核磁共振在類風溼性關節炎的角色

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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

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  • The past 15 years has seen an exponential rise in the use of MRI for the assessment of rheumatoid arthritis (RA). In this Perspectives article, we review the current and potential future role of MRI in the diagnosis, prognosis and monitoring of RA.
  • 為了早期診斷, criteria 也進步了 但是……
  • MRI is the most sensitive imaging , but very expensive. MRI is increasingly utilized in clinical studies, both in terms of identifying features for entry into clinical trials as well as monitoring disease progression over time.
  • Magnetic resonance imaging and miniarthroscopy of metacarpophalangeal joints: sensitive detection of morphologic changes in rheumatoid arthritis. Arthritis Rheum 2001; 44:2492–2502.
  • Conventional radiographic image (posteroanterior view), revealing no pathologic findings (Larsen score 0). B, Axial T1-weighted spin-echo magnetic resonance image (after intravenous gadolinium diethylenetriaminepentaacetic acid) of the second to the fifth MCP joints (numbered 2–5), showing synovial proliferation with marked enhancement in the second (arrows), third, and fourth MCP joints, accompanied by synovitis of the second flexor tendon sheath (arrowheads). C, Macroscopic image of the joint cavity of the second MCP joint as seen on miniarthroscopy (MA), showing increased hyperemia, vascularity (arrowheads), and synovial proliferation as signs of disease activity. D, Synovial biopsy section obtained from the second MCP joint at MA, showing partial separation of the synovial lining layer, fibrin deposits, necrotic fragments of hyaline cartilage, vascularization, focal proliferation of synovial stromal cells, and lymphoplasmacyte and granulocyte infiltration (hematoxylin and eosin stained; original magnification 3 50). 2497
  • 同樣都是 ACPA (+), 到底 MRI 何時才會出現有問題 或是 MRI 的 finding 是暗示著 VERA 兩個變數 ACPA 和 MRI BMI 這哪一個比較能預測 bone erosion progression 仍是待研究的 !!
  • gadolinium­-based contrast medium can diffuse into syno vial fluid, causing equilibration of signal intensity between synovium and effusion as soon as 5 min after dministration.
  • 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
  • Bilateral MR images of the hand and wrist of a 33-year-old woman with early inflammatory arthritis with a disease duration of 3 months
  • Thickening, thinning, and complete discontinuity of tendons at MR imaging are indicative of partial or complete rupture
  • 水分子在身體不同組織和障闢擴散放現有不同訊號
  • 所以最後以這張為總結 ! T1 Erosion T2 bone edema Contrast : synovitis
  • The OMERACT group defines erosion at MR imaging as a sharply marginated bone lesion with correct juxtaarticular localization and typical signal intensity characteristics that is visible in two planes, with a cortical break seen in at least one plane 
  • Bone erosion 內可見 synovial proliferation
  • marrow edema, particularly associated with sites of erosion
  • validated semiquantitative RAMRIS (Rheumatoid Arthritis Magnetic Resonance Imaging Score) system, 20 hich scores erosions (from 0 to 10, in increments of 10% of articular bone loss), osteitis (from 0 to 3, in increments of 33% of articular bone) and synovitis (from 0 to 3, in increments of 33% of the synovial cavity) in the wrist and metacarpophalangeal joints of the hand. According to the OMERACT RAMRIS scoring system, bone marrow edema is scored on a scale of 0 to 3 on the basis of the volume of edema: 0 = no edema, 1 = 1%–33% (percentage of bone that is edematous), 2 = 34%–66%, and 3 = 67%–100%
  • McGonagle, D. et al. Competing interests The authors declare no competing interests. PeRsPecTIves © 2011 Macmillan Publishers Limited. All rights reserved Borrero, C. G. et al.
