Quentin Reeves

MRI bone oedema scores are higher in the arthritis mutilans form of psoriatic arthritis and correlate with high radiographic scores for joint damage

IntroductionThe aim of this study was to investigate the magnetic resonance imaging (MRI) features of bone disease in the arthritis mutilans (AM) form of psoriatic arthritis (PsA).MethodsTwenty-eight patients with erosive PsA were enrolled (median disease duration of 14 years). Using x-rays of both hands and feet, 11 patients were classified as AM and 17 as non-AM (erosive psoriatic arthritis without bone lysis)by two observers. MRI scans (1.5T) of the dominant hand (wrist and fingers scanned separately) were obtained using standard contrast-enhanced T1-weighted and fat-saturated T2-weighted sequences. Scans were scored separately by two readers for bone erosion, oedema and proliferation using a PsA MRI scoring system. X-rays were scored for erosions and joint space narrowing.ResultsOn MRI, 1013 bones were scored by both readers. Reliability for scoring erosions and bone oedema was high (intraclass correlation coefficients = 0.80 and 0.77 respectively) but only fair for bone proliferation (intraclass correlation coefficient = 0.42). MRI erosion scores were higher in AM patients (53.0 versus 15.0, p = 0.004) as were bone oedema and proliferation scores (14.7 versus 10.0, p = 0.056 and 3.6 versus 0.7, p = 0.003 respectively). MRI bone oedema scores correlated with MRI erosion scores and X-ray erosion and joint space narrowing scores (r = 0.65, p = 0.0002 for all) but not the disease activity score 28-C reactive protein (DAS28CRP) or pain scores.ConclusionsIn this patient group with PsA, MRI bone oedema, erosion and proliferation were all more severe in the AM-form. Bone oedema scores did not correlate with disease activity measures but were closely associated with X-ray joint damage scores. These results suggest that MRI bone oedema may be a pre-erosive feature and that bone damage may not be coupled with joint inflammation in PsA.

Assessment of cartilage loss at the wrist in rheumatoid arthritis using a new MRI scoring system

Objectives To develop and test an MRI cartilage scoring system for use at the wrist in rheumatoid arthritis (RA). Methods MRI scans were obtained using a 3T MRI scanner with dedicated wrist coil in 22 early and 16 established RA patients plus 22 controls. Axial and coronal T1-weighted (precontrast and postcontrast) and T2-weighted turbo spin echo sequences were obtained. Eight wrist joints were scored for cartilage narrowing: distal radioulnar, radiolunate, radioscaphoid, triquetrum-hamate, capitate-lunate, scaphotrapezoid, second metacarpal base-trapezoid and third metacarpal base-capitate, using a system based on the Sharp van der Heijde x-ray joint space narrowing (JSN) score by three radiologists. Fifteen sites at the wrist were also scored for synovitis, bone oedema and erosion using the RA MRI score. Results Interobserver (three-reader) and intraobserver reliability (readers 1 and 2) for the cartilage score were excellent: intraclass correlations (ICC (95% CI)) 0.91, (0.86 to 0.94), 0.98 (0.96 to 1.00) and 0.94 (0.87 to 1.00), respectively. Cartilage scores (median, range) were higher in the established RA group (11.9, 2.3–27.3) than the early RA group (2.15, 0–6) (p≤0.001) but early RA scores did not differ from healthy controls (2.3, 1–8.7). Cartilage scores correlated with synovitis (R=0.52), bone oedema (R=0.63) and erosion scores (R=0.66), p<0.001 for all, and with x-ray JSN scores (R=0.68 to 0.78). Conclusion This MRI cartilage score demonstrated excellent reliability when tested in a three-reader system. However, cartilage loss in early RA could not be distinguished from that seen in healthy controls.

Bone erosions in patients with chronic gouty arthropathy are associated with tophi but not bone oedema or synovitis: new insights from a 3 T MRI study

OBJECTIVES Bone erosion has been linked with tophus deposition in gout but the roles of osteitis (MRI bone oedema) and synovitis remain uncertain. Our aims in this prospective 3 T MRI study were to investigate the frequency of these features in gout and determine their relation to one another. METHODS 3 T MRI scans of the wrist were obtained in 40 gout patients. Scans were scored independently by two radiologists for bone oedema, erosions, tophi and synovitis. Dual-energy CT (DECT) scans were scored for tophi in a subgroup of 10 patients. RESULTS Interreader reliability was high for erosions and tophi [intraclass correlation coefficients (ICCs) 0.77 (95% CI 0.71, 0.87) and 0.71 (95% CI 0.52, 0.83)] and moderate for bone oedema [ICC = 0.60 (95% CI 0.36, 0.77)]. Compared with DECT, MRI had a specificity of 0.98 (95% CI 0.93, 0.99) and sensitivity of 0.63 (95% CI 0.48, 0.76) for tophi. Erosions were detected in 63% of patients and were strongly associated with tophi [odds ratio (OR) = 13.0 (95% CI 1.5, 113)]. In contrast, no association was found between erosions and bone oedema. Using concordant data, bone oedema was scored at 6/548 (1%) sites in 5/40 patients (12.5%) and was very mild (median carpal score = 1, maximum = 45). In logistic regression analysis across all joints nested within individuals, tophus, but not synovitis, was independently associated with erosion [OR = 156.5 (21.2, >999.9), P < 0.0001]. CONCLUSION Erosions were strongly associated with tophi but not bone oedema or synovitis. MRI bone oedema was relatively uncommon and low grade. These findings highlight the unique nature of the osteopathology of gout.

