Magnetic resonance imaging of rheumatological diseases

Abstract

Magnetic resonance imaging (MRI) is extremely useful in the early diagnosis of rheumatologic diseases, as well as in the monitoring of treatment response and disease progression to optimize long-term clinical outcomes. MRI is highly sensitive and specific in detecting the common findings in rheumatologic diseases, such as bone marrow oedema, cartilage disruption, articular erosions, joint effusions, bursal effusions, tendon sheath effusions, and synovitis. This imaging modality can demonstrate structural changes of cartilage and bone destruction years earlier than radiographs. Rheumatoid arthritis, crystal deposition diseases (including gouty arthropathy and calcium pyrophosphate deposition disease), seronegative spondyloarthropathies (including psoriatic arthritis, reactive arthritis, ankylosing spondylitis), and osteoarthritis have characteristic appearances on MRI. Contrast-enhanced MRI and diffusion-weighted imaging can provide additional evaluation of active synovitis. This article describes the MRI findings of normal joints, as well as the pathophysiological mechanisms and typical MRI findings of rheumatoid arthritis, gouty arthritis, calcium pyrophosphate deposition disease, psoriatic arthritis, reactive arthritis, ankylosing spondylitis, and osteoarthritis.

Keywords: MRI; ankylosing spondylitis; calcium pyrophosphate dihydrate deposition; gout; psoriatic arthritis; rheumatoid arthritis.

Figure 1

A) Artist’s drawing of the normal synovial joint and (B) of the synovial joint affected by rheumatoid arthritis (RA). In B note synovial proliferation eroding into the bone at the bare area by the capsular attachment site not covered by the articular cartilage (arrow)

Figure 2

A 35-year-old female with rheumatoid arthritis (RA) for 5 years. A) Coronal and (B) sagittal proton density-weighted with fat-saturation (PDW FS) and (C) coronal T1-weighted (T1W) magnetic resonance (MR) images of the hand show a prominent marginal erosion at the radial aspect of the third metacarpal head (dashed arrows) with adjacent high signal intensity bone marrow oedema (BMO) in A and B extending into the metacarpal diaphysis. In A and B note large heterogenous joint effusions at the middle finger metacarpophalangeal (MCP) and proximal interphalangeal joints (PIP) (arrows)

Figure 3

A 69-year-old female with longstanding seropositive rheumatoid arthritis (RA) and palpable soft tissue mass at the volar aspect of the hand. A) Axial and (B) coronal proton density-weighted with fat-saturation (PDW FS) magnetic resonance (MR) images of the hand show intermediate increased signal intensity lobulated soft tissue mass at the volar aspect of the hand surrounding the flexor tendons in the region of ulnar bursa consistent with chronic synovitis (arrows). The lesion shows intermediate decreased signal intensity on the T1-weighted (T1W) image (C). In B and C note pancarpal joint space narrowing with associated chronic erosive changes (arrowheads). In B note heterogeneous increased signal intensity in the distended 2^nd and 4^th middle finger metacarpophalangeal (MCP) joints, in keeping with chronic active synovitis (dashed arrows)

Figure 4

A 59-year-old female with rheumatoid arthritis (RA) and chronic elbow pain and swelling. Sagittal proton density-weighted with fat-saturation (PDW FS) magnetic resonance (MR) image shows a moderate size heterogeneous synovial fluid complex in the elbow with prominent synovial thickening (arrows). Note mild reactive bone marrow oedema (BMO) in the olecranon (dashed arrow) and mild periarticular soft-tissue oedema

Figure 5

Gout. Artist’s drawing of the synovial joint demonstrates juxtaarticular deposit of the uric acid crystals (green) eroding into the capsular attachment (red arrow) and subjacent bone (black arrow)

