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MR评价类风湿关节炎患者手、腕关节改变的临床价值
中文摘要

 目的 探讨MRI在类风湿性关节炎早期诊断中的临床价值;探讨MRI定量、半定量与RA严重程度与活动性的相关性;并探索RA MRI序列优化的方法。 材料与方法 分析2001年3月至2007年10月间以多关节肿痛为主诉、最终获得明确诊断的96例患者的临床资料,全部RA诊断以1987年美国类风湿协会修订的RA诊断标准为金标准。 1.记录最终明确诊断的96例患者的临床及实验室检查结果;分析患者的MRI征象,包括滑膜炎、骨侵蚀、骨髓水肿、腱鞘炎,所有MRI征象均由两位骨放射学医师背对背观察得出。 2.对最终明确诊断的96例患者,分别以四种不同的诊断标准评价其诊断RA的敏感性、特异性和准确性。四种诊断标准分别为:1987年ARA诊断标准(简称传统诊断标准);MRI诊断标准(以双侧对称性滑膜炎为诊断标准,简称MRI诊断标准);改进的1987年美国风湿协会修订的RA诊断标准(将MRI显示的对称性滑膜炎替代原标准的第6条,简称改进的ARA诊断标准)及1987年美国风湿协会修订的RA分类树(简称分类树)。 3.对最终明确诊断的96例患者中的77例RA患者分别进行MRI评分(参照OMERACT RAMRIS评分系统,并增加近节指间关节、末节指间关节及腱鞘炎的评分)并分析其与临床化验指标的相关性,左右手MRI评分之间的相关性,MRI评分之间的相关性。 4.对最终明确诊断的96例中的12例RA患者进行动态增强扫描,分析时间信号曲线与临床、化验指标之间、MRI评分之间的相关性。 5.对最终明确诊断的25例患者的3DFSPGR MRI图像进行三维后处理,以3D FSPGR为滑膜炎的诊断标准,评价3D MIP其诊断滑膜炎的敏感性、特异性。 6.对最终明确诊断的96例中的12例RA患者进行DWI扫描,分析ADC值与临床化验指标、动态增强扫描、MRI评分之间的相关性;分析最终明确诊断中的25例患者,以3D FSPGR为滑膜炎诊断标准,评价DWI诊断滑膜炎的敏感性、特异性。 结果 经过6个月~5年的随访,167例患者中符合入选标准96例,其中77例为RA。 1.滑膜炎为RA最常见征象,出现率88.3%,最常见部位为腕骨间关节;骨侵蚀最常见部位是三角骨和月骨,骨髓水肿最常见的部位是月骨和三角骨;腱鞘炎最常见的部位是尺侧腕伸肌腱、指深浅屈肌腱、指伸肌腱。 2.传统标准诊断的敏感性、特异性、准确性分别为63.6%、94.7%、69.8%; MRI诊断标准诊断的敏感性、特异性、准确性分别为89.6%、63.2%、84.3%;改进的ARA诊断标准诊断的敏感性、特异性、准确性分别为77.9%、89.5%、80.2%;分类树诊断的敏感性、特异性、准确性分别为93.5%、和68.4%、和88.5%。分类树诊断的敏感性和准确性分别提高了 31.7%和18.7%。 3.MRI总分与临床化验指标CRP、ESR有显著相关性,r分别为0.322 (p= 0.009)和0.406 (p=0.001);骨髓水肿、腱鞘炎与CRP、腱鞘炎与疼痛关节数之间具有显著相关性,r依次为0.348 (p=0.017)、0.414 (p=0.004)和0.329 (p=0.013);滑膜炎与骨侵蚀(r=0.542, p=0.000)、骨髓水肿(r=0.365,p =0.001)、肌腱炎(r=0.610, p=0.000)之间,骨侵蚀与骨髓水肿(r=0.543, p=0.000)、腱鞘炎(r=0.430, p=0.000)之间,骨髓水肿与腱鞘炎之间(r=0.671, p=0.000)均具有显著相关性。 4.DCE-MR最高RE、平均RE与晨僵、RF,最大REE与ESR之间相关性具有统计学意义;平均REE和滑膜炎评分(r=0.910,p=0.02)、MRI总分(r=0.776, p=0.024)之间,REE45与腱鞘炎(r=0.716, p=0.046)、MRI 总分(r=0.733, p=O.038)之间均具有显著相关性。 5.3D FSPGR MRI三维后处理图像3D MIP诊断滑膜炎的敏感性、特异性分别为 91.07%和 98.57%。 6.DWI诊断滑膜炎的敏感性和特异性分别为75.6%和9.3%。 结论 1.本研究结果显示MRI对RA的早期诊断具有较高的敏感性和准确性。 2.MRI评分系统及动态增强曲线分析显示定量半定量技术在一定程度上能够反应疾病的严重程度和活动性。 3.序列优化结果显示MR扫描中3D FSPGR后处理图像、3D MIP及DWI对RA滑膜炎诊断的敏感性和特异性较高,3D MIP有助于简化诊断流程,DWI适合无法或不同意增强扫描RA患者滑膜炎的诊断。 [关键词]类风湿性关节炎;腕关节;掌指关节;核磁共振成像;动态增强扫描;后处理技术;DWI

