[Magnetic resonance imaging findings after shoulder surgery: What the radiologist needs to know]. / Besonderheiten der Magnetresonanztomographie nach operativer Schulterintervention.

Even primary diagnostic evaluation of the shoulder is a challenge for radiologists. Many imaging findings that definitely indicate abnormal findings in the untreated shoulder should be evaluated carefully in postoperative patients. Artifacts caused by implants or metal abrasion pose considerable problems in postoperative magnetic resonance imaging (MRI). Classic approaches to minimizing artifacts caused by foreign bodies include using turbo spin echo sequences, increasing bandwidth, and reducing voxel size. In recent years, several vendors have developed dedicated pulse sequences for reducing metal artifacts. Different postoperative imaging findings will be encountered, depending on the kind of surgery done. This review article describes typical postoperative MRI findings, focusing on subacromial decompression, reconstruction of the rotator cuff, labrum procedures, and biceps tenodesis.

[No exchange of information without technology : modern infrastructure in radiology]. / Kein Informationsaustausch ohne Technik : Moderne Infrastruktur einer Radiologie.

Modern radiology cannot accomplish the daily numbers of examinations without supportive technology. Even though technology seems to be becoming increasingly more indispensable, business continuity should be ensured at any time and if necessary even with a limited technical infrastructure by business continuity management. An efficient information security management system forms the basis. The early radiology information systems were islands of information processing. A modern radiology department must be able to be modularly integrated into an informational network of a bigger organization. The secondary use of stored data for clinical decision-making support poses new challenges for the integrity of the data or systems because medical knowledge is displayed and provided in a context of treatment. In terms of imaging the creation and distribution radiology services work in a fully digital manner which is often different for radiology reports. Legally secure electronic diagnostic reports require a complex technical infrastructure; therefore, diagnostic findings still need to be filed as a paper document. The internal exchange and an improved dose management can be simplified by systems which continuously and automatically record the doses and thus provide the possibility of permanent analysis and reporting. Communication between patient and radiologist will gain ongoing importance. Intelligent use of technology will convey this to the radiologist and it will facilitate the understanding of the information by the patient.

[Imaging modalities in psoriatic arthritis]. / Bildgebende Verfahren bei Psoriasisarthritis.

This review presents an overview of the range of imaging modalities used in the diagnostic evaluation of patients with psoriatic arthritis (PsA). Conventional radiography is used to detect structural changes of the joints and tendon attachments. These changes occur late in the course of PsA hence conventional radiography contributes little to the early detection of PsA; however, the detection of periosteal proliferations on radiographs allows a relatively specific diagnosis of PsA. Skeletal scintigraphy and computed tomography are rarely used in PsA. Arthrosonography (ultrasound of the joints) is gaining increasing importance in the early identification of inflammatory soft tissue signs of PsA in the peripheral joints. Sonography enables early detection of synovitis and tenosynovitis as well as superficial erosions and also inflammatory processes of the tendon attachments. Magnetic resonance imaging (MRI) is indispensable for identifying possible involvement of the axial skeleton. Moreover, it allows good visualization of periostitis and arthritis. High resolution microcomputed tomography is an interesting novel diagnostic tool which allows highly sensitive evaluation of the bone structure and can detect very tiny bone lesions where typical signs of PsA are omega-shaped erosions and small corona-like spikes. Another interesting new diagnostic technique is fluorescence optical imaging (FOI) with the Xiralite system which is highly sensitive for detecting inflammatory processes of the hands.

Quantification of periarticular demineralization and synovialitis of the hand in rheumatoid arthritis patients.

