Rheumatoid Arthritis Magnetic Resonance Imaging Scoring Research Articles

Value of Magnetic Resonance T1 Mapping in Evaluating the Early Response to Treatment for Rheumatoid Arthritis.

Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS) is usually used for the semi-quantitative evaluation of joint changes in Rheumatoid Arthritis (RA). However, this method cannot evaluate early changes in bone marrow edema (BME). To determine whether T1 mapping of wrist BME predicts early treatment response in RA. This study prospectively enrolled 48 RA patients administered oral anti-rheumatic drugs. MRI of the most severely affected wrist was performed before and after 4 (48 patients) and 8 weeks of treatment (38 patients). Mean T1 values of BME in the lunate, triangular, and capitate bones; RAMRIS for each wrist; Erythrocyte-Sedimentation Rate (ESR); and 28-joint Disease Activity Score (DAS28)-ESR score were analyzed. Patients were divided into responders (4 weeks, 30 patients; 8 weeks, 32 patients) and non-responders (4 weeks, 18 patients; 8 weeks, 6 patients), according to EULAR response criteria. Receiver operating characteristic (ROC) curves were used to evaluate the efficacy of T1 values. ESR and DAS28-ESR were not correlated with T1 value and RAMRIS at each examination (P > 0.05). Changes in T1 value and DAS28-ESR relative to the baseline were moderately positively correlated with each other at 4 and 8 weeks (r = 0.555 and 0.527, respectively; P < 0.05). At 4 weeks, the change and rate of change in T1 value significantly differed between responders and non-responders (-85.63 vs. -19.92 ms; -12.89% vs. -2.81%; P < 0.05). The optimal threshold of the rate of change in T1 value at 4 weeks for predicting treatment response was -5.32% (area under the ROC curve, 0.833; sensitivity, 0.900; specificity, 0.667). T1 mapping provides a new imaging method for monitoring RA lesions; changes in wrist BME T1 values reflect early treatment response.

Predictive Value of Magnetic Resonance Imaging-detected Tenosynovitis of the Metacarpophalangeal and Wrist Joints for the Development of Rheumatoid Arthritis among Patients with Undifferentiated Arthritis.

Objective The early diagnosis of rheumatoid arthritis (RA) improves disease outcomes. Using bilateral magnetic resonance imaging (MRI), we investigated whether or not tenosynovitis at the level of the metacarpophalangeal (MCP) and wrist joints, as well as non-symmetrical versus symmetrical involvement, predicts RA development in undifferentiated arthritis (UA) patients. Methods We collected the clinical and serological findings as well as bilateral gadolinium-enhanced 1.5-T MRI data of UA patients after 1 year. A multivariate logistic regression analysis was used to determine the association of tenosynovitis in UA with RA development. Patients and Materials Ninety-one UA patients from the Nagasaki Early Arthritis Clinic who did not meet the 2010 European League Against Rheumatism/American College of Rheumatology classification criteria for RA were selected. Tenosynovitis at the MCP and wrist joints was scored according to the RA MRI scoring system. Results Of these 91 UA patients, 29 (31.9%) progressed to RA, with a median disease duration of 3 months, despite only 10.9% being positive for anti-cyclic citrullinated peptide antibody (ACPA). A univariate analysis showed higher MCP tenosynovitis scores, MCP flexor tenosynovitis, and symmetrical MCP tenosynovitis in the RA development group than in the non-development group (p <0.05). A multivariate analysis showed that symmetrical MCP tenosynovitis was independently associated with RA development after adjusting for age, gender, swollen joint count, C-reactive protein level, and ACPA positivity (odds ratio: 4.96). The presence of symmetrical MCP tenosynovitis had low sensitivity (35%) but high specificity (87%) for RA development. Conclusion MRI-detected tenosynovitis, especially symmetrical findings at the MCP joint, is predictive of RA development in a UA population with low ACPA positivity.

Interosseous tendon inflammation in the hands of patients with clinically suspect arthralgia: analysis of MRI data from a prospective cohort study.

