I M M A N U E L K r anken h au s B e r lin

Rheumaorthopädie . Rheumatologie . Naturheilkunde

Ultrasound Grading of Power Doppler Signals in Synovitis: Does it need an Update?

Wolfgang A. Schmidt , Verena Schönau , , Britta E. Reiche , Phillip D. Oberdorfer , Sarah Ohrndorf , Marina Backhaus
1 1 2 3 3 3 3

1 Immanuel Krankenhaus Berlin, Medical Centre for Rheumatology Berlin-Buch, Germany

2 Dept. of Rheumatology and Clinical Immunology, University of Erlangen, Germany
3 Dept. of Rheumatology and Clinical Immunology, Charité – University Medicine, Berlin, Germany

Figure 1: Measurement of power

Background Doppler fraction over 3 seconds. Conclusions
Synovial Doppler ultrasound has become an important tool for evaluating inflammatory activity and prognosis in RA. The highest peak represents the  oppler grades 1-3 are not equally distributed in the currently used semi-
D
measured colour fraction quantitative Doppler score.
A semi-quantitative score (grades 0-3) is widely used.
Computerized measurement of synovial colour fraction has become available.  ean subjectively estimated colour fractions are higher than mean
M
electronically measured colour fractions.
Scoring might be improved using new quantitative scores, particularly for improving the sensitivity to change.
Quantitative scores can provide more equal distribution:
Subjective estimation: 1: >0-10%; 2: >10-25%; 3: >25%
Objectives Electronic measurement: 1: >0-6%; 2: >6-12%; 3: >12%
To compare subjective estimation with computerized quantification of synovial perfusion in active RA S uch scores would probably increase the sensitivity to change and thus
To develop new quantitative Doppler ultrasound scores improve monitoring treatment response.
To establish quantitative limit values for the respective grades in order to achieve equal distribution
To compare the new scores with the established semi-quantitative score

Results
Table 1: Semi-quantitative scoring Table 2: Doppler positive joint regions, Joint Dorsal Volar Characteristics of the 41 patients:
Grade Definition
system by M. Szkudlarek estimated/measured colour fractions • 29 females (71%)
0 No Doppler signals in the synovium Regions Estimated Measured Regions Estimated Measured
(Arthritis Rheum 2003;48:955-62) • Mean age, 62 years (SD +14)
1 Single vessel signals (≤3*) Wrist 59 19% 11% 9 12% 6% • Mean disease duration, 11 years (SD +14)
2 Confluent vessel signals in <50% of the synovium MCP 1 19 23% 15% 2 16% 4% • Mean DAS28 (CRP), 5.5 (SD +1.3)
3 Vessel signals in >50% of the synovium MCP 2 39 20% 13% 3 13% 5% • Mean CRP, 25 mg/dl (SD +40)
*suggested by E. Naredo (Arthritis Rheum 2008;59:515-22) MCP 3 34 22% 13% 1 2% 2% • Rheumatoid factor +, 66%, ACPA+, 63%
MCP 4 13 23% 15% 0 • X-rays of hands and forefeet showing erosions, 68%
MCP 5 9 22% 12% 4 8% 4% Power Doppler signals in 192 of 984 joint regions
Doppler signals most common in wrists > MCP 2 > MCP 3
Methods Total 173 21% 13% 19 11% 6%
More common in dorsal than in volar scans (Table 2)
 onsecutive RA patients (ACR/EULAR classification +, ≥ 1 swollen wrist or MCP joint with
C Table 3: Results related to semi-quan- Semi- Joint regions Estimated Measured
titative grading system by Szkudlarek quantitative score colour fraction colour fraction Mean subjectively estimated > mean measured colour fraction
detectable Doppler signals)
1 42 (21.9%) 5.3% (SD 3.6) 3.9% (SD 2.4) The highest subjectively estimated colour fraction was 70%
Bilateral volar & dorsal power Doppler ultrasound of wrists & MCP 1-5
2 139 (72.4%) 21.0% (SD 10.5) 12.6% (SD 6.9) The highest measured colour fraction was 52%
Longitudinal probe positions of up to 45° medially and laterally from the standard dorsal or volar probe positions
3 11 (5.7%) 60.9% (SD 6.6) 29.7% (SD 10.1) A colour fraction of > 50% was measured only in 1 joint region
GE Logiq E9 XD Clear with hockey stick probe (L8-18i-D)
Table 4: Suggested grading system  oppler grades are not equally distributed in the established semi-quantita-
D
Subjective estimation of maximum proportion of synovium covered by colour signals in each joint region New Estimated Joint regions Measured Joint regions
with equal distribution of grades 1-3 tive scoring system (Table 3)
Grading according to the established Szkudlarek score (0-3) score colour fraction colour fraction
Quantitative scores would provide a more equal distribution (Table 4)
Computerized grading of maximum synovial perfusion 1 >0-10% 68 >0-6% 57
2 >10-25% 70 >6-12% 69
3 >25% 54 >12% 66

Disclosures: The ultrasound equipment from this study was provided by GE Health Care . Wolfgang A. Schmidt: Research grants from GE Healthcare, Esaote and Siemens AG; Marina Backhaus: Research grants from GE Healthcare and Esaote; Other authors: No disclosures www.berlin.immanuel.de