UNLABELLED: The bone mineral density (BMD) measurement of the hand in rheumatoid arthritis (RA) patients is no standard measurement method as yet. The aim was to contribute to the standardization of the hand BMD measurement, especially of periarticular regions. As results, we found best precision values for the wrist and a significant correlation between hand and spine/femur BMD depending on disease activity and disease duration. INTRODUCTION: This study was conducted to investigate (i) the precision of periarticular hand BMD measuring, (ii) the periarticular demineralization of the hand, (iii) the correlation between periarticular hand BMD and spine/femur BMD, and (iv) the correlation of hand BMD to hand synovitis. METHODS: A number of 52 RA patients were examined by BMD measurement of the femoral neck, spine, whole hand, metacarpophalangeal (MCP) joints II-V, personal identity profile (PIP) joints II-V, and wrist using dual-energy X-ray absorptiometry (DXA). Synovitis of the hand was examined by ultrasonography and magnetic resonance imaging (MRI). Three subgroups were further analyzed: early RA, established RA with moderate and with high disease activity. Early RA and established RA patients with high disease activity were Followed up after 12 months. RESULTS: We found (1) best precision of BMD measurement for the wrist, (2) BMD in RA significantly reduced if compared to normal controls, (3) a highly significant positive correlation between hand and spine/femur BMD and the power of correlation to depend on disease activity and disease duration (high correlation in RA with moderate disease activity and early RA, very high correlation in RA with high disease activity), (4) a negative correlation between hand BMD and hand synovitis in RA with high disease activity, and (5) a significant reduction of synovitis but no change in hand BMD after 12 months, respectively. CONCLUSIONS: This study shows a highly significant correlation between hand BMD and spine/femur BMD in RA patients depending on disease activity and disease duration. We conclude to measure BMD at different sites including hands in order to quantify bone loss in RA patients most properly.

[Imaging in rheumatic diseases. Rheumatoid arthritis and differential diagnostics]. / Bildgebung rheumatischer Erkrankungen. Rheumatoide Arthritis und Differenzialdiagnosen.

Differential diagnostics of arthritides is challenging even for experienced radiologists. Nevertheless, there are simple signs that can give important clues to make a diagnosis. Close cooperation with the attending clinicians is essential to get the most from imaging studies and to provide relevant information for patient management and therapy.

Effects of etanercept versus sulfasalazine in early axial spondyloarthritis on active inflammatory lesions as detected by whole-body MRI (ESTHER): a 48-week randomised controlled trial.

PURPOSE: To evaluate the potential of etanercept versus sulfasalazine to reduce active inflammatory lesions on whole-body MRI in active axial spondyloarthritis with a symptom duration of less than 5 years. METHODS: Patients were randomly assigned to etanercept (n=40) or sulfasalazine (n=36) treatment over 48 weeks. All patients showed active inflammatory lesions (bone marrow oedema) on MRI in either the sacroiliac joints or the spine. MRI was performed at weeks 0, 24 and 48 and was scored for active inflammatory lesions in sacroiliac joints and the spine including posterior segments and peripheral enthesitis by two radiologists, blinded for treatment arm and MRI time point. RESULTS: In the etanercept group, the reduction of the sacroiliac joint score from 7.7 at baseline to 2.0 at week 48 was significantly (p=0.02) larger compared with the sulfasalazine group from 5.4 at baseline to 3.5 at week 48. A similar difference in the reduction of inflammation was found in the spine from 2.2 to 1.0 in the etanercept group versus from 1.4 to 1.3 in the sulfasalazine group between baseline and week 48, respectively (p=0.01). The number of enthesitic sites also improved significantly from 26 to 11 in the etanercept group versus 24 to 26 in the sulfasalazine group (p=0.04 for difference). 50% of patients reached clinical remission in the etanercept group versus 19% in the sulfasalazine group at week 48. CONCLUSION: In patients with early axial spondyloarthritis active inflammatory lesions detected by whole-body MRI improved significantly more in etanercept versus sulfasalazine-treated patients. This effect correlated with a good clinical response in the etanercept group.

Contrast-enhanced ultrasonography is more sensitive than grayscale and power Doppler ultrasonography compared to MRI in therapy monitoring of rheumatoid arthritis patients.

