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. 1997 Sep;56(9):526–534. doi: 10.1136/ard.56.9.526

Measurement of synovial lining volume by magnetic resonance imaging of the knee in chronic synovitis

G Clunie 1, M Hall-Craggs 1, M Paley 1, A King 1, I Wilkinson 1, P Ell 1, J Edwards 1
PMCID: PMC1752445  PMID: 9370877

Abstract

OBJECTIVES—Current methods of monitoring chronic synovitis in a single joint rely on clinical examination derived indices, such as the detection of synovial thickening. This study aimed to develop a reproducible method for quantifying the volume of synovial lining in chronic synovitis using contrast enhanced magnetic resonance (MR) imaging.
METHODS—The knees of 18 patients with chronic synovitis were examined (34 studies). A 2D T1 weighted FLASH sequence was used to evaluate the temporal enhancement of synovial structures after intravenous contrast. Synovial lining volume was calculated from subtraction of pre and post-enhancement 3D T1 weighted MP RAGE images with thresholding and pixel counting. Eleven patients were examined before and after intra-articular glucocorticoid (mean interval 14 weeks) and MR data compared with changes in clinical examination derived indices of disease activity.
RESULTS—Synovial lining volume varied from 52-267 ml. The coefficient of variation in volume calculation was 3.5% for a single observer and was 3.8% for two observers. Synovial lining volume was quantified in all patients where synovial lining thickening could not be detected clinically. A decrease in synovial lining volume of >40% was associated with an improvement in synovial lining thickening, detected clinically. Decreases in synovial lining volume were quantified by MR in two of three patients where changes in clinical examination derived indices were inconsistent.
CONCLUSIONS—A reproducible method of estimating the volume of synovial lining in patients with chronic synovitis has been developed. MR measurement of synovial lining volume may quantify changes in chronic synovitis that remain unidentified by clinical measures.



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Figure 1  .

Figure 1  

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Serial sagittal knee images using 2D FLASH (central slice) in a patient with RA (A). ROIs were placed over the suprapatellar pouch synovial lining and juxta-synovial lining synovial fluid. Signal intensity in each tissue ROI was recorded before (image 69) and at intervals (image nos 72-211) after administration of intravenous Gd-DTPA. Signal intensity in consecutive image ROIs was expressed as the ratio of post to pre-contrast values (B). Consecutive data points correspond to images in (A).

Figure 2  .

Figure 2  

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Isolation of synovial lining from 3D MP RAGE T1 weighted scans. Pre-enhancement image (A) and post-enhancement image (B) are subtracted. Signal in the synovial lining and blood vessels (C) is separated by placing a manually defined ROI around the synovial lining to create a synovial `mask' (D) used for pixel counting.   

Figure 3  .

Figure 3  

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Effect of varying pixel signal intensity threshold on % maximum area of perisynovial soft tissue (n=37), bone (n=22), synovial fluid (n=19), and synovial (n=30) ROIs (each >10 pixels) in the subtracted image. Bars represent means. Data from 64 images taken from the first six patients studied. Inclusion of non-synovial lining pixels in the manually placed synovial ROI in the subtracted image, may result in an overestimate of synovial lining area/slice. As these areas are of low signal intensity, they may be omitted by applying a pixel signal intensity threshold. However, too high a threshold may omit areas of `true' synovium leading to an underestimate of synovial lining area/slice. For example, a threshold of 36 would omit all non-synovial pixels but would reduce the synovial area/slice by over 20%. The balance of errors suggested an optimum threshold of 24. 

Figure 4  .

Figure 4  

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Enhancement pattern of synovial lining (A), juxta-synovial lining synovial fluid (B), and central suprapatellar pouch synovial fluid (C) after intravenous Gd-DTPA administration (mean (SD)). Enhancement is expressed as the ratio of post/pre-contrast image signal intensity in a ROI placed over the appropriate tissue. Baseline studies only.

Figure 5  .

Figure 5  

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Correlation between total synovial lining volume and volume of a synovial lining in a single sagittal slice (r=0.81, p<0.001 ANOVA, n=29).

Figure 6  .

Figure 6  

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Correlation between synovial lining volume and maximum synovial lining enhancement expressed as post/pre-contrast signal intensity ratio (r=0.5, p=0.01 ANOVA, n=21).

Figure 7  .

Figure 7  

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Sagittal image from a post/pre-enhancement subtracted T1 weighted 3D MP RAGE sequence (A) showing distribution of synovial lining (high signal) throughout the joint. A contiguous image from the T2 weighted 3D FISP sequence obtained 60 minutes after intravenous Gd-DTPA injection (B) showing distribution of synovial fluid (high signal) throughout the knee joint cavity. The two images are complementary. Note: there is greater enhancement of juxta-synovial lining fluid compared with central suprapatellar pouch synovial fluid in the FISP image (Gd-DTPA has diffused through the synovial lining into juxta-synovial lining fluid but has not yet diffused throughout the intra-articular cavity).

Selected References

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