Rheumatoid arthritis lesions of the wrist examined by rapid gradient-echo magnetic resonance imaging

An appraisal of magnetic resonance imaging of the wrist in rheumatoid arthritis

OBJECTIVES

To evaluate the role of magnetic resonance imaging (MRI) in the diagnosis, staging, and follow-up of the rheumatoid wrist.

METHODS

A Medline search was performed to identify all publications from the years 1985 to 1999 concerning MRI of the wrist in patients with rheumatoid arthritis (RA). Additional papers were retrieved by scanning the references to the Medline-listed articles. Details of the MRI technique, as well as clinical data, were analyzed and compared.

RESULTS

A total of 55 papers were identified. There were considerable variations in imaging sequence, section type, and slice thickness. Erosions and synovitis were the conditions that mostly profited from the adoption of MRI. Although the visualization of erosions was better detailed with MRI than with conventional radiography, erosions were only rarely related to clinical and laboratory parameters. Another advantage was that synovitis imaging, which can be enhanced by contrast agents, was amenable to quantitation. The extent of the synovial surface and the rate of contrast enhancement in a series of consecutive, rapidly acquired images were the most common measures.

CONCLUSIONS

MRI of the rheumatoid wrist is a useful technique to ascertain the criteria for diagnosis and progression of RA, and to monitor the effects of treatment. Implementation of a standardized protocol could further increase its value.

Magnetic resonance imaging-determined synovial membrane volume as a marker of disease activity and a predictor of progressive joint destruction in the wrists of patients with rheumatoid arthritis

OBJECTIVE

To evaluate the synovial membrane volume, determined by magnetic resonance imaging (MRI), as a marker of joint disease activity and a predictor of progressive joint destruction in rheumatoid arthritis (RA).

METHODS

Twenty-six patients with RA, randomized to receive disease-modifying antirheumatic drug (DMARD) therapy alone (11 patients) or DMARDs in combination with oral prednisolone (15 patients), were followed up for 1 year with contrast-enhanced MRI of the dominant wrist (months 0, 3, 6, and 12), conventional radiography (months 0 and 12), and clinical and biochemical examinations. Bone erosion (by MRI and radiography) and synovial membrane volumes (by MRI) were assessed.

RESULTS

Significant synovial membrane volume reductions were observed after 3 and 6 months in the DMARD + prednisolone group, and after 6 and 12 months in the DMARD-alone group (P < 0.01-0.02, by Wilcoxon-Pratt analysis). The rate of erosive progression on MRI was highly correlated with baseline scores and, particularly, with area under the curve (AUC) values of synovial membrane volume (Spearman's sigma = 0.69, P < 0.001), but not with baseline or AUC values of local or global clinical or biochemical parameters, or with prednisolone treatment. In none of 5 wrists with baseline volumes <5 cm3, but in 8 of 10 wrists with baseline volumes > or =10 cm3, erosive progression was found by MRI and/or radiography, indicating a predictive value of synovial membrane volumes. MRI was more sensitive than radiography for the detection of progressive bone destruction (22 versus 12 new bone erosions).

CONCLUSION

MRI-determined synovial membrane volumes are closely related to the rate of progressive joint destruction. Quantitative MRI assessment of synovitis may prove valuable as a marker of joint disease activity and a predictor of progressive joint destruction in RA.

