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Original Research |
1 Department of Radiology, Medical University Graz, Graz, Austria.
2 Department of Internal Medicine, Medical University Graz, Graz, Austria.
3 Division of Radiology, Hospital of Barmherzige Brueder, Graz, Austria.
4 Diagnostikum Graz Sued West, Weblinger Guertel 25, 8054 Graz, Austria.
Received November 19, 2004;
accepted after revision May 25, 2005.
Address correspondence to K. W. Preidler.
Abstract
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MATERIALS AND METHODS. Eighteen PsA and 21 RA patients with arthralgia of the wrist or hand joints underwent gadolinium-enhanced MRI of the wrist and hand. Two experienced radiologists interpreted abnormalities in consensus with respect to periarticular soft-tissue swelling, synovitis with or without effusion, periostitis, bone edema, bone erosions, bone cysts, and tenosynovitis. The distribution of the abnormalities also was evaluated.
RESULTS. Erosions were statistically more frequent in patients with RA (p < 0.05). Periostitis was statistically seen more frequently in patients with PsA (p < 0.05). No statistically significant difference was found in the frequency of synovitis, bone marrow edema, bone cysts, and tenosynovitis between the two groups (p > 0.05). The radiocarpal joint, the midcarpal joints, the carpometacarpal joints, and the metacarpophalangeal joints were significantly affected more frequently in patients with RA than in patients with PsA (p < 0.05), whereas the proximal interphalangeal joints were significantly more frequently affected in patients with PsA (p < 0.05).
CONCLUSION. Periostitis and synovitis of the proximal interphalangeal joints are typical MRI findings in patients with PsA, whereas synovitis with erosions of the wrist, the midcarpal joints, the carpometacarpal joints, and the metacarpophalangeal joints are typical findings in patients with RA.
Keywords: arthritis • bone • joint • MRI • musculoskeletal system
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To our knowledge, no study has been performed comparing MRI findings of the wrist and hand in patients with PsA and RA. Therefore, the aim of our study was to define typical MRI findings in these patients.
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Data Acquisition
MRI was performed with 1.5-T scanners (Magnetom Symphony, Siemens Medical
Solutions). The slew rate was 86 T/msec; the gradient amplitude was 34 mT/m.
Coronal T1-weighted spin-echo sequences (TR/TE, 440-500/20-23; bandwidth, 65
MHz; matrix size, 192 x 448; section thickness, 3 mm), transverse
inversion time or coronal T1-weighted fast low-angle shot (FLASH) sequences
with fat saturation (473-795/11; bandwidth, 70 MHz; flip angle, 60°;
matrix size, 282 x 512; section thickness, 3-5 mm), and coronal
contrast-enhanced (gadodiamide; Omniscan, Nycomed Amersham) T1-weighted
spin-echo sequences with fat saturation (540-648/23; bandwidth, 65 MHz; matrix
size, 224 x 512; section thickness, 3 mm) were obtained. In addition,
coronal T2-weighted turbo inversion recovery magnitude (TIRM) sequences
(3,000/127; inversion time, 150 milliseconds; bandwidth, 130 MHz; flip angle,
170°; matrix size, 250 x 512; turbo factor, 13; section thickness, 4
mm) were available in 10 patients. The field of view was between 150 and 180
mm.
Data Analysis
Data analysis was performed on a Magic View 1100 workstation (Siemens
Medical Solutions) in consensus by two experienced radiologists blinded to the
patients' history. Analysis was performed with special respect to joint
abnormalities (periarticular soft-tissue swelling and synovitis with or
without intraarticular effusion), bone changes (bone marrow edema, focal bone
erosions, bone cysts, and periostitis), and tenosynovitis. Synovitis and
periostitis were defined as thickened synovial membrane or thickened
periosteum with pronounced contrast enhancement compared with adjacent joints
or bones, respectively. Bone erosions were diagnosed in patients who had
evidence of a combination of focal bone marrow edema and destruction of the
cortex. In each patient, analysis was performed for the radiocarpal joint, the
midcarpal joints, the carpometacarpal joints, the metacarpophalangeal joints,
the proximal interphalangeal joints, and the interphalangeal joint of the
thumb. The distal interphalangeal joints were not evaluated because they were
not sufficiently depicted in many patients. Analysis of bone changes was
performed for the distal radius and ulna, the carpal bones, the metacarpal
bones, the proximal phalanges, and the middle phalanges. The distal phalanges
were not depicted sufficiently.
