Rheumatoid Arthritis Magnetic Resonance Imaging Scoring Research Articles

Nouvelles imageries de la PR échographie et IRM : critères et interprétation

Better evaluation of disease inflammatory activity and structural progression and research of predictive factors of bone erosion have led to improve monitoring of rheumatoid arthritis (RA) patients. Ultrasonography (US) and magnetic resonance imaging (MRI) are more sensitive than clinical examination to detect synovitis, and than X-rays to detect bone erosions. Their external validity, reliability and sensitivity to change are satisfactory in RA. While the Rheumatoid Arthritis MRI Score (RAMRIS) score in MRI has been validated and appears as the score of reference for MRI reading in RA, no US score has obtained consensus, even though several US scoring systems have been proposed.

Bone erosions at the distal ulna detected by ultrasonography are associated with structural damage assessed by conventional radiography and MRI: a study of patients with recent onset rheumatoid arthritis

Ultrasonography (US) is a sensitive tool for detecting erosions in patients with RA. The wrist is usually involved in the RA process, where the distal ulna with its superficial localization is easily accessible for US examination. In this longitudinal study, we wanted to examine the presence, localization and development of erosions at the distal ulna by US in patients with recent onset RA, and to analyse whether erosions at this localization are associated with joint damage in hands assessed by conventional radiography (CR) and MRI. Seventy patients with recent onset RA (median disease duration 106 days) were examined by US of the distal ulna, in addition to hand radiography [assessed by van der Heijde-modified Sharp score (vdHSS)] and MRI of the wrist [assessed by RA MRI scoring (RAMRIS) erosion score]. Twelve months later 58 patients were re-assessed. US detected erosions at the distal ulna in 11% of the patients at baseline and 24% at follow-up (the majority of erosions were at the ulnar side). Logistic regression analyses showed the presence of erosions at baseline to be associated with baseline RAMRIS erosion score (P < 0.001), and at follow-up to RAMRIS erosion score (P = 0.02) and vdHSS (P = 0.008). A significant number of patients had US erosions at the distal ulna at baseline, with increased prevalence after 1 year. The US-detected erosions were associated with structural joint damage in hands assessed by both MRI and CR. US of the distal ulna could thus give useful clinical information.

The OMERACT MRI Inflammatory Arthritis Group: Advances and Future Research Priorities

The OMERACT magnetic resonance imaging (MRI) in inflammatory arthritis group previously developed the rheumatoid arthritis MRI score (RAMRIS) for use in clinical studies, evaluated the use of extremity MRI, and initiated development of a psoriatic arthritis MRI score (PsAMRIS). At OMERACT 9 the group looked at clarifications of applying the RAMRIS, and presented data from a study examining how the contrast agent gadolinium affects RAMRIS outcomes. Much of the group's effort has been aimed at the iterative development of its PsA score, and reported exercises examining this score demonstrated encouraging results, allowing subsequent presentation of a preliminary PsAMRIS. The large amount of data presented were followed by discussions with the wider audience highlighting constructive suggestions for future research priorities, including further feasibility studies, understanding imaging remission, and further improvements to PsAMRIS.

Magnetic Resonance Imaging of the Hand in Psoriatic Arthritis

Although magnetic resonance imaging (MRI) studies of psoriatic arthritis (PsA) are fewer than those of rheumatoid arthritis (RA), interest in this field is growing. The type and site of the lesions, rather than the mere severity of synovitis, can help differentiate PsA from other arthritides. Extracapsular enhancement and enthesitis are features emphasized as typical of PsA, but their relevance for the diagnosis is more quantitative than qualitative. Erosions in PsA are probably less frequent and progressive than in RA. Bone edema is unlikely to predict the appearance of erosions in patients with PsA. The Rheumatoid Arthritis Magnetic Resonance Imaging Scoring (RAMRIS) system has been adapted to peripheral PsA, but standardization is still in progress. Dactylitis is a relatively specific feature of PsA. Its pathogenic mechanisms have been investigated with MRI. MRI evaluation of PsA may facilitate diagnosis, evaluation of treatment effects, and understanding of associated mechanisms.

