Abstract
Objective
To evaluate patients with clinically active rheumatoid arthritis (RA) of the shoulder for joint effusion and synovitis using conventional sonography, power Doppler (PD) sonography with and without echo-enhancing contrast agent, and contrast-enhanced MRI.
Design and patients
Twenty-four patients (mean age 64 years) with known RA had one symptomatic shoulder evaluated by conventional gray-scale sonography and PD sonography before and after intravenous administration of the echo-enhancing contrast agent Levovist (300 mg/ml, 2.5 g). The degree and extent of the altered echo pattern in the subacromial bursa, axillary recess and glenohumeral joint seen by conventional gray-scale sonography and the intensity of vascular signals of PD sonography were compared with the findings of MRI obtained with T2-weighted turbo spin-echo sequences and contrast-enhanced T1-weighted fat-saturated spin-echo sequences. MRI was evaluated by two readers in consensus without knowledge of the sonographic findings.
Results
MRI, which was used as the reference examination, detected joint effusion in 71% (17/24) and synovitis in 92% (22/24) of the patients. Conventional sonography revealed an abnormal articular echo pattern in 96% (23/24) of the patients, especially in the axillary recess and subacromial bursa, but failed to attribute the altered echo pattern to either fluid or specific synovitis. PD sonography allowed a specific diagnosis of synovitis in 33% (8 patients), which increased to 50% (12 patients) after administration of an echo-enhancing contrast agent. In 42% (10/24) of the patients, the findings of synovitis demonstrated by MRI corresponded to an altered echo pattern by conventional sonography, but vascular signals were absent by PD sonography with or without echo-enhancing contrast agent.
Conclusions
Using MRI as the "gold standard," PD sonography with and without echo-enhancing contrast agent cannot reliably identify synovitis or distinguish synovial inflammation from effusion in the shoulder joint.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
References
Hämäläinen M. Epidemiology of upper limb joint affections in rheumatoid arthritis. In: Baumgartner H, Dvorak J, Grob D, Munziger U, Simmen BR, eds. Rheumatoid arthritis. Current trends in diagnostics, conservative treatment, and surgical reconstructions. Stuttgart: Thieme, 1995:158–161.
Alasaarela E, Suramo I, Tervonen O, Lähde S, Takalo R, Hakala M. Evaluation of humeral head erosions in rheumatoid arthritis: a comparison of ultrasonography, magnetic resonance imaging, computed tomography and plain radiography. Br J Rheum 1998; 37:1152–1156.
Kieft GJ, Dijkmans BAC, Bloem JL, Kroon HM. Magnetic resonance imaging of the shoulder in patients with rheumatoid arthritis. Ann Rheum Dis 1990; 49:7-11.
Lund PJ, Heikal A, Maricic MJ et al. Ultrasonographic imaging of the hand and wrist in rheumatoid arthritis. Skeletal Radiol 1995; 24:591–596.
Newman JS, Adler RS, Bude RO, Rubin JM. Detection of soft-tissue hyperemia: value of power Doppler sonography. AJR Am J Roentgenol 1994; 163:385–389.
Breidahl WH, Newman JS, Taljanovic MS, Adler RS. Power Doppler sonography in the assessment of musculoskeletal fluid collections. AJR Am J Roentgenol 1996; 166:1443–1446.
Gibbon WW, Wakefield RJ. Ultrasound in inflammatory disease. Radiol Clin North Am 1999; 37:633–651.
Harvey CJ, Blomlex MJK, Eckersley RJ, Cosgrove DO. Developments in ultrasound contrast media. Eur Radiol 2001; 11:675–689.
Wamser G. Power-Doppler und kontrastverstärkte Duplex-sonographie: Was ist zur Zeit praktisch relevant? Röntgenpraxis 1999; 51:90–96.
Backhaus M, Kamradt T, Sandrock D, et al. Arthritis of the finger joints: a comprehensive approach comparing conventional radiography, scintigraphy, ultrasound and contrast-enhanced magnetic resonance imaging. Arthritis Rheum 1999; 42:1232–1245.
