Steven D. Needell, M.D.
Boca Radiology Group, P.A.

Magnetic Resonance Imaging (MRI) has been shown to outperform conventional radiography for detection of marginal erosions in inflammatory arthropathies (1-5). Early detection and staging of rheumatoid arthritis appears to have significant prognostic implications with disease progression (6-9), and MRI has the potential to become a powerful tool in guiding therapeutic options. Distinguishing small cortical marginal erosions (Fig A) from variant bone anatomy presents one of the most challenging aspects of accurately diagnosing joint erosions by MRI.

Evaluating the metacarpal and carpal bones is challenging because their curved surfaces contain numerous invaginations with regions of synovial infolding. Thin section (1mm or less) MR images are extremely useful in minimizing volume averaging (Figs B,C). Volume averaging results in misrepresentation of anatomy or signal intensity because of adjacent structures blending together in one image. As slice thickness decreases, so do the chances of misinterpreting a lesion due to volume averaging artifact.

GE's Applause (a.k.a. MagneVu MRI) is a portable, in-office MRI machine with protocols tailored for optimal visualization of erosions in the hands, wrist, and feet. The protocols produce small field of view, thin section microanatomy of cortical bone using 3D volume T1-weighted and STIR sequences, which have been demonstrated in the literature to be highly sensitive and specific for detection and characterization of cortical erosions (10-14). 3D T1 and corresponding STIR sequence produce images between 0.6 mm and 1 mm (Figs C,D) which allows more reliable characterization of small erosions than protocols using slices 2 or 3 mm slice thickness, which are more susceptible to volume averaging artifact.

Assessing the chronicity or acuity of an erosion is a valuable tool in staging disease and can assist in guiding therapeutic decisions (6-9). T1W images excel at visualizing bone anatomy and have been shown to be a sensitive sequence for detecting the presence of subacute and chronic erosions. STIR images are the most sensitive sequence for detecting bone marrow edema associated with acute erosions (10-14). Subacute and chronic erosions erosions appear similar in signal intensity on T1W images. On the thin section STIR sequence, subacute erosions are brighter than capsular and synovial tissue (Fig E) and chronic "burned out" erosions appear dark. The thin section STIR sequence is therefore a critical sequence in differentiating subacute from chronic erosions.

In conclusion, the ability to reliably detect and characterize early erosions in rheumatoid arthritis appears to be an effective way of staging disease and planning therapeutic intervention. Thin section (1mm or less) MRI sequences minimize volume averaging which increases specificity of erosion detection. Using a corresponding thin section 3D STIR sequence is an important adjunct to minimize volume averaging artifact and allow effective staging of the chronicity of erosions in rheumatoid arthritis.

Fig A. Erosions along dorsal capsule within lunate and capitate. Note the erosions are brighter in signal than capsular soft tissue. Without thin sections, it is difficult to differentiate such erosions from the joint capsule.
Fig B. Thin sections of wrist reveal well defined tunnel erosions along the capsular margin of lunate and triquetrum. Thin section T1W and STIR sequences allow differentiation of these erosions from capsular infolding.
Fig C. Images of wrist reveal apparent excavation within the capitate on T1W, however the corresponding thin section STIR images reveal this defect to be low intensity, indicating it represents normal variation in bone contour. 
Fig D. Images of hand reveal bright STIR signal in 3rd metacarpal. When analyzing thin sections before and after this cut, this signal is seen to represent focal synovial/capsular infolding rather than an erosion. Corrobative findings include a thin, low intensity capsule without evidence of thickening or synovitis. 
Fig. E. Imaging of the hand reveals a scoop erosion in the radial side of the 3rd metacarpal head. STIR images confirm the presence of this erosion. Bright STIR signal suggests its subacute nature.



(1) Crues J, Shellock F, Dardashti S, et al. Identification of Wrist and MCP Joint Erosions Using a Portable-MR System Compared to Conventional X-ray. J Rheumatology 2004;31:676-85.

(2) Ostergaard M, Szkudlarek M. Magnetic resonance imaging of soft tissue changes in rheumatoid arthritis joints. Seminars in Musculoskeletal Radiology 2001:5:257-273.

(3) Peterfy CG. Magnetic resonance imaging of rheumatoid arthritis: The evolution of clinical applications through clinical trials. Seminars in Arthritis and Rheumatism 2001:30:375-396.

(4) Foley-Noland D, Stack J, Ryan M, et al. Magnetic resonance imaging in the assessment of rheumatoid arthritis: a comparison with plain film radiographs. Br J Rheumatol 1991;30:101-106.

