Magnetic Resonance Imaging in Synovial Disorders

Size: px

Start display at page:

Download "Magnetic Resonance Imaging in Synovial Disorders"

Irene McKinney
5 years ago
Views:

1 Magnetic Resonance Imaging in Synovial Disorders Poster No.: P-0036 Congress: ESSR 2014 Type: Educational Poster Authors: R. Arkun, S. Orguc, M. ARGIN ; Izmir/TR, Istanbul/TR Keywords: Musculoskeletal joint, Musculoskeletal soft tissue, MR, Diagnostic procedure, Hyperplasia / Hypertrophy, Inflammation, Neoplasia DOI: /essr2014/P Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 40

2 Learning objectives We will briefly review synovial anatomy histopathologic changes of synovial disorders classification of synovial disorders MRI findings of synovial disorders related to histopathological changes Page 2 of 40

Background Synovial membrane lines the inner surface of joint capsule, all other intra articular structures with the exception of articular cartilage small gap between insertion synovial

3 Background Synovial membrane lines the inner surface of joint capsule, all other intra articular structures with the exception of articular cartilage small gap between insertion synovial membrane/capsule "BARE" area composed of: intimal layer supportive (subintimal) layer forms the lining tendon sheats and ligaments visualization of synovium suggests the presence of underlying pathological change Mechanism of synovial disorders Fig. 1: Mechanism of synovial disorders Page 3 of 40

4 References: MANISA CELAL BAYAR UNI. - Istanbul/TR Page 4 of 40

5 Imaging findings OR Procedure Details Synovial disorders inflammatory synovial disorders nonspesific chronic synovitis Rheumatoid artrithis and other sero negative arthritis septic arthritis other arthritis( iatrogenic, congenital, exc.) tumors and tumor like lesions synovial chondromatosis pigmented villonodular synovitis (PVNS) lipoma arborescens synovial hemangioma synovial sarcoma miscellaneous Synovial inflammation hyperplasia or hypertrophy of synovial cells varying degrees inflammation MRI is the gold standart in imaging same signal intensity with effusion on T1-W images lower signal intensity (SI) than effusion on T2-W images Page 5 of 40

6 Fig. 2: Knee MRI showing low T1w signal and high T2w signal of hypertrophied synovium References: Ege University Department of Radiology with i.v Gd complexes; inflamed synovium high SI joint effusion low SI Rheumatoid arthritis(ra) Rheumatoid arthritis is the most common chronic inflammatory joint disease, with a prevalence of % 2-3 times more common in women The presence of synovitis is considered a strong predictor of future erosive changes x-ray demonstrate late changes and deformities Page 6 of 40

7 Fig. 3: Advanced changes and deformities of the hand typical of rheumatoid arthritis References: Ege University Department of Radiology Key imaging findings in early RA Synovitis Bone marrow edema Bone erosions Page 7 of 40

8 Fig. 4: Typical MRI findings of RA in the hand References: MANISA CELAL BAYAR UNI. - Istanbul/TR Synovitis &RA Synovial thickening Intraarticular Tendon sheets In MRI: SE T1-W: low SI TSE T2-W with fat satturation (fs): high SI SE + C T1-W with fs: high SI Page 8 of 40

9 Fig. 5: MRI signals of synovitis in the wrist References: MANISA CELAL BAYAR UNI. - Istanbul/TR Bone erosions & RA Bone erosions are defined as a partial or complete loss of the low signal intensity that characterizes the cortical bone in both T1- and fluid-sensitive sequences. The erosion can be further characterized as active when there is significant postcontrast enhancement of adjacent bone. Page 9 of 40

10 Fig. 6: Bone erosions of the carpal bones and 4th metacarpal head (arrows) References: MANISA CELAL BAYAR UNI. - Istanbul/TR Bone marrow edema &RA Bone marrow edema, not visualized on X-R, is a pre-erosive sign of arthritic bone damage and may have prognostic value in early RA Low SI on T1-W, High SI on T2-W fluid sensitive sequences HighSI T1-W +C fs Page 10 of 40