Inflammation around the tendons of interosseous muscles of the hand (interosseous tendon inflammation) was recently observed with MRI for the first time in patients with rheumatoid arthritis and in at-risk individuals with detectable anti-citrullinated protein antibodies, generating the hypothesis that interosseous tendon inflammation precedes clinical arthritis. To better understand the role of interosseous tendon inflammation during the development of rheumatoid arthritis, we studied the frequency of interosseous tendon inflammation in healthy individuals and in those with arthralgia that was suspected of progressing to rheumatoid arthritis (ie, clinically suspect arthralgia) and the association of interosseous tendon inflammation with other symptoms of inflamed joint tissues and with clinical arthritis development. Adult (age ≥18 years) patients who presented with clinically suspect arthralgia and symptom-free (control) individuals underwent contrast-enhanced hand MRI. MRIs were evaluated for interosseous tendon inflammation on the radial and ulnar sides of the second to fifth metacarpophalangeal joints, and for synovitis, tenosynovitis, and osteitis using the rheumatoid arthritis MRI scoring system. Patients with clinically suspect arthralgia were followed up for clinical arthritis development. The presence of local tenosynovium was examined using immunohistochemistry for anti-CD55 and anti-CD68 on tissue from the hands of three embalmed bodies donated for scientific research. The primary outcome for the cross-sectional part of the study was the presence of interosseous tendon inflammation on MRI. The primary outcome for the longitudinal part of the study was development of clinical arthritis. Between April 3, 2012, and May 20, 2020, 667 patients with clinically suspect arthralgia (mean age 44 years [SD 13], 504 [76%] were women and 163 [24%] were men) underwent contrast-enhanced hand MRI. Between Nov 1, 2013, and Nov 30, 2014, 193 symptom-free controls were recruited (mean age 50 years [SD 16], 136 [70%] were women and 57 [30%] were men). Two (1%) of 193 symptom-free controls had interosseous tendon inflammation. Immunohistochemistry of cadaveric hand tissues showed no tenosynovium surrounding interosseous tendons. At inclusion, 67 (10%) of 667 patients with clinically suspect arthralgia had interosseous tendon inflammation (p<0·0001 vs symptom-free controls). Interosseous tendon inflammation occurred more frequently if synovitis (odds ratio [OR] 2·2 [95% CI 1·2-4·2]), or tenosynovitis (OR 9·7 [5·5-17·0]), was present at metacarpophalangeal joints. A three-dimensional MRI reconstruction suggested confluency of interosseous tendon inflammation with metacarpophalangeal-flexor-tenosynovitis. 91 (16%) of 558 patients with clinically suspect arthralgia developed clinical arthritis during follow-up (median total follow-up 25·3 months [95% CI 25·1-25·5]). Patients with clinically suspect arthralgia with interosseous tendon inflammation had a higher risk of developing clinical arthritis (hazard ratio [HR] 4·5 [2·8-7·2]), which was attenuated but still significant after adjusting for concomitant synovitis, tenosynovitis, or osteitis (HR 1·7 [1·02-2·8]). Interosseous tendon inflammation is almost absent in symptom-free individuals but occurs in people with clinically suspect arthralgia, in whom it correlates with symptoms and is associated with the development of clinical arthritis. The absence of local tenosynovium suggests that interosseous tendon inflammation arises from expanding local subclinical inflammation in the pre-arthritis phase of rheumatoid arthritis. European Research Council and the Dutch Arthritis Society.

Comparison between 2D FSE T2-weighted Dixon MRI and contrast-enhanced 2D FSE and 3D FSPGR T1-weighted Dixon MRI to quantify inflammation in hands of patients with early rheumatoid arthritis

PurposeThe purpose of this study was to compare two-dimensional (2D) T2-weighted, contrast-enhanced 2D T1-weighted and contrast-enhanced three-dimensional (3D) T1-weighted Dixon MRI sequences to assess disease activity using the RAMRIS scoring system in hands of patients with early rheumatoid arthritis. Materials and methodsTwenty-five patients (19 women, 6 men; mean age 51.4 years ± 12.7 years [SD], age range: 28–70 years) with rheumatoid arthritis prospectively underwent MRI examination of both hands at 1.5 T using 2D fast spin-echo (FSE) T2-weighted, contrast-enhanced 2D FSE T1-weighted and contrast-enhanced 3D fast spoiled gradient echo (FSPGR) T1-weighted Dixon sequences. Three radiologists independently assessed disease activity according to RAMRIS using Dixon water-only and fat-only images. Intraclass correlation coefficients (ICC) were calculated to assess inter-technique and interobserver agreements. ResultsAgreement to assess total RAMRIS score was very good between the MRI protocols (mean ICC ranging from 0.81 to 0.93) and between readers (mean ICC ranging from 0.91 to 0.94). Mean total RAMRIS scores of the three readers were significantly greater with contrast-enhanced 3D FSPGR T1-weighted (42.73 ± 29.39) than with contrast-enhanced 2D FSE T1-weighted (35.81 ± 25.48) and 2D FSE T2-weighted (32.20 ± 25.06) Dixon sequences. Conclusion2D FSE T2-weighted, contrast-enhanced 2D FSE T1-weighted Dixon and contrast-enhanced 3D FSPGR T1-weighted Dixon protocols are reproducible alternatives for the RAMRIS scoring in hands of patients with early rheumatoid arthritis. Coupling contrast-enhanced 3D FSPGR T1-weighted and 2D FSE T2-weighted sequences might be the most efficient option to completely assess the rheumatoid arthritis -related synovial and bone changes with the Dixon method.

The effects of hyperbaric oxygen on MRI findings in rheumatoid arthritis: A pilot study

Background: Rheumatoid arthritis is a debilitating and destructive disease for which limited therapeutic options exist. Objective: This report summarizes serial magnetic resonance imaging (MRI) findings from nine study participants treated with hyperbaric oxygen (HBO2) therapy and expands upon an earlier pilot study that showed improvement in disease activity and joint pain as determined by multiple, validated clinical measures. Methods: Rheumatoid arthritis patients received 30 hyperbaric oxygen treatments over six to 10 weeks. MRI with and without contrast was completed at baseline, and at three- and six-month intervals following initiation of HBO2 therapy. Ratings were based on Outcome Measures in Rheumatology Clinical Trials (OMERACT) Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS) criteria, the standard method for quantification of inflammation and damage by MRI in RA trials. Results: Using RAMRIS criteria, nine of nine patients demonstrated no radiologic progression of erosions, synovitis, or bone marrow edema at three- and six-month scans. Conclusion: Our findings suggest that HBO2 therapy may be useful as an adjunctive or alternative treatment to disease-modifying drugs for rheumatoid arthritis.

