Insights into Rheumatoid Arthritis from Use of MRI

Magnetic resonance imaging (MRI) is ideal for imaging the joints of rheumatoid arthritis (RA) patients. It produces anatomically detailed images of bone, cartilage, tendons and synovial membrane. It can reveal structural damage, in the form of bone erosion, cartilage thinning and/or tendon rupture, and regions of inflammation, using sequences that reveal water content and vascularity. MRI synovitis, tenosynovitis and bone oedema/osteitis all have prognostic significance, and MRI studies of RA have helped elucidate the mechanisms whereby bone and synovial inflammation lead to joint damage. Bone oedema/osteitis has become an important imaging biomarker, and can be used to help predict progression from undifferentiated arthritis to definite RA. Recent MRI studies have confirmed that subclinical inflammation is often present in patients in clinical remission, and these data may affect disease management. Finally, recent clinical trials are reviewed, in which MRI outcome measures are being established as sensitive response markers.     

磁共振成像在类风湿关节炎患者膝关节病变研究中的意义

目的　初步探讨磁共振成像 (MRI)技术在类风湿关节炎 (RA)患者膝关节病变临床诊断中的应用价值。方法　对 2 0例RA患者的 34个膝关节进行多种序列成像并分析其MRI表现。结果　MRI可清晰显示RA膝关节的滑膜增生及血管翳形成、关节软骨破坏、骨质受侵、关节囊积液、半月板及韧带异常、窝囊肿形成以及皮下结节等改变 ,并能通过血管翳的信号和强化程度判断疾病是否处于活动期。结论　与X线相比 ,MRI对RA的骨质侵蚀破坏更为敏感 (P <0 0 1)。MRI能直接显示RA患者膝关节不同时期的各种改变 ,有助于疾病的早期诊断和临床分期     

双重滤过血浆置换联合免疫抑制剂治疗对重度活动性类风湿关节炎患者磁共振成像的影响

目的 探讨双重滤过血浆置换(DFPP)联合免疫抑制剂(来氟米特+甲氨蝶呤)治疗对重度活动性类风湿关节炎(RA)患者磁共振成像(MRI)的影响.方法 纳入58例RA患者,病程6个月至12年,采用计算机自动生成的随机号,将患者随机分为治疗组和对照组.对照组予以来氟米特10 mg,每日2次,甲氨蝶呤15 mg,每周1次;治疗组在对照组治疗的基础上予以DFPP治疗3～4次,每次问隔7～14 d.随访至6个月.通过右腕关节MRI平扫加增强观察基线和治疗1、6个月时滑膜炎、关节腔积液及骨髓水肿的变化,应用RA磁共振评分标准(RAMRIS)判断对MRI滑膜炎的影响.组内比较采用配对t检验,组间比较采用独立样本t检验.结果 治疗组6个月时滑膜、血管翳、骨髓水肿计分分别为(1.4±1.6)、(0.13±0.35)、(5±4),显著低于对照组[分别为(7.9±1.3)、(2.76±0.43)、(16±12),P均<0.01];治疗组30例(100%)关节腔积液均消失,对照组无一例消失(P<0.01).治疗组达到MRI滑膜炎完伞缓解(滑膜、血管翳见强化,关节腔无积液)+疾病活动指数(DAS)28缓解标准的为16例(53%),对照组无一例达到此标准(P<0.01).1个月时治疗组DAS28、健康评估问卷(HAQ)分别由(7.5±1.0)、(2.23±0.58)下降至(3.5±1.2)、(0.50±0.73),差异有统计学意义(P<0.01);MRI影像滑膜、血管翳、关节腔积液、骨髓水肿无明显变化(P>0.05).结论 DFPP联合免疫抑制剂治疗对重度活动性RA MRI滑膜炎症有明显缓解作用.MRI对疾病活动的判断及治疗方案的选择可作为必要的手段之一.     

