Extremity Magnetic Resonance Imaging Research Articles

Cross-sectional and longitudinal reliability of semiquantitative osteoarthritis assessment at 1.0T extremity MRI: Multi-reader data from the MOST study

ObjectiveTo determine reliability among four experienced and calibrated readers in cross-sectional and longitudinal semi-quantitative MRI assessments of knee osteoarthritis (OA) in the Multicenter Osteoarthritis (MOST) study. DesignFrom all MOST participants with at least one knee with readable 60-month and 84-month paired knee MRIs (1.0 ​T extremity systems), we selected 10 subjects having a spectrum of baseline disease severity of cartilage, bone marrow lesions, and meniscal damage and a spectrum of longitudinal changes in severity at 24 months follow-up. MRIs were independently assessed using the WORMS grading system by four musculoskeletal radiologists with the chronological sequence known to the readers. Kappa statistics were used to determine agreement between each pair of readers and Kendall's coefficient of concordance to determine average agreement across readers. ResultsFor most features, cross-sectional reliability was substantial to almost perfect. Regarding longitudinal reliability (detection of longitudinal change), inter-reader reliability as weighted kappa values ranged from 0.62 to 0.78 for cartilage damage, 0.75–0.88 for bone marrow lesions, 0.75–0.92 for meniscal tears, 0.67–0.95 for meniscal extrusion, 0.51–0.77 for bone attrition, 0.43–0.76 for osteophytes, 0.31–0.70 for Hoffa-synovitis, and 0.47–0.85 for effusion-synovitis. Kendall's coefficient ranged from 0.65 to 0.98. ConclusionHigh levels of cross-sectional reliability and moderate to high longitudinal reliability was achieved using four experienced readers in semiquantitative MRI-assessment of most knee OA features.

Plasma exchange therapy in refractory inflammatory myopathy with anti-signal recognition particle antibody: a case series.

To explore the efficacy of plasma exchange (PE) therapy in refractory idiopathic inflammatory myopathy (IIM) patients with positive anti-signal recognition particle (SRP) antibody. Nine refractory IIM patients with positive anti-SRP antibody were enrolled, who received PE therapy at Ruijin Hospital from October 2017 to December 2020. The clinical manifestations, laboratory tests, chest CT and lower extremity MRI images before and after PE therapy were compared. The treatment response was evaluated by the 2016 ACR/EULAR myositis response criteria. A total of 88.9% (8/9) of subjects had achieved improvement by 3 weeks after PE therapy, with 55.6% (5/9) minimal improvement and 33.3% (3/9) moderate improvement. There were statistically significant improvements between baseline and after PE therapy at 3 weeks on the core set measures: physician global activity, patient global activity, HAQ, manual muscle testing (MMT), extramuscular disease activity, and muscle enzymes activity including creatine kinase (CK), lactate dehydrogenase (LDH), aspartate transaminase (AST), except for alanine transaminase (ALT). Moreover, the chest CT showed regression of ground glass opacities and irregular linear opacities after PE therapy in four patients with interstitial lung disease. The MRI images of lower extremity in four patients showed reduction of muscle oedema after the therapy. PE therapy is effective for refractory IIM patients with positive anti-SRP antibody. It should be considered as an alternative treatment for those patients who are resistant to the combined therapy of glucocorticoids and immunosuppressive agents.

Use of non-contrast MR in diagnosing secondary lymphedema of the upper extremities

PurposeThe purpose of the study is to determine if a combination of dermal thickening and subcutaneous fluid honeycombing on non-contrast MRI, termed the dermal rim sign (DRS), can be diagnostically analogous to dermal backflow seen on lymphoscintigraphy in patients with secondary upper extremity lymphedema. Materials and methodsUpper extremity MRI and lymphoscintigraphy were performed on patients referred to a multidisciplinary lymphedema clinic for suspicion of secondary lymphedema. Sensitivity, specificity, and positive and negative predictive values of DRS on MRI in detecting dermal backflow on lymphoscintigraphy and the correlation between DRS, Indocyanine Green (ICG) lymphography, bioimpedence L-Dex® ratio and MRI Lymphedema Staging were calculated. Weighted interobserver agreements on the presence and location of DRS on MRI were calculated. ResultsOf the 45 patients in the study, 91.1% (41/45) of patients had history of breast cancer. The average age was 58.4 ± 10.5 years, with a mean symptom duration of 4.7 ± 4.4 years. The mean BMI was 30.5 ± 7.0 kg/m2. Interobserver agreement on the presence and the extent of DRS on MRI was 0.93 [95% confidence-interval: 0.80–1]. DRS was present in 97% (32/33) of patients who demonstrated dermal backflow on lymphoscintigraphy. Sensitivity, specificity, PPV, and NPV of DRS were 96.6% [81.7%–99.9%], and 75.0% [47.6%–92.7%], 87.5% [74.9%–94.3%], and 92.3% [63.1%–98.8%]. DRS was associated with severity on ICG lymphography and bioimpedance (both p < 0.001). ConclusionsDRS on non-contrast MRI is highly predictive of dermal backflow and correlates with clinical measures of lymphedema severity. DRS may be used as an independent diagnostic biomarker to identify patients who would benefit from dedicated exams.

