Iwona Sudoł-Szopińska

Recommendations of the ESSR Arthritis Subcommittee for the Use of Magnetic Resonance Imaging in Musculoskeletal Rheumatic Diseases.

This article presents the recommendations of the European Society of Musculoskeletal Radiology Arthritis Subcommittee regarding the standards of the use of MRI in the diagnosis of musculoskeletal rheumatic diseases. The recommendations discuss (1) the role of MRI in current classification criteria of musculoskeletal rheumatic diseases (including early diagnosis of inflammation, disease follow-up, and identification of disease complications); (2) the impact of MRI on the diagnosis of axial and peripheral spondyloarthritis, rheumatoid arthritis, and juvenile spondyloarthritis; (3) MRI protocols for the axial and peripheral joints; (4) MRI interpretation and reporting for axial and peripheral joints; and finally, (5) methods for assessing MR images including quantitative, semiquantitative, and dynamic contrast-enhanced MRI studies.

Imaging and Interpretation of Axial Spondylarthritis: The Radiologist's Perspective—Consensus of the Arthritis Subcommittee of the ESSR

This article reflects the radiologists perspective on the imaging and interpretation of axial spondylarthritis (SpA). The arthritis subcommittee of the European Society of Skeletal Radiology provides a consensus for the following questions: When and how should we image? How should we analyze the images? How should we interpret the imaging findings? To answer these questions, we address the indications in imaging axial SpA and the different imaging techniques, with a special focus on magnetic resonance imaging protocols. The value of different imaging modalities is discussed. For adequate image analysis, knowledge of the anatomy and the pathologic changes in chronic and acute inflammation of the sacroiliac joints and the spine is mandatory. Differential diagnoses of inflammatory lesions of the sacroiliac joints and the spine are addressed due to their importance in image interpretation.

Comparison of contrast-enhanced with non-contrast endosonography in the diagnostics of anal fistulas

The objective of this paper is to compare the accuracy of standard, non-contrast endosonography (EAS) with contrast-enhanced endosonography (CE-EAS) in the diagnosis of anal fistulas. The group consisted of 126 patients (mean age: 43.1 years) with the clinical diagnosis of anal fistula. For anal endosonography, a Bruel & Kjaer unit with a 7.0-MHz transducer was used with a 3% solution of hydrogen peroxide as the contrast agent (1, 2, 3). In each case, EAS and CE-EAS diagnoses of the type and complexity of anal fistula, as well as the location of the internal opening, were determined. Results showed that CE-EAS was significantly more accurate in diagnosing the type of anal fistulas than NC-EAS (97 vs. 94%, respectively; P=02275), and in differentiating simple from complex tracks (92 vs. 75%, respectively; P<0.00001). CE-EAS was much more accurate in patients with recurrent fistulas (57 vs. 92%, respectively; P<0.00006), whereas in a subgroup of primary tracks, both methods were of comparable accuracy. Sensitivities of CE-EAS and EAS for internal opening were 89 and 65%, respectively. The conclusion of this paper is that CE-EAS significantly increases the accuracy of standard non-contrast EAS and is especially beneficial for the differentiation between simple and complex tracks.

Prevalence of Chronic Venous Disorders Among Employees Working in Prolonged Sitting and Standing Postures

Research was conducted to determine the prevalence and severity of chronic venous disorders (CVD) among people working in prolonged sitting or static standing postures. Clinical examination and duplex Doppler sonography were performed on 126 employees working in a sitting (96 individuals) or a standing posture (30 individuals). Evidence of CVD was found in 59.4% of individuals working in a sitting posture and in 83.4% of those working in a standing posture, and was significantly higher in employees working in a standing posture (p = .015). Incompetent perforating veins and vena saphena magna valves, and bilateral changes were the more frequent signs of CVD. The investigation showed that prolonged standing and sitting at work increases risk of developing CVD. Further, people working in a standing posture are at a significantly greater risk for CVD than those working in a prolonged sitting posture. They should thus be the subject of specific prophylaxis interventions.

Significance of bone marrow edema in pathogenesis of rheumatoid arthritis.

