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 1
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 2
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 on 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 3
Joints: Osteitis Procedure: If STIR/T2FS images are available, assess bone edema according to option 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 4
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 5
Entheses: osteitis Procedure: If STIR/T2FS images are available, assess bone edema according to option 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 6
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 Cited from J Rheumatol 2003;30:1385-6 and J Rheumatol 2009;36:1816-24. A similar grading used for soft tissue inflammation . 7
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. 8
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. 9
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. 10
Examples of normal findings Blood vessel Normal wrist joint fluid Subcutaneous blood vessels Blood vessel Normal blood vessel signal at Normal hip greater femoral joint fluid trochanter 11
Examples of normal findings Normal ankle Normal joint fluid shoulder joint fluid Normal subtalar joint fluid Normal Normal entheses in MTP-1 anterior knee joint fluid in recess 12
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. 13
Acromioclavicular joint SLICE 1 Osteitis: 3 (severe) Synovitis: 3 (severe) SLICE 2 SLICE 3 14
Acromioclavicular joint SLICE 1 Osteitis: 1 (mild) Synovitis: 1 (mild) SLICE 2 SLICE 3 15
Acromioclavicular joint SLICE 1 Osteitis: 1 (mild) Synovitis: 2 (moderate) SLICE 2 SLICE 3 16
Acromioclavicular joint. SLICE 1 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 2 SLICE 3 17
Right ACJ synovitis below threshold. SLICE 1 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 2 SLICE 3 S S 18
Left supraspinate tendon SLICE 1 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) C SLICE 2 SLICE 3 C 19
Sternoclavicular joint SLICE 1 Osteitis (clavicular part): 3 (severe) Osteitis (sternal part): 1 (mild) Synovitis: 3 (severe) SLICE 2 SLICE 3 20
Sternoclavicular joint SLICE 1 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 2 SLICE 3 21
Sternoclavicular joints. SLICE 1 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 2 SLICE 3 22
Right sternoclavicular joint. SLICE 1 V Synovitis: 0 (none) BME (clavicular part): 2 (moderate) BME (sternal part): 1 (mild) V: blood vessel SLICE 2 SLICE 3 23
Talocrural joint (ankle) SLICE 1 Osteitis : 0 (none) Synovitis: 0 (none) B A: Small area with increased signal anteriorly, below threshold. B: Some joint fluid posteriorly, below threshold. SLICE 2 SLICE 3 B A B 24
Hip joint SLICE 1 Osteitis (acetabular part): 1 (mild) Osteitis (femoral part): 0 (none) Synovitis: 2 (moderate) SLICE 2 SLICE 3 25
Hip SLICE 1 Synovitis : 2 (moderate) Osteitis: 0 (none) Synovitis is borderline 1 or 2, but because synovial tissue is seen, not only effusion, it is scored 2. SLICE 2 SLICE 3 26
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