A new low-field extremity magnetic resonance imaging and proposed compact MRI score: evaluation of anti-tumor necrosis factor biologics on rheumatoid arthritis

Magnetic resonance imaging (MRI) is a useful tool for evaluating disease activity and therapeutic efficacy in rheumatoid arthritis (RA). However, conventional whole-body MRI is inconvenient on several levels. We have therefore developed a new low-field extremity MRI (compact MRI, cMRI) and examined its clinical utility. Thirteen RA patients treated with anti-tumor necrosis factor (TNF) biologics were included in the study. The MRI was performed twice using a 0.21-T extremity MRI system. The MRI images were scored using our proposed cMRI scoring system, which we devised with reference to the Outcome Measures in Rheumatology Clinical Trials RA MRI score (OMERACT RAMRIS). In our cMRI scoring system, synovitis, bone edema, and bone erosion are separately graded on a scale from 0 to 3 by imaging over the whole hand, including the proximal interphalangeal joint. The total cMRI score (cMRIS) is then obtained by calculating the total bone erosion score × 1.5 + total bone edema score × 1.25 + total synovitis score. In this study, one patient showed a progression of bone destruction even under low clinical activity, as assessed by the disease activity score on 28 joints (DAS28); however, another patient’s cMRIS decreased concurrently with the decrease in DAS28, with the positive correlation observed between ΔDAS28 and ΔcMRIS (R = 0.055, P < 0.05). We conclude that cMRI and cMRIS are useful for assessing total disease activity and as a method linking MRI image evaluation to clinical evaluation.

Reducing Invasiveness, Duration, and Cost of Magnetic Resonance Imaging in Rheumatoid Arthritis by Omitting Intravenous Contrast Injection — Does It Change the Assessment of Inflammatory and Destructive Joint Changes by the OMERACT RAMRIS?

Gadolinium (Gd)-enhanced magnetic resonance imaging (MRI) provides highly sensitive assessment of inflammatory and destructive changes in rheumatoid arthritis (RA) joints, but intravenous (IV) Gd injection prolongs examination time and increases cost, invasiveness, and patient discomfort. We explored to what extent RA joint pathologies in wrists and metacarpophalangeal (MCP) joints can be reliably assessed by unenhanced MRI images compared with Gd-enhanced MRI as the reference method. MRI data sets from 2 RA substudies were scored according to preliminary OMERACT RA MRI scoring system (RAMRIS): Substudy A included 1.0 T/1.5 T MR images from 40 RA patients, which were scored twice by 2 experienced readers. Substudy B included 0.2 T dedicated extremity MRI (E-MRI) images from 55 patients, scored twice by one experienced reader. The first reading included only unenhanced images, whereas complete image sets were available for the second reading. Gd contrast injection appeared unimportant to MRI scores of bone erosions and bone edema in RA wrist and MCP joints. However, when post-Gd MRI was considered the standard reference, MRI without Gd provided only moderate to high agreement concerning assessment of synovitis, and omitting the post-Gd acquisitions increased the interreader variation on synovitis scores. Low-field (0.2 T) E-MRI in these exercises provided a lower sensitivity of unenhanced imaging for synovitis than MRI using higher-field strengths. Omitting IV contrast injection did not change scores of bone erosions and bone edema, but decreased the reliability of synovitis scores. However, this disadvantage may for some purposes be outweighed by the possibility to assess more joints and/or greater feasibility.

Persistent low grade synovitis without erosive progression in magnetic resonance imaging of rheumatoid arthritis patients treated with infliximab over 1 year

Disease remission is only reached by a minority of rheumatoid arthritis (RA) patients treated with infliximab. Radiological assessment reported in clinical trials support the view that even under persistent inflammatory activity there is no further structural damage. Magnetic resonance imaging (MRI) allows a highly accurate detection of synovitis, bone edema, and erosions, constituting the ideal instrument for the evaluation of treatment response. The goal of this study was to evaluate MRI changes over 1 year in RA patients treated with infliximab. Four RA patients refractory to methotrexate (MTX) therapy were treated with infliximab 3 mg/kg 8/8 weeks and followed up for 1 year. Disease Activity Score (DAS28) was measured in the day of each infliximab administration. MRI was performed at baseline, 3 months, and 1 year. A simplified OMERACT RA MRI scoring (RAMRIS) was applied to the dominant wrist: synovitis (0-3) was measured in the intercarpal-carpometacarpal joints (CMTJ); bone edema (0-39) and erosions (0-130) in the base of the metacarpal and wrist bones. Baseline DAS28 was superior to 3.2 in all patients (ranging from 4.8 up to 6.2). At 14 weeks, DAS28 was still superior to 3.2 (ranging from 3.5 up to 4.6) and at 46 weeks all patients have responded, however without having achieved clinical remission, as DAS28 was still above 2.6 (ranging from 2.6 up to 3.4). MRI showed that synovitis was reduced in all patients to a score of 1, bone edema was slightly reduced (10% reduction), and erosive score was unchanged (baseline values ranging from 2 up to 20). Despite persistent low disease activity, these four RA patients treated with infliximab had stable simplified RAMRIS erosive scores over 1 year. These results support the view that there might be an uncoupling process between inflammation and bone erosions when tumor necrosis factor alpha is targeted in RA.

