State University of Medicine and Pharmacy

N. Testemitanu

Department of Radiology and Medical Imaging

MAGNETIC RESONANCE IMAGING OF THE OSTEOARTICULAR

SYSTEM IN RHEUMATIC DISEASES

Elzhalka Afnan
Group 1646

Actuality
Magnetic resonance imaging (MRI) has important applications in
musculoskeletal medicine. It allows the visualization of the bone and soft
tissues in three dimensions using a multiplanar technique and is uniquely
suited for joint imaging, mainly the metacarpo-phalangeal joints (MCP)
and the carpal joints affected in the rheumatoid arthritis (RA).
Rheumatoid Arthritis (RA) is a chronic systemic inflammatory disease of
unknown etiology. the response to an autoimmune reactions leads to
synovial hypertrophy and chronic joint inflammation with the potential of
extraarticular manifestations
Epidemiological data: RA affects 0.5-1% of adult population worldwide, it
occurs more frequently in females than in males with a 3:1 ratio

Aims and objectives

The aims are to carry out the importance of the MRI in the assessment
of RA, and showing how MRI has demonstrated greater sensitivity for
the detection and quantification of the main radiological findings on
which early diagnosis of RA is based( bone erosions, synovitis, and
bone marrow edema).
The objectives :
the most important early changes detected by MRI observed in
patients with RA
the most frequently involved bones which demonstrate the early
pathologic changes in RA

MRI Technique
The MRI can show different types of pathologies. There are two basic
sequences in the MRI which are known as the T1-weighted and T2weighted sequences. The T1-weighted images demonstrate water as
hypointense(dark), and fat as hyperintense(bright). When thw T2weighted images water is represented as hyperintense and fat as
hypointense.
The OMERACT group recommends starting in the diagnosis with a
coronal STIR(short inversion time inversion recovery) sequence or a
fat saturated T2 sequence on the wrist and MCP joints for bone
marrow edema detection, followed by T1 sequence on the coronal
and axial plane before and after gadolinium contrast for detection of
bone erosions and synovitis

Main pattern of MRI in RA

Characteristics

Specifications

Joints regions examined

Wrist and second through fifth

MCP unilateral (dominant hand or
the most painful)

MRI damage signs

Edema, synovitis, erosions

Equipment-magnetic type

Magnetic field recommendation is

1.5 Tesla

Contrast

Gadolinium

Sequence

Coronal T1, axial T1, coronal T2

with fat saturation, contrast
enhanced axial and coronal T1
with fat saturation

Monitoring response score

OMERACT/RAMRIS ,synovium
volume measurement, scoring
contrast-enhanced dynamic

MRI Findings
Synovitis: is the earliest abnormality to appear in RA,in which the
thickening of synovial tissue caused by the rheumatoid inflammatory
process may be identified on MRI. Synovitis has an intermediate to
low signal intensity on T1-weighted images and due to the increased
water content has high signal intensity on T2-weighted images.
MRI signs of synovitis include: 1. increased synovial volume
2.increased water content 3. contrast-enhancement(increased
signal intensity after the intravenous injection of gadolinium).

Synovitis in early RA of the wrist (eight months duration) and normal radiographic
finding. (A) Coronal T1-weighted MRI shows radio carpal synovitis as low signal
intensity (arrow). (B)Coronal gadolinium-enhanced fat suppressed T1-weighted MRI
shows intense enhancement of the radio carpal synovitis.

Tomografia prin rezonana magnetic a regiunii carpiene i metacarpofalangiene: manifestri de sinovit nu se constat. A-C executate n
poziia coronarian T1 timp de relaxare longitudinal, spin-spin
articulaiilor metacarpofalangiene lipsesc arii densificate ce ar vorbi
despre sinovita n articulaiile respective.

MRI Findings
Bone marrow edema: although bone marrow edema is nonspecific
and has been well documented in traumatic, and degenerative bone
processes, it is reported to be an important MRI finding in patients
with RA, especially in the earlier phases. Bone marrow edema
manifested as ill-defined signal intensity changes in bone marrow,
with high signal intensity on fat-suppressed T2-weighted sequences
and increased signal intensity after the administration of gadoliniumbased contrast. The OMERACT defines BOM at MR imaging as a
lesion within the trabecular bone with an ill-defined margins and
signal characteristics of increased water content. The bone marrow
edema is usually located in the subchondral bone(MCP, PIP joints)

MRI Findings
Bone Erosions: the detection of erosions at MRI is important for
diagnosis and prognosis in patients with RA.
MRI provides an early diagnosis of RA by revealing erosions, whose
presence constitutes one of the ACR 1987 diagnostic criteria.
The MRI definition of erosion on T1-weighted images are:1. loss of
normal low signal intensity of cortical bone and 2. loss of normal high
signal intensity of the bone marrow cavity, with enhancement after
administration of gadolinium and 3. as high signal intensity on T2weighted images. The erosions indicate irreversible joint damage.
Early erosions start in the cartilaginous void of the joint as a result of
synovial proliferation-synovitis (mostly in MCP) indicates the
progression to erosion.

Erosions early rheumatoid arthritis of the wrist (1year duration) and normal radiographic findings. (a) Coronal contrast-enhanced fat-suppressed
T1-weighted MR image shows erosion of the base of the second metacarpal bone (arrow), with cortical discontinuity and enhancement. Synovitis
at the dorsal region of the wrist is also seen (*). (b) Axial contrast-enhanced fat-suppressed T1-weighted MR image shows the erosion of the
base of the second metacarpal bone, as well as other small erosions of the base of the third metacarpal bone (arrows). Synovitis is seen about
the flexor tendons and the bases of the metacarpal bones

The most frequently bones involved in RA disease

process
Studies show that MRI of unilateral wrist and 2nd-5th
metacarpophalangeal(MCP) joints is more sensitive to change for
erosive progression in early and established RA.
In the following study the MRI datasets from 258 RA patients(126
with early RA disease duration <6 months) were analyzed of whom
223 , including 126 with early RA, had 1 year followup MRI.all pts had
MRI of one wrist, but 86 pts had additional images of 2 nd-5th MCP
joints, 46 pts had images of the contralateral wrist. The result of this
study shows that capitate, ulna, lunate, triquetrum, and scaphoid
were the 5 bones with the most frequent early erosions and the most
frequent ones with progressive erosions.

A. Number of bones with bone erosion, per bone (n = 258). B. Number of bones with erosive progression,
per bone (n = 233).