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To evaluate the potential of MRI of finger and wrist joints for diagnosing early RA. MRI was evaluated as a stand-alone tool and in combination with ACR criteria and serum markers such as RF.Ninety-nine patients (31 men, 68 women; median age 46 years) with unspecified arthritis or suspected RA and negative X-ray findings were included. MR images of the hand and wrist of these patients were retrospectively evaluated for the presence of synovitis, erosions and tenosynovitis. The clinical diagnosis (early RA or non-RA) was made by a rheumatologist after clinical follow-up for 6-41 months. Clinical and laboratory data were collected from all patients.Fifty-eight patients had a clinical diagnosis of RA and 41 were diagnosed as non-RA. Step-wise logistic regression of all MR parameters evaluated identified tenosynovitis of the flexor tendons to be the most powerful predictor of early RA (sensitivity = 60%, specificity = 73%). Including ACR criteria in the analysis, positive serum RF and tenosynovitis were the strongest predictors of early RA (sensitivity = 83%, specificity = 63%). When serum anti-cyclic citrullinated peptides (CCP), ANA and CRP were included as additional parameters, anti-CCP and flexor tenosynovitis were the strongest predictors of early RA (sensitivity = 79%, specificity = 73%).Flexor tenosynovitis diagnosed by MRI of the hand is a strong predictor of early RA. Combining flexor tenosynovitis on MRI with positive serum anti-CCP or positive RF is an even stronger predictor of early RA.

Ankylosing spondylitis is the prototypical spondyloarthritis. Early diagnosis has gained clinical importance with the advent of new therapeutic options such as TNF-alpha inhibitors, which can dramatically improve clinical outcome when initiated early. Whole-body MRI can contribute important diagnostic information for detecting early forms of spondyloarthritis because it enables evaluation of all important joints that may be involved in the disease process as a one-stop shop modality. MRI allows much more accurate diagnostic evaluation of the thoracic spine, which is affected in the majority of patients. This article provides an overview of the use of whole-body magnetic resonance imaging (MRI) in the spondyloarthritides. The recommendations given reflect the most recent scientific data and expert opinions. The focus of this review is on MRI findings at both the axial and the appendicular skeleton and the technical feasibility of whole-body MRI in the clinical setting.

Udgivelsesdato: 2009-Oct BACKGROUND: Magnetic resonance imaging (MRI) of sacroiliac joints has evolved as the most relevant imaging modality for diagnosis and classification of early axial spondyloarthritis (SpA) including early ankylosing spondylitis. OBJECTIVES: To identify and describe MRI findings in sacroiliitis and to reach consensus on which MRI findings are essential for the definition of sacroiliitis. METHODS: Ten doctors (two radiologists and eight rheumatologists) from the ASAS/OMERACT MRI working group reviewed and discussed in three workshops MR images depicting sacroiliitis associated with SpA and other conditions which may mimic SpA. Descriptions of the pathological findings and technical requirements for the appropriate acquisition were formulated. In a consensual approach MRI findings considered to be essential for sacroiliitis were defined. RESULTS: Active inflammatory lesions such as bone marrow oedema (BMO)/osteitis, synovitis, enthesitis and capsulitis associated with SpA can be detected by MRI. Among these, the clear presence of BMO/osteitis was considered essential for defining active sacroiliitis. Structural damage lesions such as sclerosis, erosions, fat deposition and ankylosis can also be detected by MRI. At present, however, the exact place of structural damage lesions for diagnosis and classification is less clear, particularly if these findings are minor. The ASAS group formally approved these proposals by voting at the annual assembly. CONCLUSIONS: For the first time, MRI findings relevant for sacroiliitis have been defined by consensus by a group of rheumatologists and radiologists. These definitions should help in applying correctly the imaging feature "active sacroiliitis by MRI" in the new ASAS classification criteria for axial SpA.

The blood pool agent indo-cyanine green (ICG) has been investigated for early detection of rheumatoid arthritis using fluorescence imaging. Different distributions of fluorescence intensity are found for healthy and inflamed finger joints after i.v. injection of an ICG bolus .