Lower extremity MRI following 10-week supervised exercise intervention in patients with diabetic peripheral neuropathy

IntroductionThe purpose of this study was to characterize using MRI the effects of a 10-week supervised exercise program on lower extremity skeletal muscle composition, nerve microarchitecture, and metabolic function in...

Teaching NeuroImage: Immune Checkpoint Inhibitor-Related Fasciitis and Myositis With Perifascicular Atrophy.

A 58-year-old man with melanoma treated with ipilimumab/nivolumab presented with pain, limited joint mobility, and proximal weakness without oculobulbar weakness, dyspnea, or rash. EMG demonstrated positive sharp waves, fibrillations, and myopathic units. Extremity MRI showed diffuse fascial and mild muscle enhancement consistent with fasciitis/mild myositis (Figure). Creatinine kinase was normal. PET-CT demonstrated diffusely fluorodeoxyglucose-avid lymph nodes and muscles; lymph node biopsy revealed granulomatous inflammation suggesting immune checkpoint inhibitor-related inflammatory reaction. Biceps biopsy demonstrated perifascicular atrophy (PA) and fascial/perimysial perivascular inflammation (Figure).

Zero echo time pediatric musculoskeletal magnetic resonance imaging: initial experience.

Projection radiography (XR) is often supplemented by both CT (to evaluate osseous structures with ionizing radiation) and MRI (for marrow and soft-tissue assessment). Zero echo time (ZTE) MR imaging produces a "CT-like" osseous contrast that might obviate CT. This study investigated our institution's initial experience in implementing an isotropic ZTE MR imaging sequence for pediatric musculoskeletal examinations. Pediatric patients referred for extremity MRI at 3tesla (T) underwent ZTE MR imaging to yield images with contrast similar to that of CT. A radiograph-like image was also created with ray-sum image processing. We assessed ZTE-CT/XR anatomical image quality (Sanat) from 0 (nondiagnostic) to 5 (outstanding). Further, we made image comparisons on a 5-point scale (Scomp) (range of -2 = conventional CT/XR greater anatomical delineation to +2 = ZTE-CT/XR greater anatomical delineation; 0=same) for three cohorts: (1) ZTE-XR to conventional radiography, (2) ZTE-CT to conventional CT and (3) pathological lesion assessment on ZTE-XR to conventional radiography. We measured cortical thickness of ZTE-XR and ZTE-CT and compared these with conventional imaging. We calculated confidence interval of proportions, Wilcoxon rank sum test and intraclass correlation coefficients for inter-reader agreement. Cohorts 1, 2 and 3 consisted of 40, 20 and 35 cases, respectively (age range 0.6-23.0years). ZTE-CT versus CT and ZTE-XR versus radiography of cortical thicknesses were not significantly different (P=0.55 and P=0.31, respectively). Cortical delineation was rated diagnostic or better (score of 3, 4 or 5) in all cases (confidence interval of proportions = 100%) for ZTE-CT/XR. Similarly, intramedullary cavity delineation was rated diagnostic or better in all cases for ZTE-CT, and ZTE-XR was at least diagnostic in 58-63% of cases. For cohort 2, cortex and intramedullary cavity Scomp for ZTE-CT was comparable to those of conventional CT, with confidence interval of proportion (sum of score of -1 to +2) of 93-100% and 95%, respectively. Pathology visualized on ZTE-CT/XR was comparable; Scomp confidence interval of proportions was 95%/97-100%, with improved delineation of non-displaced fractures on ZTE-XR. Readers had moderate to near-perfect intraclass correlation coefficient (range=0.60-0.93). Implementation of a diagnostic-quality ZTE MRI sequence in the pediatric population is feasible and can be performed as a complementary pulse sequence to enhance musculoskeletal MRI studies. Compared to conventional CT, ZTE has comparable cortical delineation, intramedullary cavity and pathology visualization. While not intended as a replacement for conventional radiography, ZTE-XR provides similar visualization of pathology.

