Evaluation of MRI diffusion in spondylarthropathy axial skeleton lesions

Transcription

1 Evaluation of MRI diffusion in spondylarthropathy axial skeleton lesions Poster No.: C-2353 Congress: ECR 2012 Type: Scientific Paper Authors: B. Dallaudiere, R. Dautry, A. Felter, J. LINCOT, P. Koch, E. Schouman; Paris/FR Keywords: Musculoskeletal bone, Bones, Musculoskeletal system, MR, MR-Diffusion/Perfusion, CAD, Comparative studies, Experimental investigations, Epidemiology, Inflammation, Tissue characterisation DOI: /ecr2012/C-2353 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 18

2 Purpose To evaluates the interest of DWI in spinal lesions of the spondylarthritis: Correlation between DWI and the T1 / STIR weighted images Detection of complementary lesions by DWI ADC measurement of lesions and comparison to that of healthy spongious bone and normal vertebral disc.. Clinical background: The spondylarthritis spectrum includes 6 diseases: Spondylitis, the most common(1,2,3) :Enthesitis of the axial spine and sacroiliac joints, can lead to ankylosis Psoriatic arthritis. Reactive arthritis : to be differenciated from arthritis related to an infection. Arthritis associated to inflammatory bowel disease Undifferenciated spondylarthritis. SAPHO syndrome (Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis ) and other pustular osteo-arthritis. Prevalence of spondylarthritis: 0,3% to 1,9 % in general population(4, 5). Estimated at 13,6% in the HLA- B27 positive population(3). True prevalence is underestimated, because of diagnosis latency and methods employed(3). Sex ratio close to 1, with a louder phenotype in men(6). Clinical symptomes associate: A pelvi-spinal syndrome, Peripheral enthesopathy, A peripheral joint syndrome, An extra-articular syndrome (uveitis, psoriasis, balanitis, urethritis, diarrhea). Physiopathology is controversial. Enthesis is the main target (bone insertion area of tendons, ligaments, capsules et fascias). Secondary inflammation of synovium: contact with capsular and ligamentous structures. Inflammation and mechanical stress on enthesis lead to reactive osteitis. Bony constructions testify of the inflammation healing process. Page 2 of 18

3 Spinal radiological lesions(7) : Romanus spondylitis [Figure 1] :erosion of the anterolateral vertebral corners and "squaring" of the vertebral soma. Syndesmophytes: ossifications of the enthesitis (may eventually lead to the "bamboo spine" aspect). Parasyndesmophytes, mostly in psoriatic arthritis.c1-c2 subluxation, rare. Erosions of the endplates (can be a sign of trans-discal fracture). Posterior articular arthritis [Figure 2], costo-vertebral arthritis [Figure 3] and costo-transversary arthritis, inter-spinous bursitis [Figure 4]. Ossification of the posterior ligaments (characteristic feature of ankylosing spondylitis). Calcifications and ossifications of the vertebral discs on and ankylosed spine (ankylosing spondylitis). Standard MRI protocol: Sagittal slices T1 and STIR weighted. No injection of gadolinium chelate(8,9). Role Diffusion weighted MRI (DWI) not studied previously (10,11,12). Principles of DWI: Based upon loss of signal related to the brownian movements of free water molecules in the tissues(13). ADC (Apparent Diffusion Coefficient) :Quantitative parameter, calculated with the DW images. Takes into account the free water movements et capillary perfusion.the ADC varies as the diffusion of water molecules Images for this section: Page 3 of 18

4 Fig. 1: Green circle: D12-L1 active spondylitis, T1 and STIR images. Orange circle: L1L2 spondylitis sequelae, T1 and STIR images. Page 4 of 18

