pain (IBP) patients, and 26 mechanical back pain and 59 healthy volunteer controls ages ≤45 years. The exercise was repeated 6 months later on a random selection of 30 AS patients and 34 controls after calibration directed at lesions visible on T1‐weighted MRI. Specific MRI lesions were recorded according to standardized definitions. In addition to deciding on the presence/absence of SpA, readers were asked which MRI sequence and which type of lesion was the primary basis for their diagnostic conclusion.

Results

Structural lesions were detected in 98% of AS patients and 64% of IBP patients. A diagnosis of SpA was based on T1‐weighted or combined T1‐weighted/STIR sequences in 82% of AS patients and 41% of IBP patients. Calibration enhanced the diagnostic utility of MRI in the majority of readers, especially those considered less experienced; the mean positive and negative likelihood ratios (of 6 readers) were 14.5 and 0.08 precalibration, respectively, and 22.2 and 0.02 postcalibration, respectively.

Conclusion

Recognition of structural lesions on T1‐weighted MRI contributes significantly to its diagnostic utility in early SpA. Rheumatologist training directed at detection of lesions visible on T1‐weighted MRI enhances diagnostic utility.     

Magnetic resonance imaging in rheumatic disorders of the spine and sacroiliac joints

OBJECTIVE: To review the value of magnetic resonance imaging (MRI) in diagnosis and evaluation of rheumatic diseases of the spine and sacroiliac joints. METHODS: A review of the literature on MRI of the spine and sacroiliac joints in rheumatoid arthritis (RA), ankylosing spondylitis (AS), infectious spondylodiscitis, infection of the sacroiliac joint (SIJ), gout, calcium pyrophosphate deposition disease, nontraumatic vertebral compression fractures, insufficiency fracture of the sacrum, avascular necrosis of the vertebral body, sarcoidosis, and Paget's disease was performed. The reports were obtained from a Medline search. RESULTS: In RA, AS, and crystal deposition disease, synovial tissue, atlantoaxial and subaxial subluxations, crystal deposition, and neurologic compromise can be adequately diagnosed with MRI of the cervical spine. Studies on MRI of SIJs in AS indicate that MRI enables early diagnosis of sacroiliitis. In most cases of infectious spondylodiscitis, avascular necrosis of the vertebral body, nontraumatic vertebral compression fractures, and insufficiency fractures of the sacrum characteristic findings on MRI suggest the correct diagnosis. Moreover, soft tissue abnormalities and neurologic compromise can be visualized. In infection of the SIJ, MRI shows findings suggesting an inflammatory process. In Paget's disease, MRI does not provide additional information as compared with plain radiography (PR) or computed tomography (CT). CONCLUSION: In evaluation of spinal and SIJ abnormalities in many rheumatic diseases, MRI, in addition to PR, can replace conventional tomography, CT, and myelography. Moreover, MRI can visualize soft tissue abnormalities and neurologic compromise without use of intrathecal contrast.     

Short term effect of non-steroidal anti-inflammatory drugs on clinical and magnetic resonance imaging of the sacroiliac joints progression in axial spondyloarthritis patients

Aim of the workTo evaluate the short term effect of maximally tolerated dose of non-steroidal anti-inflammatory drugs (NSAIDs) on disease activity and radiographic progression of axial spondyloarthritis (axSpA) patients.Patients and methodsA six-week prospective study on thirty patients with active axSpA. All patients were assessed at baseline visit, a follow-up visit after 2 weeks, and 6 weeks of treatment with a maximally tolerated dose of NSAID. Disease activity was assessed by determining Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and Ankylosing Spondylitis Disease Activity Score (ASDAS), and functional assessment by using Bath Ankylosing Spondylitis Functional Index (BASFI). Spinal mobility was assessed by the mean improvement in Bath Ankylosing Spondylitis Metrology Index (BASMI). Magnetic Resonance Imaging (MRI) of sacroiliac joints (SIJs) was taken at baseline and at the end of the study and was evaluated according to Berlin scoring method.ResultsImprovement in laboratory activity markers and all disease activity scores has been observed at week 6 of maximally tolerated dose of NSAIDs which were significant (p < 0.001). Additionally, ASDAS clinically important improvement was achieved in 63.3% of patients, and BASDAI50 was achieved in 30% and 56.7% of patients at week 2 and week 6, respectively. Furthermore, Berlin score showed an improvement by 14.2% with a reduction in bone marrow edema signal intensity of SIJs in 40% of patients.ConclusionIn Egyptian cohort of patients with axSpA, intake of maximally tolerated dose of NSAID could improve the health-related quality of life, disease activity scores, and sacroiliac joint inflammation on MRI.     

