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DOI: 10.1148/rg.252045111
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Right arrow Magnetic Resonance Imaging
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Rheumatoid Arthritis: A Practical Guide to State-of-the-Art Imaging, Image Interpretation, and Clinical Implications1

Oliver J. Sommer, MD, Andrea Kladosek, MD, Volkmar Weiler, MD, Heinz Czembirek, MD, Martina Boeck, MD and Michael Stiskal, MD

1 From the Departments of Radiology (O.J.S., A.K., H.C., M.B., M.S.) and Rheumatology (V.W.), Hospital Lainz, Wolkersbergenstrasse 1, 1130 Vienna, Austria. Presented as an education exhibit at the 2003 RSNA Scientific Assembly. Received May 17, 2004; revision requested June 9 and received July 19; accepted July 22. All authors have no financial relationships to disclose.


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  		Figure 1.  Classification tree of the American Rheumatism Association for the diagnosis of RA. MCP = metacarpophalangeal joint.

 


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  		Figure 2.  Proposed new classification tree for the diagnosis of RA. This classification tree includes the MR imaging criterion of bilateral enhancement in the wrists, metacarpophalangeal joints (MCP), or proximal interphalangeal joints.

 


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  		Figure 3.  Schematic drawing of a synovial joint. 1 = periosteum, 2 = outer fibrous layer of the capsule, 3 = internal synovial layer of the capsule, 4 = fat and loose soft tissue, 5 = articular space, 6 = cartilage, 7 = bone, 8 = bare area.

 


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  		Figure 4.  RA in a 75-year-old woman. Coronal contrast-enhanced fat-saturated T1-weighted MR image shows hyperenhancement of small joints in the hand (arrows), a finding that reflects hyperemic synovial tissue. Erosions (arrowheads) and thickened, intensely enhancing synovium are seen at the fifth metacarpophalangeal joint.

 


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  		Figure 5.  Synovitis of the metacarpophalangeal joint. Longitudinal high-resolution (10.5-MHz) sonogram shows thickened synovial tissue (arrows).

 


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  		Figure 6.  Long-standing RA in a 52-year-old woman. Coronal contrast-enhanced fat-saturated T1-weighted MR image shows synovitis of the second and third metacarpophalangeal joints. A subcortical cyst (arrowhead) is seen near the bare area. This type of lesion is called a pre-erosion or subcortical erosion by some authors owing to the high likelihood that it will progress to a clear erosion.

 


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  		Figure 7.  Tendovaginitis and arthritis. Axial contrast-enhanced fat-saturated T1-weighted MR image obtained at the level of the first metacarpophalangeal joint shows inflamed synovium that is thickened and markedly enhanced (*).

 


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  		Figure 8.  Tendovaginitis of the extensor digitorum longus of the hand. Axial sonogram shows markedly thickened, edematous, hypoechoic synovium (*, arrow).

 


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  		Figure 9a.  Severe nonerosive arthritis of the second and third metacarpophalangeal joints in a 36-year-old woman. (a) Coronal contrast-enhanced fat-saturated T1-weighted MR image shows inflamed synovium. An area of hypoenhancement is seen within the enhancing and thickened synovial tissue (arrowheads), a finding consistent with hypovascular pannus. (b) Axial contrast-enhanced fat-saturated T1-weighted MR image shows the extent of the hypovascular pannus (*).

 


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  		Figure 9b.  Severe nonerosive arthritis of the second and third metacarpophalangeal joints in a 36-year-old woman. (a) Coronal contrast-enhanced fat-saturated T1-weighted MR image shows inflamed synovium. An area of hypoenhancement is seen within the enhancing and thickened synovial tissue (arrowheads), a finding consistent with hypovascular pannus. (b) Axial contrast-enhanced fat-saturated T1-weighted MR image shows the extent of the hypovascular pannus (*).

 


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  		Figure 10.  Acute tendovaginitis of the flexor of the middle finger in a young man with a diagnosis of RA. Axial contrast-enhanced fat-saturated T1-weighted MR image shows fluid (*) surrounded by enhancing synovium (arrowheads). T = extensor tendon.

 


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  		Figure 11.  Small joint effusion in a 20-year-old woman in whom RA was later diagnosed. Coronal steady-state gradient-echo MR image shows a small effusion of the third metacarpophalangeal joint (arrowheads).