Fig. 7: Bone marrow edema of carpal bones and 2nd metacarpal base on PD fs coronal view References: Ege University Department of Radiology Usually arthritic symptoms first

11 Fig. 7: Bone marrow edema of carpal bones and 2nd metacarpal base on PD fs coronal view References: Ege University Department of Radiology Usually arthritic symptoms first develop in the hands and wrists in a characteristic symmetric, proximal distribution. Feet and large joints like hip, knee and shoulder may also be involved. Page 11 of 40

12 Fig. 8: Synovial effusion, hypertropy, erosions of humeral head and tuberculum majus, and subchondral bone marrow edema References: Ege University Department of Radiology Page 12 of 40

Fig. 9: RA involvement of shoulder: synovial thickening, pannus formation, erosion and/or resorption articular cartilage irregularity References: Ege

13 Fig. 9: RA involvement of shoulder: synovial thickening, pannus formation, erosion and/or resorption articular cartilage irregularity References: Ege University Department of Radiology Soft tissue swelling -fusiform and periarticular. It represents a combination of joint edema and tenosynovitis Page 13 of 40

14 Fig. 10: Wrist joint effusion and flexor tenosynovitis References: MANISA CELAL BAYAR UNI. - Istanbul/TR Atlantoaxial joint may also be involved in RA. Page 14 of 40

15 Fig. 11: Involvement of atlantoaxial joint with RA demonstrating chronic changes and ankylosis References: Ege University Department of Radiology MRI is the method of choice in diagnois both in: detection of diasease activity detection of therapy response Page 15 of 40

Fig. 12: Synovial effusion, hypertrophy, enhancement, bone erosion, edemaquantitative measurement from synovial enhancement rate following Gadalinium administration with color maps and time-intensity

16 Fig. 12: Synovial effusion, hypertrophy, enhancement, bone erosion, edemaquantitative measurement from synovial enhancement rate following Gadalinium administration with color maps and time-intensity curves References: MANISA CELAL BAYAR UNI. - Istanbul/TR Juvenile idiopathic arthritis: juvenile rheumatoid arthritis (JRA): Still's disease: is the most common chronic arthritic disease of childhood, and has multiple subtypes. MRI shows synovial hypertrophy, joint effusions as well as osseous and cartilaginous erosions Page 16 of 40

17 Fig. 13: 12y/o female with knee involvement, synovial effusion, hypertrophy and small marginal erosions (arrows) References: MANISA CELAL BAYAR UNI. - Istanbul/TR Oligoarticular or polyarticular arthritis of a duration of six weeks or longer must be present to diagnose JIA Page 17 of 40

Fig. 14: Asymmetrical left sacroileitis and left hip joint effusion References: Ege University Department of Radiology Septic arthritis a destructive arthropathy caused by intra-articular infection.

18 Fig. 14: Asymmetrical left sacroileitis and left hip joint effusion References: Ege University Department of Radiology Septic arthritis a destructive arthropathy caused by intra-articular infection. clinical history localization laboratory tests duration of the disease destruction of subchondral bone on both sides of a joint juxta-articular osteoporosis MRI sensitive for early cartilaginous damage aspiration of joint fluid Page 18 of 40

19 Fig. 15: Synovial effusion similar with RA however with more extensive bone marrow edema, soft tissue inflammation and osteomyelitis References: Ege University Department of Radiology Page 19 of 40

20 Fig. 16: Post-contrast images of the same case References: Ege University Department of Radiology Brucellosis is rare case of septic arthritis Page 20 of 40

Fig. 17: 30y/o male with knee involvement Synovial effusion with higt T1w signal, hypertrophy and marginal erosions (arrows) References: MANISA CELAL BAYAR UNI.