Clinical and Neuroimaging Features in Charcot-Marie-Tooth Patients with GNB4 Mutations.

Charcot–Marie–Tooth disease (CMT) is the most common inherited peripheral neuropathy. Mutations in the GNB4 gene cause dominant intermediate CMT type F (CMTDIF). The aim of this study is to investigate phenotypic heterogeneities and characteristics of CMT patients with GNB4 mutations. We enrolled 1143 Korean CMT families and excluded 344 families with a PMP22 duplication. We further analyzed the 799 remaining families to find their GNB4 mutations using whole-exome sequencing (WES). We identified two mutations (p.Gly77Arg and p.Lys89Glu) in three families, among which a heterozygous p.Gly77Arg mutation was novel. In addition, a significant uncertain variant (p.Thr177Asn) was observed in one family. The frequency of the GNB4 mutation in the Korean population is 0.38% in PMP22 duplication-negative families. All three families showed de novo mutation. Electrophysiological findings regarding the p.Lys89Glu mutation showed that the motor nerve conduction velocity (MNCV) of the median nerve was markedly reduced, indicating demyelinating neuropathy, and sural nerve biopsy revealed severe loss of myelinated axons with onion bulb formation. Lower extremity Magnetic Resonance Imaging (MRI) demonstrated relatively more severe intramuscular fat infiltrations in demyelinating type (p.Lys89Glu mutation) patients compared to intermediate type (p.Gly77Arg mutation) patients. The anterolateral and superficial posterior compartment muscles of the distal calf were preferentially affected in demyelinating type patients. Therefore, it seems that the investigated GNB4 mutations do cause not only the known intermediate type but also demyelinating-type neuropathy. We first presented three Korean families with GNB4 mutations and found phenotypic heterogeneities of both intermediate and demyelinating neuropathy. We suggest that those findings are useful for the differential diagnosis of CMT patients with unknown GNB4 variants.

Childhood\u2010onset systemic lupus erythematosus with trisomy X and the increased risk for bone complications: a case report

BackgroundSystemic lupus erythematosus is a multi-organ inflammatory autoimmune disease; immune complexes are part of the pathogenesis, but not entirely responsible. Trisomy X is the most common female chromosomal abnormality and the role of an additional X chromosome in the development of systemic lupus erythematosus is well recognized. However, the potential complications and optimal management of childhood lupus with trisomy X remain unclear. Herein, we describe a case of childhood-onset systemic lupus erythematosus associated with severe bone complications presumably secondary to trisomy X.Case presentationA 16-year-old Japanese girl was diagnosed with childhood-onset systemic lupus erythematosus and trisomy X. A chromosomal abnormality (47, XXX) was incidentally identified on bone marrow examination initially done to determine the cause of pancytopenia. She had a persistent headache, fever for six days, diffuse hair loss, mucosal ulcers, butterfly eruptions, and palmar erythema. Furthermore, thrombocytopenia, anemia, and erythrocyte fragmentation were detected, suggesting secondary thrombotic microangiopathy. She was initially treated with intravenous methylprednisolone pulse therapy and prescribed monthly cyclophosphamide for severe disease activity, prednisolone, mycophenolate mofetil, and hydroxychloroquine as remission maintenance drugs. She developed generalized extremity pain that had been worsening throughout the disease. Extremity magnetic resonance imaging performed 12 months after the treatment onset revealed multifocal avascular necrosis, and dual-energy X-ray absorptiometry revealed further decreased bone mineral density. High plasma levels of factor VIII were detected by additional tests for coagulation functions, and we suspected the possibility that factor VIII might cause avascular necrosis due to thrombosis. Currently, she is being treated with prednisolone and MMF for SLE. However, her extremity pain has not been managed effectively even under the administration of non-steroidal anti-inflammatory drugs and pregabalin.ConclusionsAn additional X chromosome has been reported to be associated with factor VIII and osteoporosis. Additionally, elevated plasma levels of FVIII is the risk factors for thrombosis, which leads to the risk of avascular necrosis. Patients with systemic lupus erythematosus complicated by trisomy X might be at a higher risk of avascular necrosis and osteoporosis that can also manifest in childhood systemic lupus erythematosus.

