ERAMRS: a new MR scoring system for early rheumatoid arthritis of the wrist

  • Fan Xiao
  • James F. GriffithEmail author
  • Andrea L. Hilkens
  • Jason C. S. Leung
  • Jiang Yue
  • Ryan K. L. Lee
  • David K. W. Yeung
  • Lai-Shan Tam



To (i) devise a new semi-quantitative scoring system known as Early Rheumatoid Arthritis Magnetic Resonance Score (ERAMRS) to assess inflammation of the wrist on magnetic resonance imaging in early rheumatoid arthritis and to (ii) test ERAMRS and other MR scoring systems against everyday used clinical scorings.

Materials and methods

One hundred six treatment-naïve patients (81 females, 25 males, mean age 53 ± 12 years) with early rheumatoid arthritis (ERA) underwent clinical/serological testing as well as 3-T MRI examination of the most symptomatic wrist. Clinical assessment included Disease Activity Score-28 and Health Assessment Questionnaire; erythrocyte sedimentation rate and C-reactive protein were measured. MR imaging data was scored in all patients using three devised MR semi-quantitative scoring systems, namely, the (a) ERAMRS system, (b) Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS) system, and the (c) McQueen Score system.


Synovitis was present in 106 (100%), tenosynovitis in 98 (92%), and bone marrow edema in 84 (79%) of 106 ERA wrists. ERAMRS had the highest correlation with clinical disease activity scores (r = 0.476, p < 0.001) and serological parameters (r = 0.562, p < 0.001). RAMRIS system had the lowest correlation (r = 0.369, p < 0.001 for clinical disease activity; r = 0.436, p < 0.001 for serological parameters). RAMRIS synovitis subscore had a lower correlation than ERAMRS for clinical disease activity (r = 0.410, p < 0.001) and for serological parameters (r = 0.456, p < 0.001).


The ERAMRS system, designed to grade inflammation on wrist MRI in ERA, provided the best correlation with all clinical scoring systems and serological parameters, indicating its improved clinical relevance over other MR scoring systems.

Key Points

We devised a clinically relevant, easy-to-use semi-quantitative scoring system for scoring inflammation on MRI of the wrist in patients with early rheumatoid arthritis.

ERAMRS system showed better correlation with all clinical and serological assessment of inflammation in patients with early rheumatoid arthritis indicating its improved clinical relevance over other MR scoring systems.


Early rheumatoid arthritis Magnetic resonance imaging Semi-quantitative scoring system Clinical correlation 



C-reactive protein


Disease Activity Score-28 Calculator


Early rheumatoid arthritis


Early Rheumatoid Arthritis Magnetic Resonance Score


Erythrocyte sedimentation rate


Health Assessment Questionnaire


Magnetic resonance imaging


Rheumatoid Arthritis Magnetic Resonance Imaging Score



The authors state that this work has not received any funding.

Compliance with ethical standards


The scientific guarantor of this publication is James F. Griffith.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

One of the authors has significant statistical expertise.

Jason Chi Shun Leung

The Chinese University of Hong Kong Jockey Club Centre for Osteoporosis Care and Control

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.


• prospective

• cross-sectional study

• performed at one institution

Supplementary material

330_2019_6060_MOESM1_ESM.docx (41 kb)
ESM 1 (DOCX 41 kb)