  • 核磁共振在類風溼性關節炎的角色

    1. 1. The role of Magnetic resonanceimaging 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. 2. The rapid expansion of the therapeutic bioagents has thepotential to dramatically improve RA patient care.NEJM 2001NEJM, 2006.NEJM 2012
    3. 3. For the early diagnosis ~∗ 1987 RA diagnosiscriteria1. Morning stiffness2. Arthritis of 3 or morejoint areas3. Arthritis of hand joints4. Symmetric arthritis5. Rheumatoid nodules6. Serum rheumatoidfactor7. Radiographic changes∗ 2010 RA classification criteria
    4. 4. RA clinical coarseThe role of image?
    5. 5. ∗ Assessment the diagnosis in RA∗ Predicting joint damage in early RA∗ MRI as an outcome measureMRI as an Aid in Rheumatoid arthritis
    6. 6. Assessment the diagnosis in RA
    7. 7. ∗ The synovial enhancement post intravenousgadolinium contrast (Gd-DTPA) on MRI correlatedwith macroscopic signs of synovitis, and joint spacenarrowing on MRI was significantly correlated withbony changes on arthroscopy.Image and pathologic picture
    8. 8. MRI and Miniarthroscopy of MCP Joints in RA . Arthritis Rheum 2001; 44:2492–2502.Metacarpophalangeal (MCP) joints of the lefthand of a 52-year-old woman, diseaseduration 0.5 yearsTI + contrast
    9. 9. 32 women and 3 men (mean age, 45 years) with untreatedrecent-onset inflammatory arthritis participated in thisprospective study and underwent MR imaging of both wristsand hands.After 12-month follow-up, 25 patients fulfilled the criteria forRA (10 VERA and 15 ERA patients).Radiology: Volume 264: Number 3—September 2012
    10. 10. Tenosynovitis of the extensor carpi ulnaris (odds ratio, 3.21) and flexortendons of the second finger (odds ratio, 14.61) in VERA group andSynovitis of the radioulnar joint (odds ratio, 8.79) and tenosynovitis of flexortendons of the second finger (odds ratio, 9.60) in ERA group were significantlyassociated with progression to RA (P<0.05).
    11. 11. Predicting joint damage in early RA
    12. 12. incidence of subclinical synovitis, asdiagnosed by power Doppler ultrasonographyand low-field MRIFollow-up X-ray examination of 600 jointsshowed a significantly higher incidence ofbone erosion in joints with subclinicalsynovitis than in synovitis-free joints
    13. 13. 32 women and 3 men (mean age, 45 years) with untreatedrecent-onset inflammatory arthritis participated in thisprospective study and underwent MR imaging of both wristsand hands.After 12-month follow-up, 25 patients fulfilled the criteria forRA (10 VERA and 15 ERA patients).Radiology: Volume 264: Number 3—September 2012
    14. 14. Tenosynovitis of the extensor carpi ulnaris (odds ratio, 3.21) and flexortendons of the second finger (odds ratio, 14.61) in VERA group andSynovitis of the radioulnar joint (odds ratio, 8.79) and tenosynovitis of flexortendons of the second finger (odds ratio, 9.60) in ERA group were significantlyassociated with progression to RA (P<0.05).Radiology: Volume 264: Number 3—September 2012
    15. 15. Radiology: Volume 264: Number 3—September 2012
    16. 16. Image and lab and ACPApositive for ACPAsACPA-positive patients with MRI-determined bone edema could bemore likely to develop a moredestructive form of arthritis.Completely Normal!
    17. 17. MRI as an outcome measure
    18. 18. Placebo arms
    19. 19. In most studies, MRIdemonstrated reduction insynovitis and osteitis at early (12week) timepoints, and MRIpredicted subsequentradiographic findings.
