Power Doppler assessment of overall disease activity in patients with rheumatoid arthritis

In vivo quantification of collagen-induced arthritis mouse model by three-dimensional volumetric ultrasound and color Doppler

PURPOSE

Ultrasound combined with Doppler techniques has been widely utilized to evaluate joint inflammation and internal structural changes in animal models of rheumatoid arthritis. However, previous assessments using these techniques were predominantly semi-quantitative, which may limit the precision and reliability of the results. Therefore, the primary objective of this study was to explore the potential advantages of three-dimensional (3D) volumetric ultrasound and color Doppler in quantitatively assessing the progression of disease.

OBJECTIVE

To quantify the severity and progression of collagen-induced arthritis (CIA) mouse model using a micro-imaging tool, 3D volumetric ultrasound and color Doppler, and assess if 3D model-based volumetric changes of joint space and vascularity correlate with clinical, histological and bone destruction findings.

METHODS

CIA was induced in mice on a DBA/1J background at 7 ~ 8 weeks of age. 3D volumetric ultrasound and color Doppler analysis was performed on knee and ankle joints of all mice using the Vevo 2100 system at 0, 2, 4, 8 weeks after the booster immunization. Clinical, histological and bone destruction analysis were performed as usual. Correlation analysis of the volumetric changes of joint space and vascularity with clinical, histological and bone destruction score were assessed via Spearman's test.

RESULTS

It was possible to quantify the severity of joint inflammation and intra-articular changes during the progression of CIA by 3D volumetric ultrasound and color Doppler. The 3D model-based volumetric changes of joint space and vascularity have significant correlations with clinical, histological and bone destruction score of arthritis.

CONCLUSIONS

We demonstrated that 3D volumetric ultrasound and color Doppler is a noninvasive, quantitative tool for evaluating CIA mice in vivo. Despite certain limitations, those technology significantly enhance our ability to monitor disease progression and severity, assess therapeutic interventions, and reduce reliance on invasive techniques.

Reliability of Ultrasound for the Detection of Rheumatoid Arthritis

The aim of this review article was to investigate the pooled sensitivity and specificity of musculoskeletal ultrasound (MSUS) for the detection of synovitis and early bone erosion in the small joint in rheumatoid arthritis (RA). In addition, investigate the pooled sensitivity and specificity of Power Doppler ultrasonography (PDUS) for the detection of synovial hypervascularity in small joints in RA. A systematic literature search of PubMed, Wiley online library, Google Scholar, Research gate, E-book, BioMed Central, the Journal of Rheumatology and Springer Link were investigated from 2001 to 2017. Original researches related to the article written in English including RA, synovitis, bone erosion, grayscale, and PDUS were included in this study. The sample size, study design, sensitivity, and specificity were analyzed. The review summarizes the value of MSUS for the detection of RA as it is the first choice of modality. Results show the acceptable reliability of US for the diagnosis of early bone erosions, synovitis, and synovial hypervascularity.

Imaging of the Pediatric Temporomandibular Joint

Imaging of the temporomandibular joint in pediatric patients is a critical component in the evaluation and treatment of children with temporomandibular joint symptoms. MRI can provide detailed joint anatomy and identify inflammation, sometimes before symptom onset. Ultrasound scan is a convenient emerging modality to evaluate the joint and guide therapeutic injections. Radiography and computed tomography offer osseous detail to recognize early morphologic changes of the mandibular condyle and provide operative planning. Imaging promises to direct treatment to prevent future joint destruction and maintain function.

Clinical utility of eco-color-power Doppler ultrasonography and contrast enhanced magnetic resonance imaging for interpretation and quantification of joint synovitis: a review

With the introduction of new biologics such as anti-TNF-alpha antibodies and other therapies in the treatment of inflammatory arthritis, capable of halting joint destruction and functional disability, there are new pressures on diagnostic and prognostic imaging. Early demonstration of pre-erosive inflammatory features and monitoring of the long-term effects of treatment are becoming increasingly important. Early detection of synovitis offers advantages in terms of allowing early instigation of therapy and may allow the identification of those patients displaying more aggressive disease who might benefit from early intervention with expensive DMARD therapy. Advanced imaging techniques such as ultrasound (US) and magnetic resonance imaging (MRI) have focussed on the demonstration and quantification of synovitis and allow early diagnosis of inflammatory arthropathies such as rheumatoid arthritis (RA) and psoriatic arthritis (PsA). Synovitis represents a potential surrogate measure of disease activity that can be monitored using either MRI or US; the techniques have, generally, focused on monitoring synovial volume or quality as assessed by its vascularity. However to achieve these goals, standardisation and validation of US and MRI are required to ensure accurate diagnosis, reproducibility and reliability. Each modality has different strengths and weaknesses and levels of validation. This article aims to increase the awareness of radiologists and rheumatologists about this field and to encourage them to participate and contribute to the ongoing development of these modalities. Without this collaboration, it is unlikely that these modalities will reach their full potential in the field of rheumatological imaging. This review is in two parts. The first part addresses the role of US and colour or power Doppler sonography (PDUS) in the detection and monitoring of synovitis in inflammatory arthropathies. The second part will look at advanced MR imaging and Dynamic contrast-enhanced MRI techniques and in particular how they are applied to the monitoring of the disease process.