Evaluating the Clinical Tests for Adolescent Tibial Bone Stress Injuries.

Tibial bone stress injuries are common among the athletic adolescent population. A thorough patient history and clinical examination are essential to identify the location and extent of injury. However, there has been little description or any validation of clinical tests to help guide clinicians. Consequently, a formal diagnosis is usually dependent on results from proper imaging. Clinical examinations will be both highly sensitive and specific determining the incidence, grade, and location of tibial bone stress injury as compared with magnetic resonance imaging (MRI). Case-control. Level 2. A total of 80 consecutive athletic adolescents, from various sports, with greater than 1-week history of shin pain were enrolled in this institutional review board-approved study. Exclusion criteria were age >19 years and history of traumatic injury. Patients underwent a standardized clinical examination, which included a fulcrum test (FT), tap/percussion test (TT), vibration test (VT) utilizing a 128-Hz tuning fork, weight bearing lunge test (WBLT) to determine degree of dorsiflexion range of motion (ROM), and vertical single leg hop test (VSLHT) for height, landing, and pain. Bilateral lower extremity MRI was completed on the same day as clinical evaluation and served as the injury reference. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated to evaluate each clinical examination for its ability to identify a bone stress injury. A total of 159 tibiae in 80 patients were evaluated. No single test or combination of tests was both highly sensitive and specific. Individual clinical tests demonstrated sensitivity ranging from 0.11 to 0.72 and specificity ranging from 0.37 to 0.93. The VSLHT noting an increase in pain was the most sensitive test (0.72; 95% CI, 0.62-0.78); however, its specificity was only 0.37 (95% CI, 0.19-0.55), with a PPV of 0.84 (95% CI, 0.78-0.91) and NPV of 0.20 (95% CI, 0.089-0.31). The WBLT demonstrated a mean ROM of 8 cm, with side-to-side differences (range 0-4 cm) not influencing incidence of injury. Combinations of tests demonstrated low sensitivity (0.03-0.40), with better specificity (0.63-1.0). When considering ability to identify higher grades of injury (grade III/IV), all tests had a high NPV indicating that if clinical tests were negative, there was a high likelihood that the patient did not have a grade III or IV injury. No single test or combination of tests was both highly sensitive and specific. Clinicians cannot solely rely on clinical examination for determining extent or severity of bone stress injury in the athletic adolescent population, but when combinations of tests are negative, there is likely not a high-grade bone stress injury. Clinical tests utilized in the evaluation of adolescent tibial bone stress injury may help indicate the presence or absence of higher grade tibial bone stress injury.

Management of Pregnancy-and Lactation-Related Osteoporosis: Case Series.

To share the experience regarding management and follow-up of patients with Pregnancy- and lactation-related osteoporosis (PLRO) who were effectively treated. This case series presented 10 patients diagnosed with PLRO and treated from January 2010 to December 2019. Visual analog scale and laboratory findings were evaluated. Spinal and extremity magnetic resonance imaging was obtained for patients with spinal and extremity pains. Dual energy X-ray absorptiometry was used for the measurement of bone mineral density. Values assessed on dual energy X-ray absorptiometry were L1?L4 T score, L2?L4 T score, and femoral neck T score. In the first-month follow-ups, all patients had meaningful pain relief and symptom resolution. The mean duration of pain control during the treatment period was 2.4 months. Two patients who continued breast-feeding were also the patients whose pain control was achieved at the latest. One patient required vertebroplasty. Patients with PLRO should be promptly treated and followed up. Discontinuation of breast-feeding will provide rapid advantage and should be the first step of the management. Early diagnosis and treatment of calcium and vitamin D with conservative procedures with spinal braces are very important for the treatment of PLRO patients. Additionally, bisphosphonates or teriparatide can improve the bone mineral density in patients with PLRO.

Using an Office-Based, Dedicated Extremity MRI Scanner for Depicting Important Structures in Common Wrist Pathologies: A Pilot Comparison with a Conventional MRI Scanner.