Figure 6

A 60-year-old male with gout and left foot swelling and ulcerations. A) Axial and (B) coronal short tau inversion recovery (STIR) and (C) coronal T1-weighted (T1W) magnetic resonance (MR) images of the foot show erosive bone changes at the medial and plantar aspect of the 1st metatarsal head and proximal phalangeal base (arrows) with associated heterogeneous deposits of intermediate to slightly increased signal in A and B and intermediate to low signal in C consistent with gouty arthropathy (podagra). D) Corresponding anteroposterior foot radiograph shows well-defined erosions with overhanging edges at the medial aspect of the first metatarsal head and proximal phalangeal base (arrow) and to a lesser extent at the lateral aspect related to gouty arthropathy. In A and D note postsurgical fusion of the great toe interphalangeal joint

Figure 7

A 56-year-old male with gout. (a) Sagittal proton density-weighted with fat-saturation (PDW FS) magnetic resonance (MR) image of the elbow shows complex distended olecranon bursa with peri bursal oedema (arrows) eroding into the olecranon related to gouty arthropathy. Note a large erosion at the posterior olecranon (dashed arrow) with adjacent mild bone marrow oedema (BMO). B) Corresponding lateral radiograph shows thickening of the olecranon bursa (white arrows) with subjacent osseous erosion at the posterior olecranon (dashed arrow) and osseous debris (black arrow), which was not well seen on the MR image

Figure 8

A 66-year-old male with chronic wrist pain and calcium pyrophosphate deposition (CPPD) arthropathy. A) Coronal proton density-weighted with fat-saturation (PDW FS) and (B) coronal T1-weighted (T1W) magnetic resonance (MR) images show numerous cyst-like and erosive changes throughout the carpal bones, metacarpal bases, and distal radius and ulna surrounded by heterogeneous synovial fluid complexes, which show intermediate increased signal in A and intermediate low signal in B consistent with CPPD and chronic synovitis (arrows). C) Coronal reformatted computed tomography (CT) image redemonstrates extensive cyst-like and erosive changes and calcific deposits in all wrist compartments (arrows)

Figure 9

An 84-year-old female with neck pain and calcium pyrophosphate deposition (CPPD) arthropathy with “crowned dens”. A) Axial T2-weighted (T2W) magnetic resonance (MR) image shows a low signal intensity halo within the atlantoaxial joint surrounding dens (arrows) consistent with CPPD. Calcium deposits in the same anatomic location are better characterized on the corresponding axial computed tomography (CT) image (arrows)

Figure 10

Psoriatic arthritis. Artist’s drawing of the synovial joint demonstrates inflammation at the capsular attachment site consistent with enthesitis (red arrow) and adjacent bone erosion (green arrow) and proliferation (black arrow)

Figure 11

Enthesitis in 2 different patients with psoriatic arthritis. A) Coronal proton density-weighted with fat-saturation (PDW FS) magnetic resonance (MR) image of the knee in a 47-year-old male shows oedema and thickening of the lateral collateral ligament proper with periligamentous oedema (arrow) consistent with enthesitis. Note bone marrow oedema in the subjacent lateral femoral condyle (dashed arrow) [Courtesy of Girish Gandikota MBBS FRCR RMSK, Ann Arbor, Michigan, USA]. B) Coronal T2-weighted with fat-saturation (T2W FS) image of the hand in a 38-year-old female shows high signal intensity involving the periosteum and capsular attachments about the index finger proximal interphalangeal joint consistent with periostitis, enthesitis, and capsulitis (arrows) [Courtesy of Ali Balci MD, Izmir, Turkey]

Figure 12

A 39-year-old female with psoriatic arthritis (PsA) and several-year history of intermittent finger pain and swelling. A) Coronal T2-weighted with fat-saturation (T2W FS) magnetic resonance (MR) image shows erosive and proliferative bone changes involving the index finger distal interphalangeal (DIP) joint with associated bone marrow oedema (BMO) (arrow). Note moderate size, high signal intensity synovial fluid complex in the middle finger proximal interphalangeal joints (PIP) joint (dashed arrow) related to synovitis and high signal intensity mild distension of the flexor tendon sheath consistent with tenosynovitis (arrowhead). B) Sagittal T1-weighted (T1W) MR image of the index finger shows erosive changes of the middle phalangeal head and distal phalangeal base in keeping with early pencil-in-cup deformity (arrow). C) Corresponding posteroanterior (PA) radiograph of the hand shows peripheral and central erosive and proliferative bone changes of the index finger DIP joint consistent with psoriatic arthritis