PURPOSE: To evaluate wrist and finger joints in patients with rheumatoid arthritis (RA) by grayscale, power Doppler (PD) and contrast-enhanced musculoskeletal ultrasonography (US) and to compare these findings with MRI, clinical (DAS28) and laboratory (ESR; CRP) data. MATERIALS AND METHODS: US was performed at baseline (t0) and after three, six and twelve (t12) months before and after a change of medical treatment. MRI was carried out at t0 and t12 and used as the reference method. Contrast-enhanced US was used to assess one clinically most affected joint region. Different semiquantitative synovitis scores were calculated by grayscale and PD US. RESULTS: Contrast-enhanced US results evaluated by enhancement, slope and semi-quantitative assessment significantly correlated to each other, to grayscale US, CRP, as well as to MRI with the highest correlation coefficients for the used contrast-enhanced US modes (r = 0.56, r = 0.55, r = 0.57; each p < 0.05). Sum scores evaluated by grayscale US showed that synovial inflammation in finger joints was detected significantly more frequently in the palmar aspect than on the dorsal side (p = 0.001). Using power Doppler US, the wrists were significantly more inflamed from dorsal than on the palmar side (p = 0.0004). Significant longitudinal correlations between grayscale and power Doppler US scores were detected. CONCLUSION: Grayscale, power Doppler and contrast-enhanced US are accurate tools for the detection and follow-up of synovitis in RA wrist and finger joints, with contrast-enhanced US being most sensitive compared to MRI. All imaging methods reflected a good response to TNFα blocking therapy.

Defining active sacroiliitis on magnetic resonance imaging (MRI) for classification of axial spondyloarthritis: a consensual approach by the ASAS/OMERACT MRI group.

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 Assessment of SpondyloArthritis international Society (ASAS) handbook: a guide to assess spondyloarthritis.

The field of spondyloarthritis (SpA) has experienced major progress in the last decade, especially with regard to new treatments, earlier diagnosis, imaging technology and a better definition of outcome parameters for clinical trials. In the present work, the Assessment in SpondyloArthritis international Society (ASAS) provides a comprehensive handbook on the most relevant aspects for the assessments of spondyloarthritis, covering classification criteria, MRI and x rays for sacroiliac joints and the spine, a complete set of all measurements relevant for clinical trials and international recommendations for the management of SpA. The handbook focuses at this time on axial SpA, with ankylosing spondylitis (AS) being the prototype disease, for which recent progress has been faster than in peripheral SpA. The target audience includes rheumatologists, trial methodologists and any doctor and/or medical student interested in SpA. The focus of this handbook is on practicality, with many examples of MRI and x ray images, which will help to standardise not only patient care but also the design of clinical studies.

[Vasculopathy in Sjögren's syndrome]. / Vaskulopathien bei Sjögren-Syndrom.

Sjögren's syndrome is a systemic autoimmune disease with a predominant involvement of exocrine glands leading to sicca symptoms. Extraglandular involvement occurs in about 40% of patients with skin, musculoskeletal, neurological and organ manifestations. Systemic vasculitic manifestations of Sjögren's syndrome can be assumed in approximately 5%-10% of patients. Leukocytoclastic or cryoglobulinemic vasculitis represent classic vasculitic manifestations of Sjögren's syndrome. In the pathogenesis of vasculitis, B-cell-driven autoimmune processes play a major role by producing autoantibodies against the Ro/SS-A and La/SS-B antigens and cryoglobulins. In patients with Sjögren's syndrome, manifestation of vasculitis, non-Hodgkin's lymphoma and glomerulonephritis, as well as positive cryoglobulins and decreased levels of complement factors, are considered negative prognostic markers. Various immunosuppressive strategies, usually in co-medication with glucocorticoids, are used for the treatment of vasculitis in Sjögren's syndrome. For refractory and severe manifestations, a B-cell-targeted therapy with Rituximab should be also considered.

[Peripartum changes of the pelvic ring: usefulness of magnetic resonance imaging]. / Peripartale Veränderungen des Beckenringes: Wie sinnvoll ist die Magnetresonanztomografie?