Towards a simplified fluid-sensitive MRI protocol in small joints of the hand in early arthritis patients: reliability between modified Dixon and regular Gadolinium enhanced TSE fat saturated MRI-sequences.

MRI of small joints plays an important role in the early detection and early treatment of rheumatoid arthritis. Despite its sensitivity to demonstrate inflammation, clinical use is hampered by accessibility, long scan time, intravenous contrast, and consequent high costs. To improve the feasibility of MRI implementation in clinical practice, we introduce a modified Dixon sequence, which does not require contrast and reduces total acquisition time to 6min. Because the reliability in relation to conventional MRI sequences is unknown, we determined this. In 29 consecutive early arthritis patients, coronal and axial T2-weighted modified Dixon acquisitions on 3.0T MRI scanner were acquired from metacarpophalangeal 2-5 to the wrist, followed by the standard contrast-enhanced protocol on 1.5T extremity MRI. Two readers scored osteitis, synovitis and tenosynovitis (summed as total MRI-inflammation), and erosions (all summed as total Rheumatoid Arthritis MRI Score (RAMRIS)). Intraclass correlation coefficients (ICCs) between readers, and comparing the two sequences, were studied. Spearman correlations were determined. Performance between readers was good/excellent. Comparing modified Dixon and conventional sequences revealed good/excellent reliability: ICC for total MRI-inflammation score was 0.84 (95% CI:0.70-0.92), for erosions 0.90 (95% CI:0.79-0.96), and for the total RAMRIS score 0.88 (95% CI:0.77-0.94). The scores of total MRI-inflammation, total erosions, and total RAMRIS were highly correlated (ρ = 0.80, ρ = 0.81, ρ = 0.82, respectively). The modified Dixon protocol is reliable compared to the conventional MRI protocol, suggesting it is accurate to detect MRI inflammation. The good correlation may be the first step towards a patient-friendly, short and affordable MRI protocol, which can facilitate the implementation of MRI for early detection of inflammation in rheumatology practice.

Intermetatarsal Bursitis, a Novel Feature of Juxtaarticular Inflammation in Early Rheumatoid Arthritis Related to Clinical Signs: Results of a Longitudinal Magnetic Resonance Imaging Study.

Intermetatarsal bursae in the forefeet possess a synovial lining similar to joints and tendon sheaths. Inflammation of these bursae (intermetatarsal bursitis [IMB]) was recently identified as specific for early rheumatoid arthritis (RA). The present study was undertaken to determine if IMB is indeed an RA feature by assessing the following: 1) the association with other local inflammatory measures (synovitis, tenosynovitis, and osteitis), 2) the association with clinical signs, and 3) whether it responds to disease-modifying antirheumatic drug (DMARD) therapy similarly to other local inflammatory measures. One hundred fifty-seven consecutive early RA patients underwent unilateral contrast-enhanced 1.5T forefoot magnetic resonance imaging (MRI) at diagnosis. MRIs were evaluated for IMB presence and for synovitis, tenosynovitis, and osteitis in line with the RA MRI Scoring (RAMRIS) system (summed as RAMRIS inflammation). MRIs at 4, 12, and 24 months were evaluated for IMB presence and size in patients who had IMB at baseline and received early DMARD therapy. Logistic regression and generalized estimating equations were used. Anti-citrullinated protein antibody (ACPA) stratification was performed. Sixty-nine percent of RA patients had ≥1 IMB. In multivariable analysis on bursa level, presence of IMB was independently associated with local presence of synovitis and tenosynovitis, with odds ratios (OR) of 1.69 (95% confidence interval [95% CI] 1.12, 2.57) and 2.83 (95% CI 1.80, 4.44), respectively, but not osteitis. On the patient level, IMB presence was most strongly associated with tenosynovitis (OR 2.92 [95% CI 1.62, 5.24]). IMB presence was associated with local joint swelling (OR 2.7 [95% CI 1.3, 5.3]) and tenderness (OR 1.7 [95% CI 1.04, 2.9]) independent of RAMRIS inflammation. During treatment, IMB size decreased between 0 and 12 months. This decrease associated with decrease in RAMRIS inflammation, which was driven by synovitis decrease. Within ACPA-positive and ACPA-negative RA, similar results were obtained. IMB particularly accompanies inflammation of the synovial lining of joints and tendon sheaths, showed a similar treatment response after DMARD initiation, and associates with typical clinical signs. These findings suggest that IMB represents a frequently present novel RA feature of juxtaarticular synovial inflammation.