Purpose To evaluate the incidence of MRI-related claustrophobia and prematurely terminated MRI (ptMRI) examinations due to claustrophobia in a large-scale cohort study. Materials and Methods The hospital's computerized radiology information system (RIS) was retrospectively analyzed for all 1.5-Tesla MRI examinations and reports during the year 2004. Data collected included demographic information, body part examined, known claustrophobia, and whether the examination was prematurely terminated. All information available on the MRI examinations and the patient-based data (i.e., excluding any additional examinations per patient) were analyzed. Results A total of 5798 MRI reports of 4821 patients were evaluated. A total of 95 patients (1.97%) suffered from claustrophobia and 59 (1.22%) prematurely terminated the examination due to claustrophobia. The incidence of ptMRI was higher in women than men (no statistical significance). The majority of patients with ptMRI were between 20 and 80 years old. Patients undergoing head MRI showed the highest incidence of ptMRI and those undergoing extremity, breast, or pelvic MRI had the lowest. Prone compared to supine positioning results in the lowest ptMRI incidence (P < 0.05). Conclusion Claustrophobic reactions cause a relatively low incidence of ptMRI and are influenced by sex, body part examined, and positioning within the MR scanner. Sedation and prone positioning might help overcome these reactions. J. Magn. Reson. Imaging 2007. © 2007 Wiley-Liss, Inc.

Purpose of review The past 18 months has seen considerable advances in the use of MRI for assessment of ankylosing spondylitis, to quantify active inflammation in the spine and sacroiliac joints which may not otherwise be detectable and to therefore measure change due to therapeutic interventions. Recent findings Characterization of the extension and morphology of inflammation in ankylosing spondylitis is now possible with MRI techniques. A number of randomized controlled trials of anti-tumour necrosis factor agents in ankylosing spondylitis have now been published showing regression of inflammatory lesions in the spine by MRI. Furthermore, the role of MRI for the early diagnosis of spondyloarthritis has become clearer. This review discusses the techniques used, the capabilities and the shortcomings of MRI in assessing ankylosing spondylitis patients. Summary MRI techniques have implications for early identification and intervention in patients with ankylosing spondylitis.

Magnetic resonance imaging (MRI) of the spine is increasingly important in the assessment of inflammatory activity in clinical trials with patients with ankylosing spondylitis (AS). We investigated feasibility, inter-reader reliability, sensitivity to change, and discriminatory ability of 3 different scoring methods for MRI activity and change in activity of the spine in patients with AS.Thirty sets of spinal MRI at baseline and after 24 weeks of followup, derived from a randomized clinical trial comparing a tumor necrosis factor (TNF)-blocking drug (n = 20) with placebo (n = 10) and selected to cover a wide range of activity at baseline and change in activity, were presented electronically in a partial latin-square design to 9 experienced readers from different countries (Europe, Canada). Readers scored each set of MRI 3 times, using 3 different methods including the Ankylosing Spondylitis spine Magnetic Resonance Imaging-activity [ASspiMRI-a, grading activity (0-6) per vertebral unit in 23 units]; the Berlin modification of the ASspiMRI-a; and the Spondyloarthritis Research Consortium of Canada (SPARCC) scoring system, which scores the 6 vertebral units considered by the reader as the most abnormal, with additional scores for "depth" and "intensity." Both the order of the methods used by each reader and the timepoints (before/after treatment) were randomized. Feasibility of each scoring system was evaluated by measuring the mean time needed to score each set of MRI, and inter-reader reliability was evaluated by smallest detectable change (SDC) and by intraclass correlation coefficients (ICC) for all readers together and for all possible reader pairs separately. Sensitivity to change was investigated by calculating Guyatt's effect size on change scores. Discriminatory ability was assessed using Z-scores (Mann-Whitney test) comparing change in score between patients treated with TNF-blocking drug and placebo.The mean time to score one set of MRI was shortest for the Berlin method. SDC was lowest for the Berlin method and highest for SPARCC. Overall inter-reader ICC per method were between 0.49 and 0.77 for scoring activity status, and between 0.46 and 0.72 for scoring activity change. ICC for all possible reader pairs showed much more fluctuation per method, with lowest observed values of about 0.05 (very low agreement) and highest observed values over 0.90 (excellent agreement). In general, ICC for SPARCC were consistently higher than for other systems. Sensitivity to change differed per reader, and was more consistent with SPARCC than with the other methods, but was in general excellent for all 3 methods. Discrimination between groups (TNF-blocker vs placebo) assessed by Z-scores was good and comparable among methods.This experiment demonstrates the feasibility of multiple-reader MRI scoring exercises for method comparison, provides evidence for the feasibility, reliability, sensitivity to change, and discriminatory capacity of all 3 tested scoring systems to be used in assessing spinal activity on MRI in patients with AS in clinical trials. On the basis of these results it is not possible to prioritize one of the 3 methods.