Peterfy CG. MR-imaging. Baillières Clin Rheumatol 1996; 10:635–678.
Alasaarela E, Takalo R, Tervonen O, Hakala M, Suramo I. Sonography and MRI in the evaluation of painful arthritic shoulder. Br J Rheum 1997; 36:996–1000.
Gaffney K, Cookson J, Blake D, Coumbe A, Blades S. Quantification of rheumatoid synovitis by magnetic resonance imaging. Arthritis Rheum 1995; 38:1610–1617.
Lange U, Teichmann J, Stracke H, Bretzel RG, Neeck G. Elderly onset rheumatoid arthritis and polymyalgia rheumatica: ultrasonographic study of the glenohumeral joints. Rheumatol Int 1998; 17:229–232.
Folkman J. Angiogenesis in cancer, vascular, rheumatoid and other disease. Nat Med 1995;1:27–31.
Newman JS, Laing TJ, McCarthy CJ, Adler RS. Power Doppler sonography of synovitis: assessment of therapeutic response: preliminary observations. Radiology 1996; 198:582–584.
Cardinal E, Lafortune M, Burns P. Power Doppler US in synovitis: reality or artifact? Radiology 1996; 200:868–869.
Hau M, Schultz H, Tony HP, et al. Evaluation of pannus and vascularization of the metacarpophalangeal and proximal interphalangeal joint in rheumatoid arthritis by high-resolution ultrasound (multidimensional linear array). Arthritis Rheum 1999; 42:2303–2308.
Gaffney K, Cookson J, Blades S, Coumbe A, Blake D. Quantitative assessment of the rheumatoid synovial microvascular bed by gadolinium-DTPA enhanced magnetic resonance imaging. Ann Rheum Dis 1998; 57:152–157.
Scherer A, Ostendorf B, Engelbrecht V, et al. MR-morphological changes of the metacarpophalangeal joints in patients with rheumatoid arthritis: comparison of early and chronic stages. Fortschr Rontgenstr 2001; 173:902–907.
Ostergaard M, Stoltenberg M, Lovgreen P. Magnetic resonance imaging-determined synovial membrane and joint effusion volumes in rheumatoid arthritis and osteoarthritis: comparison with the macroscopic and microscopic appearance of the synovium. Arthritis Rheum 1997; 40:1856–1867.
Veale DJ, Reece RJ, Parsons W, et al. Intra-articular primatised anti-CD4: efficacy in resistant rheumatoid knees. A study of combined arthroscopy, magnetic resonance imaging, and histology. Ann Rheum Dis 1999; 58:342–349.
König VH, Bolze X, Sieper J, Wolf KJ. Quantitative evaluated dynamic MRI in rheumatoid arthritis of the knee joint: follow-up after intra-articular steroid therapy. Fortschr Rontgenstr 1992; 157:140–144.
Jacobson PB, Morgan SJ, Wilcox DM, et al. A new spin on an old model: in vivo evaluation of disease progression by magnetic resonance imaging with respect to standard inflammatory parameters and histopathology in the adjuvant arthritic rat. Arthritis Rheum 1999; 42:2060–2073.
Ernst H, Hahn EG, Balzer T, Schlief R, Heyder N. Color Doppler ultrasound of liver lesions: signal enhancement after intravenous injection of the ultrasound contrast agent Levovist. J Clin Ultrasound 1996; 24:31–35.
Albrecht T, Urbank A, Mahler M, et al. Prolongation and optimization of Doppler enhancement with a microbubble US contrast agent by using continuous infusion: preliminary experience. Radiology 1998; 207:339–347.
Acknowledgement
The authors would like to thank Dr. Simon Ostlere for his help in the manuscript preparation.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Wamser, G., Bohndorf, K., Vollert, K. et al. Power Doppler sonography with and without echo-enhancing contrast agent and contrast-enhanced MRI for the evaluation of rheumatoid arthritis of the shoulder joint: differentiation between synovitis and joint effusion. Skeletal Radiol 32, 351–359 (2003). https://doi.org/10.1007/s00256-003-0632-2
Received:
Revised:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00256-003-0632-2