Local infliximab injection of sacroiliac joints in non-radiographic axial spondyloarthritis: Impact on clinical and magnetic resonance imaging parameters of disease activity

Abstract

Objectives. To evaluate the effectiveness of infliximab (IFX) injection into sacroiliac joints (SIJs) of non-radiographic axial spondyloarthritis (nr-axial SpA) and its impact on clinical and MRI parameters of disease activity.

Methods. Thirty-seven patients fulfilling the Association of Spondyloarthritis International Society (ASAS) criteria for axial SpA were initially studied, with disease duration not exceeding 1 year and failed to respond to non-steroidal anti-inflammatory drugs (NSAIDs). Only SpA having active sacroiliitis on MRI without spondylitis (number = 7) were selected to receive bilateral SIJ injection of 20 mg IFX. Follow-up MRI was done at 24 weeks post-injection. Patients were clinically evaluated before, and 12 and 24 weeks after SIJ injection. Evaluation included back pain and stiffness scores, and Bath Ankylosing Spondylitis (BAS) Disease indices and C-reactive protein (CRP) levels. ASAS response criteria were also assessed.

Results. Twelve and twenty-four weeks after injection, there was significant decrease in back pain, stiffness, and BAS Disease Activity and Global indices. BAS Functional index, CRP, and mean bone marrow edema score of SIJs were decreased without reaching statistical significance. All patients achieved ASAS20 and five (71.4%) achieved ASAS40.

Conclusion. SIJ injection of IFX could be a therapeutic option in early nr-axial SpA who failed to respond to NSAIDs.     

Magnetic resonance imaging of sacroiliac joint inflammation

A consecutive series of 27 patients with symptoms compatible with sacroiliitis underwent magnetic resonance imaging (MRI) of the sacroiliac joints. The diagnostic sensitivity of MRI was similar to that of computed tomography or conventional radiography. However, MRI seems to have the potential of providing unique information about the disease process in sacroiliitis by demonstrating abnormalities in subchondral bone and periarticular bone marrow. The results of this study suggest that early inflammatory changes in sacroiliitis occur in the subchondral structures of the sacroiliac joints.     

Colonography by magnetic resonance imaging

Dark-lumen magnetic resonance colonography has been shown to be an appropriate diagnostic tool for the detection of colorectal pathologies. This review describes the underlying techniques of dark-lumen magnetic resonance colonography concerning data acquisition, image interpretation and diagnostic accuracy for the detection of colorectal pathologies. In addition, techniques to improve patients' acceptance are discussed.     

Myocardial perfusion imaging by cardiac magnetic resonance.

Cardiovascular magnetic resonance (CMR) has been shown to provide high quality data on cardiac and valvular function, perfusion, viability, blood flow, and potentially, on cardiac metabolism as well. Several of these CMR applications (eg, function and viability assessment) matured during the past years and are now established components of a cardiac workup. Perfusion-CMR is close to this status and is already a major contributor to cardiac examinations in a growing number of expert centers. Large multicenter perfusion-CMR trials comparing the diagnostic performance of CMR with other techniques were recently reported yielding areas under the receiver-operator-characteristics curve as a high as 0.85 for coronary artery disease detection (MR-IMPACT). Anticipating a growing role for perfusion-CMR in cardiology in the near future, this article discusses the principles of perfusion-CMR and its integration into the workup of patient with coronary artery disease (CAD). In addition to a functional study, this integration is mainly composed of a perfusion-CMR part, followed by a viability assessment by late enhancement CMR techniques. The principal characteristics of these CMR techniques are compared with those of single photon emission computed tomography (SPECT) and positron emission tomography (PET). After introduction into principles and techniques of perfusion-CMR, some open questions in perfusion-CMR and challenges for the future are addressed. Finally, newer CMR applications are shortly mentioned utilizing hyperpolarized carbon-13 compounds in experimental models for quantification of myocardial perfusion and for real-time assessment of metabolic pathways in postischemic myocardium.     