A young girl suffering from ankle pain occurring after gymnastics classes was referred to the rheumatology department by an orthopedic surgeon because a rheumatological condition was suspected to cause her symptoms. MRI was useful in pointing to the correct diagnosis of accessory navicular bone (AN). The morphological classification of ANs is discussed and the imaging modalities for diagnosis are presented.

Objective To compare MRI evaluation of a painful hindfoot of patients with spondyloarthritides (SpA) on low-field (0.2 T) versus high-field (1.5 T) MRI. Materials and methods Patients with SpA and hindfoot pain were randomly referred to either high-field or low-field MRI. Twenty-seven patients were evaluated (male/female: 17:10; mean age: 39 ± 1.4 years). Fifteen patients were examined by low-field and 12 by high-field MRI. Two patients (evaluated by high-field MRI) were excluded. Images were separately read by two radiologists who later reached a consensus. In each patient the prevalence of erosions, fluid, synovitis or bone marrow edema of the hindfoot joints, tendinosis or tenosynovitis of tendons, enthesitis of the plantar fascia and Achilles tendon and retrocalcaneal bursitis were recorded. Clinical and demographic parameters were comparable between both groups. Results MRI evaluation of joints and tendons of the hindfoot revealed no significant differences in patients with SpA groups for all parameters. Analyzing all joints or tendons together, there was no statistically significant difference between the two groups. Conclusion Low-field and high-field MRI provide comparable information for evaluation of inflammatory hindfoot involvement. Thus, low-field MRI can be considered as a reliable diagnostic tool for the detection of hindfoot abnormalities in SpA patients.

Magnetic resolution imaging (MRI) is a promising tool in the assessment of inflammation and structural damage in clinical trials in ankylosing spondylitis (AS). The ASAS/OMERACT MRI in AS working group, a collaborative initiative of rheumatologists and musculoskeletal radiologists with a special interest in this field, collected data on all available scoring methods for both sacroiliac (SI) joints and spine, and tested them with respect to the OMERACT filter. These data were presented together with the technical specifications of all methods at the OMERACT 7 conference. In addition, the results of 2 separate experiments on the inter-reader reliability of scoring methods to assess activity in SI joints, and on the comparison of STIR sequence versus T1 post-gadolinium (Gd) sequence for the spine, were presented. Thereafter, 8 groups discussed these data and proposed a research agenda, each on a different topic. This information was reported back to all participants and a prioritized research agenda was compiled by voting. Research on scoring methods for assessing disease activity, in both the spine and SI joints, was considered most important. Research on assessing structural damage was considered less important. The specific process and results of this initiative are discussed.