OP0070 INTERVENTION WITH METHOTREXATE IN ARTHRALGIA AT RISK FOR RHEUMATOID ARTHRITIS TO REDUCE THE DEVELOPMENT OF PERSISTENT ARTHRITIS AND ITS DISEASE BURDEN (TREAT EARLIER): A DOUBLE-BLIND, RANDOMISED, PLACEBO-CONTROLLED TRIAL

BackgroundRheumatoid arthritis (RA) is the most common autoimmune disease, and requires long-term treatment to suppress inflammation. Currently, methotrexate is initiated as first-line treatment when arthritis becomes clinically apparent with joint swelling. However, disease processes begin long before and become clinically recognizable when patients develop symptoms. We hypothesized that the ‘at risk phase’ of symptoms and subclinical joint-inflammation is a therapeutic window to permanently modify the disease course.ObjectivesWe studied if intervention in the pre-arthritis phase of arthralgia and subclinical joint inflammation prevents the development of clinical arthritis or reduces the burden of disease.MethodsIn this randomised, double-blind, 2-year proof-of-concept trial, adults with arthralgia clinically suspected of progressing to RA and MRI-detected subclinical joint-inflammation, recruited from all rheumatology outpatient-clinics in the southwest-Netherlands, were randomly assigned (1:1) to a single intramuscular glucocorticoid injection (120 mg) and a one-year course of oral methotrexate (up to 25 mg/week), or placebo injection and placebo tablets. Subsequently, participants were followed for another year without study medication. The primary endpoint was the development of clinically detectable arthritis (fulfilling the 2010 RA-criteria or involving ≥2 joints) that persisted for at least 2 weeks. Patient reported physical functioning, along with symptoms and workability, were key secondary endpoints and measured 4-monthly. Additionally, the course of MRI-detected inflammation was studied (the sum of tenosynovitis, synovitis, osteitis, scored with the RA-MRI Scoring (RAMRIS) method). All participants entered the intention-to-treat analysis. We performed two prespecified subgroup analyses. Firstly, analyses were restricted in participants with high risk of clinical arthritis development (PPV ≥70%). Secondly, analyses were stratified for ACPA-status. The trial is registered with the Netherlands Trials Registry (NTR4853 trial NL4599).ResultsFrom April 16th, 2015 to September 11th, 2019, we randomly assigned 236 participants to treatment (n=119) or placebo (n=117). After 24 months, arthritis free survival was similar in both groups (80% versus 82%, HR 0.81 (95%CI 0.45, 1.48)). Physical functioning improved more in the treatment-group during the first months and remained better (mean between-group difference over two-years HAQ -0·1(-0·2,-0·03;p=0·004). Similarly, pain (-9 on scale 0-100: (95%CI -12,-4; p&lt;0·001), morning stiffness (-12 (95%CI -16,-8;p&lt;0·001), presenteeism (-8% (95%CI -13%,-3%;p=0·001) showed sustained improvement compared to placebo. MRI-detected joint-inflammation was also persistently improved (mean difference over 2 years -1·4 points (95%CI -2·0,-0.9;p&lt;0·001). High-risk participants in the treatment group showed a delay in clinical arthritis development: they developed the endpoint less often during treatment, but frequencies became similar at 24 months (67% in both groups). A similar delaying effect was observed in ACPA-positive participants, where 48% and 52% had developed persistent clinical arthritis at 24 months. The number of serious adverse events was equal between the groups; adverse events were as expected from methotrexate.ConclusionMethotrexate, the cornerstone treatment of RA, initiated at the pre-arthritis stage of joint symptoms and subclinical inflammation, did not prevent the development of clinical arthritis, but modified the disease course as measured by sustained improvement in MRI-detected inflammation, related symptoms and impairments. These findings of sustained disease modification may open up a new treatment landscape in a pre-arthritis phase of RA, where limitations can be just as severe as at the onset of clinical arthritis.Figure 1.AcknowledgementsWe thank Prof. dr. R. ten Cate, prof. dr. S. le Cessie and dr. A.M.J. Langers for their role in the Data Safety and Monitoring Board. We thank all participants, and all rheumatologist of the following hospitals: Albert Schweitzer Hospital, Alrijne Hospital, Erasmus Medical Center, Haven-policlinic Rotterdam, IJselland Hospital, Ikazia Hospital, Franciscus Gasthuis &amp; Vlietland Hospital, Groene Hart Hospital, Haaglanden Medical Center (all locations), Haga Hospital, Langeland Hospital, Meander Medical Center, Maasstad, Hospital, Reinier de Graaf Gasthuis, Reumazorg Zuid-West Nederland and Spaarne Gasthuis. We acknowledge the team of treating rheumatologists and research nurses of the LUMC, in particular Dr F.J. van der Giesen. Our gratitude also goes to the PhD students who scored MRIs for trial screening, in particular dr. H.W. van Steenbergen, dr. W. Nieuwenhuis, dr. R.M. ten Brink, dr. D.M. Boeters, dr. L. Mangnus, X.M.E. Matthijssen and F. Wouters. We thank dr. M. Reijnierse, prof. dr. S.C. Cannegieter and prof. dr. D. van der Heijde for their advice, and dr. J. Schoones for his help with the systematic literature search. We acknowledge the funder of the study: NWO ZonMW grant (program ‘translationeel onderzoek’, project number 95104004).Disclosure of InterestsNone declared.