PURPOSE: Postpartum pelvic pain beyond the normal level poses a problem to obstetricians. Beyond normal physiologic loosening of the pubic symphysis and sacroiliac joints (SIJs) during pregnancy, symphyseal separation and rupture must be excluded. The aim of this prospective study was to determine whether magnetic resonance imaging (MRI) allows for reliable differentiation of normal postpartum findings and pathologic lesions. MATERIAL AND METHODS: The study included a total of 77 women (mean age 30), among them 21 healthy subjects (group A), 21 asymptomatic postpartum women (group B), and 35 patients with postpartum pelvic pain (group C). The analyzed parameters comprised symphyseal and iliosacral tenderness, subjective pain assessed on a visual analog scale, and data pertaining to obstetric history. All 77 women underwent 1.5T MRI of the pelvic ring using oblique angulated coronal T 1-weighted and STIR sequences for imaging of the symphysis and SIJs in one slice package. Analysis of the MR images comprised signal intensities of pelvic bone marrow, width of the symphyseal cleft, and the symphyseal capsule. RESULTS: Subjects in group A in general had a normal bone marrow signal. The STIR sequence showed increased signal intensity of the pubic bone near the symphysis in 16 women (76 %) of group B and 31 patients of group C (86 %) (not significant). An increased periarticular bone marrow signal of the SIJs on the STIR images was seen in 13 women (62 %) of group B and 23 patients (63 %) of group C. The mean width of the symphyseal cleft differed significantly among the three groups (3.4 mm vs. 5.4 mm vs. 6.7 mm). A width >10 mm was observed in only 4 cases (11 %). Moreover, associated findings such as interpubic hematoma (n=23) or tears of the symphyseal capsule (n=7) were detected in patients of group C. CONCLUSION: The wide overlap of findings between symptomatic and asymptomatic postpartum patients does not allow reliable differentiation by MRI of normal and abnormal findings. MRI contributes to the differentiation of symphyseal contusion and rupture and provides information on severe associated changes.

[Imaging of enthesitis: a new field for the radiologist?]. / Bildgebung der Enthesitis: Ein neues Feld für den Radiologen?

Entheses are sites where tendons, ligaments, joint capsules, or fasciae attach to bone. Their function is to provide a mechanism for reducing stress at the bony interface by dissipating the biomechanical load acting on the bone. Enthesitis may occur in traumatic, endocrinologic, metabolic, degenerative, or inflammatory conditions and is a major symptom in patients with seronegative spondyloarthritis (SpA). The increasing interest in inflammation of the entheses associated with rheumatoid diseases has fundamentally changed our understanding of the clinical presentation, pathogenesis, and therapy of enthesitis. Conventional radiographs and computed tomography (CT) allow good evaluation of chronic changes of the entheses, such as soft-tissue calcification, erosions, and new bone formation. The method of first choice to evaluate acute enthesitis is magnetic resonance imaging (MRI), which depicts both soft-tissue changes and intraosseous abnormalities. The purpose of this overview is to discuss the MRI appearance of enthesitis in patients with SpA and to provide a morphologic survey of the predominantly affected entheses.

[Sacroiliitis in children with spondyloarthropathy: therapeutic effect of CT-Guided intra-articular corticosteroid injection]. / Sakroiliitis bei Kindern mit Spondylarthropathie: Therapeutischer Effekt der CT-gestützten intraartikulären Kortikosteroid-Injektion.