Statistical Analysis
Statistical analysis was performed using the SPSS software package. The
significance of differences in frequency and localization between both groups
was tested using the chi-square test. Two-tailed values were used, and
probability values of less than 0.05 were considered significant.
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The radiocarpal joint, the midcarpal joints, the carpometacarpal joints, and the metacarpophalangeal joints were significantly more frequently affected in patients with RA than in patients with PsA (p < 0.05). Thirty-nine percent of patients with RA showed synovitis, bone marrow edema, erosions, or cysts of the radiocarpal joint compared with 6% of patients with PsA. The midcarpal joints were affected in 78% of the patients with RA compared with 11% of patients with PsA. The carpometacarpal joints were affected in 62% of patients with RA and in 17% of patients with PsA. The metacarpophalangeal joints were affected in all patients with RA compared with 72% of patients with PsA. The proximal interphalangeal joints were significantly affected more frequently in patients with PsA. Seventy-eight percent of patients with PsA had affected proximal interphalangeal joints compared with 43% of patients with RA.
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In contrast, MRI has reportedly enabled physicians to detect bone marrow edema and active synovitis visually long before changes are detectable on conventional radiographs [3, 6, 7, 15-18]. It is reported that introducing MRI into the diagnostic criteria for early RA may contribute to a more accurate diagnosis in patients suspected of having RA. Sugimoto et al. [8] achieved a sensitivity of 96% and a specificity of 86% for the diagnosis of RA using MRI. In their study, the MRI criterion for RA was gadolinium enhancement with a bilateral distribution in the wrist, metacarpophalangeal joint, proximal interphalangeal joints, or all three. In the same patient population, ARA-revised criteria for RA showed sensitivities of 69% and 77% and specificities of 96% and 91% for the traditional format and classification tree format, respectively. McQueen et al. [15, 16] reported that a high proportion of RA patients develop MRI erosions very early in their disease when conventional radiography is frequently normal and that MRI scans of the wrist, taken when patients first present with RA, can predict radiographic erosions at 2 years. In a study by Ostergaard et al. [17], MRI detection of new radiographic erosions preceded conventional radiography detection by a median of 2 years.
Few studies have investigated MRI findings of the hand in patients with PsA [5, 10]. Offidani et al. [10] showed that in patients with psoriasis but without clinically evident arthritis, joints were frequently affected. They reported periarticular edema and synovitis/intraarticular effusion as the two most frequent findings (36% and 44%, respectively). Periostitis, a frequent finding in our patient population with PsA, was not addressed as a typical finding in the study by Offidani et al. [10]. We consider the different patient populations (absence of acute clinical arthropathy in the study by Offidani et al. versus acute clinical arthropathy in our study) as the reason for this. Savnik et al. [5] reported that MRI of the wrist and finger joints in inflammatory joint disease at 1-year intervals predicts bone erosions in patients with RA but not in patients with PsA. In another study [19], the authors reported a significantly higher frequency of bone marrow edema in patients with established RA (> 3 years) compared with patients with early RA (< 3 years), arthritis other than RA (including patients with reactive arthritis, PsA, and mixed connective tissue disease), or arthralgia. However, patients with PsA (eight patients) were only a small subgroup in this study, and therefore they were not evaluated separately. Jevtic et al. [9] reported that the degree and extent of periarticular soft-tissue involvement was greater in six of 13 patients with PsA compared with patients with RA. The authors stated that the joint capsule may not be the primary target of the disease process in PsA but may become involved later in the disease course. In our study population, the difference in periarticular soft-tissue swelling between patients with PsA and those with RA was 16%, with the higher incidence in the PsA group, but the difference did not reach statistical significance. However, the disease duration in the study by Jevic et al. [9] was less than 2 years; and findings in an early disease course of RA and PsA cannot be transferred to established disease courses as present in our study.