Comparison of 1.0-T Extremity MR and 1.5-T Conventional High-Field-Strength MR in Patients with Rheumatoid Arthritis

To prospectively determine the comparability of 1.0-T extremity magnetic resonance (MR) imaging and 1.5-T conventional MR for the evaluation of the hand and wrist in assessment of patients with rheumatoid arthritis (RA). Institutional ethics approval and written informed consent were obtained. Thirty-two patients (30 women, two men; mean age, 52 years) with RA twice underwent MR of either the most symptomatic hand (n = 21) or wrist (n = 11), once performed with a 1.0-T extremity MR system and once with a 1.5-T conventional MR system. The MR examinations were independently assessed by two radiologists blinded to imaging platform and patient clinical information for erosions, synovitis, and bone marrow edema (BME), according to the Rheumatoid Arthritis MR Imaging Score (RAMRIS). One radiologist reevaluated all cases a second time to determine the intraobserver variability for each system. Patient comfort was assessed with a questionnaire. Intraclass correlation coefficients (ICCs) and smallest detectable differences (SDDs) were measured. ICCs for intermachine agreement were 0.97-0.99 for erosions, 0.88-0.97 for synovitis, and 0.98-0.99 for BME for both readers. The SDDs between the two systems, expressed as a percentage of the maximum score, ranged from 3.3% to 12.2% for erosions, from 7.4% to 14.8% for synovitis, and from 5% to 9.9% for BME for both readers. ICCs for interreader agreement ranged from 0.69 to 0.99 and for intrareader agreement, from 0.88 to 0.99. There were substantial differences in the subjective patient assessment of confinement, system noise, and difficulty with immobilization, and 95.8% of patients preferred examinations performed with extremity MR. The 1.0-T extremity MR system demonstrates synovial and osseous changes in RA equally as well as a 1.5-T conventional MR system and is preferred by patients.

A new low-field extremity magnetic resonance imaging and proposed compact MRI score: evaluation of anti-tumor necrosis factor biologics on rheumatoid arthritis

Magnetic resonance imaging (MRI) is a useful tool for evaluating disease activity and therapeutic efficacy in rheumatoid arthritis (RA). However, conventional whole-body MRI is inconvenient on several levels. We have therefore developed a new low-field extremity MRI (compact MRI, cMRI) and examined its clinical utility. Thirteen RA patients treated with anti-tumor necrosis factor (TNF) biologics were included in the study. The MRI was performed twice using a 0.21-T extremity MRI system. The MRI images were scored using our proposed cMRI scoring system, which we devised with reference to the Outcome Measures in Rheumatology Clinical Trials RA MRI score (OMERACT RAMRIS). In our cMRI scoring system, synovitis, bone edema, and bone erosion are separately graded on a scale from 0 to 3 by imaging over the whole hand, including the proximal interphalangeal joint. The total cMRI score (cMRIS) is then obtained by calculating the total bone erosion score × 1.5 + total bone edema score × 1.25 + total synovitis score. In this study, one patient showed a progression of bone destruction even under low clinical activity, as assessed by the disease activity score on 28 joints (DAS28); however, another patient’s cMRIS decreased concurrently with the decrease in DAS28, with the positive correlation observed between ΔDAS28 and ΔcMRIS (R = 0.055, P < 0.05). We conclude that cMRI and cMRIS are useful for assessing total disease activity and as a method linking MRI image evaluation to clinical evaluation.

Erosive progression is minimal, but erosion healing rare, in patients with rheumatoid arthritis treated with adalimumab. A 1 year investigator-initiated follow-up study using high-resolution computed tomography as the primary outcome measure

Objective:With computed tomography (CT) and radiography, to investigate if repair of bone erosions, defined as regression of erosion scores, occurs during adalimumab treatment of patients with rheumatoid arthritis (RA).Methods:Fifty-two patients...

Detection of rheumatoid arthritis bone erosions by two different dedicated extremity MRI units and conventional radiography

Objectives:To compare the ability of two different dedicated extremity MRI (E-MRI) units and conventional radiography (CR) for identifying bone erosions in rheumatoid arthritis (RA) metacarpophalangeal (MCP) and wrist joints.Methods:CR and...

