Background/Purpose:

The role of ultrasonography (US) in early rheumatoid arthritis (ERA) for detecting synovial hypertrophy and its vascularity has already been demonstrated. Contrast enhanced ultrasonography (CEUS) may be superior to US in detecting synovial inflammation by visualizing and quantifying blood flow, making possible the differentiation of an active synovitis from fibrosis or necrosis. However, there is not a clear role of CEUS in daily rheumatological clinical practice. 

The objective of this pilot study was to analyse CEUS in ERA patients and to correlate CEUS parameters with clinical and US markers of synovial inflammation. 

Methods:

Patients diagnosed with ERA or with early undifferentiated arthritis within the previous 24 months on the basis of the 2010 ACR/EULAR classification criteria, and having DAS28≥3.2, who presented in a tertiary department of Rheumatology were consecutively enrolled. Subjects without a known joint involvement were recruited as controls. All patients underwent clinical examination, laboratory determination of acute phase reactants, RF and ACPA. US was performed by the same experienced sonographer using a Siemens Acuson S2000. The most clinically affected wrist (patients) or the dominant hand (controls) was scanned on the dorsal aspect. Synovial inflammation was scored semi-quantitatively (grade 0-3) by grey scale and by Power Doppler (PD). CEUS was performed using SonoVue contrast agent (Bracco, S.p.A, Italia). The region of interest was selected as the area corresponding to the synovial hypertrophy of the wrist. CEUS was quantified on a semiquantitative scale, according to the degree of enhancement: 0 without, 1 mild, 2 increased. A dedicated software was used to calculate the time intensity curves (TIC). Statistical analysis was performed using SPSS 15.0.

Results:

Sixteen patients (F:M=12:4, mean age 55.31±15.71 years, mean disease duration 10.2±6.82 months) and 9 controls (F:M=8:1, mean age 37.22±4.52) were enrolled. The 2010 ACR/EULAR classification criteria for RA were fulfilled by 81.25% of patients. RF and ACPA positivity were found in 68.8% and 50% of patients, respectively. Mean DAS 28 score was 5.02±1.20. US synovial hypertrophy was seen in 81.2% of patients (grade 1-3) and in 22.2% of controls (grade 1) (p=0.001). Positive PD was found in 50% of patients and in none of the controls (p=0.01).

Positive CEUS was detected in 93.7% of patients (56.3% grade 2) and in 22.2% of controls (grade 1) (p<0.001). CEUS correlated with DAS28 (r=0.51, p=0.04), but not with PD (r=0.28, p=0.29)

The analysis of the time-intensity curves showed differences in patients compared to controls for peak (27.98±6.36 vs. 21.14±4.57 s, p=0.01), area under the curve (AUC) (835.95±216.08 vs. 1087.85±405.01 %s, p=0.09) and slope (0.080±0.04 vs. 0.111±0.03 %/s, p=0.04). Significant negative correlations were found between time to peak, mean transit time and PD (r=-0.58, p=0.02) and clinical parameters of disease activity, respectively. 

Conclusion:

CEUS showed significant enhancement in patients with ERA or with early undifferentiated arthritis compared to controls. Peak and slope values significantly differed between groups. TIC parameters correlated with clinical and US markers of disease activity.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/contrast-enhanced-ultrasonography-in-patients-diagnosed-with-early-arthritis-a-preliminary-experience/