Contrast-enhanced CT techniques and MRI perform equally well in arthritis imaging of the hand: a prospective diagnostic accuracy study

ObjectivesTo investigate the performance of dual-energy CT (DECT)-generated iodine maps (iMap) and CT subtraction (CT-S) in the detection of synovitis, tenosynovitis, and peritendonitis/paratenonitis compared to magnetic resonance imaging (MRI) using musculoskeletal ultrasound (MSUS) as standard of reference.MethodsThis IRB-approved prospective study consecutively investigated patients with undifferentiated arthritis. All patients underwent MSUS, MRI and contrast-enhanced DECT of the hand; from the latter conventional CT-S, image-based iMap (iMap-I) and raw data-based iMap (iMap-RD) were reconstructed. CT and MRI datasets were scored for synovitis and tenosynovitis/paratenonitis applying the modified Rheumatoid Arthritis MRI Score (RAMRIS). Sensitivity, specificity, and diagnostic accuracy were calculated. Non-inferiority was tested using the one-tailed McNemar test. Correlation of sum scores was assessed using Pearson’s test. Interreader reliability was assessed using Cohen’s kappa.ResultsOverall, 33 patients were included. MSUS was positive for synovitis and tenosynovitis/paratenonitis in 28 patients with a sum score of 6.91. Excellent correlation with MSUS was shown for CT-S (sum score 6.38; r = 0.91), iMap-RD (sum score 9.74; r = 0.82), MRI (sum score 12.70; r = 0.85), and iMap-I (sum score 6.94; r = 0.50). CT-S had the highest diagnostic accuracy of 83%, followed by iMap-I (78%), MRI (75%), and iMap-RD (74%). All modalities showed non-inferiority. Reader agreement was good for CT-S and MRI (κ = 0.62; 0.64) and fair for iMap-RD and iMap-I (κ = 0.31; 0.37).ConclusionCT-S and iMap allow highly standardized arthritis imaging and are suitable for clinical practice. MSUS still has the highest availability for arthritis imaging and served as gold standard for this study.Key Points• CT subtraction, iodine map with dual-energy CT, and MRI showed non-inferiority to musculoskeletal ultrasound.• MRI was the most sensitive but least specific imaging technique compared with CT subtraction and dual-energy CT.• CT subtraction showed the best correlation with musculoskeletal ultrasound.

To Contrast or Not to Contrast? On the Role of Contrast Enhancement in Hand MRI Studies of Patients with Rheumatoid Arthritis.

Currently, clinical indications for the application of gadolinium-based contrast agents (GBCA) in magnetic resonance imaging (MRI) are increasingly being questioned. Consequently, this study aimed to evaluate the additional diagnostic value of contrast enhancement in MRI of the hand in patients with rheumatoid arthritis (RA). Thirty-one patients with RA (mean age, 50 ± 14 years (range, 18–72 years)) underwent morphologic MRI scans on a clinical 3 T scanner. MRI studies were analyzed based on (1) the Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS) and (2) the GBCA-free RAMRIS version, termed RAMRIS Sine-Gadolinium-For-Experts (RAMRIS-SAFE), in which synovitis and tenosynovitis were assessed using the short-tau inversion-recovery sequence instead of the post-contrast T1-weighted sequence. The synovitis subscores in terms of Spearman’s ρ, as based on RAMRIS and RAMRIS-SAFE, were almost perfect (ρ = 0.937; p < 0.001), while the tenosynovitis subscores were less strongly correlated (ρ = 0.380 p = 0.035). Correlation between the total RAMRIS and RAMRIS-SAFE was also almost perfect (ρ = 0.976; p < 0.001). Inter-rater reliability in terms of Cohen’s κ was high (0.963 ≤ κ ≤ 0.925). In conclusion, RAMRIS-SAFE as the GBCA-free version of the well-established RAMRIS is a patient-friendly and resource-efficient alternative for assessing disease-related joint changes in RA. As patients with RA are subject to repetitive GBCA applications, non-contrast imaging protocols should be considered.

Fractal analysis of perfusion imaging in synovitis: a novel imaging biomarker for grading inflammatory activity based on assessing angiogenesis

ObjectivesThe mutual and intertwined dependence of inflammation and angiogenesis in synovitis is widely acknowledged. However, no clinically established tool for objective and quantitative assessment of angiogenesis is routinely available. This...

CT-like images in MRI improve specificity of erosion detection in patients with hand arthritis: a diagnostic accuracy study with CT as standard of reference

ObjectiveTo compare the diagnostic accuracy of susceptibility-weighted imaging (SWI), standard T1-weighted (T1w) images and high-resolution 3D-gradient echo sequences (volumetric interpolated breath-hold examination (VIBE)) for detection of erosions in patients with...

Bone erosions by MRI in first-degree relatives of patients with RA: an exploratory study.

First-degree relatives (FDR) of patients with rheumatoid arthritis (RA) are at increased risk of RA diagnosis. Magnetic resonance imaging (MRI) has been proposed as a useful tool to detect subclinical synovitis and bone abnormalities as predictors of progression to RA. The presence of grade ≥ 2 bone erosions in RA MRI scoring system (RAMRIS) was reported to be RA-specific. We aim to describe the prevalence and characteristics of MRI findings in RA patients and FDR. A cross-sectional and exploratory study of 60 individuals was performed in 38 RA patients and 22 FDR with hand arthralgia without clinical arthritis and positive rheumatoid factor or anticitrullinated protein antibodies. All patients underwent an MRI and were evaluated for synovitis, bone erosion, and bone marrow edema. We evaluated second to fifth metacarpophalangeal joints of the dominant hand according to RAMRIS. Among the total population, eighteen (30%) subjects had grade ≥ 2 bone erosions, and 42 (70%) had at least one erosion of any grade. In patients with grade ≥ 2 bone erosions, 12 (31.6%) were from RA patients and 6 (27.2%) from FDR (p = 0.72). In patients with erosions of any grade, 26 (68.4%) were from RA patients and 15 (68.2%) were from FDR (p = 0.98). A high prevalence of bone erosions was found in RA patients' FDR who had symptoms without clinical arthritis and positive serology. MRI might be helpful in this population for an early detection of RA-specific erosions. The prognosis and the treatment decisions in these subjects should be elucidated. • First-degree relatives (FDR) of rheumatoid arthritis (RA) patients with positive serology and joint symptoms constitute a select subpopulation of individuals with an increased risk of developing RA. • Magnetic resonance imaging (MRI) of FDR shows a high prevalence of bone erosions of any grade, grade ≥ 2 erosions, and synovitis. • MRI might be helpful in FDR of RA patients to screen for the presence of RA-specific erosions or clinically undetectable synovitis.