Magnetic resonance imaging findings in 84 patients with early rheumatoid arthritis: bone marrow oedema predicts erosive progression

Objectives:To examine the spectrum and severity of magnetic resonance imaging (MRI) findings in patients with early rheumatoid arthritis (RA), and to investigate the predictive value of MRI findings for subsequent...

Dynamic contrast enhanced MRI of bone marrow oedema in rheumatoid arthritis

Aims:The aim of this work was to assess the feasibility of using dynamic contrast enhanced (DCE) MRI of bone marrow oedema, to compare it with conventional marrow oedema scoring systems,...

A modification of the Omeract RA MRI score for erosions for use with an extremity MRI system with reduced field of view

Objectives:To develop and test the reliability of a modified version of the OMERACT rheumatoid arthritis magnetic resonance imaging score (RAMRIS) for erosions using extremity MRI (eMRI) with reduced field of...

High-resolution MRI of the wrist and finger joints in patients with rheumatoid arthritis: comparison of 1.5 Tesla and 3.0 Tesla

The goal of this study was to compare magnetic resonance (MR) image quality at different field strengths for evaluating lesions in wrist and finger joints of patients with rheumatoid arthritis (RA) in order to determine whether the higher field strength provides diagnostic gain. The hand mainly affected in 17 RA patients was examined at 1.5 Tesla (T) and 3.0 T with comparable MR imaging (MRI) protocols. MR images were reviewed twice by two experienced radiologists using the Rheumatoid Arthritis MRI Scoring System (RAMRIS) of the OMERACT (Outcome Measures in Rheumatoid Arthritis Clinical Trials) group. Image quality was rated on a five-point scale using Friedmann's test and Kendall's W-test for statistical analysis. Image comparison revealed better image quality at higher field strength. Image quality of T1-weighted images was rated 14-22% better at 3.0 T compared with 1.5 T by both readers. Moreover, the rating for the T2-weighted-images acquired at 3.0 T was one point better in the five-point scale used. Inter-reader correlation for image quality, bone erosions/defects, edema and synovitis ranged between 0.6 and 0.9 at 3.0 T and between 0.6 and 0.8 at 1.5 T. Intra-reader correlation for these parameters was high at 0.8-1.0. MRI image quality of RA hands is superior at 3.0 T, while an acceptable image quality is achieved at 1.5 T, which improves the evaluation of extent of bone edema, synovitis and identification of small bone erosions.

Bone oedema predicts erosive progression on wrist MRI in early RA--a 2-yr observational MRI and NC scintigraphy study

To investigate if disease assessment by contrast-enhanced dynamic and static magnetic resonance imaging (MRI) and quantitative nanocolloid (NC) scintigraphy gives useful additional information in early rheumatoid arthritis (RA). Twenty-seven patients with early RA (disease duration < or =12 months) were followed up for 1 yr and 24 of them for 2 yrs with contrast-enhanced MRI and NC scintigraphy of the wrist joint. Synovial inflammation was assessed by measuring time-dependent enhancement rates (E-rate) from dynamic MRI scans and technetium(99m)-labelled nanocolloid ((99m)Tc-NC) uptake from scintigraphy scans. Synovial membrane hypertrophy, bone oedema and erosions were semiquantitatively scored according to the Outcome Measures in Rheumatology Clinical Trials RA-MRI scoring system from static MR images. Response to the treatment was evaluated based on whether or not > or = 50% improvement was achieved in the tender and swollen joint scores and the Health Assessment Questionnaire score, with normal C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) levels. Progression of the erosion score on wrist MRI was evaluated as the outcome. The baseline MRI bone oedema score (rho= 0.67), MRI synovitis score (rho= 0.57), ESR (rho= 0.56), CRP (rho= 0.48), E-rate (rho= 0.47) and (99m)Tc-NC uptake (rho= 0.45) were related with the change in the MRI erosion score from baseline to 2 yrs (rho= Spearman's correlation). In the multivariate logistic regression model, the bone marrow oedema score was the only baseline variable that predicted erosive progression at 2 yrs' follow-up (OR 4.2, 95% CI 1.3-13.8). The median (interquartile range) change in the erosion score from baseline to 2 yrs was 0 (0, 0) and 4 (2, 5) in the patients with (n= 9) and without (n= 15) a persistent clinical response over the 2 yrs, respectively (P= 0.001). The non-responders who presented with erosive progression from 1 yr to 2 yrs had higher MRI synovitis scores, bone oedema scores, E-rate and (99m)Tc-NC uptake at 1-yr follow-up than the non-responders without progressive bone damage. The degree of local synovial inflammation at baseline, evaluated by dynamic and static MRI and quantitative NC scintigraphy, is closely related to the progression of wrist joint erosions during the first 2 yrs of the disease. Furthermore, at follow-up, if no persistent clinical response is achieved, these imaging methods may help to predict future erosiveness and help in clinical therapeutic decision making.