A Combined Ultrasonographic and Conventional Radiographic Assessment of Hemophilic Arthropathy

Hemophilic arthropathy (HA) can be diagnosed by a number of imaging studies. However, it is difficult with conventional radiography to find soft tissue structures around joints, and ultrasonography has limited effectiveness in evaluating internal bony structures. We attempt to determine whether a combination of ultrasonography for soft tissue around joints and conventional radiography for bony structures can be used as a cost-effective imaging tool for evaluating HA and whether it reflects the functional status of hemophilic patients. Thirty-six males (median age 16.5 years; severe 34, mild 2) with hemophilia were recruited. We evaluated the severity of HA using combined imaging score that consisted of modified Petterson X-ray score (mPXS) and the modified ultrasonographic score (mUS). Joint impairment was clinically assesses using the World Federation of Hemophilia-Physical Examination (WFH-PE) scale and the Hemophilic joint health score (HJHS). We assessed the Hemophilia activities list (HAL) for the functional level. We performed a comparative analysis between the combined imaging score and the joint impairment scores as well as the functional scores. The mean mUS was 4.97 ± 3.99 points, and the mean mPXS was 2.85 ± 2.91 points; the combined imaging score was 7.83 ± 6.31 points. The combined imaging score was significantly correlated with the HJHS (p = 0.006) and WFH-PE scores (p = 0.019) as well as the HAL score (p = 0.002). A combination of conventional radiological and ultrasongraphic study might ultimately impact the optimal evaluation of joint impairment and functional status in hemophilic patients.

Ultrasound of the hand and wrist

There have been immense technical innovations and broadened clinical applications of ultrasound in the musculoskeletal system over the past 20 years. Specifically with regard to the hand and wrist, the advent of higher resolution transducers and postprocessing software applications have resulted in overall enhanced visualization of soft tissue structures (tendons/ligaments) as well as surface osseous lesions such as subclinical erosions in rheumatoid arthritis. Quantitative ultrasound, using either power Doppler or contrast-enhanced imaging, has become a central outcomes measure used to evaluate and document patient response to treatment in inflammatory arthropathies such as rheumatoid arthritis. This review will summarize the current state of clinical applications of ultrasound in the evaluation of the hand and wrist, with a summary of technical advances and specific applications in rheumatologic conditions.This review was exempt from institutional review board approval.

Doppler US in rheumatic diseases with special emphasis on rheumatoid arthritis and spondyloarthritis

Developments in digital ultrasonography (US) technology and the use of high-frequency broadband transducers have increased the quality of US imaging, particularly of superficial tissues. Thus, US, particularly color US or power Doppler US, in which high-resolution transducers are used, has become an important imaging modality in the assessment of rheumatic diseases. Furthermore, therapeutic interventions and biopsies can be performed under US guidance during the assessment of lesions. In this era of effective treatments, such as biologics, improvements in synovial inflammation in rheumatoid arthritis as well as changes in enthesitis in spondyloarthropathies, including ankylosing spondylitis and psoriatic arthritis, can be monitored effectively using gray-scale and/or power Doppler US. US is also a good imaging modality for crystal arthropathies, including gout and pseudogout, in which synovitis, erosions, tophi, and crystal deposition within or around the joint can be visualized readily. Vascular and tenosynovial structures, as well as the salivary glands, can be assessed with US in vasculitis and connective tissue disorders, including systemic lupus erythematosus and Sjögren's syndrome. Current research is focused on improving the sensitivity, specificity, validity, and reproducibility of US findings. In this review, we summarized the role of US, particularly power Doppler US, in rheumatic diseases and inflammation in superficial tissues.

Sonographic diagnosis of neurogenic heterotopic ossification in patients with severe acquired brain injury in a neurorehabilitation unit

PURPOSE

To illustrate the ultrasonographic (US) and power Doppler US (PDUS) features of neurogenic heterotopic ossification (NHO) in consecutive patients with severe acquired brain injury and to evaluate the role of bedside US in diagnosis of NHO.

METHODS

Ninety-two consecutive patients with severe acquired brain injury underwent clinical and laboratory screening for NHO. In 6 of 92 patients, bedside US confirmed the clinical suspicion of NHO. US diagnosis of NHO was then confirmed by other imaging methods.