Summary Assessing the pathology of the synovium, its thickening and increased vascularity through ultrasound and magnetic resonance examinations (more often an ultrasound study alone) is still considered a sensitive parameter in the diagnosis of rheumatoid arthritis and in monitoring of treatment efficacy. Magnetic resonance studies showed that, aside from the joint pannus, the subchondral bone tissue constitutes an essential element in the development of rheumatoid arthritis. Bone marrow edema correlates with inflammation severity, joint destruction, clinical signs and symptoms of rheumatoid arthritis, and thus is considered a predictor of rapid radiological progression of the disease. The newest studies reveal that bone marrow edema may be a more sensitive indicator of the response to therapy than appearance of the synovium. Bone marrow edema presents with increased signal in T2-weighted images, being most visible in fat saturation or IR sequences (STIR, TIRM). On the other hand, it is hypointense and less evident in T1-weighted images. It becomes enhanced (hyperintense) after contrast administration. Histopathological studies confirmed that it is a result of bone inflammation (osteitis/osteomyelitis), i.e. replacememt of bone marrow fat by inflammatory infiltrates containing macrophages, T lymphocytes, B lymphocytes, plasma cells and osteoclasts. Bone marrow edema appears after a few weeks from occurrence of symptoms and therefore is considered an early marker of inflammation. It correlates with clinical assessment of disease activity and elevated markers of acute inflammatory phase, i.e. ESR and CRP. It is a reversible phenomenon and may become attenuated due to biological treatment. It is considered a “herald” of erosions, as the risk of their formation is 6-fold higher in sites where BME was previously noted

Enthesopathies and enthesitis. Part 2: Imaging studies.

The pathologies of tendon and ligament attachments are called enthesopathies. Enthesitis is one of enthesopathies and it is considered a characteristic sign of rheumatic diseases from the spondyloarthritis group, including peripheral spondyloarthritis. Therefore, enthesitis has been included in a number of clinical classifications for diagnosing these diseases. Clinical diagnosis of enthesitis is based on rather non-specific clinical signs and results of laboratory tests. It is believed that imaging examinations might improve diagnosis, particularly because numerous papers prove that differentiating enthesitis from other enthesopathic processes is possible. On the other hand, a number of authors report the lack of specific signs in imaging as well as typical histological and immunological features that would enable confirmation of clinical diagnosis of enthesitis. The first part of the publication presented theories on the etiopathogenesis of enthesitis (inflammatory, mechanical, autoimmune and associated with the synovio-entheseal complex) as well as on the formation of enthesophytes (inflammatory, molecular and mechanical). This paper – the second part of the article, is a review of the state-of-the-art on the ability of imaging examinations to diagnose enthesitis. It turns out that none of the enthesitis criteria used in imaging examinations is specific for inflammation. As enthesitis may be the only symptom of early spondyloarthritis (particularly in patients with absent HLA-B27 antigen), the lack of its unambiguous picture in ultrasound and magnetic resonance imaging prompts the search for other signs characteristic of spondyloarthritis and more specific features in imaging in order to make a diagnosis as early as possible.

Role of inflammatory factors and adipose tissue in pathogenesis of rheumatoid arthritis and osteoarthritis. Part I: Rheumatoid adipose tissue.

For many years, it was thought that synovial cells and chondrocytes are the only sources of proinflammatory cytokines and growth factors found in the synovial fluid in patients suffering from osteoarthritis and rheumatoid arthritis. Currently, it is more and more frequently indicated that adipose tissue plays a significant role in the pathogenesis of these diseases as well as that a range of pathological processes that take place in the adipose tissue, synovial membrane and cartilage are interconnected. The adipose tissue is considered a specialized form of the connective tissue containing various types of cells which produce numerous biologically active factors. The latest studies reveal that, similarly to the synovial membrane, articular adipose tissue may take part in the local inflammatory response and affect the metabolism of the cartilage and subchondral osseous tissue. In in vitro conditions, the explants of this tissue obtained from patients suffering from osteoarthritis and rheumatoid arthritis produce similar pro- and anti-inflammatory cytokines to the explants of the synovial membrane. At this stage already, knowledge translates into imaging diagnostics. In radiological images, the shadowing of the periarticular soft tissues may not only reflect synovial membrane pathologies or joint effusion, but may also suggest inflammatory edema of the adipose tissue. On ultrasound examinations, abnormal presentation of the adipose tissue, i.e. increased echogenicity and hyperemia, may indicate its inflammation. Such images have frequently been obtained during ultrasound scanning and have been interpreted as inflammation, edema, hypertrophy or fibrosis of the adipose tissue. At present, when the knowledge concerning pathogenic mechanisms is taken into account, abnormal echogenicity and hyperemia of the adipose tissue may be considered as a proof of its inflammation. In the authors’ own practice, the inflammation of the adipose tissue usually accompanies synovitis. However, we also diagnose cases in which the inflammatory process in the joint is no longer active, but abnormal vascularity still persists in the adipose tissue. There are also cases where abnormal adipose tissue is the only sign of inflammation. Therefore, ultrasound examination confirms the existence of the additional site of inflammation, i.e. the adipose tissue which should be evaluated at the stage of initial diagnosis and during follow-up, also in terms of remission.