    20. 20. 好不好奇他們手怎麼固定的 ?Monitoring cartilage loss in the hands and wrists in rheumatoid arthritis withmagnetic resonance imaging in a multi-center clinical trial:IMPRESS(NCT00425932) ( Mabthera)Arthritis Research & Therapy 2013, 15:R44 doi:10.1186/ar4202
    21. 21. Nat. Rev. Rheumatol. 7, 85–95 (2011);doi:10.1038/nrrheum.2010.173
    22. 22. RA in MRI∗ Synovitis∗ Tenosynovitis∗ Bone Erosions∗ Bone Marrow Edema∗ Bursitis
    23. 23. Synovitis in RAT2 weight imagingT1-weighted gadolinium-enhanced imageDynamic contrast-enhanced MRIDiffusion tensor imaging (DTI)Basic: synovitisLow on T1-weighted images (fat high signals T1)High on T2-weighted images(water high signals T2)
    24. 24. ∗ T1 -weighted images: Synovitis signal is intermediateto low∗ T2-weighted images : Synovitis signal is high∗ The OMERACT group defines synovitis as an area inthe synovial compartment with increased contrastenhancement whose thickness exceeds the width ofthe normal synoviumSynovitis
    25. 25. ∗ contrast-enhanced MRI depicted more abnormalitieswithin the osseous structures of the rheumatoid wristthan corresponding fat-suppressed T2-weighted fastspin-echo imaging.Contrast-enhanced T1-weighted images are consideredmore sensitive and specific in the assessment of acutesynovitisAJR:187, August 2006
    26. 26. ∗ Synovitis was the area in the synovial compartmentthat showed enhancement of a thickness greaterthan the width of the joint capsule after gadolinium.Synovitis
    27. 27. T1-weighted MR imageT2-weightedcontrast material–enhancedfatsuppressed T1-weighted MRimageRadioGraphics 2010; 30:143–16
    28. 28. TenosynovitisAJR:189, December 2007
    29. 29. Contrast-enhanced axial T1-weighted fat-saturatedRadiology: Volume 264: Number 3—September 2012Tenosynovitis ofthe flexor tendons of the secondand third digits on the right hand
    30. 30. Contrast-enhanced axial T1-weighted fat-saturated MR image
    31. 31. Tenosynovitis∗ Tenosynovitis is a common finding in patients withearly rheumatoid arthritis.∗ Although any tendon may be affected, the flexordigitorum, extensor digitorum, and extensor carpiulnaris are frequently involved .∗ Dorsal extensor compartments of the wrist are morecommonly involved than the volar compartment .
    32. 32. Synovitis of MCPJs 2–4Gd-DTPA MRIextensive flexor tenosynovitis intendons 2–5McGonagle, D. et al. Nat. Rev. Rheumatol. 7, 185–189(2011); published online 19 October 2010;
    33. 33. ∗ is a procedure that can be used to measure parametersrelated to the transfer of contrast medium betweenintravascular and extravascular spaces.Dynamic contrast--enhanced MRI(DCE-MRI)
    34. 34. Diffusion tensor imagin∗ an alternative MRI approach for determining theextent of synovial inflammation.∗ DTI is of particular interest in that it is a non-contrast-based MRI technique, thus avoiding the risksassociated with the use of gadolinium-based contrastagents.∗ The principle underlying DTI is the measurement ofthe restrictions on the Brownian motion of watermolecules.擴散張量影像
    35. 35. ∗ DTI proved that the restricted motion of water in thejoints of patients with RA is a result of inflammatorycell aggregation.
    36. 36. Bone marrow edemaSTIR : Short TI Inversion RecoveryFat-suppressed T2-weighted MRIsequences
    37. 37. ∗ The OMERACT group defines bone edema at MRimaging as a lesion within the trabecular bone thathas ill-defined margins and signal intensitycharacteristics consistent with increased watercontent and may be seen alone or surrounding anerosion or some other bone abnormalityBone marrow edema
    38. 38. Bone marrow edema∗ Bone edema could occur alone or surround a“defect” or “erosion” and was defined as a lesionwith ill defined margins that was neither erosion nordefect and had high signal intensity on T2 weightedsequences.∗ STIR 比 T2 weighted 更易於觀察 bone marrowedema
    39. 39. Loose fat !!Bone marrow edema occurs as a result of the activation ofosteoclasts during the earliest stages of bone resorption.