  1. 1.
    Scott DL (2007) Early rheumatoid arthritis. Br Med Bull 81-82:97–114CrossRefGoogle Scholar
  2. 2.
    Raza K, Buckley CE, Salmon M, Buckley CD (2006) Treating very early rheumatoid arthritis. Best Pract Res Clin Rheumatol 20:849–863CrossRefGoogle Scholar
  3. 3.
    Fleming A, Crown JM, Corbett M (1976) Incidence of joint involvement in early rheumatoid arthritis. Rheumatol Rehabil 15:92–96CrossRefGoogle Scholar
  4. 4.
    McQueen F, Beckley V, Crabbe J, Robinson E, Yeoman S, Stewart N (2005) Magnetic resonance imaging evidence of tendinopathy in early rheumatoid arthritis predicts tendon rupture at six years. Arthritis Rheum 52:744–751CrossRefGoogle Scholar
  5. 5.
    Navalho M, Resende C, Rodrigues AM et al (2012) Bilateral MR imaging of the hand and wrist in early and very early inflammatory arthritis: tenosynovitis is associated with progression to rheumatoid arthritis. Radiology 264:823–833CrossRefGoogle Scholar
  6. 6.
    Suresh E (2004) Diagnosis of early rheumatoid arthritis: what the non-specialist needs to know. J R Soc Med 97:421–424CrossRefGoogle Scholar
  7. 7.
    Rahmani M, Chegini H, Najafizadeh SR, Azimi M, Habibollahi P, Shakiba M (2010) Detection of bone erosion in early rheumatoid arthritis: ultrasonography and conventional radiography versus non-contrast magnetic resonance imaging. Clin Rheumatol 29:883–891CrossRefGoogle Scholar
  8. 8.
    Sugimoto H, Takeda A, Masuyama J, Furuse M (1996) Early-stage rheumatoid arthritis: diagnostic accuracy of MR imaging. Radiology 198:185–192CrossRefGoogle Scholar
  9. 9.
    Ostergaard M (1997) Different approaches to synovial membrane volume determination by magnetic resonance imaging: manual versus automated segmentation. Rheumatology 36:1166–1177CrossRefGoogle Scholar
  10. 10.
    Chand AS, McHaffie A, Clarke AW et al (2011) Quantifying synovitis in rheumatoid arthritis using computer-assisted manual segmentation with 3 tesla MRI scanning. J Magn Reson Imaging 33:1106–1113CrossRefGoogle Scholar
  11. 11.
    Yang H, Rivoire J, Hoppe M et al (2015) Computer-aided and manual quantifications of MRI synovitis, bone marrow edema-like lesions, erosion and cartilage loss in rheumatoid arthritis of the wrist. Skeletal Radiol 44:539–547CrossRefGoogle Scholar
  12. 12.
    Crowley AR, Dong J, McHaffie A et al (2011) Measuring bone erosion and edema in rheumatoid arthritis: a comparison of manual segmentation and RAMRIS methods. J Magn Reson Imaging 33:364–371CrossRefGoogle Scholar
  13. 13.
    Aizenberg E, Shamonin DP, Reijnierse M, van der Helm-van Mil AHM, Stoel BC (2018) Automatic quantification of tenosynovitis on MRI of the wrist in patients with early arthritis: a feasibility study. Eur Radiol.
  14. 14.
    Wolfe F (2009) The many myths of erythrocyte sedimentation rate and C-reactive protein. J Rheumatol 36:1568–1569CrossRefGoogle Scholar
  15. 15.
    McQueen FM, Stewart N, Crabbe J et al (1998) Magnetic resonance imaging of the wrist in early rheumatoid arthritis reveals a high prevalence of erosions at four months after symptom onset. Ann Rheum Dis 57:350–356CrossRefGoogle Scholar
  16. 16.
    Østergaard M, Edmonds J, McQueen F et al (2005) An introduction to the EULAR-OMERACT rheumatoid arthritis MRI reference image atlas. Ann Rheum Dis 64(Suppl 1):i3–i7CrossRefGoogle Scholar
  17. 17.
    Østergaard M, Peterfy CG, Bird P et al (2017) The OMERACT rheumatoid arthritis magnetic resonance imaging (MRI) scoring system: updated recommendations by the OMERACT MRI in Arthritis Working Group. J Rheumatol 44:1706–1712CrossRefGoogle Scholar
  18. 18.
    Haavardsholm EA, Ostergaard M, Ejbjerg BJ et al (2005) Reliability and sensitivity to change of the OMERACT rheumatoid arthritis magnetic resonance imaging score in a multireader, longitudinal setting. Arthritis Rheum 52:3860–3867CrossRefGoogle Scholar
  19. 19.
    Heidari B (2011) Rheumatoid arthritis: early diagnosis and treatment outcomes. Casp J Intern Med 2:161–170Google Scholar
  20. 20.
    Davis JM, Matteson EL (2012) My treatment approach to rheumatoid arthritis. Mayo Clin Proc 87:659–673CrossRefGoogle Scholar
  21. 21.