To our knowledge, no study has been performed comparing MRI findings in patients with PsA and RA. Our results showed statistically significant differences in MRI findings of the hand and the wrist in patients with RA and PsA. Periosteal contrast enhancement as a sign of periostitis was significantly more frequent in patients with PsA than in patients with RA. Seventy-eight percent of patients with PsA showed periostitis; however, none of the patients with RA did. Conversely, bone erosions were significantly more frequent in patients with RA than in patients with PsA. The frequency of findings in patients with RA is in accordance with a study by Boutry et al. [20], who reported synovitis of the wrist and metacarpophalangeal joints in 93% and 90%, respectively, of patients with early RA. In our study, 95% of patients with RA showed synovitis. Bone erosions were reported in the wrist joints in 80% and in the metacarpophalangeal joints in 77% of patients. In our study, 86% of patients with RA had bone erosions. The similar frequency of these findings despite the different patient population (early disease in the study by Boutry et al. [20] vs established disease in our study) can be explained by the fact that the patients in our study also had acute clinical arthropathy and thus also showed signs of acute arthritis.
Aside from the difference in frequency of joint and bone abnormalities, patients with RA and PsA also showed significant differences in articular distribution of abnormalities. The radiocarpal joint, the midcarpal joints, the carpometacarpal joints, and the metacarpophalangeal joints were significantly more frequently affected in patients with RA than in patients with PsA, whereas the proximal interphalangeal joints were more frequently affected in patients with PsA. The frequency of proximal interphalangeal joint involvement in patients with PsA seems quite high and might be explained by the long-term disease course of our study population because it is well known that in PsA the distal interphalangeal joints are affected first, followed by the proximal interphalangeal joints and the remaining joints of the hand and the wrist.
The MRI protocol in this study was the standard protocol of our institutions for diagnosis of inflammatory disorders, including T1-weighted spin-echo, T1-weighted fat-saturated FLASH, and contrast-enhanced fatsaturated T1-weighted spin-echo sequences. T2-weighted TIRM sequences were also performed but were not available in all patients. However, Schmid et al. [21] reported that STIR images and T1-weighted contrast-enhanced fat-suppressed MR images show almost identical imaging patterns in bone marrow abnormalities. One can assume that this is also valid for TIRM images.
Our study has several potential limitations. First, it was a retrospective analysis of a small patient population, which might have influenced the significance of the findings. However, the tendency toward PsA or RA was pronounced in some findings. This is especially valid for periosteal enhancement as a sign of acute periostitis, which was a frequent finding in patients with PsA and was not found in patients with RA. This seems consistent because periosteal thickening and bone proliferations are typical signs of PsA on radiographs [12] and can be considered as later signs of periostitis. Second, only patients classified as having RA or PsA were included in our retrospective study; therefore, the results cannot be extrapolated to all patients who complain of arthralgia or arthritis because of the assessment of selected subjects. Prospective studies are necessary to prove whether the findings shown in our study can help differentiate these two arthritides at a subclinical or early clinical stage. Third, MRI was only performed of the wrist and hand, although RA and PsA are systemic diseases with the involvement of multiple joints, especially RA. However, the wrist and hand joints are frequently affected in RA and affected in 85% of patients with PsA. In addition, the distal interphalangeal joints were not evaluated because of lack of sufficient depiction in many patients. That might have influenced the results because PsA predominantly affects these joints.
In conclusion, MRI may not only detect radiologic features supporting the development of an inflammatory disorder but may also help discriminate between RA and PsA, particularly in those patients who present with a polyarthritis involving the hand and wrist joints. Further studies are necessary to prove whether the findings shown in our study can help differentiate PsA and RA at an early stage.
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