New insights into an old disease: advanced imaging in the diagnosis and management of gout

Advanced imaging modalities including MRI, ultrasound (US), CT and dual energy CT have important applications in gout. While conventional radiography (X-ray) remains the most widely used form of imaging in the clinical setting and is helpful in revealing erosions in chronic gout, these new imaging tools can reveal joint damage and tophi at a much earlier stage. As all are multiplanar techniques, they can define the position and dimensions of tophi, with startling clarity, as well as the size and extent of bone erosions. US and MRI also reveal the severity of inflammation within and adjacent to the joint and can capture information about the composite, vascular nature of many tophaceous deposits. These features can be used as imaging outcome measures, to monitor responses to anti-inflammatory and urate lowering therapies. The new possibility that gout could be diagnosed using imaging, without aspirating the joint, is on the horizon. This review discusses the clinical and research applications of advanced imaging in gout with particular focus on diagnosis and monitoring of joint inflammation and damage.

Measuring bone erosion and edema in rheumatoid arthritis: a comparison of manual segmentation and RAMRIS methods.

To investigate the reliability, feasibility, and validity of a computer‐assisted manual segmentation (outlining) technique for measuring magnetic resonance imaging (MRI) bone erosion and edema at the wrist in rheumatoid arthritis (RA).

DECT urate deposits: now you see them, now you don't

Dual energy CT (DECT) scanning has recently been applied to the detection of urate deposits in patients with gout.1 It is highly specific, with potential for use as a diagnostic tool.2 However, few studies have compared DECT with other advanced imaging modalities. We have recently studied a group of gout patients using 3T MRI scanning as well as DECT imaging and have discovered that a significant anomaly exists for the identification of urate which is contingent upon DECT software settings. This could have a major impact on the diagnosis of gout in individual patients. We performed DECT scans of the dominant wrist in 10 patients with tophaceous gout,3 with an average disease duration of 19 years. All participants provided written informed consent and this study was approved by the Northern X Regional Ethics Committee of New Zealand. A dual x-ray tube 128-detector-row scanner (Siemens Medical, Erlangen, Germany) was used. Patients were scanned prone with arm outstretched from finger-tips to distal radius with acquisitions at 40×0.6 mm and pitch of 0.7. Tube A was operated at 80 kV/260 mAs and tube B at 140 kV/130 mAs. Images were reconstructed using bone and soft tissue algorithms, 512 matrix, 0.75-mm slices with 0.5-mm increment. Data were treated in two …

Quantifying synovitis in rheumatoid arthritis using computer‐assisted manual segmentation with 3 tesla MRI scanning

To investigate the reliability, validity and feasibility of a computer‐assisted manual segmentation method for determining the synovial membrane volume as a surrogate measure for synovitis in patients with rheumatoid arthritis (RA).

A comparative MRI study of cartilage damage in gout versus rheumatoid arthritis

Magnetic resonance imaging (MRI) is useful for detecting joint inflammation and damage in the inflammatory arthropathies. This study aimed to investigate MRI cartilage damage and its associations with joint inflammation in patients with gout compared with a group with rheumatoid arthritis (RA).

FRI0231 A Comparative MRI Study of Cartilage Damage Patterns and Severity in Gout VS Rheumatoid Arthritis