PURPOSE: The prospective investigation of the therapeutic effect of CT-guided intra-articular corticosteroid injection into inflammatory sacroiliac (SI) joints compared to conventional treatment with nonsteroidal anti-inflammatory drugs (NSAIDS) in children with juvenile spondyloarthropathy (jSpA) and the determination of the role of dynamic magnetic resonance imaging (MRI) in establishing the indication and monitoring the therapy. MATERIALS AND METHODS: The study comprises 89 children with known jSpA who were diagnosed by MRI to have a unilateral or bilateral sacroiliitis. Therapy with NSAIDS was initiated or continued in all 89 patients. Four weeks after the diagnostic MRI, two groups were distinguished according to the clinical response to NSAIDS, with group 1 consisting of 33 responders and group 2 of 56 non-responders. The patients of group 2 were treated with CT-guided intra-articular corticosteroid injection (low-dose injection) while the therapy with NSAIDS was continued. A total of 83 SI joints were punctured without complications, 27 bilaterally and 29 unilaterally. The indication for the intervention was based on inflammatory activity as determined by MRI. The therapy was monitored by clinical follow-up every 8 to 12 weeks over a period of 20 months. Follow-up by dynamic MRI was performed in all 56 children of group 2 and in 15 of the 33 children of group 1 within 8 +/- 4 months of the initial examination. RESULTS: A total of 87.5% of the children in group 2 showed a statistically significant decrease in their subjective complaints from 6.9 +/- 3.4 to 1.8 +/- 1.7 (p < 0.05) as measured on a visual analog scale (VAS from 0 to 10). Improvement was seen as early as 1.5 +/- 1.0 weeks after the intervention and lasted for a mean of 12 +/- 6 months. The children in group 1 already showed similar improvement of the VAS from 6.8 +/- 3.2 to 1.5 +/- 1.4 (p < 0.05) during the initial four weeks of NSAIDS therapy, with the improvement lasting for the 20-month observation period. The follow-up dynamic MRI (0.1 mmol/kg body weight) during therapy showed a statistically significant lower contrast-enhancement in both groups (group 1: 117 +/- 43 % versus 38 +/- 24 %, p < 0.05; group 2: 127 +/- 59 % versus 38 +/- 22 %, p < 0.05). One third of the patients of group 2 showed progression of joint destruction despite absence of subjective complaints. CONCLUSION: CT-guided intra-articular corticosteroid injection has proven an effective, symptomatic, and uncomplicated therapy of acute sacroiliitis in patients with jSpA. Dynamic MRI has a role in establishing the indication for intervention but its role for any follow-up is restricted to cases with inconclusive clinical response.

[Imaging of the coronary arteries by means of multislice helical CT: optimization of image quality with multisegmental reconstruction and variable gantry rotation time]. / Darstellung der Koronararterien mittels Mehrschicht-Spiral-CT: Optimierung der Bildqualität mittels Multisegment-Rekonstruktion und variabler Gantry-Rotationszeit.

PURPOSE: To evaluate the potential of multisegmental reconstruction and variable gantry rotation time for reducing motion-induced artifacts in coronary artery imaging by multislice helical CT. MATERIALS AND METHODS: The data sets of 20 patients (8 with HR < 60 bpm, 12 with HR > 60 bpm) were analyzed. The patients underwent multislice helical CT (Aquilion 8, Toshiba, Otawara, Japan) using the following parameters: 0.5 mm slice thickness, 250 mA, 120 kV, pitch of 0.25 and variable gantry rotation times of 400, 500, or 600 msec. Images were generated by halfscan and multisegmental reconstruction. In 9 coronary segments of each patient, the presence and severity of motion artifacts were assessed and graded on a scale between 5 (no artifacts) and 1 (heaviest artifacts). RESULTS: Diagnostically relevant motion artifacts were rare at low heart rates (< 60 bpm) for both types of image reconstruction (4 % of all segments). Higher heart rates (> 60 bpm) were associated with an increase in motion artifacts on halfscan reconstructions (33% of all segments, p < 0.05) but not on multisegmental reconstructions (4% of all segments). At low heart rates mean image quality did not differ between multisegmental and halfscan reconstruction (4.28 +/- 0.37 vs. 4.22 +/- 0.41; p > 0.05), whereas at higher heart rates image quality was better for multisegmental reconstruction than for halfscan reconstruction (4.23 +/- 0.47 vs. 3.11 +/- 0.63; p < 0.05). CONCLUSION: Multisegmental reconstruction with variable gantry rotation times suppresses motion artifacts and thus improves assessment of the coronary arteries in patients with higher heart rates.