(5) Jorgensen C, Cyteval C, Anaya JM, Baron MP, Lamarque JL, Sany J. Sensitivity of magnetic resonance imaging of the wrist in very early rheumatoid arthritis. Clin Exp Rheumatol 1993;11:163-8.

(6) Breedveld FC. New perspectives on treating rheumatoid arthritis [editorial; comment]. N Engl J Med 1995;333:183-4.

(7) Emery P. Early rheumatoid arthritis: therapeutic strategies. Scand J Rheumatol Suppl 1994;100:3-7.

(8) Emery P. Therapeutic approaches for early rheumatoid arthritis. How early? How aggressive? Br J Rheumatol 1995;34(suppl 2):87-90.

(9) Emery P. Evidence supporting the benefit of early intervention in rheumatoid arthritis. Journal of Rheumatology 2002;29:3-8

(10) Irvine S, Munro R, Porter D. Early referral, diagnosis, and treatment of rheumatoid arthritis: evidence for changing medical practice. Ann Rheum Dis 1999;58:510-513.

(11) Klarlund M, Østergaard M, Gideon P, Sørensen K, Henriksen O, Lorenzen I. Wrist and finger joint MR imaging in rheumatoid arthritis. Acta Radiol 1999;40:400-9.

(12) Klarlund M, Østergaard M, Jensen KE, Lysgård J, Madsen JL, Skjødt H, et al and the TIRA group. Magnetic resonance imaging, radiography, and scintigraphy of the finger joints: one year follow up of patients with early arthritis. Ann Rheum Dis 2000;59:521-8.

(13) Ostergaard M, Stoltenberd M, Lovgreen-Nielsen P, Volck B, Jensen CH, Lorenzen IB. Magnetic resonance imaging-determined synovial membrane and joint effusion volumes in rheumatioid arthritis and osteoarthritis. Arthritis & Rheumatism 1997:40:1856-1867.

(14) Lindegaard H, Vallo J, Horslev-Petersen K, Junker P, Ostergaard M. Low field dedicated magnetic resonance imaging in untreated rheumatoid arthritis of recent onset. Annals of the Rheumatic Diseases 2001;60;770-776.


Other references:


H M Lindegaard, J Vallø, K Hørslev-Petersen, P Junker, and M Østergaard. Low-cost, low-field dedicated extremity magnetic resonance imaging in early rheumatoid arthritis: a 1-year follow-up study. Ann Rheum Dis, Sep 2006; 65: 1208 - 1212.


Helmut Schoellnast; Hannes A. Deutschmann; Josef Hermann; Gottfried J. Schaffler; Pia Reittner; Fritz Kammerhuber; Dieter H. Szolar; Klaus W. Preidler. Psoriatic Arthritis and Rheumatoid Arthritis: Findings in Contrast-Enhanced MRI. Am J Roentgenol. 2006;187(2):351-357


David E. Yocum, Philip G. Conaghan, Ewa Olech, Charles G. Peterfy. Office-based low-field extremity magnetic resonance imaging: Is the glass half empty or half full? Arthritis & Rheumatism 2006; 54:1048-1050.


B J Ejbjerg, E Narvestad, S Jacobsen, H S Thomsen, and M Østergaard. Optimised, low cost, low field dedicated extremity MRI is highly specific and sensitive for synovitis and bone erosions in rheumatoid arthritis wrist and finger joints: comparison with conventional high field MRI and radiography. Ann Rheum Dis, Sep 2005; 64: 1280 - 1287.


P Conaghan, P Bird, B Ejbjerg, P O’Connor, C Peterfy, F McQueen, M Lassere, P Emery, R Shnier, J Edmonds, and M Østergaard. The EULAR–OMERACT rheumatoid arthritis MRI reference image atlas. Ann Rheum Dis, 2005 64.


Sommer O, Kladosek A, Weiler V, et al. Rheumatoid Arthritis: A Practical Guide to State-of-the-Art Imaging, Image Interpretation, and Clinical Implications. RadioGraphics 2005;25:381-398.


M Østergaard, J Edmonds, F McQueen, C Peterfy, M Lassere, B Ejbjerg, P Bird, P Emery, H Genant, and P Conaghan. EULAR–OMERACT rheumatoid arthritis MRI reference image atlas
Ann Rheum Dis, Feb 2005; 64.


C G Peterfy. MRI of the wrist in early rheumatoid arthritis. Ann Rheum Dis, May 2004; 63: 473 - 477.


N Benton, N Stewart, J Crabbe, E Robinson, S Yeoman, and F M McQueen. MRI of the wrist in early rheumatoid arthritis can be used to predict functional outcome at 6 years
Ann Rheum Dis, May 2004; 63: 555 - 561.



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