During development of rheumatoid arthritis, intermetatarsal bursitis may occur before clinical joint swelling: a large imaging study in patients with clinically suspect arthralgia.

ObjectivesIntermetatarsal bursitis (IMB) represents juxta-articular synovial inflammation of the intermetatarsal bursae. Recent MRI studies identified IMB as feature of early RA, but whether IMB already occurs in the pre-arthritic phase is unknown. We performed a large MRI study in clinically suspect arthralgia (CSA) to assess the occurrence and prognostic value of IMB.MethodsA total of 577 consecutive CSA patients underwent contrast-enhanced MRI of the forefoot, metacarpophalangeal joints and wrist. MRIs were evaluated for subclinical synovitis/tenosynovitis/osteitis in line with the RA MRI scoring system (summed as RAMRIS inflammation) and for IMB. IMB was considered present if uncommon in the general population at the same location (i.e. size scored above the 95th percentile in age-matched symptom-free controls). The relation of IMB with other MRI-detected subclinical inflammation (synovitis/tenosynovitis/osteitis) was studied. Cox-regression assessed the association with clinical arthritis development during median 25 months follow-up. ACPA stratification was performed.ResultsAt presentation with CSA, 23% had IMB. IMB was more frequent in ACPA-positive than ACPA-negative CSA (47% vs 19%, P < 0.001). Patients with IMB were more likely to also have subclinical synovitis [OR 3.4 (95% CI 1.8, 6.5)] and tenosynovitis [5.9(2.8, 12.6)]. IMB conferred higher risk of developing arthritis [HR 1.6(1.0–2.7) adjusted for other subclinical inflammation]. IMB-presence predicted arthritis development in ACPA-positive CSA [adjusted HR 2.2(1.0–4.7)], but not in ACPA-negative CSA-patients [0.8(0.4–1.7)].ConclusionApproximately a quarter of CSA patients have IMB, which is frequently accompanied by subclinical synovitis and tenosynovitis. IMB precedes development of clinical arthritis, particularly in ACPA-positive CSA. These results reinforce the notion that juxta-articular synovial inflammation is involved in the earliest phases of RA development.

Distribution of bony erosions in feet and performance of two bone erosion scores: A dual-energy computed tomography study of 61 patients with gout.

ObjectivesTo assess the distribution of bone erosions and two erosion scores in the feet of patients with gout and analyze the association between erosion scores and monosodium urate (MSU) crystal deposition using dual-energy computed tomography (DECT).Materials and methodsWe included all patients who underwent DECT of both feet between 2016 and 2019 in our radiology department, with positive detection of MSU deposits. Data on sex, age, treatment, serum urate, and DECT urate volumes were obtained. CT images were analyzed to score bone erosions in 31 sites per foot by using the semi-quantitative method based on the Rheumatoid Arthritis MRI Scoring (RAMRIS) system and the Dalbeth-simplified score. Reproducibility for the two scores was calculated with intraclass correlation coefficients (ICCs). Correlations between clinical features, erosion scores and urate crystal volume were analyzed by the Spearman correlation coefficient (r).ResultsWe studied 61 patients (mean age 62.0 years); 3,751 bones were scored. The first metatarsophalangeal joint and the midfoot were the most involved in terms of frequency and severity of bone erosions. The distribution of bone erosions was not asymmetrical. The intra- and inter-observer reproducibility was similar for the RAMRIS and Dalbeth-simplified scores (ICC 0.93 vs 0.94 and 0.96 vs 0.90). DECT urate volume was significantly correlated with each of the two erosion scores (r = 0.58–0.63, p < 0.001). There was a high correlation between the two scores (r = 0.96, p < 0.001).ConclusionsDECT demonstrates that foot erosions are not asymmetric in distribution and predominate at the first ray and midfoot. The two erosion scores are significantly correlated with DECT urate volume. An almost perfect correlation between the RAMRIS and Dalbeth-simplified scores is observed.

Morning stiffness precedes the development of rheumatoid arthritis and associates with systemic and subclinical joint inflammation in arthralgia patients.