MRI in psoriatic arthritis: Insights into pathogenesis and treatment response

Psoriatic arthritis (PsA) is a clinically heterogeneous condition, and not surprisingly, its MRI features are diverse. Synovitis and accompanying synovial effusions are clearly depicted, and enthesitis is characterized by extracapsular inflammation at the insertions of ligaments and tendons plus accompanying bone edema at bony attachments. Other forms of MRI bone edema include subchondral and diaphyseal involvement; the latter seeming relatively specific to PsA. The pathology of dactylitis can also be elucidated by MRI, which frequently reveals tenosynovitis and soft tissue edema in conjunction with various degrees of synovitis, bone edema, and erosion. Bone erosions differ from those seen in rheumatoid arthritis in their distribution and associated features such as bone proliferation and sometimes periostitis. Finally, MRI can be used to score and quantify these pathologic features, providing a sensitive tool with which to evaluate disease progression.     

Evidence for a different anatomic basis for joint disease localization in polymyalgia rheumatica in comparison with rheumatoid arthritis

OBJECTIVE: The anatomic basis for joint disease localization in polymyalgia rheumatica (PMR) is poorly understood. This study used contrast-enhanced and fat suppression magnetic resonance imaging (MRI) to evaluate the relationship between synovial and extracapsular inflammation in PMR and early rheumatoid arthritis (RA). METHODS: Ten patients with new-onset PMR and 10 patients with early RA underwent dynamic contrast-enhanced MRI and conventional MRI of affected metacarpophalangeal (MCP) joints. Synovitis and tenosynovitis were calculated based on the number of enhancing voxels, initial rate of enhancement, and maximal enhancement of gadolinium diethylenetriaminepentaacetic acid (Gd-DTPA). Periarticular bone erosion and bone edema were scored according to the OMERACT (Outcome Measures in Rheumatology Clinical Trials) scoring system in both groups. The degree of extracapsular Gd-DTPA enhancement was assessed in both conditions using semiquantitative scoring. RESULTS: No significant differences were seen in the volume of synovitis (P = 0.294), degree of flexor tenosynovitis (P = 0.532), periarticular erosions (P = 0.579), or degree of bone edema (P = 0.143) between RA and PMR joints. However, despite comparable degrees of synovitis, the proportion of MCP joints showing extracapsular enhancement was higher in the PMR group (100%) than in the RA group (50%) (P = 0.030). One PMR patient, but none of the RA patients, had bone edema at the capsular insertion. CONCLUSION: Despite degrees of synovitis and tenosynovitis comparable with those in RA, PMR-related hand disease is associated with prominent extracapsular changes, suggesting that inflammation in these tissues is more prominent than joint synovitis, which is common in both conditions. This suggests that the anatomic basis for joint disease localization differs between RA and PMR.     

Is early rheumatoid arthritis the same disease process as late rheumatoid arthritis?

Thoughts on treatment for the early control of synovitis have stimulated research on pathobiological events at the site of inflammation in patients with early rheumatoid arthritis. Several studies have thus been conducted to examine synovial biopsy samples at various stages of the disease. The most important conclusion from these studies is that all features of chronic synovial inflammation can be observed in so-called early rheumatoid arthritis. This suggests that no arguments exist for the effect of therapeutic intervention on synovitis varying in different phases of rheumatoid arthritis. In end-stage rheumatoid arthritis, factors that are secondary to the disease may contribute to the perpetuation of synovial inflammation. Mutations in key regulatory genes could play a role in the autonomous progression of the disease. In addition, it is conceivable that the release of bone and cartilage fragments might elicit an inflammatory response in patients with destructive rheumatoid arthritis.     

The diagnostic dilemma of undifferentiated inflammatory synovitis of the knee joint/joints: a comprehensive approach

Objective: The objective of this pilot study was to describe clinical features, laboratory investigations and enhanced MRI features in patients presenting with undifferentiated inflammatory synovitis of the knee. Patient and methods: Fifteen patients with undifferentiated inflammatory synovitis of the knee joint were recruited for this study. All patients underwent full history‐taking, detailed rheumatological examination, synovial fluid analysis including polarized microscopy, rheumatoid factor (RF), anti‐nuclear antibody (ANA), anti‐cyclic citrullinated peptide (CCP), C‐reactive protein, and erythrocyte sedimentation rate. MRI/gadolinium‐enhanced MRI was done for all patients with unilateral presentation and for the most symptomatic knee in cases of bilateral knee involvement. Results: Enhanced MRI showed the following findings: synovial enhancement and effusion 15/15, pannus formation 13/15, bone marrow edema 3/15, bone erosions 2/15, cartilaginous erosions 1/15, synovial cysts 2/15, Baker's cyst 2/15, periarticular soft tissue edema 3/15, and lipoma arborescencs 2/15. Conclusions: Undifferentiated synovitis of the knee is not necessarily a benign condition. It represents a diagnostic dilemma in rheumatological practice that deserves early identification and early treatment in order to prevent inevitable and irreversible articular damage if left untreated. The ability of MRI to detect early changes like bone marrow edema and bony and cartilaginous erosions (usually not obvious on plain X‐rays) makes this a highly sensitive tool for evaluation of patients presenting with undifferentiated synovitis affecting the knee joint. When combined with gadolinium, it allows accurate assessment of the degree of synovial thickening (pannus) and picks up local intra‐articular lesions especially in patients with unilateral disease.     