Background Compared with the conventional magnetic resonance imaging (MRI), dedicated MRI scanners are more accessible. Images of a dedicated 1.0-T MRI specifically developed for the hand and wrist were compared with images of a conventional 1.5-T MRI. Methods Paired images of the right wrist were randomized and separately graded by two experienced radiologists for the quality of anatomical details, including the triangular fibrocartilage complex, carpal ligaments, intercarpal cartilage, median and ulnar nerves, overall image quality, and artifacts. Interrater reliability was measured with the percentage of exact agreement and agreement within a range of ± 1 score point. Participant experience of undergoing the examination in both MRI scanners was evaluated using a questionnaire. Results The overall image quality of all sequences was considered to be moderate to high. In 25 of 38 paired images, no statistically significant difference was found between the MRI scanners. Ten scores were found to be in favor of the dedicated extremity MRI. Within a range of ± 1 score point, the extremity MRI and the conventional MRI demonstrated an interrater agreement of 67 to 100% and 70 to 100%, respectively. Among the respondents of the questionnaire, the extremity MRI scored better for participant satisfaction when compared with the conventional MRI. Conclusions In healthy volunteers, the dedicated extremity MRI generally is similar or superior to the conventional MRI in the depiction of anatomical structures of the wrists, image quality, and artifacts, and significantly scored better on participant satisfaction. Future clinical studies should focus on defining the diagnostic value of the extremity MRI in wrist pathologies.

MRI changes in calf muscles of two children with cerebral palsy following Botulinum Toxin Type A injections: a preliminary report.

Intramuscular injections of Botulinum Toxin Type A (BoNT-A) in children with spastic cerebral palsy (CP) have been introduced in clinical practice with the aim of reducing muscle tone, preventing muscle contractures and, ultimately, improving function. The aim of this study was to evaluate prospectively the MRI changes in the calf muscles, gastrocnemius (GN) and soleus (S) of two children with unilateral spastic CP (US-CP), prior and more than 1-year following BoNT-A injections. Two male patients with US-CP were injected at the level of the GN and S muscles. Patients underwent a first lower extremity MRI prior to the first BoNT-A injection at the level of GN and S muscles of the affected side. A second MRI was perfomed 34 and 22 months after the index procedure, respectively. Both legs were investigated together symmetrically, to allow a precise comparison between muscles and structures. The MRI protocol included three sequences: axial-T2 weighted tse, SPACE and axial-T1 weighted. We found that BoNT-A injected GN and S muscles had increased signal intensity on the MRI performed 22 and 34 months after index procedure, when compared to the contralateral, not placebo injected (NaCl) leg. To the best of our knowledge, no previous studies have investigated the changes induced in muscle structures in ambulatory children with US-CP managed by BoNT-A injections. Level of evidence: II.

Knee Pain And Swelling - Volleyball Player

HISTORY: An 18 year old volleyball player presented with acute swelling and pain of her right knee with associated nausea, vomiting, and subjective fevers. Aside from an abrasion beneath her knee sustained during practice 2 weeks prior, she denied inciting injury or trauma. She complained of knee tightness, but denied feelings of instability or mechanical symptoms. She denied history of skin or soft tissue infections. PHYSICAL EXAM: On initial examination, she was febrile to 102°F (38.9°C). She had notably increased warmth and erythema along the lateral aspect of her right knee with tenderness to palpation. She had evidence of a healed abrasion inferior to her right knee without an associated joint effusion. There did appear to be swelling localized to the lateral aspect of her knee. She had full range of motion of her right knee without any indication of ligamentous injury. Her gait was non-antalgic. DIFFERENTIAL DIAGNOSIS: 1. Septic prepatellar bursitis 2. Necrotizing infection (cellulitis, myositis, fasciitis) 3. Septic arthritis 4. Morel-Lavallée Lesion 5. Reactive arthritis (gonococcal, chlamydial) TESTS AND RESULTS: 1. Pertinent labs: White blood cell count 27,000 X 109/L, sodium 127 mEq/L, potassium 3.2 mEq/L 2. Blood cultures negative times 2 3. Lower extremity MRI: Extensive cellulitis and probable phlegmon in subcutaneous fat throughout the distal thigh and knee; myositis in the distal vastus lateralis muscle and biceps femoris 4. Gram stain from I&D right thigh: Positive strep pyogenes (group A) 5. Surgical findings consistent with necrotizing fasciitis. FINAL/WORKING DIAGNOSIS: Subacute necrotizing fasciitis TREATMENT AND OUTCOMES: 1. She was initially treated with broad spectrum antibiotics, subsequently tailored to culture and sensitivities. 2. She underwent three surgical explorations to assess underlying muscle and fascia, including I&D of necrotic tissue along iliotibial tract. 3. With both subjective and objective improvement, she was discharged from the hospital to complete one week of IV Ceftriaxone. 4. She was cleared to start her rehabilitation and progressed to walk/jog/jump for four weeks focusing on quadriceps strengthening. 5. After one week of non contact play and sport specific drills, she returned to full contact practice six weeks after hospital discharge.

