Reducing Invasiveness, Duration, and Cost of Magnetic Resonance Imaging in Rheumatoid Arthritis by Omitting Intravenous Contrast Injection — Does It Change the Assessment of Inflammatory and Destructive Joint Changes by the OMERACT RAMRIS?

MIKKEL ØSTERGAARD; PHILIP G. CONAGHAN; PHILIP O’CONNOR; MARCIN SZKUDLAREK; METTE KLARLUND; PAUL EMERY; CHARLES PETERFY; HARRY GENANT; FIONA M. McQUEEN; PAUL BIRD; MARISSA LASSERE; BO EJBJERG

doi:10.3899/jrheum.090350

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Figure 1.
Low-field dedicated E-MRI of RA wrist and 2nd–5th MCP joints. Coronal (a-b) and axial (d-e) T1-weighted gradient-echo images and coronal STIR image (c) of the wrist and MCP joints before (a, c, and d) and after (b and e) IV contrast injection. Synovitis in 2nd and 3rd MCP joints and in the wrist (arrows) is seen both on STIR images and on contrast-enhanced images (arrows).

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Table 1.

MRI acquisitions in Exercises A and B.

Center/MRI unit	Sequence	Plane	FS	Gd	TR (ms)	TE (mm)	ST (mm)	TI (ms)	Gap (mm)	FOV (mm)	Matrix	Time (min)
Exercise A
Leeds	T1 SE	Cor	−	−	485	20	1.5	−	0.1	100 × 50	256 × 256	4.10
1.5 T Philips	T2 TSE SPIR	Cor	+	−	2000	100	2.0	−	0.2	100 × 100	198 × 256	3.44
Gyroscan	T1 SE	Ax	−	+/−	485	20	1.5	−	0.1	100 × 50	205 × 256	3.21
Gyroscan	T1 SPIR	Cor	+	+	450	20	1.5	−	0.1	100 × 100	192 × 256	8.44
Copenhagen	T1 SE	Cor	−	+/−	600	15	3.0	−	0.0	109 × 145	192 × 256	3.53
1.0 T Siemens	T1 SE	Ax	−	+/−	600−700	15	3.0	−	0.0	109 × 145	192 × 256	3.53–4.32
Impact	STIR	Cor	−	−	4500	30	3.0	150	0.0	108 × 145	182 × 256	5.5
Exercise B
Copenhagen	3D-GE	Cor/Ax	−	+/−	30	18	1.0	−	0.0	140 × 140	256 × 256	6.5
0.2 T Esaote Artoscan	STIR	Cor	−	−	1100	24	3.0	85	0.3	140 × 140	192 × 160	5.5

FOV: field of view; FS: spectral fat saturation (+: yes; − no); Gd: IV injection of gadolinium contrast (−: sequence obtained before injection; +: sequence obtained after injection); GE: gradient echo; 3D-GE: T1-weighted 3-dimensional gradient echo sequence with subsequent multiplanar reconstruction. The flip angle was 65°. SPIR: spectral prepulse inversion recovery; ST: slice thickness; STIR: short-tau inversion recovery; T: tesla; T1-SE: T1-weighted spin-echo; TE: echo time; TI: inversion time; TR: repetition time.

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Table 2.

Exercise A: detection of synovitis, bone erosion, and bone edema by unenhanced MRI, when gadolinium-enhanced MRI is considered the gold standard reference, and interobserver agreement evaluating MR images without and with gadolinium injection.

Type of Pathology	Joints	Image Sets	Performance of Unenhanced (−Gd) MRI^*						Interobserver Agreement^**
Type of Pathology	Joints	Image Sets	Sensitivity	Specificity	PPV	NPV	Accuracy	ICC	ICC −Gd^†	ICC + Gd^†
Bone erosion	MCP	All	0.94	0.94	0.95	0.94	0.94	0.92	0.85	0.92
	MCP	1.5 T, T2 FS	0.95	0.93	0.95	0.93	0.94	0.91	0.81	0.95
	MCP	1.0 T, STIR	0.91	0.96	0.93	0.95	0.94	0.95	0.92	0.87
	Wrist	All	0.89	0.84	0.83	0.93	0.87	0.87	0.74	0.73
Bone edema	MCP	All	0.71	0.88	0.73	0.88	0.83	0.75	0.63	0.71
	MCP	1.5 T, T2 FS	0.74	0.84	0.76	0.83	0.79	0.74	0.58	0.66
	MCP	1.0 T, STIR	0.72	0.95	0.70	0.96	0.92	0.78	0.73	0.81
	Wrist	All	0.83	0.96	0.80	0.97	0.94	0.91	0.77	0.79
Synovitis	MCP	All	0.90	0.49	0.90	0.47	0.84	0.67	0.61	0.88
	MCP	1.5 T, T2 FS	0.93	0.31	0.93	0.38	0.78	0.69	0.72	0.88
	MCP	1.0 T, STIR	0.86	0.79	0.83	0.54	0.77	0.63	0.40	0.87
	Wrist	All	0.87	0.42	0.83	0.49	0.77	0.76	0.59	0.60

↵* Values are means of values for observer 1 and observer 2. No major or systematic differences between observers were observed.
↵** ICC: single measures intraclass correlation coefficient between readings on unenhanced and enhanced MRI (can be considered a “worst-case scenario” intraobserver ICC).
↵^† ICC −Gd: ICC for intraobserver agreement based on assessment of unenhanced images only; ICC + Gd: ICC for intraobserver agreement based on assessment of entire image sets, including Gd-enhanced images. PPV: positive predictive value of presence of pathology on unenhanced MRI, with Gd-enhanced MRI as the gold standard reference; NPV: negative predictive value of absence of pathology on unenhanced MRI, with Gd-enhanced MRI as the gold standard reference; MCP: metacarpophalangeal joints; STIR: short-tau inversion recovery; T: tesla; T2FS T2-weighted images with spectral fat saturation.

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Table 3.
Exercise B. Detection of synovitis and bone erosion by unenhanced low-field E-MRI, when gadolinium-enhanced MRI is considered the gold standard reference.
Type of pathology Joints Performance Unenhanced (−Gd) MRI^*
Sensitivity Specificity Accuracy ICC^**
Erosion Wrist and MCP 0.93 0.99 0.97 0.99
Synovitis Wrist and MCP 0.60 0.96 0.76 0.61

↵* Values are means of values for observer 1 and observer 2. No major or systematic differences between observers were observed.

↵** ICC single measures intraclass correlation coefficient between readings on unenhanced and enhanced MRI (this value can be considered a “worst-case” scenario intraobserver ICC).