Etiopathogenesis of the rheumatoid arthritis–like disease in MRL/1 mice. I. The histomorphologic basis of joint destruction

MRL/1 mice spontaneously develop a hindlimb arthropathy, as well as a number of immunologic abnormalities, including circulating rheumatoid factors. Although previous studies have suggested that this arthropathy is primarily an inflammatory process, we performed a comprehensive histomorphologic study which indicated that inflammation is a late manifestation of MRL/1 arthritis. The pathologic changes that occur in the joints of these mice can be divided into 3 stages. The first stage develops between the ages of 7 and 13 weeks and consists of synovial cell proliferation in the joint recesses. The second stage is characterized by continued proliferation of synovial cells which take on an appearance similar to that of transformed mesenchymal cells. The earliest destructive changes occur in the second stage and include marginal erosions, followed soon after by progressive destruction of articular and meniscal cartilage. The final stage is characterized by a diminution of synovial cell proliferation, extensive cartilage destruction, formation of scar tissue and fibrocartilage, and a very moderate infiltration of the synovial stroma by mononuclear and polymorphonuclear inflammatory cells. Throughout the disease progression there is a striking dissociation between inflammatory cell infiltration or exudation and tissue destruction. The histomorphologic similarities between human rheumatoid synovitis and the arthritis of MRL/1 mice, as well as the presence of rheumatoid factors, make this mouse strain an excellent model for studying human rheumatoid arthritis.     

An introduction to the EULAR-OMERACT rheumatoid arthritis MRI reference image atlas

This article gives a short overview of the development and characteristics of the OMERACT rheumatoid arthritis MRI scoring system (RAMRIS), followed by an introduction to the use of the EULAR-OMERACT rheumatoid arthritis MRI reference image atlas. With this atlas, MRIs of wrist and metacarpophalangeal joints of patients with rheumatoid arthritis can be scored for synovitis, bone oedema, and bone erosion, guided by standard reference images.     

高分辨力超声检查在类风湿关节炎膝肘腕关节滑膜炎的应用

目的本研究应用高分辨力超声及多普勒超声技术,观察类风湿关节炎(RA)膝关节、肘、腕关节超声声像特点及血流动力学特点,探讨超声检查在RA诊断中的价值。方法研究了40例RA患者(共240个关节)及20名健康志愿者(共120个关节)的膝关节、肘关节和腕关节滑膜炎的超声声像特征。每例均行双侧对比扫查,超声检查采用美国GE公司LogiQ-9彩色超声诊断仪,高频率线阵式探头,探头中心频率10MHz,直接扫查法扫查。结果RA组共检出191个关节积液,总阳性率79.5%,共检出174个关节滑膜增厚,总阳性率72.5%,检出165个关节内血管过度增生,总阳性率68.7%。结论超声检查为RA关节病变的诊断和炎症活动性的评估提供了一种简便易行,安全有效的方法。     

Baseline MRI bone erosion predicts the subsequent radiographic progression in early rheumatoid arthritis patients who achieved sustained good clinical response

Objective: To examine whether magnetic resonance imaging (MRI) findings at baseline predict radiographic progression in early-stage rheumatoid arthritis (RA) patients who have achieved sustained good clinical response.

Methods: This is a sub-analysis from the one-year observational study of Nagasaki University Early Arthritis Cohort. Definition of ‘good clinical response’ was a decrement of disease activity score (DAS) 28?≧?1.2 at three months with achievement of DAS28 remission through 6–12 months. Gd-enhanced MRI of both wrists and finger joints were examined at baseline and scored using rheumatoid arthritis magnetic resonance imaging score (RAMRIS). Annual increment of Genant-modified Sharp score (GSS)?>?0 was defined as ‘radiographic progression’. Predictors of radiographic progression were determined by logistic regression analysis.