Magnetic resonance imaging (MRI) of the sacroiliac (SI) joints and the spine is increasingly important in the assessment of inflammatory activity and structural damage in clinical trials with patients with ankylosing spondylitis (AS). We investigated inter-reader reliability and sensitivity to change of several scoring systems to assess disease activity and change in disease activity in patients with AS. Twenty sets of consecutive MRI, derived from a randomized clinical trial comparing an active drug with placebo and selected on the basis of the presence of activity at baseline, were presented electronically to 7 experienced readers from different countries (Europe, Canada). Readers scored the MRI by 3 different methods including: a global score (grading activity per SI joint); a more comprehensive global score (grading activity per SI joint per quadrant); and a detailed scoring system [Spondyloarthritis Research Consortium of Canada (SPARCC) scoring system], which scores 6 images, divided into quadrants, with additional scores for "depth" and "intensity." A fourth and a fifth scoring system were constructed afterwards. The fourth method included the SPARCC score minus the additional scores for "depth" and "intensity," and the fifth method included the SPARCC slice with the maximum score. Inter-reader reliability was investigated by calculating intraclass correlation coefficients (ICC) for all readers together and for all possible reader pairs. Sensitivity to change was investigated by calculating standardized response means (SRM) on change scores that were made positive. Overall inter-reader ICC per method were between 0.47 and 0.58 for scoring status, and between 0.40 and 0.53 for scoring change. ICC per possible reader pairs showed much more fluctuation per method, with lowest observed values close to zero (no agreement) and highest observed values over 0.80 (excellent agreement). In general, agreement of status scores was somewhat better than agreement of change scores, and agreement of the comprehensive SPARCC scoring system was somewhat better than agreement of the more condensed systems. Sensitivity to change differed per reader, but in general was somewhat better for the comprehensive SPARCC system. This experiment under "real life," far from optimal conditions demonstrates the feasibility of scoring exercises for method comparison, provides evidence for the reliability and sensitivity to change of scoring systems to be used in assessing activity of SI joints in clinical trials, and sets the conditions for further validation research in this field.

Depiction of inflammatory lesions by magnetic resonance imaging (MRI) in ankylosing spondylitis (AS) is possible both by short-tau inversion recovery (STIR) imaging and by gadolinium-enhanced T1-weighted imaging with fat saturation (T1/Gd). The aim of this prospective study was to investigate whether Gd-enhanced sequences add relevant information compared to STIR imaging alone in the detection of active spinal lesions. MRI of the spine was performed in 48 patients with AS, who participated in a clinical trial of tumor necrosis factor blocking drugs, by STIR and T1/Gd at baseline and after 6 months. Images were evaluated separately for the 2 techniques by 2 readers blinded for true time sequence and treatment. The ASspiMRI-a scoring method was used, in which 23 vertebral units are graded for inflammation from 0 to 6 (total score 0 to 138). Mean scorings of both techniques within readers were in the same range (reader 1: STIR 7.8, T1/Gd 7.7; reader 2: STIR 4.4, T1/Gd 4.7). Intraclass correlation coefficients comparing STIR and T1/Gd where high for both status scores (reader 1: 0.88; reader 2: 0.90) and change scores (both readers: 0.88). Bland and Altman analysis for both sequences showed homogeneous interreader variability along the entire spectrum of scorings, for both status scores and change scores. Smallest detectable change for status scores was 6.2 for STIR and 6.7 for T1/Gd, and for change scores 6.5 and 6.3, respectively. Standardized response means were comparable for both methods (range: 0.80-1.09). In conclusion, both STIR and T1/Gd sequences measure inflammation of the spine, as well as change of inflammation, with a high level of agreement between the 2 sequences. For future clinical randomized trials with MRI of the spine as outcome measure, STIR could be considered for use as the sole imaging technique.

To perform a prospective long term follow up study comparing conventional radiography (CR), ultrasonography (US), and magnetic resonance imaging (MRI) in the detection of bone erosions and synovitis in rheumatoid arthritis (RA) finger joints.The metacarpophalangeal and proximal interphalangeal joints II-V (128 joints) of the clinically dominant hand of 16 patients with RA were included. Follow up joint by joint comparisons for erosions and synovitis were made.At baseline, CR detected erosions in 5/128 (4%) of all joints, US in 12/128 (9%), and MRI in 34/128 (27%). Seven years later, an increase of joints with erosions was found with CR (26%), US (49%) (p0.001 each), and MRI (32%, NS). In contrast, joint swelling and tenderness assessed by clinical examination were decreased at follow up (p = 0.2, p0.001). A significant reduction in synovitis with US and MRI (p0.001 each) was seen. In CR, 12 patients did not have any erosions at baseline, while in 10/12 patients erosions were detected in 25/96 (26%) joints after 7 years. US initially detected erosions in 9 joints, of which two of these joints with erosions were seen by CR at follow up. MRI initially found 34 erosions, of which 14 (41%) were then detected by CR.After 7 years, an increase of bone erosions was detected by all imaging modalities. In contrast, clinical improvement and regression of synovitis were seen only with US and MRI. More than one third of erosions previously detected by MRI were seen by CR 7 years later.

