Whole-Body Magnetic Resonance Imaging Index for Inflammation of - - PowerPoint PPT Presentation

Whole-Body Magnetic Resonance Imaging Index for Inflammation of Peripheral Joints and Entheses— Definitions, scoring methodology and image examples OMERACT MRI in Arthritis Working Group

Note: This draft slideshow is used for the April 2018 pilot longitudinal readout. It is a draft and will require modifications. Feel free to send any comments to simonkrabbe@gmail.com Version 1.1 – April 23, 2018

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Inflammation in joints is assessed separately for:

• Soft tissues (synovitis)
• Bone (osteitis)

Inflammation at entheses (enthesitis) is assessed separately for:

• Soft tissue (soft tissue inflammation)
• Bone (osteitis)

Cited from: J Rheumatol 2017;44;1699-1705

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Joints: Synovitis

Procedure: If T1-postGd images are available, synovitis should be assessed according to option a. If only STIR/T2FS images are available: Synovitis/effusion should be assessed according to option b. Definitions:

• Option a: Definition of synovitis, based on T1-postGd images: An area in the

synovial compartment that shows above-normal post-gadolinium enhancement

• n T1-weighted images, of a thickness greater than the width of the normal

joint capsule.

• Option b: Definition of synovitis/effusion, based on STIR/T2FS images: An area

in the synovial compartment that shows high signal intensity on T2-weighted fat- saturated or STIR images, of a thickness greater than the width of the normal joint capsule and joint fluid. Cited from: J Rheumatol 2017;44;1699-1705

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Joints: Osteitis

Procedure: If STIR/T2FS images are available, assess bone edema according to

• ption a. If only T1-postGd images are available: Assess intraosseous post-Gd

enhancement according to option b. Definitions:

• Option a: Definition of osteitis, based on STIR/T2FS images: A lesion within the

trabecular bone, with ill-defined margins and high signal intensity on T2-weighted fat-saturated and STIR images (“bone marrow edema”)

• Option b: Definition of osteitis, based on T1-postGd images): A lesion within the

trabecular bone marrow, with ill-defined margins, which shows above-normal post-gadolinium enhancement on T1-weighted images (“bone marrow post- contrast enhancement”) Cited from: J Rheumatol 2017;44;1699-1705

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Entheses: Entheseal soft tissue inflammation

Procedure: If T1-postGd images are available, entheseal soft tissues should be assessed according to option a. If only STIR/T2FS images are available, entheseal soft tissues should be assessed according to option b. Definitions:

• Option a: Definition of entheseal soft tissue inflammation, based on T1-postGd

images: Above-normal post-gadolinium enhancement of entheseal soft tissues on T1-weighted images.

• Option b. Definition of entheseal soft tissue inflammation, based on STIR/T2FS

images: High signal intensity of the entheseal soft tissues on T2-weighted fat- saturated or STIR images. Cited from: J Rheumatol 2017;44;1699-1705

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Entheses: osteitis

Procedure: If STIR/T2FS images are available, assess bone edema according to

• ption a. If only T1-postGd images are available: Assess intraosseous post-Gd

enhancement according to option b. Definitions

• Option a: Definition of osteitis, based on STIR/T2FS images: A lesion within the

entheseal bone marrow, with ill- defined margins and high signal intensity on T2- weighted fat-saturated and STIR images (“bone marrow edema”).

• Option b. Definition of osteitis, based on T1-postGd images): A lesion within the

entheseal bone marrow, with ill-defined margins, which shows above-normal enhancement (signal intensity increase) on T1-weighted after iv. Gadolinium contrast injection (“bone marrow post-contrast enhancement”). Cited from: J Rheumatol 2017;44;1699-1705

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Grading of 1 (mild) vs. 2 (moderate) vs. 3 (severe)