5 Fig. 2: L4-L5 posterior arthritis: STIR and DWI sagittal slices Page 5 of 18

6 Fig. 3: D5-D6 and D9-D10 costo-vertebral arthritis: T1 & STIR sagittal slices Page 6 of 18

7 Fig. 4: L2-L3 and L3-L4 interspinous bursitis (T1 and STIR sagittal slices) Page 7 of 18

8 Methods and Materials Patients Inclusion criteria: Patients with a clinically or biologically suspected spondylarthritis. Patient diagnosed with spondylarthritis, whether or not under treatment. Patients included in the DESIR study. Exclusion criteria: Contraindication to MRI. Suspicion of brucellosis. No age or gender criteria. Technique: 1.5 Tesla.Spine MRI Coil: CTL Array by USAI: 6 elements, 6 canals.protocole:2 acquisitions FOV 48cm (cervicothoracic / thoraco-lumbar). Sequences: Sagittal T1 TSE (TR 660 ms, TE 9,5 ms, Duration 2,53 min)sagittal STIR (TR 4700 ms, TE 68 ms, Duration 3,36 min). Cervicothoracic axial Diffusion (EPI b0 et b1000) (TR 7075 ms, TE 87,4 ms, Duration 4,57 min) [Figure 5] with ADC map. Lumbar sagittal Diffusion (EPI b0 and b1000) (TR 6000 ms, TE 111,4 ms, Duration 2,06 min) with ADC map [Figure 6]. Image interpretation: By two musculo-squeletal radiologist: a senior and a resident. Double independant reading, of each examination by each radiologist. Standardized reading grid: Spinal spondylarthritis lesions. Calculation of the inter- and intra-reader consistency rates Comparison to DWI : correlation to T1 / STIR sequences, search for new lesions. ADC measurement (4 pixels at least) of the lesions seen on DWI, and comparison to the ADC values of degenerative bone and normal spongious bone. Statistical Analysis: Software: Medcalc vs11.0 Assessment of the evaluation criteria (reading grid): Page 8 of 18

9 Qualitative criteria: presence of lesions Quantitative criteria (ADC) Inter- et intra-rater correlation: For qualitative criterias (calcul of kappa coefficient, standard deviation and CI 95%). For quantitative variable: ADC (mean and standard deviation, comparison by a Student t test). Images for this section: Fig. 5: Cervical spine: DWI axial slices Page 9 of 18

10 Fig. 6: Normal lumbar spine: ADC and color ADC mapping Page 10 of 18

11 Results Clinical data (before MRI) Gender 27 female / 19 men Mean age 43 Median age 43,8 Suspected spondylarthritis 27 Diagnosed spondylarthritis 19 (dont 15 sous traitement) Ankylosing spondylitis 14 Psoriatic arthritis 3 Spondylarthritis associated to IBD 2 Other spondylarthritis 0 Radiological findings: Inflammatory lesions Number of lesions Correlation to DWI DWI new detection Romanus spondylitis 16 46/46 (100%) 0 46/46 (100%) 0 45/46 (98%) 0 45/46 (98%) 0 lesion 3 -cervico-thoracic spine- lumbar spine 13 Anderson discitis 2 -cervico-thoracic 0 spine- lumbar spine 2 Posterior arthritis 5 -cervicothoracic 0 spine- lumbar spine 5 Costo-vertebral / 4 costo-transversary arthritis ADC was measured on: Page 11 of 18

12 16 spondylitis [Figure 7] 2 discitis [Figure 8] 1 posterior arthritis There were 18 acute degeneretive lesions, and ADC could be measured on 14 of them [Figure 9 & 10]. ADC values: Inflammatory lesion Degenerative lesion Normal spongious bone (17 values) (14 values) (14 values) ADC 0,797±0,211 0,560±0,200 0,445±0,180 Inter-rater consistancy rate: Significant and high for discitis. Significant for spondylitis and posterior arthritis Null and non significant for costo-vertebral and costo-transversary arthritis Inter-rater rate consistancy Kappa IC 95% Romanus spondylitis 0,48 +/- 0,13 0,22 à 0,74 Anderson discitis 0,79 +/- 0,20 0,39 à 1,00 Posterior arthritis 0,46 +/- 0,23 0,01 à 0,90 Costo-vertebral / costo- 0,00 +/- 0,00 transversary arthritis 0,00 à 0,00 Intra-rater consistancy rate are significant and very high. Intra-rater rate consistancy Kappa IC 95% Romanus spondylitis 0,78 +/- 0,17 0,21 à 0,84 Anderson discitis 0,89 +/- 0,50 0,29 à 1,00 Posterior arthritis 0,86 +/- 0,14 0,01 à 0,90 Costo-vertebral / costo- 1,00 +/- 0,00 transversary arthritis 0,00 à 0,90 Page 12 of 18