To develop an ultrasonographic (US) synovitis scoring system suitable for evaluation of finger joint inflammation in patients with active rheumatoid arthritis (RA) and to compare semiquantitative US scoring with quantitative US measurements.US was performed at the palmar and dorsal sides of the second through fifth metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints in 10 healthy subjects and in the clinically more affected hand in 46 RA patients. Ten patients additionally underwent magnetic resonance imaging (MRI). Synovitis was measured, standardized, and scored according to a semiquantitative method. The 2 methods (semiquantitative US scoring, quantitative US) were compared and statistical cutoffs were identified using receiver operating characteristic (ROC) curve analysis. MRI results were compared with semiquantitative US scoring and quantitative US results. The optimal US scoring method from 6 joint combinations was identified (ROC curve analysis).Synovitis was most frequently detected in the palmar proximal area (86% of affected joints). We found no significant differences between individual PIP joints or between individual MCP joints, indicating that all fingers within each of these joint groups should be treated equally for statistical calculations, although each joint group as a whole should be treated separately. The optimal cutoff point to distinguish between "health" and "pathology" was 0.6 mm both for MCP joints (sensitivity 94%, specificity 89%) and for PIP joints (sensitivity 90%, specificity 88%). There was no significant difference between semiquantitative US scores and quantitative US measurements. The best results for joint combinations were achieved using the "sum of 4 fingers" (second through fifth MCP and PIP joints) and "sum of 3 fingers" (second through fourth MCP and PIP joints) methods. Comparison of MRI results with semiquantitative US scores revealed high concordance.US evaluation of finger joint synovitis can be considerably simplified by focusing on the palmar side and by applying semiquantitative grading instead of quantitative measurements. For evaluation of treatment efficacy based on synovitis in RA patients, we recommend using the "sum of 3 fingers" method in longitudinal trials.

Objective: To evaluate the interobserver reliability among 14 experts in musculoskeletal ultrasonography (US) and to determine the overall agreement about the US results compared with magnetic resonance imaging (MRI), which served as the imaging "gold standard". Methods: The clinically dominant joint regions (shoulder, knee, ankle/toe, wrist/finger) of four patients with inflammatory rheumatic diseases were ultrasonographically examined by 14 experts. US results were compared with MRI. Overall agreements, sensitivities, specificities, and interobserver reliabilities were assessed. Results: Taking an agreement in US examination of 10 out of 14 experts into account, the overall κ for all examined joints was 0.76. Calculations for each joint region showed high κ values for the knee (1), moderate values for the shoulder (0.76) and hand/finger (0.59), and low agreement for ankle/toe joints (0.28). κ Values for bone lesions, bursitis, and tendon tears were high (κ = 1). Relatively good agreement for most US findings, compared with MRI, was found for the shoulder (overall agreement 81%, sensitivity 76%, specificity 89%) and knee joint (overall agreement 88%, sensitivity 91%, specificity 88%). Sensitivities were lower for wrist/finger (overall agreement 73%, sensitivity 66%, specificity 88%) and ankle/toe joints (overall agreement 82%, sensitivity 61%, specificity 92%). Conclusion: Interobserver reliabilities, sensitivities, and specificities in comparison with MRI were moderate to good. Further standardisation of US scanning techniques and definitions of different pathological US lesions are necessary to increase the interobserver agreement in musculoskeletal US.

