整理完的最後結論是, 還好我不是放射科....我物理最不好了~_~'' 怎麼振怎麼晃動 和我的距離都是好遠啊

1. The role of Magnetic resonance
imaging in Rheumatoid arthritis
台北醫學大學附設醫院
風濕免疫科
蔡凱倫
2013/05/25

2. The rapid expansion of the therapeutic bioagents has the
potential to dramatically improve RA patient care.
NEJM 2001
NEJM, 2006.
NEJM 2012

3. For the early diagnosis ~
∗ 1987 RA diagnosis
criteria
1. Morning stiffness
2. Arthritis of 3 or more
joint areas
3. Arthritis of hand joints
4. Symmetric arthritis
5. Rheumatoid nodules
6. Serum rheumatoid
factor
7. Radiographic changes
∗ 2010 RA classification criteria

4. RA clinical coarse
The role of image?

5. ∗ Assessment the diagnosis in RA
∗ Predicting joint damage in early RA
∗ MRI as an outcome measure
MRI as an Aid in Rheumatoid arthritis

6. Assessment the diagnosis in RA

7. ∗ The synovial enhancement post intravenous
gadolinium contrast (Gd-DTPA) on MRI correlated
with macroscopic signs of synovitis, and joint space
narrowing on MRI was significantly correlated with
bony changes on arthroscopy.
Image and pathologic picture

8. MRI and Miniarthroscopy of MCP Joints in RA . Arthritis Rheum 2001; 44:2492–2502.
Metacarpophalangeal (MCP) joints of the left
hand of a 52-year-old woman, disease
duration 0.5 years
TI + contrast

9. 32 women and 3 men (mean age, 45 years) with untreated
recent-onset inflammatory arthritis participated in this
prospective study and underwent MR imaging of both wrists
and hands.
After 12-month follow-up, 25 patients fulfilled the criteria for
RA (10 VERA and 15 ERA patients).
Radiology: Volume 264: Number 3—September 2012

10. Tenosynovitis of the extensor carpi ulnaris (odds ratio, 3.21) and flexor
tendons of the second finger (odds ratio, 14.61) in VERA group and
Synovitis of the radioulnar joint (odds ratio, 8.79) and tenosynovitis of flexor
tendons of the second finger (odds ratio, 9.60) in ERA group were significantly
associated with progression to RA (P<0.05).

11. Predicting joint damage in early RA

12. incidence of subclinical synovitis, asdiagnosed by power Doppler ultrasonography
and low-field MRI
Follow-up X-ray examination of 600 joints
showed a significantly higher incidence of
bone erosion in joints with subclinical
synovitis than in synovitis-free joints

14. 32 women and 3 men (mean age, 45 years) with untreated
recent-onset inflammatory arthritis participated in this
prospective study and underwent MR imaging of both wrists
and hands.
After 12-month follow-up, 25 patients fulfilled the criteria for
RA (10 VERA and 15 ERA patients).
Radiology: Volume 264: Number 3—
September 2012

15. Tenosynovitis of the extensor carpi ulnaris (odds ratio, 3.21) and flexor
tendons of the second finger (odds ratio, 14.61) in VERA group and
Synovitis of the radioulnar joint (odds ratio, 8.79) and tenosynovitis of flexor
tendons of the second finger (odds ratio, 9.60) in ERA group were significantly
associated with progression to RA (P<0.05).
Radiology: Volume 264: Number 3—
September 2012

16. Radiology: Volume 264: Number 3—
September 2012

17. Image and lab and ACPA
positive for ACPAs
ACPA-positive patients with MRI-
determined bone edema could be
more likely to develop a more
destructive form of arthritis.
Completely Normal!

18. MRI as an outcome measure

19. Placebo arms

20. In most studies, MRI
demonstrated reduction in
synovitis and osteitis at early (12
week) timepoints, and MRI
predicted subsequent
radiographic findings.