The rheumatoid wrist: bilateral MR analysis of the distribution of rheumatoid lesions in axial plan in a female population

In this case-control study, we analyzed 146 wrists: a) to search for the distribution pattern of the rheumatoid lesions and, b) to correlate the distribution pattern of these lesions with the clinical parameters. Thirty-one patients with rheumatoid arthritis (RA) and 42 controls-all women-were examined by means of a bilateral MR fast field echo (FFE) sequence, in axial plan. The wrist was divided into three regions: metacarpal (level I), carpal (level II) and radioulnar (level III). Erosions were present in thirty (97%) patients and in six (14%) controls. They were asymmetrically distributed at all levels, mainly at level II. Marrow infiltration and bone destruction were seen in 35% of the patients in an asymmetrical pattern at level I and II, respectively. These lesions were absent in the control group. Subchondral cysts were asymmetrically present in both groups-in 48% of the patients at levels II and III, and in 11% of the controls at level II. In the patient group, this asymmetrical pattern of the lesions correlated with the disease duration at levels I and II (p = 0.011 and p = 0.013, respectively). Most lesions were found at the radial force-bearing column of the wrist, more in the right side. Synovial hypertrophy and hyperintense median nerve were evident in 96% and 70% of the patients, respectively. We concluded that contrary to common belief rheumatoid damages to the carpal bones become rather asymmetrical as the disease progresses. The line of force along the radial side of the wrist possibly influences the distribution pattern of the rheumatoid lesions.

Magnetic resonance imaging of the wrist in rheumatoid arthritis: comparison with other inflammatory joint diseases and control subjects

The aim of this study was to evaluate magnetic resonance images (MRI) of the wrist of rheumatoid arthritis (RA) patients. MRI and plain X-ray of the wrists were performed in 15 patients with RA, 7 patients with another chronic inflammatory joint disease (CIJD), and 10 control subjects. Patients had only minor changes on plain X-ray. Coronal T1 weighted spin echo sequences were performed before and after an intravenous pulse of gadolinium (GD). Contiguous 3 mm thick slices were obtained. Synovitis was frequently objectivized in the two groups of patients. MRI detected far more erosions and central bone geodes than plain X-ray. Geodes were frequent among controls while cortical bone erosions were frequent in patients. Most of the erosions were enhanced after GD injection in the RA patients but not in the 2 other groups. Thus MRI is not only useful in diagnosing inflammatory changes of the wrist but also in distinguishing early stage RA from other CIJD.

Bilateral fast MR imaging of the rheumatoid wrist

To evaluate the structural changes in the carpal tunnel and possible intrinsic median nerve damages in RA patients, quantitative bilateral magnetic resonance imaging (MRI) of the wrists was performed by means of a fast imaging sequence. Thirty-three women with RA and 42 controls were examined. The length of the carpal tunnel, the carpal tunnel volume/wrist volume (CTV/WV) ratio and the signal intensity of the nerve were calculated in both groups, bilaterally. The CTV/WV ratio was 0.12 in the patients and 0.11 in the control group (p = 0.007). A negative association was found between disease duration and carpal tunnel volume/wrist volume ratio (p = 0.049). Mean distal latency in the right motor median nerve was 3.0 +/- 0.4 msec (patients) and 3.4 +/- 0.6 msec (controls) (p = 0.002). Mean values in the right sensory branch were 1.2 +/- 0.1 msec (patients) and 1.4 +/- 0.3 (controls) (p = 0.01). The lack of association between the size of the carpal canal and neurophysiological parameters found in this study may suggest a possible protection of the median nerve by the increased canal size in patients with RA.

Ultrasonography in detection of effusion in the radiocarpal and midcarpal joints

Sixty radiocarpal and midcarpal joints in 30 healthy adults and 20 swollen wrists in 20 patients with chronic arthritis were examined by dorsal longitudinal ultrasonography (US). In five other patients intraarticular application of fluid into the radiocarpal joint could be seen as a change in the US scan. In 49 out of the 60 healthy wrists the unechogenic zone dorsally above the scaphoid bone was less than two millimetres, and the measurement did not change in dorsal or volar flexion. The side difference was less than one millimetre. In the healthy wrists the midcarpal area above bones was echogenic in US. In 15 radiocarpal and in 10 midcarpal joints out of the 20 swollen wrists, effusion could be depicted with US as an unechogenic zone. It was two millimetres or more in radiocarpal joint and it got bigger in dorsal and smaller in volar flexion.