 


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  		Figure 12.  Paraarticular osteoporosis in a patient with RA. Radiograph shows increased bone lucency at the radiocarpal, carpometacarpal, metacarpophalangeal, and proximal interphalangeal joints and in the carpus.

 


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  		Figure 13.  Acute painful arthritis of the third metacarpophalangeal joint. Coronal contrast-enhanced fat-saturated T1-weighted MR image shows extensive thickening and hyperenhancement, findings consistent with synovitis. The enhancement of the bone marrow (*) is indicative of inflammatory involvement or a reactive response. The cortical layer of the metacarpal head is thinned.

 


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  		Figure 14.  Narrowing of joint spaces in long-standing RA. Radiograph (detail view) shows narrowing of the joint spaces of the second and fourth metacarpophalangeal joints (*). The concentricity of the narrowing is a hallmark of arthritis, whereas joint space narrowing due to degenerative changes is eccentric.

 


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  		Figure 15.  RA of the wrist. Radiograph (detail view) shows a ballooned ulnar styloid process. There are small cysts (*) in the styloid process and scaphoid bone. The radiocarpal joint space is narrowed.

 


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  		Figure 16.  Incidentally discovered bone cyst in a middle-aged patient with RA. Coronal spin-echo T2-weighted MR image of the hand shows a hyperintense cyst with a sclerotic rim (arrow).

 


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  		Figure 17.  RA of the wrist. Axial contrast-enhanced fat-saturated T1-weighted MR image shows a carpal cyst (arrow) that communicates with the inflamed synovium via a small extension (arrowhead). This cyst is a typical "subcortical erosion."

 


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  		Figure 18a.  (a) Radiograph (detail view) of the right hand shows cysts along the radial aspect of the head of the second metacarpal (*). No erosions are seen. (b) Axial spin-echo T1-weighted MR image shows an erosion at the bare area at the base of the third proximal phalanx (*).

 


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  		Figure 18b.  (a) Radiograph (detail view) of the right hand shows cysts along the radial aspect of the head of the second metacarpal (*). No erosions are seen. (b) Axial spin-echo T1-weighted MR image shows an erosion at the bare area at the base of the third proximal phalanx (*).

 


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  		Figure 19.  Bone erosion in a patient with RA. Longitudinal high-resolution sonogram shows an irregular erosion of the metacarpophalangeal joint (arrowheads). The diagnosis was confirmed with CT.

 


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  		Figure 20.  CT image shows shallow erosions with sclerotic and well-demarcated margins at the second and fifth metacarpophalangeal joints (arrowheads).

 


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  		Figure 21.  Long-standing mutilating RA. Coronal spin-echo T1-weighted MR image of the left hand shows severe destructive changes in the carpus and radiocarpal joint. The carpometacarpal joints are less severely affected. Active arthritis of the third metacarpophalangeal joint is associated with reactive edema of the bone marrow (*).

 


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  		Figure 22.  Advanced RA. Radiograph of the hand shows severe destruction and mutilation of the radiocarpal, intercarpal, carpometacarpal, and metacarpophalangeal joints. Intercarpal ankylosis is noted. There is also subluxation and deviation of the fourth and fifth fingers.

 


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  		Figure 23.  Axial contrast-enhanced fat-saturated T1-weighted MR image of the wrist shows multiple intrasynovial rice bodies (arrows).

 


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  		Figure 24.  Axial spin-echo T1-weighted MR image of the left wrist shows extensive synovitis of the ulnar aspect (*) and erosions and deformity of the ulnar styloid process (arrowhead).

 


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  		Figure 25.  RA of the metatarsophalangeal joints. Radiograph (detail view) of the left foot shows concentric joint space narrowing and subcortical cysts in all of the metatarsophalangeal joints. Erosions are seen in the second and fourth metatarsophalangeal joints, which are deformed to some extent.

 


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  		Figure 26.  Advanced RA. Radiograph (detail view) shows mutilation and deformity of the left elbow. Secondary degenerative osteophytes are seen.

 


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  		Figure 27.  RA of the atlantodental joint. Axial contrast-enhanced fat-saturated spin-echo T1-weighted MR image shows hypervascular pannus (*) around the dens axis.

 


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  		Figure 28.  Longstanding arthritis of the shoulder joint. Radiograph (detail view) of the left shoulder shows a deep erosion (*) at a typical site.

 




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