ObjectivesMorning stiffness (MS) is characteristic of RA and associates with markers of systemic and local inflammation in RA patients. In patients with arthralgia, MS is a cardinal symptom to recognize arthralgia at-risk for RA development [i.e. clinically suspect arthralgia (CSA)]. In CSA, MS is also assumed to reflect inflammation, but this has never been studied. Therefore we aimed to study whether MS in CSA patients is associated with systemic and subclinical joint inflammation.MethodsA total of 575 patients presenting with CSA underwent laboratory investigations and contrast-enhanced 1.5 T MRI of the hand and forefoot (scored according to the Rheumatoid Arthritis MRI Score method). Associations of MS (duration ≥60 min) with the presence of subclinical joint inflammation (synovitis, tenosynovitis and osteitis) and increased CRP (≥5 mg/l) were determined with logistic regression. Additionally, the effect of MS duration (≥30, ≥60 and ≥120 min) was studied.ResultsA total of 195 (34%) CSA patients experienced MS. These patients more often had subclinical synovitis [34% vs 21%; odds ratio (OR) 1.95 (95% CI 1.32, 2.87)], subclinical tenosynovitis [36% vs 26%; OR 1.59 (95% CI 1.10, 2.31)] and increased CRP [31% vs 19%; OR 1.93 (95% CI 1.30, 2.88)] than patients without MS. In multivariable analyses, subclinical synovitis [OR 1.77 (95% CI 1.16, 2.69)] and CRP [OR 1.78 (95% CI 1.17–2.69)] remained independently associated with MS. In CSA patients who later developed RA, and thus in retrospect were ‘pre-RA’ at the time of CSA, MS was more strongly associated with subclinical synovitis [OR 2.56 (95% CI 1.04, 6.52)] and CRP [OR 3.86 (95% CI 1.45, 10.24)]. Furthermore, associations increased with longer MS durations.ConclusionInflammation associates with MS in the CSA phase that preceded clinical arthritis. These results increase our understanding of MS when assessing arthralgia in clinical practice.

Novel quantitative digital image analysis methodology for assessment of inflammatory changes in MRI data in a post-hoc analysis of data acquired from a phase IIb study of baricitinib in patients with active rheumatoid arthritis

PurposeTo evaluate a novel quantitative methodology to assess inflammatory changes in magnetic resonance imaging (MRI) data from patients with rheumatoid arthritis (RA) and the impact of image quality on imaging outcomes compared to the RA Magnetic Resonance Imaging Score (RAMRIS). MethodsThree-dimensional, T1-weighted, fat-suppressed MRI sequences of the hand/wrist before and after intravenous Gadolinium contrast from patients with RA in a placebo-controlled clinical trial (NCT01185353) were re-evaluated post hoc. The methodology was integrated into proprietary software (DYNAMIKA®) and assessed inflammation through pixelated measurements of the contrast-enhancing (inflammatory) volume. A semi-automatic approach outlined contrast-enhancing synovial tissue in the wrist and second to fifth metacarpophalangeal joints with a rough region of interest (ROI); quantitative imaging biomarkers were generated by means of quantitative total volume of inflammation and quantitative degree of inflammation relative to the signal in a 1 cm in diameter ROI in the center of the thenar or lumbrical muscle for internal reference. The time from Gadolinium injection to finalization of the post-contrast images was calculated from the images’ Digital Imaging and Communications in Medicine header. An experienced reader graded image quality as poor, acceptable, or good. ResultsResults from this quantitative methodology, especially when excluding images with poor quality scores (14–32%), provided a more pronounced and monotonically increasing dose-response than the original RAMRIS results on synovitis and osteitis. ConclusionsThis computer-aided quantitative scoring method provided continuous measures of inflammatory changes relative to muscle and may be more sensitive and interpretable concerning dose/response separation between RA treatment groups.

Comparison between 1.5T and 3.0T MRI: both field strengths sensitively detect subclinical inflammation of hand and forefoot in patients with arthralgia

Objective: Magnetic resonance imaging (MRI) of small joints sensitively detects inflammation. This inflammation, and tenosynovitis in particular, has been shown to predict rheumatoid arthritis (RA) development in arthralgia patients. These data have predominantly been acquired on 1.0–1.5 T MRI. However, 3.0 T is now commonly used in practice. Evidence on the comparability of these field strengths is scarce and has never included subtle inflammation in arthralgia patients or tenosynovitis. Therefore, we assessed the comparability of 1.5 T and 3.0 T in detecting subclinical inflammation in arthralgia patients.Method: A total of 2968 locations (joints, bones, tendon sheaths) in the hands and forefeet of 28 patients with small-joint arthralgia, at risk for RA, were imaged on both 1.5 and 3.0 T MRI. Two blinded readers independently scored erosions, osteitis, synovitis, and tenosynovitis, in line with the Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS). Features were summed into inflammation (osteitis, synovitis, tenosynovitis) and RAMRIS (inflammation and erosions). Agreement was assessed with intraclass correlation coefficients (ICCs) for continuous scores and after dichotomization into presence or absence of inflammation, on patient and location levels.Results: Interreader ICCs were excellent (> 0.90). Comparing 1.5 and 3.0 T revealed an ICC of 0.90 for inflammation and RAMRIS. ICCs for individual inflammation features were: tenosynovitis 0.87 (95% confidence interval 0.74–0.94), synovitis 0.65 (0.24–0.84), and osteitis 0.96 (0.91–0.98). Agreement was 83% for inflammation and 89% for RAMRIS. Analyses on the location level showed similar results.Conclusion: Agreement on subclinical inflammation between 1.5 T and 3.0 T was excellent. Although synovitis scores were slightly different, synovitis often occurs simultaneously with other inflammatory signs, suggesting that scientific results on the predictive value of MRI-detected inflammation for RA, obtained on 1.5 T MRI, can be generalized to 3.0 T MRI.