Temporomandibular joints in patients with rheumatoid arthritis using magnetic resonance imaging

The aim of this study was to determine the relationship between the pathogenic duration of rheumatoid arthritis in joints other than the temporomandibular joint and bone and soft tissue involvement of the temporomandibular joint using magnetic resonance imaging. Twenty-six symptomatic patients diagnosed with rheumatoid arthritis were enrolled in this study. All patients were classified according to the duration of rheumatoid arthritis in joints other than the temporomandibular joint. The relationships between the duration of rheumatoid arthritis in these various joints and magnetic resonance findings in the temporomandibular joint were analyzed using the chi-square test. Bony changes in the mandibular condyle were observed in 43 of 52 (82.7 %) temporomandibular joints, but the frequency of such changes was not significantly correlated with the duration of rheumatoid arthritis in other joints. We found a significant correlation between the duration of rheumatoid arthritis in other joints and the type and number of bony changes in the mandibular condyle (P?<?0.05). Superior disc positions were observed in 27 of 52 (51.9 %) temporomandibular joints. T2-weighted images demonstrated effusion in the joint space in 38 of 52 (73.1 %) temporomandibular joints. A biplanar disc configuration was the most frequent configuration in all groups. The duration of rheumatoid arthritis in other joints was significantly correlated with the mobility of the mandibular condyle (P?<?0.05). The type and number of bony changes and mobility of the mandibular condyle showed significant relationships with the duration of rheumatoid arthritis in other joints in the body (P?<?0.05).     

Myocardial perfusion imaging by magnetic resonance imaging

In the diagnosis and treatment of patients with suspected or known coronary artery disease, noninvasive methodologies for assessing myocardial perfusion have been invaluable. Clinically, nuclear techniques such as single photon emission tomography thallium and sestamibi have predominated. They are limited, however, by the radiation burden, relatively poor spatial resolution, and attenuation artifact caused by soft tissue. In contrast, magnetic resonance imaging (MRI) is notable for its anatomic detail, sharp tissue contrast, excellent spatial and temporal resolution, versatility, and lack of ionizing radiation. It is therefore a potentially attractive alternative to nuclear imaging for the assessment of myocardial perfusion. This review summarizes the principles of MRI myocardial perfusion measurement, discusses recent clinical applications, and highlights future developments in the field.     

Validation of whole‐body against conventional magnetic resonance imaging for scoring acute inflammatory lesions in the sacroiliac joints of patients with spondylarthritis

Objective

To compare the performance of whole‐body magnetic resonance imaging (MRI) versus conventional MRI in assessing acute inflammatory lesions of the sacroiliac (SI) joints in patients with established and active spondylarthritis (SpA) using the Spondyloarthritis Research Consortium of Canada (SPARCC) MRI index. This study is validating whole‐body MRI against the current MRI standard for assessing active inflammatory lesions of the SI joints in patients with SpA.

Methods

Thirty‐two SpA patients with clinically active disease (Bath Ankylosing Spondylitis Disease Activity Index score ≥4) fulfilling the modified New York criteria were scanned by whole‐body and conventional MRI of the SI joints. The MRIs were scored independently in random order by 3 readers blinded to patient identity. Active inflammatory lesions of the SI joints were recorded on a Web‐based SPARCC index. Pearson's correlation coefficients were used to compare scores for whole‐body and conventional MRI for each reader, whereas intraclass correlation coefficients (ICCs) were used to compare interobserver reliability.

Results

The Pearson's correlation coefficients between whole‐body and conventional MRI per rater were 0.94, 0.87, and 0.93. The mean sum scores for conventional versus whole‐body MRI were statistically significantly higher for all 3 readers, although all patients showing inflammatory lesions on conventional MRI also demonstrated them on whole‐body MRI. The ICCs(2,1) were 0.69, 0.78, and 0.95 for conventional MRI, and 0.79, 0.85, and 0.96 for whole‐body MRI for the 3 possible reader pairs.

Conclusion

Whole‐body and conventional MRI scores show a strong correlation and comparable reliability for the detection of inflammatory lesions of the SI joints.     

Cardiac imaging by nuclear magnetic resonance

Proton nuclear magnetic resonance (NMR) imaging has been developed and improved over the past few years to the state that images of static structures have recently shown spatial resolution equivalent or superior to other techniques such as X rays, ultrasound, or gamma ray-emitting radionuclides. The current state of NMR development is described; however, use of this exciting new diagnostic modality depends on the results of extensive clinical trials.     