Objectives: To compare the performance of two different MRI sequences—T1 weighted, fat saturated, spin echo after application of contrast medium, and short τ inversion recovery (STIR) sequences—to detect spinal inflammation in patients with ankylosing spondylitis (AS). Methods: Both MRI sequences were performed in 38 patients with active AS and compared using the MRI activity scoring system, ASspiMRI-a. One vertebral unit (VU) was defined as the region between two virtual lines drawn through the middle of each vertebral body. Results: Intraclass correlation coefficients were excellent—0.91 and 0.86 for the Gd-DTPA and STIR sequences, respectively. The overall correlation of the single MRI scores for both sequences was also good (r = 0.84, p = 0.01). The intrarater variance was 6.71 and 9.41 and the interrater variance was 13.16 and 19.04 for the Gd-DTPA and STIR sequences, respectively. The smallest detectable distance was 4.7 and 5.6 for the Gd-DTPA and STIR sequences, respectively. The concordance rate for both sequences was 83.5% (range 80.5–87.7% in the three spinal segments). Inflammatory spinal lesions were found in 10.1% of the VUs in the STIR sequence but not in the T1/Gd-DTPA sequence, while the T1/Gd-DTPA sequence showed inflammatory lesions in 6.4% of the VUs that were found normal by STIR. Conclusions: Both MRI techniques can evaluate active spinal lesions in patients with AS. More spinal lesions are detected by the STIR sequence, but the reliability between readings and readers is better for the Gd-DTPA sequence. The ASspiMRI-a is a reliable instrument for evaluating acute spinal changes in AS.

The axial skeleton is a target for both spondyloarthritis and rheumatoid arthritis. While conventional radiography allows the clear documentation of the late stages of inflammatory changes, magnetic resonance imaging (MRI) is sensitive enough to depict early inflammatory lesions. It is, therefore, of particular importance for radiologists and clinicians to know the MRI appearances of inflammatory changes of the axial skeleton in rheumatoid diseases. Typical lesions in ankylosing spondylitis and related conditions comprise spondylitis (Romanus lesion), spondylodiscitis (Andersson lesion), arthritis of the apophyseal joints, the costovertebral and costotransverse joints, and insufficiency fractures of the ankylosed vertebral spine (non-inflammatory type of Andersson lesion). Sacroiliitis is associated with chronic changes such as sclerosis, erosions, transarticular bone bridges, periarticular accumulation of fatty tissue and ankylosis. In addition, acute findings include capsulitis, juxta-articular osteitis and the enhancement of the joint space after contrast medium administration. Another important sign of spondyloarthritis is enthesitis, which affects the interspinal and supraspinal ligaments of the vertebral spine and the interosseous ligaments in the retroarticular space of the sacroiliac joints. The main site of manifestation of spinal involvement in rheumatoid arthritis is the cervical spine. Typical changes are the destruction of the atlantoaxial complex by pannus tissue with subsequent atlantoaxial subluxation, basilar impression and erosion of the dens axis. Changes in the lower segments of the cervical spine are destruction of the apophyseal joints resulting in the so-called stepladder phenomenon. Because of the uniform response of the discovertebral complex to different noxae, a number of different conditions must be distinguished on the basis of the patient's clinical findings and history in combination with their imaging appearance. These conditions comprise degenerative disc disease, septic spondylodiscitis, Scheuermann's disease, Paget's disease and diffuse idiopathic skeletal hyperostosis (DISH).

Objective: To identify classifiers in images obtained with sagittal laser optical tomography (SLOT) that can be used to distinguish between joints affected and not affected by synovitis. Methods: 78 SLOT images of proximal interphalangeal joints II–IV from 13 patients with rheumatoid arthritis were compared with ultrasound (US) images and clinical examination (CE). SLOT images showing the spatial distribution of scattering and absorption coefficients within the joint cavity were generated. The means and standard errors for seven different classifiers (operator score and six quantitative measurements) were determined from SLOT images using CE and US as diagnostic references. For classifiers showing significant differences between affected and non-affected joints, sensitivities and specificities for various cut off parameters were obtained by receiver operating characteristic (ROC) analysis. Results: For five classifiers used to characterise SLOT images the mean between affected and unaffected joints was statistically significant using US as diagnostic reference, but statistically significant for only one classifier with CE as reference. In general, high absorption and scattering coefficients in and around the joint cavity are indicative of synovitis. ROC analysis showed that the minimal absorption classifier yields the largest area under the curve (0.777; sensitivity and specificity 0.705 each) with US as diagnostic reference. Conclusion: Classifiers in SLOT images have been identified that show statistically significant differences between joints with and without synovitis. It is possible to classify a joint as inflamed with SLOT, without the need for a reference measurement. Furthermore, SLOT based diagnosis of synovitis agrees better with US diagnosis than CE.