Osteitis should be assessed in the bone from the articular surface/entheseal insertion to a depth of 1 cm on all available images. Grading scale: The scale is 0-3 based on the proportion of bone with edema, compared to the “assessed bone volume”, judged on all available images: 0: no edema; 1: 1-33% of bone edematous; 2: 34-66% of bone edematous; 3: 67-100%. Synovitis should be assessed in the entire synovial compartment on all available images. Grading scale: Score 0 is normal, while 1-3 is mild, moderate, severe, by thirds of the maximum potential volume of enhancing tissue in the synovial compartment Soft tissue inflammation should be assessed inside the ligament/tendon and in the immediate surroundings of the ligament/tendon to a distance of 1 cm from the entheseal insertion. Grading scale: Score 0 is normal, while 1-3 is mild, moderate, severe, by thirds of the maximum potential volume of enhancing tissue

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Cited from J Rheumatol 2003;30:1385-6 and J Rheumatol 2009;36:1816-24. A similar grading used for soft tissue inflammation .

Three pragmatic rules:

• A positive score of 1 should only be made when the reader is more confident than

not that there is an abnormality. All synovial joints contain normal joint fluid; this should not be scored. The scoring system aims at scoring inflammation. If the reader is hesitating whether to score a possible lesion 1 (mild) or 0 (none), it should probably be scored 0 (none).

• If the lesion is judged borderline 1 vs. 2 or 2 vs. 3, lesion intensity may be taken into
• account. E.g. if a lesion is borderline between 1 (mild) and 2 (moderate), it may be

scored 1 (mild) if not judged intense. Similarly, e.g. if a lesion is borderline between 2 (moderate) and 3 (severe), it may be scored 3 (severe) if judged intense.

• When there is an increased amount of synovial tissue, not just effusion, and the

lesion is judged borderline between two scores, the higher score may be assigned.

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Practical advice:

• Appropriate windowing and zooming is necessary, especially if using a

small laptop screen. Preferentially use a large monitor.

• Lighting in the room may need to be dimmed.
• Keep a reasonable pace during the readout.

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The next two slides shows examples of normal findings.

• Please also go through the images of 4 normal cases that are now

available at www.carearthritis.com

• TIP: You may compare findings in the patients with similar sites in the

healthy controls, if you open up two browser windows and log into the “Normal cases” in one browser window and the “April 2018 Longitudinal Study” in another browser window.

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Blood vessel Normal wrist joint fluid Normal hip joint fluid Normal blood vessel signal at greater femoral trochanter Subcutaneous blood vessels Blood vessel

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Examples of normal findings

Normal MTP-1 joint fluid in recess Normal shoulder joint fluid Normal ankle joint fluid Normal subtalar joint fluid Normal entheses in anterior knee

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Examples of normal findings

Please note:

• In the following examples, for conciseness, only 3 STIR slices are shown. When

actually scoring MR images, an overall assessment must be made based on all slices that depict the anatomical structure

• T1W images may better identify fluid-containing structural changes (e.g. bone

cysts, erosions); these structural changes should not be scored as inflammation.

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Acromioclavicular joint Osteitis: 3 (severe) Synovitis: 3 (severe) SLICE 1 SLICE 2 SLICE 3

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Acromioclavicular joint Osteitis: 1 (mild) Synovitis: 1 (mild) SLICE 1 SLICE 2 SLICE 3

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Acromioclavicular joint Osteitis: 1 (mild) Synovitis: 2 (moderate) SLICE 1 SLICE 2 SLICE 3

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Acromioclavicular joint. Osteitis : 2 (moderate) Synovitis: 1 (mild) Osteitis is borderline 2 or 3, but the increased signal is not intense and therefore scored as 2. SLICE 1 SLICE 2 SLICE 3

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Right ACJ synovitis below threshold. Normal shoulder joint fluid. Erosion/bone cysts in caput humeri should not be scored as BME; the T1W sequence should be reviewed. Signal in soft tissue below threshold. SLICE 1 SLICE 2 SLICE 3

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S S

Left supraspinate tendon Erosion/bone cysts (”C”) should not be scored positive for osteitis. There is, however, osteitis on slice 2 just above threshold. Osteitis: 1 (mild) Soft tissue inflammation: 0 (none) SLICE 1 SLICE 2 SLICE 3 C C

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Sternoclavicular joint Osteitis (clavicular part): 3 (severe) Osteitis (sternal part): 1 (mild) Synovitis: 3 (severe) SLICE 1 SLICE 2 SLICE 3