21 Fig. 17: 30y/o male with knee involvement Synovial effusion with higt T1w signal, hypertrophy and marginal erosions (arrows) References: MANISA CELAL BAYAR UNI. - Istanbul/TR Familial Hypertrophic Synovitis (Jakobs syndrome) A rare chromosomal genetic syndrome where the male person has an extra Y male chromosome, becoming XYY instead of normal XY or XX Page 21 of 40

Fig. 18: Bilateral hip involvement with synovial effusion References: Ege University Department of Radiology Reactive (foreign body) Synovitis The detection of foreign body is especially important

22 Fig. 18: Bilateral hip involvement with synovial effusion References: Ege University Department of Radiology Reactive (foreign body) Synovitis The detection of foreign body is especially important because it may serve as an unrecognized nidus for infection. The retained foreign matter may result in cellulitis, abscess, or fistula formation. It may result in synovitis if the joint and osteomyelitis if bone are violated. Page 22 of 40

Fig. 19: foreign body causing synovitis in knee joint of a child References: Ege University Department of Radiology Noninflammatory synovial disorders

23 Fig. 19: foreign body causing synovitis in knee joint of a child References: Ege University Department of Radiology Noninflammatory synovial disorders Pigmented villonodular synovitis(pvns) proliferation of synovium with deposit of lipid and hemosiderin diffuse form : knee, hip, elbow, wrist Page 23 of 40

24 Fig. 20: diffuse form of PVNS of the knee References: Ege University Department of Radiology subchondral bone invasion, erosion and cyst formation Page 24 of 40

25 Fig. 21: Secondary degenerative changes due to PVNS References: Ege University Department of Radiology locular nodular form (giant cell tumor of tendon sheat) Page 25 of 40

Fig. 22: Giant cell tumor of the tendon sheat located at the flexor tendon of the 4th finger of the foot with low T2w signal components. References: MANISA CELAL BAYAR UNI.

26 Fig. 22: Giant cell tumor of the tendon sheat located at the flexor tendon of the 4th finger of the foot with low T2w signal components. References: MANISA CELAL BAYAR UNI. - Istanbul/TR dark synovium on both T1-W & T2-W images bone erosions Hemophilia Haemophilia A accounts for around 80% of cases and results from a deficiency of coagulation Factor VIII. incidence: 1 in 5000 male births. Approximately a third of affected individuals have no family history. Haemophilia B (Christmas disease) accounts for the remaining 20% of cases and results from a deficiency of coagulation Factor IX. Incidence : 1 in 25,000 male births. Page 26 of 40

27 Around 70% of patients have the severe form of the disease characterized by spontaneous haemorrhage or haemorrhage following minor trauma. The hallmark of the disease is haemorrhage, particularly into joints and/or soft-tissue hemophilic arthropaty - in almost all individuals hemophilic pseudotumor - in ~2% soft tissue haematoma, may lead to contractures serious life-threatening haemorrhage (intracranial, thoracic, abdominal) Fig. 23: Low signal in the ankle joint representing chronic blood products with destructive changes of the joint References: MANISA CELAL BAYAR UNI. - Istanbul/TR Early degenerative joint desease with widening of the intercondylar notch, bulbous medial femoral condyle, juxtaarticular osteoperosis and joint space narrowing is secondary to recurrent intraarticular bleeding. Page 27 of 40

Fig. 24: Early degenerative joint desease of the right knee References: Ege University Department of Radiology Synovial chondromatosis chondroid changes of synovium primary : no underlying disease :

28 Fig. 24: Early degenerative joint desease of the right knee References: Ege University Department of Radiology Synovial chondromatosis chondroid changes of synovium primary : no underlying disease : chondroid metaplasia of synovium : multiple intraarticular chondral bodies secondary : Degenerative joint disease : small incorporated cartilage fragments situmulate metaplasia of the synovium Page 28 of 40

29 Fig. 25: Intraarticular bodies may show signal similar to the cartilage, cortical (yellow arrows) or trabecular (red arrows) bone depending to its internal composition References: MANISA CELAL BAYAR UNI. - Istanbul/TR Page 29 of 40

30 Fig. 26: Calcified intraarticular lesion with low signal on all sequences like cortical bone References: Ege University Department of Radiology Page 30 of 40

31 Fig. 27: Multiple small free intraarticular bodies, synovial thickening and enhancement References: MANISA CELAL BAYAR UNI. - Istanbul/TR Page 31 of 40