Results: Twenty-four subjects were selected in the present study. Each median RAMRIS synovitis, bone edema, bone erosion, and GSS at baseline were 6.5, 0.5, 0, and 0, respectively. Five patients developed radiographic progression at one year. Multivariate logistic regression analysis has shown that RAMRIS bone erosion at baseline is the only independent predictor of radiographic progression at one year (p?=?.032).

Conclusions: Our data suggest that MRI bone erosion predicts poor radiographic outcome of early-stage RA even if it has been successfully treated.     

Magnetic resonance imaging-determined synovial membrane and joint effusion volumes in rheumatoid arthritis and osteoarthritis. Comparison with the macroscopic and microscopic appearance of the synovium

Objective. To evaluate the relationship between synovial membrane and joint effusion volumes determined by magnetic resonance imaging (MRI) and macroscopic and microscopic synovial pathologic findings in patients with rheumatoid arthritis (RA) and osteoarthritis (OA). Methods. Synovial biopsies were performed, and macroscopic grades of synovitis assigned, at preselected knee sites during arthroscopy or arthrotomy in 17 knees with RA and 25 with OA. Synovial inflammation and 9 separate tissue characteristics were graded histologically. Synovial membrane and joint effusion volumes were determined by preoperative MRI, enhanced with intravenous gadopentetate dimeglumine. Results. MRI-determined synovial membrane volumes were correlated with the overall histologic assessment of synovial inflammation (Spearman's σ = 0.55, P < 0.001), with fibrin deposition, with subsynovial mononuclear and polymorphonuclear leukocyte infiltration (σ = 0.51-0.59), and less significantly with macroscopic synovitis, vessel proliferation, and granulation tissue formation (σ = 0.40-0.42). No correlation with synovial lining multiplication, perivascular edema, villous formation, or fibrosis was found (σ < 0.30). Conclusion. MRI-determined synovial volumes are correlated with synovial inflammatory activity. Synovial volumes probably mainly reflect the mass of cell-infiltrated, vascularized subsynovial tissue, but may also be influenced by the cumulative synovial proliferative activity. MRI-determined synovial membrane and effusion volumes may be sensitive markers and/or predictors of disease activity and treatment outcome in RA.     

Sensitivity and significance of nuclear magnetic tomography findings of finger joints in rheumatoid arthritis

Evaluation of the sensitivity and value of magnetic resonance imaging (MRI) findings and miniarthroscopic investigations (mini-/needle-arthroscopy = MA) of metacarpophalangeal (MCP) joints in patients with rheumatoid arthritis (RA). 30 patients with RA (21 female, 9 male), disease duration 2 months to 22 years and mean disease activity score (DAS) of 3.90 (range: 2.00-7.67) were examined by MRI of the hand (MCP region) and following MA of the MCP-II joints. MRI parameters for arthritis (synovial enhancement, synovial extension, cortical alterations, joint gap width) and corresponding macroscopic items (synovial extension, synovial hyperemia and vascularity, cortical alterations) by MA, scored semiquantitatively for synovitis (graduated from 0-III degree), were correlated. Additionally, normal radiographs of the hands were performed and compared with MRI findings concerning the detection of bony lesions. Evaluation of the 30 MRI and MA examination revealed highly significant correlations (p < 0.0001) for the parameters of synovial extension (MRI/MA), cortical alterations (MRI/MA) and synovial enhancement (MRI) compared to synovial hyperemia and vascularity (MA). We found significant correlations for parameters of activity and chronicity of RA pathology as assessed by MRI and MA. The detection rate of cortical lesions by MRI was two and a half times higher than by X-ray. MRI findings of MCP-II joints compared to those of MCP III-V showed that the MCP-II joint was more strongly involved.     