Reliability and sensitivity to change of the OMERACT rheumatoid arthritis magnetic resonance imaging score in a multireader, longitudinal setting

To assess the intra- and interreader reliability and the sensitivity to change of the Outcome Measures in Rheumatology Clinical Trials (OMERACT) Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS) system on digital images of the wrist joints of patients with early or established rheumatoid arthritis (RA). Ten sets of baseline and 1-year followup MR images of the wrists of patients with progressive changes on conventional hand radiographs were scored independently by 4 readers on 2 consecutive days, preceded by reader training and calibration. The MR images were acquired and scored according to the recommendations from the OMERACT MRI group. The intra- and interreader agreement (evaluated by intraclass correlation coefficients [ICCs]) and the sensitivity to change (evaluated by the smallest detectable difference [SDD]) were determined for scores of synovitis, erosion, and bone marrow edema status and for change scores. Intrareader ICCs were generally very high, both for status scores (median baseline and followup 0.89 and 0.90 for synovitis, 0.91 and 0.90 for erosion, and 0.90 and 0.98 for edema) and for change scores (median 0.80 for synovitis, 0.96 for erosion, and 0.97 for edema). The SDDs were generally low, suggesting a high potential to detect changes. Interreader single-measure ICCs were high for status scores (mean baseline and followup 0.69 and 0.78 for synovitis, 0.83 and 0.73 for erosion, and 0.79 and 0.95 for edema) and for change scores (mean 0.74 for synovitis, 0.67 for erosion, and 0.95 for edema). The average-measure ICCs were > or =0.94 for all components of both the status scores and change scores. The RAMRIS showed very good intrareader reliability, good interreader reliability, and a high level of sensitivity to change. The results suggest that the RAMRIS may be a suitable system for use in monitoring joint inflammation and destruction in RA.

MR Imaging Findings in Hands in Early Rheumatoid Arthritis: Comparison with Those in Systemic Lupus Erythematosus and Primary Sjögren Syndrome

To evaluate prospectively the use of magnetic resonance (MR) imaging for differentiating true rheumatoid arthritis (RA) from systemic lupus erythematosus (SLE) or primary Sjögren syndrome in patients who have inflammatory polyarthralgia of the hands but no radiographic evidence of RA. This study had institutional review board approval, and patient informed consent was obtained. Twenty-eight patients (16 female and 12 male patients; mean age, 42 years) with early RA and 19 patients (18 female and one male patient; mean age, 46 years) with SLE (n = 14) or primary Sjögren syndrome (n = 5) underwent MR imaging of both hands. All patients had inflammatory polyarthralgia of the hands and no evidence of erosive changes on radiographs. Coronal T2-weighted short inversion time inversion-recovery, transverse T1-weighted spin-echo, transverse fat-suppressed gadolinium-enhanced T1-weighted spin-echo, and transverse gadolinium-enhanced three-dimensional gradient-echo MR images were obtained. The following MR imaging variables were assessed in the wrist and nonthumb metacarpophalangeal joints: synovitis, bone lesions (erosion, defect, and edema), and tenosynovitis. Synovitis and bone lesions were scored with the OMERACT RA-MRI scoring system. Findings in patients with RA and those without RA were compared by means of Mann-Whitney, chi2, and Fisher exact tests. The only significant difference between the two groups in terms of individual scores for synovitis, bone lesions, and tenosynovitis was the more frequent presence of tenosynovitis of the right fourth extensor tendon in patients without RA (P = .04). There were no significant differences between patients with RA and those without RA in terms of global scores for synovitis, bone lesions, and tenosynovitis. However, bone marrow edema in the metacarpophalangeal joints was seen more frequently in patients with RA (P < .001). It may be impossible to distinguish between patients with early RA and those without RA (ie, those with SLE or primary Sjögren syndrome) by means of MR imaging.

The EULAR–OMERACT rheumatoid arthritis MRI reference image atlas: the wrist joint

This paper presents the wrist joint MR images of the EULAR–OMERACT rheumatoid arthritis MRI reference image atlas. Reference images for scoring synovitis, bone oedema, and bone erosions according to the...

The development of the EULAR–OMERACT rheumatoid arthritis MRI reference image atlas

Based on a previously developed rheumatoid arthritis MRI scoring system (OMERACT 2002 RAMRIS), the development team agreed which joints, MRI features, MRI sequences, and image planes would best illustrate the...