    40. 40. ∗ bone marrow edema is nonspecific and has been welldocumented in traumatic, neoplastic anddegenerative bone processes,∗ it is reported to be a distinctive MRI finding inpatients with RA, especially in the earlier phases ofthe disease.∗ Bone marrow edema has been found in 39%–75% ofrheumatoid arthritis patients with disease duration ofless than 1 year
    41. 41. T1-weightedT2-weighted image with fat saturationT1-FS + gadolinium-based contrastRadiographics 30, 143–163 (2010).bone edema
    42. 42. ∗ In early rheumatoid arthritis, bone marrow edema isusually located in the subchondral bone.∗ bone marrow edema is rare in the absence ofsynovitis in early rheumatoid arthritis
    43. 43. ∗ In early rheumatoid arthritis, bone marrow edema isusually located in the subchondral bone.∗ Bone marrow edema may be seen alone orsurrounding bone erosions and is considered to be apotentially reversible phenomenon .∗ Histologic studies of joint replacement specimenshave shown that bone marrow edema corresponds toinflammatory cellular infiltrates in the bone marrow,representing osteitis
    44. 44. Bone erosionT1The detection of erosions in patients with earlyrheumatoid arthritis is a key imaging finding, since itindicates irreversible joint damage
    45. 45. Bone erosion∗ The OMERACT group defines erosion at MR imagingas a bone defect with sharp margins, visible in 2planes (when 2 planes are available) with a corticalbreak seen in at least one plane.∗ A bone defect was defined as a sharply marginatedarea of trabecular loss without a visible cortical break.
    46. 46. ∗ In early rheumatoid arthritis, MR imaging helpsidentify bone erosions in 45%–72% of patients withdisease of less than 6 months duration (30,64),compared with 8%–40% for radiography.∗ The contrast enhancement of erosions implies thepresence of inflamed synovium within the defect andis useful in differentiating them from fluid-filled cysticlesions
    47. 47. Radiology September 2010 vol. 256 no. 3 863-869T1-weighted images,
    48. 48. Bone erosionT1Fat is whiteSTIR : Short TI Inversion Recovery(suppress the signal from fat.)erosions in triquetrumAJR:197, September 2011
    49. 49. Transverse fat-suppressed gadolinium-enhanced 3D gradient-echo MR imageJ Rheumatol 2003; 30:671–679Synovitis -> bone erosion
    50. 50. Cartilage lossArthritis Research & Therapy 2013, 15:R44doi:10.1186/ar4202
    51. 51. Week-24Weeks -12progressive joint-spacenarrowing associated withloss of cartilage over botharticular surfaces of this jointArthritis Research & Therapy 2013, 15:R44doi:10.1186/ar4202
    52. 52. Scoring system
    53. 53. Rheumatoid Arthritis MagneticResonance Imaging Score (RAMRIS )OMERACT Rheumatoid Arthritis Magnetic Resonance Imaging Studies. Core set of MRIacquisitions, joint pathology definitions, and the OMERACT RA-MRI scoring system.J Rheumatol. 2003 Jun;30(6):1385-6. Østergaard Msynovitiserosions and edema
    54. 54. RAMRIS …..too many joints to read
    55. 55. 沒有把 PIPjs 納入,有人很不服氣
    56. 56. D/D
    57. 57. 謝謝聆聽T1 :Bone erosionT2/STIR: Bone edemaContrast : Synovitis
    58. 58. Nat. Rev. Rheumatol. 7, 185–189 (2011); published online 19 October 2010;doi:10.1038/nrrheum.2010.172Nat. Rev. Rheumatol. 7, 85–95 (2011); published online 2 November 2010;doi:10.1038/nrrheum.2010.173

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