Figure 13

A 29-year-old male with psoriatic arthritis (PsA) and 2-year history of 4^th toe pain and swelling. A) Sagittal short tau inversion recovery (STIR) magnetic resonance (MR) image shows high signal intensity bone marrow oedema (BMO) and periosteal oedema involving the 4^th toe proximal phalanx with adjacent high signal intensity flexor tenosynovitis at the plantar aspect (arrow) and extensor peritendinitis at the dorsal side (solid arrowhead) and additional surrounding soft tissue inflammation at both plantar and dorsal aspect aspects. There is mild cortical irregularity of the 4^th toe proximal phalangeal base and a mildly increased synovial fluid complex in the 4^th metatarsophalangeal (MTP) joint (open arrowhead). B) On the post-contrast T1-weighted fat-saturation magnetic resonance (T1W FS MR) image note enhancing BMO and periosteal oedema in the 4^th toe proximal phalanx (solid arrowhead), enhancing flexor tenosynovitis (arrows), and surrounding soft tissue inflammation (dashed arrow). C) Corresponding anterior posterior (AP) foot radiograph shows mild soft tissue oedema about the 4^th toe with subtle periostitis about the proximal phalanx (arrows)

Figure 14

A 53-year-old female with intermittent bilateral hand arthralgias, stiffness, and swelling, right greater than left, for several months after having had COVID. Dynamic contrast-enhanced (DCE) imaging of the right hand was performed with coronal T1-weighted fat-saturation (T1W FS) volumetric interpolated breath-hold examination (VIBE) imaging every 12 seconds for 120 seconds. These images were performed before intravenous contrast administration (A), and at 24 (B), 96 (C), and 120 (D) sec following contrast administration, and show progressive synovial enhancement of the first carpometacarpal (CMC) (arrows) and 5^th middle finger metacarpophalangeal (MCP) (dashed arrows) joints, and milder enhancement of the flexor bursa and 4^th flexor tendon sheath at the level of the MCP joint (white arrowhead). E) Delayed postcontrast T1W FS spin echo coronal image demonstrates enhancement in a similar distribution, although the flexor bursal and fourth flexor tendon sheath synovitis is more conspicuous (white arrowheads), and there is mild flexor pollicis longus tenosynovitis (black arrowhead) that was not well-seen on the dynamic sequences. F) Axial subtraction imaging of pre- and post-contrast T1 axial SE imaging shows synovial enhancement around the first CMC joint (arrow) and the flexor bursa (arrowhead), consistent with active synovitis. Finally, axial non-contrast diffusion-weighted imaging (DWI) of the hand, including the (G) B50 and (H) B800 imaging and (I) apparent diffusion coefficient (ADC) map, shows areas of restricted diffusion around the 1^st CMC joint (arrows) and 4^th flexor tendon sheath/flexor bursa (arrowheads), in areas of active synovitis

Figure 15

A 61-year-old male with ankylosing spondylitis (AS) and bilateral sacroiliitis. A) Anterior posterior (AP) radiograph of the pelvis shows subchondral sclerosis and cortical irregularities consistent with erosive bone changes about both sacroiliac joints related to sacroiliitis (arrows). B) Axial T1-weighted (T1W), (C) axial short tau inversion recovery (STIR), and (D) axial T1-weighted with fat-saturation (T1W FS) post-contrast magnetic resonance (MR) images of the pelvis redemonstrate erosive bone changes involving both sacroiliac joints with associated bone marrow oedema (BMO), significantly more pronounced about the right sacroiliac joint, showing intermediate signal intensity in B, high signal intensity in C, and enhancement in D consistent with chronic active sacroiliitis. Note enhancing synovial fluid complex in the right sacroiliac joint related to active synovitis

