Magnetic resonance imaging of rheumatoid arthritis: The evolution of clinical applications through clinical trials*

https://doi.org/10.1053/sarh.2001.22497Get rights and content

Abstract

Powerful techniques are being developed for evaluating rheumatoid arthritis with magnetic resonance imaging (MRI). Much of this development is being driven by the pharmaceutical and biotechnology industries searching for novel therapies for this disease. Accordingly, the imaging tools that ultimately will be used to direct patients to specific therapies and then to monitor treatment effectiveness and safety are currently being refined and validated in rigorous multicenter and multinational clinical trials aimed at gaining regulatory approval of these new therapies. As these trials approach completion, rheumatologists can anticipate an increased demand for expertise and experience in evaluating disease progression and treatment response with these techniques and the emergence of MRI systems specifically designed for this market. The following discussion reviews this novel pathway for evolving imaging techniques for clinical use through clinical drug trials, lists the most promising MRI markers available today for evaluating joint destruction in rheumatoid arthritis, and speculates on how these techniques will find their way into clinical practice. Semin Arthritis Rheum 30:375-396. Copyright © 2001 by W.B. Saunders Company

Section snippets

How MRI works

MRI creates images by causing hydrogen nuclei (protons) within tissues to align with the strong magnetic field within the bore of an MRI magnet, much like a compass needle aligns with the magnetic field of the earth 5, 8, 9. Exposing these protons to an additional alternating or rotating magnetic field perpendicular to the static main magnetic field and tuned to the resonant frequency of the protons (ie, applying a radio-frequency pulse) causes the protons to realign with this new field.

Fundamental advantages of MRI

MRI offers 3 principal advantages over conventional radiography for evaluating diarthroidial joints: 1) multiplanar tomography, 2) unparalleled soft tissue contrast, and 3) digital image format.

Specialized MRI systems

A number of new MRI systems have recently been developed that differ radically from the traditional whole-body design of conventional MRI and that offer intriguing alternatives for imaging patients with arthritis (13). These systems come in various sizes and field strengths (Fig 9) and offer a variety of potential advantages over conventional MRI, including significantly lower cost (potentially less than one quarter that of conventional MRI); greater patient comfort and safety, including fewer

MRI evaluation of bone erosion in arthritis

The ability of MRI to evaluate bone has been the subject of considerable debate and misconception. Because of the relative lack of constituent hydrogen protons in cortical and trabecular bone, these structures generally offer no detectable signal on conventional MRI images. On the surface, this may appear as a fundamental limitation of the technique for imaging this tissue. In reality, however, it is the very basis for image contrast, because the linear signal voids of cortical and trabecular

MRI evaluation of synovial changes in arthritis

Before bone erosion in rheumatoid arthritis there is thickening and inflammation of the synovium and accumulation of joint effusion. The goal of modern therapy is to prevent bone erosion from ever developing by suppressing inflammation and synovitis early in the disease process. As with cartilage loss, radiography cannot show these inflammatory and synovial changes directly. MRI, however, is well suited to this. Normal synovium is generally too thin to visualize with conventional MRI. Moreover,

MRI evaluation of articular cartilage

The high water content (proton density) of articular cartilage forms the basis for its signal on MRI. Water content in this tissue depends on the delicate balance between the swelling pressure of the aggregated proteoglycans and the counterresistance provided by the fibrous collagen matrix, but in general terms, changes in cartilage proton density tend to be relatively small (typically less than 20%). Because the water constitutes approximately 70% of the weight of normal articular cartilage,

Imaging complications of arthritis and its treatment

In addition to monitoring changes in the bones, cartilage, and synovium of arthritic joints, MRI is the technique of choice for evaluating many of the complications that may arise because of the disease or the therapy used to treat it. One serious complication is tendon rupture. This may result from mechanical fraying of tendons passing over jagged osteophytes and sharp-edged erosions or from direct tenosynovial invasion of the tendon 74, 75. Tendon avulsion at sites of enthesitis may also

Conclusion

Powerful tools for evaluating the integrity of articular cartilage are emerging from clinical trials designed to test the efficacy and safety of new therapies for rheumatoid arthritis. These clinical trials represent a provocative environment in which imaging techniques originally developed to answer questions about cruciate ligament and meniscal integrity are being forged into new markers designed to serve therapeutic applications in rheumatoid arthritis that are just entering clinical

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    *

    Address correspondence to Charles G. Peterfy, MD, PhD, Chief Medical Officer, Synarc Inc, 455 Market St, Suite 1850, San Francisco, CA 94105. E-mail: [email protected]

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