32 Fig. 28: Calcified intraarticular bodies (arrows) are easily demonstrated with x-ray and computed tomography References: MANISA CELAL BAYAR UNI. - Istanbul/TR Lipoma arborescens diffuse fatty replacement villous proliferation mostly knee joint rare Page 32 of 40

33 Fig. 29: Villous proliferation and fatty replacement of the synovium of the right knee References: MANISA CELAL BAYAR UNI. - Istanbul/TR Related to osteoarthritis diabetes mellitus and trauma Page 33 of 40

34 Fig. 30: Lipoma arborescens with calcified intraarticular calcified bodies References: MANISA CELAL BAYAR UNI. - Istanbul/TR Synovial Hemangioma Synovial haemangioma is a rare benign vascular malformation that occurs in relation to the joint. It is sometimes considered a sub type of soft tissue heamangioma The lesions typically present in children and young adults. Page 34 of 40

Fig. 31: Hemangioma in the knee joint with vascular channels References: Ege University Department of Radiology Occasionally patients can have recurrent heamarthroses Intraarticular synovial sarcoma

35 Fig. 31: Hemangioma in the knee joint with vascular channels References: Ege University Department of Radiology Occasionally patients can have recurrent heamarthroses Intraarticular synovial sarcoma While these tumour arise near joints, it is rare form them to arise from the joint itself and despite their name, they do not arise from synovial structures, e.g. joints, tendon sheaths and bursae. Page 35 of 40

Fig. 32: Enhanching intraarticular mass lesion References: Ege University Department of Radiology Synovial sarcoma Synovial sarcomas typically present in adolescents and young adults (15-40 years of

36 Fig. 32: Enhanching intraarticular mass lesion References: Ege University Department of Radiology Synovial sarcoma Synovial sarcomas typically present in adolescents and young adults (15-40 years of age). There may be a mild (M:F 1.2:1) male predilection. The most common location for these tumours is within the soft tissues adjacent to large joints, e.g the knee and popliteal fossa MRI is the modality of choice to locally stage the tumour. The mass is usually large and variably well-defined Fluid-fluid levels are seen in up to 10-25% of cases Calcifications seen in 30% of cases are non-specific and not usually osteoid or chondroid in appearance Page 36 of 40

37 Fig. 33: Synovial sarcoma involving the soft tissues of the knee and destructiive changes of the tibia References: Ege University Department of Radiology Page 37 of 40

38 Fig. 34: Synovial sarcoma of the plantar soft tissues of the foot References: Ege University Department of Radiology Page 38 of 40

39 Conclusion MRI is gold standart in evaluating synovial disorders MRI findings are related to histopathologic changes Better evaluation both intraarticular and paraarticular structures Early detection of cartilage and subchondral bone changes Quantitative measurement of therapeutic efficasy and follow up patients Better grading than plain radiography for inflammatory synovial diseases For the differential diagnosis of tumors and tumor like lesions plain radiography shuld be obtained Page 39 of 40

40 References 1. Gabriel SE. The epidemiology of rheumatoid arthritis. Rheum. Dis. Clin. North Am. 2001;27 (2): Sommer OJ, Kladosek A, Weiler V et-al. Rheumatoid arthritis: a practical guide to stateof-the-art imaging, image interpretation, and clinical implications. Radiographics. 25 (2): doi: /rg SugimotoH, Takeda A, Hyodo K. Early-stage rheumatoid arthritis: prospective study of the effectiveness of MR imaging for diagnosis. Radiology2000; 216: Orguc S,T#k#z C, Aslanalp Z, Erbay PD. Comparison of OMERACT-RAMRIS Scores and Computer Aided Dynamic Magnetic Resonance Imaging Findings of Hand and Wrist as a Measure of Activity in Rheumatoid Arthritis. Rhematology International (Rheumatol Int Jul;33(7): Page 40 of 40

Figuring out the "fronds"-synovial proliferative disorders of the knee.

Figuring out the fronds-synovial proliferative disorders of the knee. Figuring out the "fronds"-synovial proliferative disorders of the knee. Poster No.: C-1209 Congress: ECR 2014 Type: Educational Exhibit Authors: S. Sivasubramanian; Tamil Nadu/IN Keywords: Imaging sequences,