POS0257 TOWARDS A SIMPLIFIED FLUID-SENSITIVE MRI-PROTOCOL IN SMALL JOINTS OF THE HAND IN EARLY ARTHRITIS PATIENTS: RELIABILITY BETWEEN MDIXON AND REGULAR FSE FAT SATURATION MRI-SEQUENCES

Background:MRI facilitates early recognition of rheumatoid arthritis (RA) by depicting inflammation. Contrast-enhanced T1-weighted and T2-weighted fat-suppressed sequences have been sensitive and thus recommended, but are hampered by invasiveness, costs and long scan time. Therefore we introduced a modified Dixon-sequence (mDixon) which is more patient-friendly, reduces cost, and scan times by 83%. However, it is not known if this mDixon-sequence is reliable in relation to regular MRI-sequences with and without contrast (T1- and T2-weighted, respectively).Objectives:We determined the reliability between regular MRI-sequences with and without contrast (T1- and T2-weighted, respectively) and mDixon-MRI in early arthritis patients.Methods:29 early arthritis patients underwent regular fat-suppressed-MRI (T1- and T2-weighted) and mDixon-sequences, of metacarpophalangeal-2-5 and wrist-joints. Two readers scored erosions, osteitis, synovitis and tenosynovitis. Intraclass correlation coefficients (ICCs) between readers, and comparing the two sequences, were studied. Spearman correlations were determined.Results:Performance between the two readers with the regular-MRI sequences, was good to excellent (ICCs all ≥0.88). The between reader ICC was also good to excellent for the mDixon-MRI (ICCs all ≥0.76). Next, ICCs between the two sequences was investigated to determine the reliability of mDixon. ICCs were good to excellent for total RAMRIS score 0.87 (95%CI 0.74-0.94), for erosions 0.88 (95%CI 0.69-0.95), and total inflammation score 0.84 (95%CI 0.69-0.82). The individual MRI-inflammation scores, had ICCs for osteitis 0.97 (95%CI 0.93-0.98), for tenosynovitis 0.78 (95%CI 0.58-0.89), and for synovitis 0.57 (95%CI 0.26-0.77). In addition, scores were highly correlated for total RAMRIS, erosions, and total MRI-inflammation score (ρ=0.82, ρ=0.81, ρ=0.80, respectively).Conclusion:Regular-MRI sequences and mDixon-MRI perform equally well, this suggests that mDixon-sequence is reliable to detect joint inflammation. Thus, this is the first step towards an simplified and abridged MRI-protocol in small hand-joints in early arthritis patients. The ultimate goal will be implementation of this mDixon-MRI sequence. Validation in larger studies is warranted.Disclosure of Interests:None declared

Contrast-enhanced T1-weighted Dixon water- and fat-only images to assess osteitis and erosions according to RAMRIS in hands of patients with early rheumatoid arthritis

PurposeTo assess the agreement between readers using contrast-enhanced T1-weighted Dixon water- and fat-only images and OMERACT-recommended sequences for the scoring of osteitis and erosions according to the rheumatoid arthritis (RA) MRI scoring system (RAMRIS) in hands of patients with early RA. Materials and methodsBoth hands of 24 patients (16 women, 8 men; mean age, 45.7±14.5 [SD] years; age range: 25–70 years) with early RA were prospectively imaged with fat-saturated T2-weighted sequences, non-Dixon T1-weighted imaging prior to contrast material injection and T1-weighted Dixon imaging after contrast material injection at 1.5T. There were Two radiologists separately quantified osteitis and erosions according to RAMRIS using contrast-enhanced T1-weighted Dixon water-only and fat-saturated T2-weighted images for osteitis and contrast-enhanced T1-weighted Dixon fat-only and T1-weighted images prior to contrast material injection for erosions. Intraclass correlation coefficients (ICC) were calculated to assess inter-technique, intra-observer and inter-observer agreement. ResultsMean ICC for the agreement between Dixon and non-Dixon images ranged from 0.68 (95%CI: 0.20–0.90) to 0.99 (95%CI: 0.95–1.00) for the scoring of osteitis and from 0.77 (95%CI: 0.38–0.93) to 0.99 (95%CI: 0.95–1.00) for the scoring of erosions. Mean ICC for the agreement between first and second readings ranged from 0.94 (95%CI: 0.81–0.98) to 0.97 (95%CI: 0.91–0.99) for the scoring of osteitis using Dixon and 0.91 (95%CI: 0.72–0.97) to 0.98 (95%CI: 0.92–0.99) using non-Dixon images and from 0.80 (95%CI: 0.45–0.94) to 0.97 (95%CI: 0.91–0.99) for the scoring of erosions using Dixon and 0.72 (95%CI: 0.29–0.91) to 0.98 (95%CI: 0.92–0.99) using non-Dixon images. ConclusionContrast-enhanced T1-weighted Dixon water- and fat-only images can serve as an alternative to fat-saturated T2-weighted and T1-weighted MRI sequences for the assessment of osteitis and erosions according to the RAMRIS scoring system in hands of patients with early RA.