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Sternoclavicular joint Osteitis (clavicular part): 2 (moderate) Osteitis (sternal part): 3 (severe) Synovitis: 3 (severe) In this case, the right SCJ is only well depicted on slices 2 and 3. SLICE 1 SLICE 2 SLICE 3

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Sternoclavicular joints. Right: Osteitis (clavicular part): 3 (severe) Osteitis (sternal part): 1 (mild) Synovitis: 1 (mild) Left: Osteitis (clavicular part): 3 (severe) Osteitis (sternal part): 1 (mild) Synovitis: 2 (moderate) SLICE 1 SLICE 2 SLICE 3

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Right sternoclavicular joint. Synovitis: 0 (none) BME (clavicular part): 2 (moderate) BME (sternal part): 1 (mild) V: blood vessel SLICE 1 SLICE 2 SLICE 3

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V

Talocrural joint (ankle) Osteitis : 0 (none) Synovitis: 0 (none) A: Small area with increased signal anteriorly, below threshold. B: Some joint fluid posteriorly, below threshold. SLICE 1 SLICE 2 SLICE 3 A B B B

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Hip joint Osteitis (acetabular part): 1 (mild) Osteitis (femoral part): 0 (none) Synovitis: 2 (moderate) SLICE 1 SLICE 2 SLICE 3

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Hip Synovitis : 2 (moderate) Osteitis: 0 (none) Synovitis is borderline 1 or 2, but because synovial tissue is seen, not

• nly effusion, it is scored 2.

SLICE 1 SLICE 2 SLICE 3

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Greater trochanter Osteitis: 0 (none) Soft tissue inflammation: 0 (none) Bone marrow signal is very faint and has similar appearance as signal change further inside the bone (”C”), below threshold. SLICE 1 SLICE 2 SLICE 3 C C

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Hip Osteitis (acetabular): 0 (none) Osteitis (femoral): 0 (none) Synovitis: 0 (none) Normal joint fluid, at threshold but

• below. No synovial tissue can be seen

inside the fluid. SLICE 1 SLICE 2 SLICE 3

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Hip joint: Osteitis (acetabular): 2 (moderate) Osteitis (femoral): 0 (none) Synovitis: 1 (mild) Greater trochanter: Osteitis: 2 (moderate) Soft tissue inflammation: 0 (none) SLICE 1 SLICE 2 SLICE 3

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Greater trochanter. Osteitis : 1 (mild) Soft tissue inflammation: 2 (moderate) SLICE 1 SLICE 2 SLICE 3

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Hip Synovitis : 1 (mild) Osteitis: 0 (none) SLICE 1 SLICE 2 SLICE 3

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Greater trochanter Osteitis: 0 (none) Soft tissue inflammation: 1 (mild) Signal changes in underlying bone is below threshold. Severe hip joint synovitis (”S”) is also present. SLICE 1 SLICE 2 SLICE 3 S S S S

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Greater trochanter. Osteitis : 0 (none) Soft tissue inflammation: 0 (none) Increased soft tissue signal below threshold. SLICE 1 SLICE 2 SLICE 3

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Hip Osteitis (acetabular): 0 (none) Osteitis (femoral): 0 (none) Synovitis: 3 (severe) Synovial tissue may be seen on STIR when image is windowed appropriately. SLICE 1 SLICE 2 SLICE 3

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Knee joint Synovitis: 2 (moderate) SLICE 1 SLICE 2 SLICE 3

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Knee joint Synovitis: 1 (mild) Increased signal may be due to synovitis and/or fluid. Even with

• ptimal windowing it may not be

possible to discriminate on STIR/T2FS. SLICE 1 SLICE 2 SLICE 3

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Knee joint. Synovitis: 0 (none) Patellar osteitis: 0 (none) Normal knee joint fluid. Small area with increased signal in patellar bone marrow too subtle to be scored positive. SLICE 1 SLICE 2 SLICE 3

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Knee joint. Synovitis: 0 (none) Normal knee joint fluid. SLICE 1 SLICE 2 SLICE 3