SAT-337 Ga-DOTATATE and Tumor Induced Osteomalacia: Finding the Culprit Lesion

IntroductionTumor-induced osteomalacia (TIO) is a very rare paraneoplastic disorder caused by tumors that produce fibroblast growth factor 23 (FGF23) resulting in phosphate wasting and inadequate bone mineralization. Complete resection can be curative; however, these tumors are typically difficult to identify due to size and location.Clinical caseA 43-year-old man was referred to Endocrinology for evaluation of recurrent fractures and hypophosphatemia. First stress fracture was diagnosed at age 41, followed by musculoskeletal pain in several locations. Lower extremity MRI showed chronic left fibular stress fracture, new stress fracture in fifth metatarsal and right tibia. Tc99m-MDP bone scan revealed multiple foci of increased tracer uptake in bilateral ribs, hips, and lower extremities. Laboratory evaluation showed normal calcium (9.3 mg/dL, normal range [NR]: 8.7-10.2), low phosphorus (1.5 mg/dL, NR: 2.5-4.7), low 1,25-dihydroxyvitamin D (13 pg/mL, NR: 19.9-79.3), low 24-hour urine calcium (78mg), high phosphate excretion fraction in urine (27%, normal <5%), high ALP (163 U/L, NR: 38-126), and high FGF23 (238 RU/mL, NR<180). 25 OH vitamin D (36 ng/mL) and iPTH (5.7 pmol/L, NR: 1.6-6.9) were normal. Patient was started on calcitriol and phosphate supplements. Due to concern for TIO, a PET scan with 68Ga-DOTATATE was performed which showed multiple somatostatin avid lesions concerning for metastatic disease. However, after re-review with radiology, it was felt that other areas of uptake were due to fractures and not tumor given remarkably higher SUV in left acetabular lesion (SUV 20 vs 4-5). The left acetabular lesion was biopsied, followed by surgical resection. Pathology was consistent with phosphaturic mesenchymal tumor with uninvolved margins. FGF23 normalized within 24 hours after surgery (127 RU/mL) and calcitriol and phosphate supplements were discontinued on post-operative day 10.Clinical lessonTIO is a rare paraneoplastic syndrome commonly caused by phosphaturic mesenchymal tumors that secrete FGF23. Once the diagnosis of TIO is confirmed, the tumor is localized by anatomical or functional imaging. 68Ga-DOTATATE scan is currently the imaging modality of choice for localization. However, there are other pathologic processes, such as fractures, that could affect the interpretation of PET scans. Osteoblastic activity is increased in fractures, which results in increased uptake in Ga-DOTATATE PET scan since osteoblasts express somatostatin receptor. Our patient was initially thought to have multiple avid lesions concerning for metastatic disease, but culprit lesion was differentiated based on SUVs and confirmed with biopsy. Clinical and biochemical abnormalities resolved after surgery. Early recognition of culprit lesion in TIO is crucial, as successful surgery is curative and would lead to significant improvement in the quality of life of patients.

Upper and Lower Extremities in Duchenne Muscular Dystrophy Evaluated with Quantitative MRI and Proton MR Spectroscopy in a Multicenter Cohort.