Imaging in rheumatoid arthritis--why MRI and ultrasonography can no longer be ignored

Implementing the modern treatment strategy in rheumatoid arthritis (RA), i.e. early initiation and optimal adjustments of aggressive therapies, requires methods for early diagnosis and sensitive monitoring of the disease process. In rheumatoid arthritis clinical trials and routine management, conventional radiography is the pivotal method for diagnosing and monitoring structural joint damage. However, it is insensitive to bone damage at its earliest stages and totally incapable of capturing the primary feature of rheumatoid disease, the synovitis. In comparison with radiography, magnetic resonance imaging (MRI) offers assessment of bone damage with improved sensitivities to early pathology and to change. In addition, detailed assessment of soft tissue changes, including synovitis and tenosynovitis, is possible and MRI findings are of prognostic value for the long-term radiological outcome. Ultrasonography (US) is less validated than MRI, but available data suggests that US offers comparable information on both inflammatory and destructive changes in RA finger and toe joints. Issues of reliability, standardization and documentation limit its value in clinical trials, This article reviews current knowledge on conventional radiography, computed tomography, MRI and US for assessment of peripheral joints in RA. The rationale is provided for MRI being the new gold standard for assessment of RA joints and US becoming a routine bedside tool for improved joint assessments and injections by rheumatologists. Pursuing the goal of improving patient care and disease outcome, rheumatologists can no longer afford to ignore MRI and US as means to measure disease activity and joint damage in rheumatoid arthritis.     

Bone edema determined by magnetic resonance imaging reflects severe disease status in patients with early-stage rheumatoid arthritis

OBJECTIVE: To determine the significance of bone edema, detected by magnetic resonance imaging (MRI), in early-stage rheumatoid arthritis (RA). METHODS: We simultaneously examined serologic variables, MRI of wrist sites and finger joints of both hands, clinical disease activity score (DAS), and HLA-DR typing at entry in 80 patients with early-stage RA. RESULTS: The number of bones scored as positive for bone edema correlated with the number of sites scored as positive for MRI synovitis and MRI bone erosion, rate of enhancement (E-rate), and serum C-reactive protein (CRP), matrix metalloproteinase 3 (MMP-3), and interleukin 6 (IL-6). Findings for MRI synovitis and MRI bone erosion, E-rate, CRP, MMP-3, IL-6, seropositivity, and titer of anti-cyclic citrullinated peptide antibody (anti-CCP antibody), DAS28-CRP and HLA-DRB1*0405 allele carriership, were significantly higher in the positive versus the negative bone edema group. CONCLUSION: Bone edema based on our scoring system may reflect severe disease status in patients with early-stage RA. However, its clinical value at entry in prognostication of RA should be examined through prospective clinical followup studies.     

Limits and perspectives of ultrasound in the diagnosis and management of rheumatic diseases

Abstract

Musculoskeletal sonography (MSUS) has played a growing role in the diagnosis and management of rheumatic diseases, enabling the imaging of synovitis, bone erosion, and cartilage damage in the early phase of arthritis. “Dynamic” evaluation of tendons and help in guiding needle positioning in interventional manoeuvres are some of the other reasons for its success. MSUS, particularly when coupled with power Doppler (PD) examination, has recently been shown to be an efficient tool for monitoring disease activity and progression in rheumatoid arthritis, spondyloarthritis, crystal-related arthropathy, and osteoarthritis, with general consensus on its interesting results. More specifically, the PD signal has proved to be a simple and promising tool for short-term monitoring of synovial vascularity changes induced by steroids or biological agents in RA patients. MSUS has some limits, because of the physical properties of US and the quality of the equipment; it is, moreover, an operator-related imaging technique, with few standardized protocols. Future goals should be standardization of the examining approach in grey scale and Doppler ultrasound (US), including use of new equipment (3D US), extensive use in other fields (i.e. connective tissue diseases and vasculitis), and possible new applications (e.g. thoracic US).     

The rheumatoid knee before and after arthrocentesis and Prednisolone injection: Evaluation by Gd-enhanced MRI

Summary In patients with rheumatoid arthritis, intraarticular injection of corticosteroids is an accepted means of treating a symptomatic joint. It has previously been impossible to precisely quantitate the effects of these injections on synovial effusion and pannus. Magnetic resonance imaging (MRI) is a safe, effective means of evaluating joint anatomy, and the use of intravenous gadolinium (Gd)-containing contrast allows clear differentiation of fluid from abnormal synovial tissue. The current study utilized MRI with Gd-labeled diethylene-triamene pentacetic acid (Gd-DTPA) contrast to evaluate serial changes in 6 knees of 6 patients with rheumatoid arthritis, following arthrocentesis and intraarticular injection of prednisolone. One week after the corticosteroid was injected, 2 patients had reduction of pannus width to 20% and 68% of baseline measurements. In these same individuals, follow-up sagittal views showed decreases of total effusion and fluid-plus-pannus width. The other 4 patients, who were followed for 4 weeks, had minimal changes in fluid and synovium. Gd-DTPA-enhanced MRI permits precise assessment of effects of intraarticular injections on synovial fluid and pannus in the rheumatoid knee.     