    Irvine S, Munro R, Porter D (1999) Early referral, diagnosis, and treatment of rheumatoid arthritis: evidence for changing medical practice. Ann Rheum Dis 58:510–513CrossRefGoogle Scholar
  22. 22.
    Burgers LE, Nieuwenhuis WP, van Steenbergen HW et al (2016) Magnetic resonance imaging-detected inflammation is associated with functional disability in early arthritis—results of a cross-sectional study. Rheumatology 55:2167–2175CrossRefGoogle Scholar
  23. 23.
    Glinatsi D, Baker JF, Hetland ML et al (2017) Magnetic resonance imaging assessed inflammation in the wrist is associated with patient-reported physical impairment, global assessment of disease activity and pain in early rheumatoid arthritis: longitudinal results from two randomized controlled trials. Ann Rheum Dis 76:1707–1715CrossRefGoogle Scholar
  24. 24.
    Gul HL, Ferreira JF, Emery P (2015) Remission in rheumatoid arthritis: is it all the same? Expert Rev Clin Pharmacol 8:575–586CrossRefGoogle Scholar
  25. 25.
    Gandjbakhch F, Conaghan PG, Ejbjerg B et al (2011) Synovitis and osteitis are very frequent in rheumatoid arthritis clinical remission: results from an MRI study of 294 patients in clinical remission or low disease activity state. J Rheumatol 38:2039–2044CrossRefGoogle Scholar
  26. 26.
    Haavardsholm EA, Lie E, Lillegraven S (2012) Should modern imaging be part of remission criteria in rheumatoid arthritis? Best Pract Res Clin Rheumatol 26:767–785CrossRefGoogle Scholar
  27. 27.
    Anandarajah A, Thiele R, Giampoli E et al (2014) Patients with rheumatoid arthritis in clinical remission manifest persistent joint inflammation on histology and imaging studies. J Rheumatol 41:2153–2160CrossRefGoogle Scholar
  28. 28.
    Møller-Bisgaard S, Ejbjerg BJ, Eshed I et al (2017) Effect of a treat-to-target strategy based on methotrexate and intra-articular betamethasone with or without additional cyclosporin on MRI-assessed synovitis, osteitis, tenosynovitis, bone erosion, and joint space narrowing in early rheumatoid arthritis: results from a 2-year randomized double-blind placebo-controlled trial (CIMESTRA). Scand J Rheumatol 46:335–345CrossRefGoogle Scholar
  29. 29.
    Gandjbakhch F, Foltz V, Mallet A, Bourgeois P, Fautrel B (2011) Bone marrow oedema predicts structural progression in a 1-year follow-up of 85 patients with RA in remission or with low disease activity with low-field MRI. Ann Rheum Dis 70:2159–2162CrossRefGoogle Scholar
  30. 30.
    Nieuwenhuis WP, van Steenbergen HW, Stomp W et al (2016) The course of bone marrow edema in early undifferentiated arthritis and rheumatoid arthritis: a longitudinal magnetic resonance imaging study at bone level. Arthritis Rheumatol 68:1080–1088Google Scholar
  31. 31.
    Tam LS, Griffith JF, Yu AB, Li TK, Li EK (2007) Rapid improvement in rheumatoid arthritis patients on combination of methotrexate and infliximab: clinical and magnetic resonance imaging evaluation. Clin Rheumatol 26:941–946CrossRefGoogle Scholar
  32. 32.
    Gaffney K, Cookson J, Blades S, Coumbe A, Blake D (1998) Quantitative assessment of the rheumatoid synovial microvascular bed by gadolinium-DTPA enhanced magnetic resonance imaging. Ann Rheum Dis 57:152–157CrossRefGoogle Scholar
  33. 33.
    Griffith JF, Wang YX, Antonio GE et al (2007) Modified Pfirrmann grading system for lumbar intervertebral disc degeneration. Spine 32:E708–E712CrossRefGoogle Scholar
  34. 34.
    Mangnus L, van Steenbergen HW, Reijnierse M, van der Helm-van Mil AH (2016) Magnetic resonance imaging-detected features of inflammation and erosions in symptom-free persons from the general population. Arthritis Rheumatol 68:2593–2602CrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  1. 1.Department of Imaging & Interventional RadiologyPrince of Wales Hospital, The Chinese University of Hong KongShatin, N.T.Hong Kong
  2. 2.Department of Jockey Club Centre for Osteoporosis Care and Control, Prince of Wales HospitalThe Chinese University of Hong KongShatin, N.T.Hong Kong
  3. 3.Department of Medicine & Therapeutics, Prince of Wales HospitalThe Chinese University of Hong KongShatin, N.T.Hong Kong

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