Background Upper extremity MRI and proton MR spectroscopy are increasingly considered to be outcome measures in Duchenne muscular dystrophy (DMD) clinical trials. Purpose To demonstrate the feasibility of acquiring upper extremity MRI and proton (1H) MR spectroscopy measures of T2 and fat fraction in a large, multicenter cohort (ImagingDMD) of ambulatory and nonambulatory individuals with DMD; compare upper and lower extremity muscles by using MRI and 1H MR spectroscopy; and correlate upper extremity MRI and 1H MR spectroscopy measures to function. Materials and Methods In this prospective cross-sectional study, MRI and 1H MR spectroscopy and functional assessment data were acquired from participants with DMD and unaffected control participants at three centers (from January 28, 2016, to April 24, 2018). T2 maps of the shoulder, upper arm, forearm, thigh, and calf were generated from a spin-echo sequence (repetition time msec/echo time msec, 3000/20-320). Fat fraction maps were generated from chemical shift-encoded imaging (eight echo times). Fat fraction and 1H2O T2 in the deltoid and biceps brachii were measured from single-voxel 1H MR spectroscopy (9000/11-243). Groups were compared by using Mann-Whitney test, and relationships between MRI and 1H MR spectroscopy and arm function were assessed by using Spearman correlation. Results This study evaluated 119 male participants with DMD (mean age, 12 years ± 3 [standard deviation]) and 38 unaffected male control participants (mean age, 12 years ± 3). Deltoid and biceps brachii muscles were different in participants with DMD versus control participants in all age groups by using quantitative T2 MRI (P < .001) and 1H MR spectroscopy fat fraction (P < .05). The deltoid, biceps brachii, and triceps brachii were affected to the same extent (P > .05) as the soleus and medial gastrocnemius. Negative correlations were observed between arm function and MRI (T2: range among muscles, ρ = -0.53 to -0.73 [P < .01]; fat fraction, ρ = -0.49 to -0.70 [P < .01]) and 1H MR spectroscopy fat fraction (ρ = -0.64 to -0.71; P < .01). Conclusion This multicenter study demonstrated early and progressive involvement of upper extremity muscles in Duchenne muscular dystrophy (DMD) and showed the feasibility of MRI and 1H MR spectroscopy to track disease progression over a wide range of ages in participants with DMD. © RSNA, 2020 Online supplemental material is available for this article.

The Utilization of Immobilization Device to Reduce Motion Artifact Caused by Breathing in Upper Extremity MRI

The Utilization of Immobilization Device to Reduce Motion Artifact Caused by Breathing in Upper Extremity MRI

MRI staging of upper extremity secondary lymphedema: correlation with clinical measurements.

Staging of upper extremity lymphedema is needed to guide surgical management, but is not standardized due to lack of accessible, quantitative, or precise measures. Here, we established an MRI-based staging system for lymphedema and validate it against existing clinical measures. Bilateral upper extremity MRI and lymphoscintigraphy were performed on 45 patients with unilateral secondary lymphedema, due to surgical intervention, who were referred to our multidisciplinary lymphedema clinic between March 2017 and October 2018. MRI short-tau inversion recovery (STIR) images were retrospectively reviewed. A grading system was established based on the cross-sectional circumferential extent of subcutaneous fluid infiltration at three locations, labeled MRI stage 0-3, and was compared to L-Dex®, ICG lymphography, volume, lymphedema quality of life (LYMQOL), International Society of Lymphology (ISL) stage, and lymphoscintigraphy. Linear weighted Cohen's kappa was calculated to compare MRI staging by two readers. STIR images on MRI revealed a predictable pattern of fluid infiltration centered on the elbow and extending along the posterior aspect of the upper arm and the ulnar side of the forearm. Patients with higher MRI stage were more likely to be in ISL stage 2 (p= 0.002) or to demonstrate dermal backflow on lymphoscintigraphy (p= 0.0002). No correlation was found between MRI stages and LYMQOL. Higher MRI stage correlated with abnormal ICG lymphography pattern (rs= 0.63, p< 0.0001), larger % difference in limb volume (rs= 0.68, p< 0.0001), and higher L-Dex® ratio (rs= 0.84, p< 0.0001). Cohen's kappa was 0.92 (95% CI, 0.85-1.00). An MRI staging system for upper extremity lymphedema offers an improved non-invasive precision marker for lymphedema for therapeutic planning. • Diagnosis and staging of patients with secondary upper extremity lymphedema may be performed with non-contrast MRI, which is non-invasive and more readily accessible compared to lymphoscintigraphy and evaluation by lymphedema specialists. • MRI-based staging of secondary upper extremity lymphedema is highly reproducible and could be used for long-term follow-up of patients. • In patients with borderline clinical measurements, MRI can be used to identify patients with early-stage lymphedema.

The Clinical Utility of MRI in Evaluating for Osteomyelitis in Patients Presenting with Uncomplicated Cellulitis

