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Magnetresonanztomographie der Sakroiliitis: Anatomie, Pathohistologie, MR-Morphologie und Graduierung

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Zusammenfassung

Neben Anamnese und klinischer Untersuchung bildet das Röntgenbild der Sakroiliakalgelenke (SIG) die Basis für die Diagnosestellung einer Spondyloarthritis. Bei klinisch-radiologischer Befunddiskrepanz hat sich für die frühe Diagnostik einer Sakroiliitis die kontrastmittelgestützte Magnetresonanztomographie als sensitives Verfahren bewährt. Die Kenntnis der Morphologie der Sakroiliakalgelenke und der pathologischen Mikro- und Makroanatomie der Sakroiliitis und Enthesitis sind hilfreich für das Verständnis der magnetresonanztomographischen Befunde. Zu den Charakteristika einer SIG-Arthritis gehören subchondrale Sklerosierungen, Erosionen, transartikuläre Knochenbrücken, periartikuläre Fettakkumulationen, juxtaartikuläre Osteitiden, Synovitiden, Kapsulitiden und Enthesitiden. Histologisch dominiert bei aktiver Sakroiliitis ein proliferatives, pannusartiges Bindegewebe, welches Knorpel und Knochen destruiert. Dieses besteht neben Fibroblasten und Fibrozyten aus T-Zellen und Makrophagen. Dabei ist die CD4/CD8-Ratio zugunsten der CD4-T-Helferzellen verschoben. Die bewährte Graduierung der magnetresonanztomographischen Befunde durch einen Chronizitätsgrad und einen Aktivitätsindex, der quantitativ auf der Basis der dynamischen MRT ermittelt wird, soll durch einen alternativ anzuwendenden semiquantitativen Aktivitätsgrad erweitert werden. Auf Basis der Short-tau-inversion-recovery-(STIR-)Sequenz oder der T1-gewichteten fettgesättigten Spinechosequenz wurden folgende Abstufungen pro Quadrant (iliakal ventral, iliakal dorsal, sakral ventral, sakral dorsal) des SIG definiert:

  • 0: keine Signalvermehrungen,

  • 1: Signalvermehrungen lokalisiert im Gelenkspalt bzw. in Erosionen,

  • 2: geringe juxtaartikuläre Signalvermehrungen,

  • 3: mäßige paraartikuläre Signalvermehrungen,

  • 4: flächige Signalvermehrungen.

Die Werte pro Quadrant werden zum Aktivitätsgrad summiert (Spanne 0–16). Diese Modifikation des Graduierungsschemas soll zu einer weiteren Verminderung des Untersuchungs- und Befundungsaufwands beitragen.

Abstract

The diagnosis of spondyloarthropathy is based on radiography of the sacroiliac joints, beside the patient’s history and clinical examination. In cases where the clinical examination and radiography yield discrepant findings, contrast-enhanced magnetic resonance imaging (MRI) is a sensitive modality for the diagnosis of early sacroiliitis. Knowledge of the morphologic anatomy of the sacroiliac joints and of their abnormal micro- and macroanatomy in sacroiliitis and enthesitis are helpful for interpreting MR images. Arthritis of the sacroiliac joints is characterized by subchondral sclerosis, erosions, transarticular bone bridges, accumulation of periarticular fat, juxta-articular osteitis, synovitis, capsulitis, and enthesitis. The major histologic finding in active sacroiliitis is the presence of proliferative, pannus-like connective tissue destroying cartilage and bone. This tissue contains fibroblasts and fibrocytes as well as T cells and macrophages with a shift of the CD4/CD8 ratio toward the CD4 T helper cell population. The well-established grading of MRI findings by means of a chronicity and activity index, which are determined quantitatively from dynamic MR images, is supplemented by an alternative, semiquantitative grading of activity. The following grades were defined for the short tau inversion recovery (STIR) sequence or the T1-weighted, fat-saturated spin-echo sequence for each quadrant (iliac anterior, iliac posterior, sacral anterior, sacral posterior):

  • 0: no signal increase,

  • 1: local signal increase in the joint cavity or within erosions,

  • 2: small areas of increased juxta-articular signal,

  • 3: moderate sized areas of increased juxta-articular signal,

  • 4: large areas of increased juxta-articular signal.

Values of the 4 quadrants are summed to an activity score (range 0–16). The new grading system is proposed to facilitate the examination and shorten image interpretation time.

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Hermann, KG.A., Braun, J., Fischer, T. et al. Magnetresonanztomographie der Sakroiliitis: Anatomie, Pathohistologie, MR-Morphologie und Graduierung. Radiologe 44, 217–228 (2004). https://doi.org/10.1007/s00117-003-0992-6

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  • DOI: https://doi.org/10.1007/s00117-003-0992-6

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