RESULTS

The incidence of clinical NHO was 7% (9/92) with one patient having multifocal involvement. In NHO of the hip, US demonstrated the classic pattern of zone phenomenon, and PDUS demonstrated vascular signal within mineralized NHO and in outer hypoechoic area. No vascular signal was observed in the central hypoechoic core. In NHO of the knee, a heterogeneously hypoechoic mass was seen and in the elbow a hyperechoic mineralized mass was visualized, with vascular signals seen within the lesions. Spectral wave analysis demonstrated low resistance vessels in NHO.

CONCLUSIONS

Bedside US is a useful tool in the diagnosis of NHO. PDUS adds data regarding neoangiogenetic activity of NHO.

Ultrasound detects joint damage and bleeding in haemophilic arthropathy: a proposal of a score

Haemarthrosis triggers haemophilic arthropathy (HA) because bleeding starts synovitis immediately, damages cartilage and leads to loss of function and disability. The aim of our study was to investigate the capacity of ultrasonography (US) in detecting bleeding and joint damage in HA. The joints of 62 patients (pts) with haemophilia A or haemophilia B were consecutively evaluated and scored (score ranging from 0 to 21) for effusion (E), bone remodelling (BR), cartilage damage (CD), synovial hypertrophy (SH), haemosiderin (H), osteophytes (O), haemarthrosis (Hae), erosion (Er) and fibrotic septa (FS) with US. X-rays [Pettersson Score (PXS)] were performed in 61 patients and clinical evaluation [World Federation Haemophiliac orthopaedic score (WFHO)] was performed in all patients. A total of 20 healthy subjects and 20 patients affected by Rheumatoid Arthritis (RA) were used as controls. Power Doppler US (PDUS) was performed in all patients on the knee, ankle and elbow joints. A total of 83 joints were studied (50 knees; 12 elbows and 21 ankles). US showed effusion in 57 joint, bone remodelling in 62, cartilage damage in 64, synovial hypertrophy in 45, haemosiderin in 39, osteophytes in 30, haemarthrosis in 24, erosion in 5 and fibrotic septa in 3. The X-rays score showed remodelling in 47 joints, narrowing joint space in 44, displacement/angulation in 39, osteoporosis in 42, subchondral irregularity in 44, subchondral cyst formation in 37, osteophytes in 36 and erosions in 25. The US score in healthy subjects was always ≤ 5 (range 0 to 4). In haemophiliacs, 34 of 83 joints showed US score ≤ 5, and 49 US score > 5. Joints with US score ≤ 5 had a low PXS (SRCC = 0.375, P < 0.01) and joints with US score > 5 showed a high PXS (SRCC = 0.440, P < 0.01). A significant correlation between US score and PXS for bone remodelling [Spearman's rho Correlation Coefficient (SRCC) = 0.429, P < 0.01] and for osteophytes (SRCC = 0.308, P < 0.05) was found. The correlation between the US score and number of bleedings in 83 joints was very significant (SRCC = 0.375, P < 0.01). A total of 24 bleeding joints were identified and verified with aspiration of haematic fluid. US may detect bone and cartilage alterations and synovitis. Indeed, PDUS identified bleeding also in asymptomatic joints and was able to show different entity of haemarthrosis. US may be a feasible and reliable tool to evaluate joint modifications in HA.

Power Doppler and spectral Doppler measurements of knee-joint synovitis in rheumatoid arthritis patients with superficial pattern signals and in those with deep pattern signals

Power Doppler and spectral Doppler ultrasonography were used to scan 127 knee joints of 72 patients with rheumatoid arthritis (RA). Synovial effusion thickness and synovial proliferation (pannus) thickness, as well as the flow signal diameter, were measured on ultrasonogram prints of the power Doppler using digital calipers. In addition, color-flow signal grades on power Doppler and the resistance index (RI) values on spectral Doppler were evaluated. The values of these five variables were compared among 58 joints with superficial pattern flow signals and 69 joints with deep pattern flow signals. Compared with the joints with deep pattern signals, the joints with superficial pattern signals had significantly higher mean values of effusion thickness (P < 0.0001) and flow signal grades (P < 0.0001), and significantly lower mean RI (P < 0.0001). On the other hand, the joints with deep pattern signals had a significantly higher value of signal diameter (P = 0.0125) and had a trend to higher value of pannus thickness (P = 0.079) as well. Significant correlations were observed between effusion thickness and signal grades (P < 0.0001); effusion thickness and RI (P < 0.0001); signal diameter and pannus thickness (P = 0.0102); signal diameter and RI (P < 0.0001); and signal grades and RI (P < 0.0001). The ultrasonographic measurements of synovitis in RA patients provide valuable information on synovial inflammation.