Figure 16

A 40-year-old male with ankylosing spondylitis (AS) and acute on chronic sacroiliitis. Coronal oblique short tau inversion recovery (STIR) magnetic resonance (MR) image of the sacrum and sacroiliac joints shows joint space narrowing with erosive bone changes about both sacroiliac joints with areas of subchondral low signal intensity related to fatty marrow and subchondral sclerosis associated with chronic post-inflammatory changes (arrows). Note scattered ill-defined foci of subchondral high signal intensity, most pronounced at iliac side of the right sacroiliac joint consistent with bone marrow oedema (BMO) related to active inflammation (dashed arrow)

Figure 17

A 57-year-old male with longstanding ankylosing spondylitis (AS). Axial T1-weighted (T1W) magnetic resonance (MR) image shows osseous fusion of the right greater than left sacroiliac joints (arrows) with areas of high signal intensity prominent fatty marrow on the sacral sides in keeping with post-inflammatory change

Figure 18

A 73-year-old male with longstanding ankylosing spondylitis (AS). Sagittal T1-weighted (T1W) magnetic resonance (MR) image shows ankylosis throughout the thoracic spine with anterior and posterior syndesmophytes. There is abnormal intermediate signal through the anterior syndesmophyte (arrow) at the inferior T6 vertebral body endplate, and intervertebral disc (fracture equivalent). There is no significant retropulsion

Figure 19

Andersson lesion and shiny corner. Artist’s drawing of the spine shows erosive bone changes at the opposed vertebral body endplates (black arrows) related to Andersson lesion and reactive sclerosis at the periphery of several superior and inferior vertebral body endplates consistent with shiny corners secondary to inflammatory erosions (green arrows)

Figure 20

A 32-year-old male with ankylosing spondylitis (AS). A) Sagittal reformatted computed tomography (CT) image of the lumbar spine shows reactive sclerosis at the periphery of the superior and inferior endplates at multiple levels consistent with shiny corners secondary to inflammatory erosions (arrows). Note mild anterior squaring of the vertebral bodies, most prominent at L5 and partial fusion of the posterior elements. Sagittal (B) T2-weighted with fat-saturation and (C) T1-weighted (T1W) magnetic resonance (MR) images show signal hyperintensity at the shiny corners (arrows)

Figure 21

A 31-year-old male HLA-B27 positive with ankylosing spondylitis (AS). A) Sagittal T2-weighted with fat-saturation (T2W FS) and (B) sagittal T1-weighted with fat-saturation (T1W FS) post-contrast magnetic resonance (MR) images show high T2 signal (A) enhancing (B) bone marrow oedema about the erosive bone changes in the opposing vertebral body endplates at the L1-L2 level consistent with Andersson lesion. Note high T2 signal (A), enhancing (B) inflammatory erosion at the posterior superior endplate of L3 related to Romanus lesion (arrowhead). In A there is a high signal intensity throughout the posterior elements (dashed arrows) with enhancement at multiple levels in B related to osteitis and enthesitis [Courtesy of Blair Winegar MD, Salt Lake City, Utah, USA]

Figure 22

A 77-year-old female with end-stage knee osteoarthritis (OA). Coronal proton density-weighted with fat-saturation (PDW FS) magnetic resonance (MR) image shows scattered minimal subchondral bone marrow oedema (BMO) and cyst-like changes along the weightbearing surfaces of the medial compartment with near denudation of the overlying hyaline articular cartilage (arrows). Note marked narrowing of the lateral joint space compartment with overlying diffuse grade 2-3 chondral loss (dashed arrows) and large marginal osteophytes at the periphery of the femoral condyles (arrowheads)

Figure 23

A 62-year-old female with chronic hand/finger pain and erosive osteoarthritis (EOA). A) Coronal proton density-weighted with fat-saturation (PDW FS) magnetic resonance (MR) image shows central erosive bone changes about the index finger distal interphalangeal (DIP) joint (arrow) related to chronic EOA without significant bone marrow oedema (BMO). B) Corresponding PA hand radiograph shows central erosive bone changes with “gull wing” configuration about the index, middle, and ring finger interphalangeal joints in keeping with EOA