21. 好不好奇他們手怎麼固定的 ?
Monitoring cartilage loss in the hands and wrists in rheumatoid arthritis with
magnetic resonance imaging in a multi-center clinical trial:
IMPRESS(NCT00425932) ( Mabthera)
Arthritis Research & Therapy 2013, 15:R44 doi:10.1186/ar4202

22. Nat. Rev. Rheumatol. 7, 85–95 (2011);
doi:10.1038/nrrheum.2010.173

23. RA in MRI
∗ Synovitis
∗ Tenosynovitis
∗ Bone Erosions
∗ Bone Marrow Edema
∗ Bursitis

24. Synovitis in RA
T2 weight imaging
T1-weighted gadolinium-enhanced image
Dynamic contrast-enhanced MRI
Diffusion tensor imaging (DTI)
Basic: synovitis
Low on T1-weighted images (fat high signals T1)
High on T2-weighted images(water high signals T2)

25. ∗ T1 -weighted images: Synovitis signal is intermediate
to low
∗ T2-weighted images : Synovitis signal is high
∗ The OMERACT group defines synovitis as an area in
the synovial compartment with increased contrast
enhancement whose thickness exceeds the width of
the normal synovium
Synovitis

26. ∗ contrast-enhanced MRI depicted more abnormalities
within the osseous structures of the rheumatoid wrist
than corresponding fat-suppressed T2-weighted fast
spin-echo imaging.
Contrast-enhanced T1-weighted images are considered
more sensitive and specific in the assessment of acute
synovitis
AJR:187, August 2006

27. ∗ Synovitis was the area in the synovial compartment
that showed enhancement of a thickness greater
than the width of the joint capsule after gadolinium.
Synovitis

28. T1-weighted MR image
T2-weighted
contrast material–enhanced
fatsuppressed T1-weighted MR
image
RadioGraphics 2010; 30:143–16

29. Tenosynovitis
AJR:189, December 2007

30. Contrast-enhanced axial T1-weighted fat-saturated
Radiology: Volume 264: Number 3—
September 2012
Tenosynovitis of
the flexor tendons of the second
and third digits on the right hand

31. Contrast-enhanced axial T1-
weighted fat-saturated MR image

32. Tenosynovitis
∗ Tenosynovitis is a common finding in patients with
early rheumatoid arthritis.
∗ Although any tendon may be affected, the flexor
digitorum, extensor digitorum, and extensor carpi
ulnaris are frequently involved .
∗ Dorsal extensor compartments of the wrist are more
commonly involved than the volar compartment .

33. Synovitis of MCPJs 2–4Gd-DTPA MRI
extensive flexor tenosynovitis in
tendons 2–5
McGonagle, D. et al. Nat. Rev. Rheumatol. 7, 185–189
(2011); published online 19 October 2010;

34. ∗ is a procedure that can be used to measure parameters
related to the transfer of contrast medium between
intravascular and extravascular spaces.
Dynamic contrast--enhanced MRI
(DCE-MRI)

36. Diffusion tensor imagin
∗ an alternative MRI approach for determining the
extent of synovial inflammation.
∗ DTI is of particular interest in that it is a non-contrast-
based MRI technique, thus avoiding the risks
associated with the use of gadolinium-based contrast
agents.
∗ The principle underlying DTI is the measurement of
the restrictions on the Brownian motion of water
molecules.
擴散張量影像

37. ∗ DTI proved that the restricted motion of water in the
joints of patients with RA is a result of inflammatory
cell aggregation.

39. Bone marrow edema
STIR : Short TI Inversion Recovery
Fat-suppressed T2-weighted MRI
sequences

40. ∗ The OMERACT group defines bone edema at MR
imaging as a lesion within the trabecular bone that
has ill-defined margins and signal intensity
characteristics consistent with increased water
content and may be seen alone or surrounding an
erosion or some other bone abnormality
Bone marrow edema

41. Bone marrow edema
∗ Bone edema could occur alone or surround a
“defect” or “erosion” and was defined as a lesion
with ill defined margins that was neither erosion nor
defect and had high signal intensity on T2 weighted
sequences.
∗ STIR 比 T2 weighted 更易於觀察 bone marrow
edema

42. Loose fat !!
Bone marrow edema occurs as a result of the activation of
osteoclasts during the earliest stages of bone resorption.