Magnetic resonance imaging (MRI) is vital in the diagnosis of osteomyelitis (OM) in patients presenting with cellulitis. Typically, cellulitis is treated with oral antibiotics; however, patients with concomitant OM may require long-term intravenous antibiotics or surgical intervention. We reviewed lower extremity MRIs in patients presenting with cellulitis and clinical concern for OM. We found 488 patient examinations spanning 5 years (2011 to 2016); 47 patients were excluded (final N = 441). Each MRI was interpreted by a radiologist to determine the rate of OM, abscess, ulceration, and imaging diagnosis of cellulitis. Concurrent assessment of the electronic medical record was performed to review patient demographics, the presence of abscess and/or ulceration, and comorbidities such as diabetes, hyperlipidemia (HLD), atherosclerotic disease, and peripheral vascular disease. Of the 441 lower extremity MRIs included, 170 (39%) were diagnosed with OM, 236 (54%) had ulcers, and 66 (15%) had abscesses. Age, laterality, and reporting physician were not statistically significant independent variables in the rate of reported OM. Diabetes and HLD/atherosclerotic disease were both statistically significant variables with regard to OM rates. Clinical documentation and MRI diagnosis of ulceration were both statistically significant variables in the rate of OM. Regression analysis determined that body part, ulceration, HLD/atherosclerosis, and sex were independent predictors of OM. In our study, of the population of patients with a high clinical suspicion for OM, 39% had OM diagnosed on MRI. However, the incidence of OM in uncomplicated cellulitis was only 11.8% compared with 43.9% in complicated cellulitis. When considering the forefoot alone, patients with ulceration at MRI were 5.6 times more likely to have underlying OM than those without.

Pembrolizumab-Induced Seronegative Arthritis and Fasciitis in a Patient with Lung Adenocarcinoma

Background: Immune checkpoint inhibitors (CPIs) are new promising anti-cancer drugs that block negative costimulation of T-cells leading to an enhanced anti-tumor immune response. Pembrolizumab, an a monoclonal antibody, targeting the programmed cell death protein 1 (PD-1) pathway. CPIs have been associated with a number of immune-related adverse events (AEs), including musculoskeletal and rheumatic disease.Objective: To present a case with lung adenocarcinoma treated with pembrolizumab, which developed inflammatory arthritis and fasciitis.Case Report: A 73-year-old male patient was referred to the rheumatology outpatient clinic with complaints of pain in the pretibial area, pain and swelling in both ankles joints and the right fırst metacarpophalangeal (MCP) joint. Three months ago he had diagnosed with lung adenocarcinoma and pembrolizumab was started. Locomotor system complaints were started after receiving two infusions of pembrolizumab. Physical examination revealed both ankle arthritis, mild edema in the pretibial region, tenderness in the muscles and arthritis in the right fırst MCP joint. Laboratory examinations showed mild acute phase reactants elevation. Lower extremity MRI showed diffuse edema in both gastrocnemius muscle and fascia, compatible with fasciitis. Pembrolizumab-related fasciitis and seronegative arthritis were diagnosed. Low dose corticosteroid was started and a significant regression was observed in the patient's complaints.Conclusion: Inflammatory myositis with fasciitis and inflammatory arthritis in lower extremities appears to be a new adverse effect of pembrolizumab therapy.

Diagnostic performance of contrast-enhanced and unenhanced combined pulmonary artery MRI and magnetic resonance venography techniques in the diagnosis of venous thromboembolism.

We aimed to determine the diagnostic performance of the contrast-enhanced and unenhanced combined pulmonary arterial MRI and magnetic resonance venography techniques in the diagnosis of venous thromboembolism (VTE). 44 patients who underwent CT pulmonary angiography (CTPA) for suspected PE constituted the study population. Patients underwent combined pulmonary and lower extremity MRI, and Doppler ultrasonography within 72 h after CTPA. Combined MRI included two sequences: unenhanced steady-state free precession (SSFP) and contrast-enhanced three-dimensional (3D) gradient echo (GRE). The presence of emboli in pulmonary arteries and thrombi in lower extremity veins on 3D-GRE and SSFP sequences was recorded. CTPA showed a total of 244 emboli in 33 (75%) patients whereas contrast-enhanced 3D-GRE MRI showed deep vein thrombosis (DVT) in 34 (77%) subjects. Sensitivities for SSFP vs 3D-GRE MRI respectively in PE detection were 87.9 vs 100% on a per-patient basis, and 53.7 vs 73% on a per-embolus basis. Of 34 patients with established DVT, 31 (91%) were detected by Doppler ultrasound and 29 (85%) were detected by SSFP technique respectively. Both contrast-enhanced and unenhanced combined MRI of acute PE and DVT are feasible one-stop-shopping techniques in patients with suspected thromboembolism. Pulmonary VTE is a common disease with high mortality. Non-invasive techniques withhigh accuracy are required for the assessment of VTE. CT-related radiation and contrast material risks cause concerns. MRI is a radiation-free technique evaluating the vessels with and without contrast. Combined contrast enhancedor unenhanced pulmonary and lower extremity MRI is feasible in patients with suspected thromboembolism.