Ectopic Decidual Reaction in the Urinary Bladder Presenting as a Vesical Tumor

A urinary bladder tumor in young pregnant women is a very rare finding. It may bring diagnostic problems despite use of advanced imaging techniques. We report on a case of an exceedingly rare occurrence of a decidual reaction in the urinary bladder of a pregnant young woman. To the best of our knowledge, it is the first such case reported in published medical data. The final diagnosis was possible only after histopathologic assessment of a specimen obtained during diagnostic cystoscopy, which showed typical decidual changes within detrusor muscle, without ectopic endometrium, which could suggest more frequent vesical endometriosis.

Doppler imaging of orbital vessels in the assessment of the activity and severity of thyroid-associated orbitopathy

Patients with symptoms of thyroid-associated orbitopathy are classified on the basis of the clinical activity score (CAS) proposed by Mourits in 1989. Despite its undoubted clinical usefulness, it has several limitations which can decide about the success or failure of the implemented treatment. Numerous reports mention the presence of hemodynamic changes in orbital and bulbar vessels in the course of an orbitopathy called Graves’ disease. The usage of Doppler sonography in the diagnosis of numerous ophthalmologic vascular diseases suggests that changes in thyroid-associated orbitopathy can correlate with the activity and severity of the disease. This paper presents the overview of the state-of-the-art concerning the usefulness of Doppler imaging in patient selection for the treatment of thyroid-associated orbitopathy. It has been shown that the velocity of blood flow in the superior ophthalmic vein, which is the most susceptible to changes in anatomical conditions in the enclosed orbital space, decreases in a statistically significant way. A decrease in blood flow velocity is closely associated with the active stage of the disease whereas reverse flow or its absence attest to severe orbitopathy and constitute a risk factor of ocular neuropathy. The activity of the inflammatory process in the eyeball is also confirmed by an increase in peak systolic velocity (PSV) in the ophthalmic artery and central retinal artery as well as end-diastolic velocity (EDV) in the ophthalmic artery. Resistance index values decrease in the ophthalmic artery and increase in the central retinal artery mainly in cases with considerable expansion of the extraocular muscles.

Normal and sonographic anatomy of selected peripheral nerves. Part II: Peripheral nerves of the upper limb.

The ultrasonographic examination is frequently used for imaging peripheral nerves. It serves to supplement the physical examination, electromyography, and magnetic resonance imaging. As in the case of other USG imaging studies, the examination of peripheral nerves is non-invasive, well-tolerated by patients, and relatively inexpensive. Part I of this article series described in detail the characteristic USG picture of peripheral nerves and the proper examination technique, following the example of the median nerve. This nerve is among the most often examined peripheral nerves of the upper limb. This part presents describes the normal anatomy and ultrasound picture of the remaining large nerve branches in the upper extremity and neck – the spinal accessory nerve, the brachial plexus, the suprascapular, axillary, musculocutaneous, radial and ulnar nerves. Their normal anatomy and ultrasonographic appearance have been described, including the division into individual branches. For each of them, specific reference points have been presented, to facilitate the location of the set trunk and its further monitoring. Sites for the application of the ultrasonographic probe at each reference point have been indicated. In the case of the ulnar nerve, the dynamic component of the examination was emphasized. The text is illustrated with images of probe positioning, diagrams of the normal course of the nerves as well as a series of ultrasonographic pictures of normal nerves of the upper limb. This article aims to serve as a guide in the ultrasound examination of the peripheral nerves of the upper extremity. It should be remembered that a thorough knowledge of the areas topographic anatomy is required for this type of examination.