Limits and perspectives of ultrasound in the diagnosis and management of rheumatic diseases

Musculoskeletal sonography (MSUS) has played a growing role in the diagnosis and management of rheumatic diseases, enabling the imaging of synovitis, bone erosion, and cartilage damage in the early phase of arthritis. “Dynamic” evaluation of tendons and help in guiding needle positioning in interventional manoeuvres are some of the other reasons for its success. MSUS, particularly when coupled with power Doppler (PD) examination, has recently been shown to be an efficient tool for monitoring disease activity and progression in rheumatoid arthritis, spondyloarthritis, crystal-related arthropathy, and osteoarthritis, with general consensus on its interesting results. More specifically, the PD signal has proved to be a simple and promising tool for short-term monitoring of synovial vascularity changes induced by steroids or biological agents in RA patients. MSUS has some limits, because of the physical properties of US and the quality of the equipment; it is, moreover, an operator-related imaging technique, with few standardized protocols. Future goals should be standardization of the examining approach in grey scale and Doppler ultrasound (US), including use of new equipment (3D US), extensive use in other fields (i.e. connective tissue diseases and vasculitis), and possible new applications (e.g. thoracic US).     

Ultrasonography detection of early bone erosions in the metacarpophalangeal joints of patients with rheumatoid arthritis

OBJECTIVE: To compare ultrasonography (US) and magnetic resonance imaging (MRI) in their capability to detect bone erosions in early-advanced rheumatoid arthritis, where no erosion was evident on conventional radiography (X-ray). METHODS: Metacarpophalangeal (MCP), radiocarpal and ulnocarpal joints of 13 patients with rheumatoid arthritis, with bone erosion that was not detected by conventional X-ray, were examined by US and MRI. Ten controls underwent examination of the same joints by US. RESULTS: None of the controls showed bone erosions at US examination. No significant difference between US and MRI in detecting bone erosion was observed in wrist joints, whereas a significantly higher number of erosions was detected by US in MCP joints. CONCLUSION: US is at least as sensitive as MRI in detecting bone erosions in MCP and wrist joints. Since US examination is a more easily available and less expensive procedure than MRI, our findings justify its use as a diagnostic tool for early arthritis. In addition US may also be utilized in the follow up of patients with an established diagnosis of inflammatory arthritis.     

Etiopathogenesis of the rheumatoid arthritis-like disease in MRL/l mice. I. The histomorphologic basis of joint destruction

MRL/l mice spontaneously develop a hindlimb arthropathy, as well as a number of immunologic abnormalities, including circulating rheumatoid factors. Although previous studies have suggested that this arthropathy is primarily an inflammatory process, we performed a comprehensive histomorphologic study which indicated that inflammation is a late manifestation of MRL/l arthritis. The pathologic changes that occur in the joints of these mice can be divided into 3 stages. The first stage develops between the ages of 7 and 13 weeks and consists of synovial cell proliferation in the joint recesses. The second stage is characterized by continued proliferation of synovial cells which take on an appearance similar to that of transformed mesenchymal cells. The earliest destructive changes occur in the second stage and include marginal erosions, followed soon after by progressive destruction of articular and meniscal cartilage. The final stage is characterized by a diminution of synovial cel proliferation, extensive cartilage destruction, formation of scar tissue and fibrocartilage, and a very moderate infiltration of the synovial stroma by mononuclear and polymorphonuclear inflammatory cells. Throughout the disease progression there is a striking dissociation between inflammatory cell infiltration or exudation and tissue destruction. The histomorphologic similarities between human rheumatoid synovitis and the arthritis of MRL/l mice, as well as the presence of rheumatoid factors, make this mouse strain an excellent model for studying human rheumatoid arthritis.