Takayasu’s arteritis and primary biliary cirrhosis (PBC) are two unrelated autoimmune diseases without a so far reported coincidence, probably because they occur at different ages.1,2 As a systemic vasculitis, Takayasu’s arteritis affects predominantly the aorta and its branches in female patients before the age of 40 years. The clinical manifestations are variable and severe anatomical lesions can lead to life threatening ischaemia. We report an unusual case, where, after the initial diagnosis of a coincident severe Takayasu’s arteritis with PBC, subsequent immunosuppressive treatment led to a striking clinical improvement of vasculitic symptoms in an elderly woman. A 70 year old woman was referred to our hospital with generalised weakness and disseminated painful cutaneous, erythematous nodules on the extensor sites of both lower legs. A rheumatic disorder had been suspected since 1960 because of remittent nausea, attacks of fulminant headaches, and an erythema nodosum. Clinical examination showed a diminished bilateral radial and an absent carotid pulse as well as hypotensive blood pressure on both arms (85/60 and 90/60 mm …

To determine the role of ultrasound and magnetic resonance imaging (MRI) compared with conventional radiography in the detection of chronic and acute inflammatory manifestations of rheumatoid arthritis (RA) of the shoulder joint.Forty-three consecutive patients with known RA prospectively underwent clinical examination, radiography, ultrasound, and MRI of the shoulder joints. Each patient was assigned a clinical/laboratory score consisting of 7 parameters, including measurements of shoulder mobility, the erythrocyte sedimentation rate, and C-reactive protein level. Conventional radiography was standardized and performed in 2 planes. Ultrasound was performed in 10 predefined planes using a 7.5-MHz linear transducer. MRI at 1.5T comprised transverse and oblique coronal T1- and T2*-weighted fast spin-echo, gradient-echo (GRE), and inversion-recovery sequences with a matrix size of up to 512 pixels. A dynamic T1-weighted GRE sequence was acquired with intravenous administration of contrast medium. Erosions were assessed using all 3 imaging techniques on a 4-point scale. Soft-tissue involvement was evaluated according to the presence of synovitis, tenosynovitis, and bursitis on ultrasound and MRI. The results in the study group were compared with those obtained in a control group of 10 patients with shoulder pain.In the study group, erosions of the humeroscapular joint were detected by conventional radiography in 26 patients, by ultrasound in 30 patients, and by MRI in 39 patients; the differences were statistically significant for the comparisons of conventional radiography with MRI and for ultrasound versus MRI (P0.0001). Conventional radiography detected 12 erosions of the scapula and MRI detected 15. Synovitis was demonstrated in 12 patients by ultrasound and in 27 patients by MRI (P = 0.0003). Tenosynovitis was observed in 15 patients by ultrasound and in 28 patients by MRI (P = 0.0064). Bursitis was detected in 13 patients by ultrasound and in 18 patients by MRI. The findings on dynamic contrast-enhanced MRI correlated significantly with the detection of synovitis by ultrasound and erosions by static MRI (P0.05).Ultrasound and MRI supplement conventional radiography in assessing the shoulder joint. Although conventional radiography can be used as the sole method of following up known joint destruction in RA, ultrasound and, preferably, MRI are recommended as additional techniques in the initial diagnostic evaluation when radiography yields negative results.

The authors report on the estimation of the age of an unidentified deceased adolescent in connection with the body's identification. A physical examination by a forensic physician and an examination by a forensic dentist, including determination of the dental status and an X-ray of the teeth were used to estimate the age. In addition, an X-ray of the left hand as well as an X-ray and MRT scan of the clavicles were carried out by forensic radiologists. Combining the results of the individual examinations, the age of the deceased was estimated to range between 18 and 21 years. In the course of the police investigation it was found out that the deceased was 20 years and 7 months old. This has led to the conclusion that combined use of methods allows the age even of adolescents to be determined with relatively high accuracy and a minimum of time and effort.