Cardiac function by magnetic resonance imaging

Summary Gated magnetic resonance imaging of the heart displays cardiac structures with excellent resolution. This ability should be useful for assessment of cardiac physiology where acquisition of systolic and diastolic images is required. In this study, left ventricular ejection fraction was determined in 50 patients from oblique long axis views of the left ventricle using the area length formula. Angulated views were obtained by electronic gradient angulation. For comparison, all patients had monoplane angiocardiography in the RAO position. Forty-five patients were also studied by radionuclide ventriculography. Ejection fractions determined by MRI and angiocardiography were closely correlated (r=0.90). Correlation between MRI and radionuclide ventriculography was also acceptable (r=0.79).In addition to global left ventricular function, MR images provide information about regional wall motion. In order to acquire a three-dimensional set of images at various phases of the cardiac cycle, shorter imaging times are mandatory. A new imaging technique with potential for functional studies uses low flip angles, short repetition times and gradient refocused echoes. Up to 40 images can be obtained within one cardiac cycle. When displayed in a looped fashion, visual assessment of cardiac motion, intracardiac blood flow, and systolic wall thickening is possible. Potential advantages of functional studies by MRI are the concomitant acquisition of anatomical information and the three dimensional frame of reference.This work was supported by a research grant from Deutsche Forschungsgemeinschaft, Bonn.     

Application of the OMERACT filter to scoring methods for magnetic resonance imaging of the sacroiliac joints and the spine. Recommendations for a research agenda at OMERACT 7

Magnetic resolution imaging (MRI) is a promising tool in the assessment of inflammation and structural damage in clinical trials in ankylosing spondylitis (AS). The ASAS/OMERACT MRI in AS working group, a collaborative initiative of rheumatologists and musculoskeletal radiologists with a special interest in this field, collected data on all available scoring methods for both sacroiliac (SI) joints and spine, and tested them with respect to the OMERACT filter. These data were presented together with the technical specifications of all methods at the OMERACT 7 conference. In addition, the results of 2 separate experiments on the inter-reader reliability of scoring methods to assess activity in SI joints, and on the comparison of STIR sequence versus T1 post-gadolinium (Gd) sequence for the spine, were presented. Thereafter, 8 groups discussed these data and proposed a research agenda, each on a different topic. This information was reported back to all participants and a prioritized research agenda was compiled by voting. Research on scoring methods for assessing disease activity, in both the spine and SI joints, was considered most important. Research on assessing structural damage was considered less important. The specific process and results of this initiative are discussed.     

Baseline sacroiliac joint magnetic resonance imaging abnormalities and male sex predict the development of radiographic sacroiliitis

We evaluated the relationship between the baseline sacroiliac joint (SIJ) magnetic resonance imaging (MRI) findings and the development of radiographic sacroiliitis and tested their prognostic significance in cases of ankylosing spondylitis. Patients who had undergone an SIJ MRI at the rheumatology department were identified. Individuals for whom pelvic X-rays were available after at least 1 year of MRI were included in the analysis. All radiographs and MRI examinations were scored by two independent readers. Medical records of the patients were reviewed to obtain potentially relevant demographic and clinical data. We identified 1,069 SIJ MRIs, and 328 fulfilled our inclusion criteria. Reliability analysis revealed moderate to good inter- and intra-observer agreement. On presentation data, 14 cases were excluded because they had unequivocal radiographic sacroiliitis at baseline. After a mean of 34.8 months of follow-up, 24 patients developed radiographic sacroiliitis. The presence of active sacroiliitis (odds ratio (OR) 15.1) and structural lesions on MRI (OR 8.3), male sex (OR 4.7), fulfillment of Calin’s inflammatory back pain criteria (P?=?0.001), and total MRI activity score (P?<?0.001) were found to be related to the development of radiographic sacroiliitis. By regression modeling, the presence of both active inflammatory and structural damage lesions on MRI and male sex were found to be predictive factors for the development of radiographic sacroiliitis. Our present results suggest that the occurrence of both active inflammatory and structural lesions in SIJs revealed by MRI is a significant risk factor for radiographic sacroiliitis, especially in male patients with early inflammatory back pain.     

Magnetic resonance imaging assessment of sacroiliac joint involvement in Gaucher's disease.

A young woman with Gaucher's disease experienced acute pain in her right sacroiliac (SI) joint. Although pelvic radiographs and computed tomographic scan showed no significant change in the right SI joint, magnetic resonance imaging demonstrated an area of high signal intensity in the iliac part of the right SI joint, and a periosseous collection of blood. This skeletal location is rarely reported in Gaucher's disease; the mechanism of bone crisis is still controversial and our case suggests the occurrence of a bone infarct.