英文摘要

 Objective To explore the role of MRI in the assessment of early RA, to study the MRI quantitation and semi-quantitation for assessment of RA activity, and to optimize the scan sequences of MRI. Materials and methods MRI on both wrists and the 2nd to 5th metacarpophalangeals of 96 patients with polyarthralgia and final diagnosis from March, 2001 to October, 2007 were analyzed. 1.Clinical datas and laboratory test were obtained at the same time. MRI findings including synovitis, bone erosion, bone edema and tenosynovitis were reviewed. 2.The diagnostic sensitivity, specificity and accuracy of MR diagnostic criteria (bilateral and symmetrical synovitis, designated: diagnostic criteria of MRI), ARA diagnostic criteria (the sixth criteria was substituted by MR diagnostic criteria, designated: improved diagnostic criteria) and classification tree revised by ARA were evaluated respectively(designated: classification tree). 3.MRI score was in accordance with OMERACT RAMRIS Scoring System (added the proximal interphalangeal joints, distal interphalangeal joints and tenosyvistis scoring). The relationships between MRI score of each sign, between MRI score and clinical data, between MRI score of right hand and left hand were analyzed respectively. 4.The relationships between DCE-MR with clinical data, laboratory examinations, between MRI score and DE-MR were analyzed respectively. 5.The diagnostic sensitivity and specificity of 3D MIP from 3D FSPGR for synovitis were evaluated. 6.The diagnostic sensitivity and specificity of DWI were compared with 3D FSPGR and the relationships between ADC of synovitis with clinical datas, MRI score and DCE-MR were analyzed respectively. Results Of 167 patients screened, 96 cases met the inclusion criteria with follow up of 6-60 months and 77 were RA. 1.Synovitis is the most common MR manifestation (88.3%) and the most common site was intercarpal joint. Bone erosion occured mostly at triquetrium and lunate; bone edema at lunate and triquetrium, tenosynovtis at musculus extensor carpi ulnaris, flexor disitorum profundus and icialis, extensor tendon. 2.The diagnostic sensitivity, specificity and accuracy of ARC diagnostic criteria and diagnostic tree were 77.9%, 93.5% and 89.5%, and 68.4%, 80.2% and 88.5% respectively. 3.There was a significant correlation between MRI total score and CRP (r=0.322,p=0.009), ESR (r= 0.406,p=0.001), between bone edema score, tenosynovitis score and CRP (r=0.348 and 0.414, p=0.017 and 0.004), between tenosynovitis score and the number of pain joints (r=0.329,p=0.013), betwwen synovitis score and bone erosion score(r=0.542,p=0.000), bone edema score (r=0.365,p=0.001), tenosynovits score (r=0.610,p=0.000), betwwen bone erosion score and bone edema score (r=0.543,p=0.000), tenosynovitis score (r=0.430,p= 0.000), betwwen bone edema score and the tenosynovitis score (r=0.671, p=0.000). 4.A significant positive correlation was also found between maximum RE and morning stiffness, RF, between average RE and morning stiffness, RF, between maximum REE and ESR, between average REE and synovitis score (r=0.910,p=0.02), MRI total score (r=0.776,p=0.024), bewwen REE45 and tenosynovitis (r=0.716,p= 0.046), MRI total score (r=0.733,p=0.038). 5.The diagnostic sensibility and specificity of 3D MIP for synonitis were 91.07% and 98.57% respectively. 6.The diagnostic sensibility and specificity of DWI were 75.6% and 89.3% respectively. Conclusions 1.MRI is more sensitive and preciser in the diagnosis of early RA. 2.MRI score can be used to assess the activity of RA to some extents. 3D MIP and DWI were more sensitive and specific for synovitis. 3.3D MIP can display multi-joints concisely and intuitively while DWI may play an important rule in the diagnosis of synovitis for the patient who can't undergo or disagree the enhanced MR.. Keyword Rheumatoid arthritis; Wrist; Metacarpophalangeal; Magnectic resonance imaging; Dynamic enhancement scan; Post-process; Diffusion weighted imaging

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