Background MRI of the wrist can be used to measure cartilage damage in rheumatoid arthritis (RA) (1) and this is usually diffuse in distribution, involving multiple joints. We have recently developed a score for quantifying cartilage damage in gout (2) and now explore the pattern of involvement and associations with joint inflammation. Objectives To compare MRI cartilage damage in gout with RA, focussing on distribution and severity. To investigate associations between cartilage damage and joint inflammation indicated by MRI synovitis and bone marrow edema (BME) in gout vs RA. Methods Two cohorts were studied using 3T high field MRI with wrist coil and cartilage-sensitive sequences (1). 40 gout and 38 RA patients were scanned (mean disease duration 18 and 7.6 yrs respectively). Cartilage damage was scored using validated criteria: AMRICS [1] for RA and the gout MRI cartilage scoring system [2]. Comparisons used the 6 carpal sites common to both systems. The total cartilage damage score was expressed as % possible maximum. Synovitis and BME were scored using RAMRIS. Ordinal logistic regression was used to compare the number of cartilage sites involved between gout and RA patients, and also to compare total cartilage scores, both adjusted for disease duration and synovitis. Results Many fewer sites were affected by cartilage damage in gout compared with RA despite the much longer disease duration (p=0.001). 42.5% of gout patients had 0 sites involved and 15% had 3-6 sites involved vs 10.5% and 60.5% respectively for RA patients (Figure 1). Ordinal logistic regression revealed that the association (fewer abnormal cartilage sites in gout compared with RA) was significant (p=0.001). % Max total cartilage scores were significantly lower in gout compared with RA (p=0.0009), adjusting for synovitis and duration. In gout, increasing total synovitis scores were associated with increasing number of cartilage sites (p=0.02) but there was no association between % Max total cartilage score and synovitis in gout. The Spearmans correlation between cartilage damage and synovitis in gout did not reach significance (R =0.31, p=0.10) compared with a strong correlation in RA (R =0.60, p<0.0001). Examining the differences in BME between the 2 conditions: the median (min,max) RAMRIS BME score for gout was low at 0 (0, 6) compared with RA at 10 (0, 29) and there was no correlation between BME and cartilage scores in gout (R =0.10, p=0.55) as opposed to a highly significant correlation in RA (R =0.70, p<0.0001). Gout RA p-value* N Median Min Max N Median Min Max No. cartilage sites 40 1 0 5 38 3 0 6 0.0002 Total synovitis 29 2 0 5 38 4 0 8 <0.0001 Total BME 40 0 0 6 38 10 0 29 <0.0001 Total erosion 40 3 0 39 38 13.5 0 41 0.0016 * Median 2-sample test. Conclusions Patterns of cartilage damage at the wrist differ for these 2 conditions. In gout, cartilage damage is focal and mild compared with RA where it is diffuse and more severe. Cartilage damage is associated with synovitis and osteitis in RA but not in gout. Pathways leading to cartilage damage are likely to differ in these 2 diseases. References McQueen F, Clarke A, McHaffie A, et al. ARD 2010;69:1971-75. 2) Popovich I, Dalbeth N, Doyle A, et al. Skeletal Radiol. Revision submitted Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2070

FRI0230 Exploring Cartilage Damage in Gout Using 3T Mri: Developing A Scoring System

Background Few imaging studies have investigated cartilage damage in gout. Magnetic Resonance Imaging (MRI) can produce high quality images of cartilage damage in this disease and also reveal other features of gouty arthropathy. Objectives To develop and validate a system for quantifying cartilage damage in gout. To test this system for scoring reliability and validity. To explore associations between cartilage damage and other disease manifestations in gout. Methods 3T-MRI scans of the wrist were obtained in 40 gout patients using a dedicated wrist coil and cartilage-specific sequences (1). MRI cartilage damage was quantified using an adaptation of the radiographic Sharp van der Heidje (SvdH) score. Two readers scored cartilage loss at 7 wrist joints (distal radio-ulnar, radioscaphoid, radiolunate, triquetrum-hamate, lunate-capitate, scaphoid-capitate, and scaphotrapezoid); 0 (normal), 1 (partial narrowing), 2 (complete narrowing) and concomitant osteoarthritis was recorded. Bone erosion and bone marrow edema (BME) were scored using the RAMRIS system and tophi were assessed. The SvdH score was used to assess radiographic erosion and jsn in the same group. Reliability of the MRI cartilage score was determined and correlations with the radiographic jsn score were investigated as were the associations between MRI cartilage damage, bone erosion and BME. Results A total of 280 joints were scored for MRI cartilage damage (N=40). The gout MRI cartilage score was highly correlated with the total SvdH score and the jsn component (R =0.8 and 0.71 respectively, p<0.001). Reliability for scoring MRI cartilage damage was high (intraobserver, interobserver ICCs =0.87 [0.57-0.97], 0.64 [0.41–0.79] respectively). Reliability and validity of data were retested in the groups given IV contrast, N=28 and not given contrast (impaired renal function), N=12. Reliability was lower in the contrast vs the non-contrast group (interobserver ICCs =0.40 [0.03 - 0.67] vs 0.82 [0.49 - 0.95] respectively). The correlation between the MRI cartilage and SvdH jsn scores was also lower in the contrast group vs the non-contrast group (R =0.66 vs R =0.86 respectively). In the total group, MRI cartilage damage was identified by one or both readers in 40/280 (14%) of joints. Cartilage lesions were focal (Grade 1) at 82% of these sites. The following joints were most frequently involved: distal radioulnar (33% of patients), radiolunate (21%) and radioscaphoid (20%). We repeated the analysis using data for joints where both readers agreed (as to presence or absence of MRI cartilage damage) and this revealed 14 of 229 (6.1%) of sites to be abnormal. Of these, 12 sites (85.7%) had evidence of concomitant OA. Cartilage scores correlated with MRI bone erosion (R =0.57, p<0.001), and tophus size (R =0.52, p=0.001), but not BME scores. Conclusions MRI can be used to investigate cartilage in gout. The use of non-contrast enhanced sequences leads to optimal reliability and validity of the MRI cartilage score. Cartilage damage was relatively uncommon in gout, focal and frequently associated with OA. Cartilage scores correlated with scores for bone erosions and tophus size but not BME. These findings emphasize the unique pathophysiology of gout. References McQueen F, Clarke A, McHaffie A, et al. ARD 2010;69:1971-75. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2275