43. ∗ bone marrow edema is nonspecific and has been well
documented in traumatic, neoplastic and
degenerative bone processes,
∗ it is reported to be a distinctive MRI finding in
patients with RA, especially in the earlier phases of
the disease.
∗ Bone marrow edema has been found in 39%–75% of
rheumatoid arthritis patients with disease duration of
less than 1 year

44. T1-weighted
T2-weighted image with fat saturation
T1-FS + gadolinium-based contrast
Radiographics 30, 143–163 (2010).
bone edema

45. ∗ In early rheumatoid arthritis, bone marrow edema is
usually located in the subchondral bone.
∗ bone marrow edema is rare in the absence of
synovitis in early rheumatoid arthritis

46. ∗ In early rheumatoid arthritis, bone marrow edema is
usually located in the subchondral bone.
∗ Bone marrow edema may be seen alone or
surrounding bone erosions and is considered to be a
potentially reversible phenomenon .
∗ Histologic studies of joint replacement specimens
have shown that bone marrow edema corresponds to
inflammatory cellular infiltrates in the bone marrow,
representing osteitis

47. Bone erosion
T1
The detection of erosions in patients with early
rheumatoid arthritis is a key imaging finding, since it
indicates irreversible joint damage

48. Bone erosion
∗ The OMERACT group defines erosion at MR imaging
as a bone defect with sharp margins, visible in 2
planes (when 2 planes are available) with a cortical
break seen in at least one plane.
∗ A bone defect was defined as a sharply marginated
area of trabecular loss without a visible cortical break.

49. ∗ In early rheumatoid arthritis, MR imaging helps
identify bone erosions in 45%–72% of patients with
disease of less than 6 months duration (30,64),
compared with 8%–40% for radiography.
∗ The contrast enhancement of erosions implies the
presence of inflamed synovium within the defect and
is useful in differentiating them from fluid-filled cystic
lesions

51. Radiology September 2010 vol. 256 no. 3 863-
869
T1-weighted images,

52. Bone erosion
T1
Fat is white
STIR : Short TI Inversion Recovery
(suppress the signal from fat.)
erosions in triquetrum
AJR:197, September 2011

53. Transverse fat-suppressed gadolinium-
enhanced 3D gradient-echo MR image
J Rheumatol 2003; 30:671–679
Synovitis -> bone erosion

54. Cartilage loss
Arthritis Research & Therapy 2013, 15:R44
doi:10.1186/ar4202

55. Week-24Weeks -12
progressive joint-space
narrowing associated with
loss of cartilage over both
articular surfaces of this joint
Arthritis Research & Therapy 2013, 15:R44
doi:10.1186/ar4202

56. Scoring system

57. Rheumatoid Arthritis Magnetic
Resonance Imaging Score (RAMRIS )
OMERACT Rheumatoid Arthritis Magnetic Resonance Imaging Studies. Core set of MRI
acquisitions, joint pathology definitions, and the OMERACT RA-MRI scoring system.
J Rheumatol. 2003 Jun;30(6):1385-6. Østergaard M
synovitis
erosions and edema

58. RAMRIS …..too many joints to read

59. 沒有把 PIPjs 納入，有人很不服
氣

60. D/D

61. 謝謝聆聽
T1 :Bone erosion
T2/STIR: Bone edema
Contrast : Synovitis

62. Nat. Rev. Rheumatol. 7, 185–189 (2011); published online 19 October 2010;
doi:10.1038/nrrheum.2010.172
Nat. Rev. Rheumatol. 7, 85–95 (2011); published online 2 November 2010;
doi:10.1038/nrrheum.2010.173