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Knee Synovitis: 1 (mild) No synovial tissue can be seen. Fluid signal may be misinterpreted as osteitis on e.g. slice 3. However, when scrolling carefully through the images, this signal is seen to belong to the suprapatellar recess. SLICE 1 SLICE 2 SLICE 3

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Pubic symphysis Osteitis (right side): 3 (severe) Osteitis (sternal part): 3 (severe) Soft tissue inflammation: 2 (severe) Soft tissue inflammation > 1 cm away from the pubic symphysis is not taken into account when scoring. SLICE 1 SLICE 2 SLICE 3

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Left ischial tuberosity Osteitis: 2 (moderate) Soft tissue inflammation: 1 (mild) SLICE 1 SLICE 2 SLICE 3

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Achilles tendon insertion Osteitis: 1 (mild) Soft tissue inflammation: 2 (moderate) Retrocalcaneal bursitis is scored as soft tissue inflammation of the Achilles tendon insertion if within 1 cm. Bright fluid (”F”) is more than 1 cm away from insertion and is therefore not taken into account. SLICE 1 SLICE 2 SLICE 3 F

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Talocrural joint Osteitis: 0 (none) Synovitis: 2 (moderate) Insertion of Achilles tendon Osteitis: 0 (none) Soft tissue inflammation: 1 (mild) SLICE 1 SLICE 2 SLICE 3

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Plantar fascia Osteitis: 2 (moderate) Soft tissue inflammation: 2 (moderate) Blood vessels (”V”) should be disregarded when scoring. SLICE 1 SLICE 2 SLICE 3 V V V?

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Insertion of Achilles tendon Osteitis: 2 (moderate) Soft tissue inflammation: 2 (moderate) Even though slice 3 does not show the entheseal insertion, it is partly within 1 cm from the entheseal insertion and therefore should also be taken into account. SLICE 1 SLICE 2 SLICE 3

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MTP-1 Osteitis: 0 (none) Synovitis: 0 (none) Normal amount of joint fluid Blood vessels (”V”) should not be scored. SLICE 1 SLICE 2 SLICE 3 V V

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MTP-1 Osteitis: 0 (none) Synovitis: 1 (mild) SLICE 1 SLICE 2 SLICE 3

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MTP-1 Osteitis: 2 (moderate) Synovitis: 2 (moderate) The proximal phalanx has normal trabecular bone. Osteitis is scored

• verall for both bones. When the T1W

images are reviewed, part of the increased signal on slice 3 corresponds to erosion, i.e. a structural lesion; that part is not scored as inflammation. SLICE 1 SLICE 2 SLICE 3

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Distal radioulnar joint Synovitis: 1 (moderate) Vessel (”V”) should not be scored. SLICE 1 SLICE 2 SLICE 3 V

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Distal radioulnar joint Osteitis: 0 (none) Synovitis: 1 (mild) Radiocarpal joint Osteitis: 0 (none) Synovitis: 2 (moderate) Carpometacarpal/intercarpal joints: Osteitis: 0 (none) Synovitis 2 (moderate) SLICE 1 SLICE 2 SLICE 3

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Radiocarpal joint Normal amount of joint fluid Carpometacarpal/intercarpal Normal amount of joint fluid SLICE 1 SLICE 2 SLICE 3

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Radiocarpal joint Synovitis: 1 (mild) Vessel (”V”) should not be scored. SLICE 1 SLICE 2 SLICE 3 V

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CMC-1 Osteitis: 1 (mild) Synovitis: 1 (mild) At this resolution, scoring of small joints is difficult, e.g. this CMC-1 is

• nly visible on two slices (1-2) and it is

difficult to tell which parts of bright signal that is osteitis or synovitis. SLICE 1 SLICE 2 SLICE 3

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5th proximal interphalangeal joint Osteitis: 0 (none) Synovitis: 2 (moderate) At this resolution, it is hard to tell if the increased signal may also represent osteitis on slice 1, but the bone appears normal on slice 2. SLICE 1 SLICE 2 SLICE 3

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MCP2-MCP5 Normal amount of joint fluid SLICE 1 SLICE 2 SLICE 3

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END

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