13 Images for this section: Fig. 7: L2-L3 spondylitis: ADC & color ADC mapping Page 13 of 18

14 Fig. 8: L5-S1 Inflammatory spondylodiscitis sagittal slices: STIR, DWI, ADC color map and ADC measurements (x 10-3 mm2/s) : - normal bone: 0,656 - pathological bone: 0,1558 Page 14 of 18

15 Fig. 9: From left to right: - Normal lumbar ADC mapping. - L5-S1 inflammatory spondylodiscitis ADC mapping. - L4-L5 MODIC 1 ADC mapping. Page 15 of 18

16 Fig. 10: MODIC 1 L5-S1 degenerative lesion: T1, STIR & DWI slices Page 16 of 18

17 Conclusion Results show: Very good correlation between standard sequences ( T1, STIR) and DWI. No new lesions detected by DWI. Significantly higher ADC 0,797±0,211 in spondylitis compared to normal spongious bone and acute degenerative bone lesions Moderate global inter-rater consistancy rate. Very good intra-rater consistancy rate. Limits of the study: DWI was more artefacted on the cervicothoracic spine (cardiac pulse, artefacts linked to swallowing). Datas were collected on a patient basis, not on a lesions basis. Results are statistically significant only for spondylitis (low number of patients). The low inter-rater consistancy rate for posterior arthritis, and costo-vertebral and costo-transversary arthritis can be explained by the higher experience level required to detect this lesions IN CONCLUSION There is a very good correlation between standard sequences ( T1, STIR) and DWI. This is to be weighted by the fact that in our experience, cervicothoracic lesions were less frequent, and cervicothoracic DWI more artefacted. ADC is significantly higher in spondylitis compared to normal spongious bone and degenerative bone lesions. But ADC could be calculated only on vertebral bodies. References Cotten A, et al. Imagerie musculosquelettique, pathologies générales. p Masson Laredo J D, et al. Imagerie ostéo-articulaire, pathologies générales. Flammarion Médecine Haute Autorité de Santé : Recommandations pour la pratique professionnel ; Diagnostic des spondylarthrites, décembre Page 17 of 18

18 Saraux A, et al. Prevalence of spondyloarthropathies in France: Ann Rheum Dis 2005;64(10): Sieper J, et al. Concepts and epidemiology of spondyloarthritis. Best Pract Res Clin Rheumatol 2006;20(3): Breban M. Genetics of spondyloarthritis. Best Pract Res Clin Rheumatol 2006;20(3): Herman KG, et al. Spinal Changes in Patients with Spondyloarthritis: Comparison of MR Imaging and Radiographic Appearances. Radiographics May-Jun (3) : Althoff CE, Feist E, Burova E, Eshed I, Bollow M, Hamm B, Hermann KG. MRI of active sacroiliitis: do we really need gadolinium? Eur JRadiol ;71(2): Jevtic V, Kos-Golja M, Rozman B, McCall I. Mar- ginal erosive discovertebral "Romanus" lesions in ankylosing spondylitis demonstrated by contrast enhanced Gd-DTPA magnetic resonance imag- ing. Skeletal Radiol 2000; 29: Khoo MM, Tyler PA, et al. Diffusion weighted imaging (DWI) in musculoskeletal MRI: a critical review. Skeletal Radiol Jun;40(6): Gaspersic N, et al. Monitoring ankylosing spondylitis therapy by dynamic contrast-enhanced and diffusion-weighted magnetic resonance imaging. Skeletal Radiol Feb;37(2): Meurin A, Dousset V. Diffusion-weighted MR imaging of the spine and cord. J Radio Mar ; 91 : Hagmann P, et al. Understanding diffusion MR imaging techniques: from scalar diffusion-weighted imaging to diffusion tensor imaging and beyond. Radiographics Oct;26 Suppl 1:S Bozgeyik Z, Ozgocmen S, Kocakoc E. Role of diffusion-weighted MRI in the detection of early active sacroiliitis. AJR Am J Roentgenol. 2008Oct;191(4): Personal Information Page 18 of 18