15 Marzo 2014 Aspetti radiologici dei disordini vestibolari: approccio multidisciplinare

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1 15 Marzo 2014 Aspetti radiologici dei disordini vestibolari: approccio multidisciplinare MR Imaging of inner ear endo-perilymphatic spaces at 3T after intratympanic contrast agent administration in Definite Ménière s Disease S. Salice, M. Colasurdo, A. Centonze, G. Neri, A. Tartaro

2 BACKGROUND Diagnosis of Meniere's Disease AAO-HNS Committee of Hearing and Equilibrium Possible Meniere's disease Episodic vertigo of the Meniere's type without documented hearing loss, or Sensorineural hearing loss, fluctuating or fixed, with dysequilibrium but without definitive episodes Other causes excluded Probable Meniere's disease One definitive episode of vertigo Audiometrically documented hearing loss on at least one occasion Tinnitus or aural fullness in the treated ear Other causes excluded Definite Meniere's disease Two or more definitive spontaneous episodes of vertigo lasting 20 minutes or longer Audiometrically documented hearing loss on at least one occasion Tinnitus or aural fullness in the treated ear Other causes excluded Certain Meniere's disease Definite Meniere's disease, plus histopathologic confirmation

3 BACKGROUND HISTOPATHOLOGIC DEFINITION 78 years old man, with sensorineural hearing loss and recurrent vertigo Severe endolymphatic hydrops affecting the cochlea and saccule Hydrops affecting the ampulla of the lateral semicircular canal Merchant et al. 2005

4 BACKGROUND

5 PEI (positive endolimph image): optimal shortening of inversion time of 3D-FLAIR 24 hours after intra-tympanic administration of gadolinium PPI (positive perilimph image): 3D-FLAIR 24 hours after IT administration of gadolinium HYDROPS (HYbriD of Reversed image Of Positive endolymph signal and native image of positive perilymph Signal) PEI PPI BACKGROUND SEQUENCES PEI PPI HYDROPS PEI: ht 2 W-3D-FLAIR (heavily T2 weighted 3D FLAIR) 4 hours after intra-venous administration of single dose of gadolinium PPI: ht 2 W-3D-FLAIR (heavily T2 weighted 3D FLAIR) 4 hours after intra-venous administration of single dose of gadolinium PEI: ht 2 W-3D-FLAIR PPI: ht 2 W-3D-FLAIR HYDROPS 3D-real IR 3D inversion recovery sequence with real reconstruction after intratympanic administration of gadolinium Pyykko 2013 Naganawa D-real IR Naganawa 2012

6 PURPOSE - To demonstrate endolymphatic hydrops in patients with Definite Ménière s Disease in vivo; - to correlate hydrops features with audio-vestibular functional tests.

7 MATERIALS AND METHODS PATIENTS - This study was approved by our local ethics committee and institutional review board; - informed consent was obtained from all participants; - 16 patients with Definite Ménière s Disease according to the diagnostic criteria proposed by the AAO-HNS * were enrolled for the study from April 2012 to October 2013; - 6 men and 10 women, (mean age 54y, range: 31y-74y); - 10 patients had unilateral involvement of Meniere s disease, (5 left, 5 right); - 6 patients had bilateral involvement of Meniere s disease, affecting predominantly left ear in 2 and right ear in 4; - all patients underwent a physical examination and audiovestibular tests, including Pure Tone Audiometry (PTA) and cervical Vestibular Evoked Myogenic Potentials (cvemp). - exclusion criteria: - history of chronic otitis media; - any ear surgery; - invasive management for Ménière s disease, such as intratympanic gentamycin injection. AGE % 6 37% * American Academy of Otolaryngology Head and Neck Surgery (AAO-HNS) bil 6 38% sn 7 44% mono 10 62% dx 9 56%

8 MATERIALS AND METHODS CONTRAST AGENT ADMINISTRATION - Transtympanic injection of ml of gadobutrol diluted eightfold with saline (v/v, 1:7) with a 25 G needle and a 1 ml syringe; - following the injection, patients remained in the supine position for 60 with his/her head turned approximately 60 away from the sagittal line, toward the healthy ear; - as it was already shown*, intratimpanically administered gadolinium passes the round window membrane and enters the perilymphatic space. * Nakashima T. Laryngoscope. 2007

9 MATERIALS AND METHODS IMAGE ACQUISITION - 3T whole-body scanner equipped with an eight-channel head coil - just before and 24 hours after intra-tympanic contrast agent administration. Fluid Attenuated Inversion Recovery 3D (FLAIR 3D) Acquisition time: 16:21.0 TR: 9000 (ms) TE: 458 (ms) TI: 2500 (ms) Flip angle: 120 Echo-train length: 110 Acquisition matrix: 212 x 165 (Recon: 224) Voxel size: 0.8 x 0.8 x 0.8 (AP mm x RL mm x FH mm) FOV: 170 x 170 x 24 (AP mm x RL mm x FH mm) Num of slices: 30 T2W 3D DRIVE Acquisition time: 01:50.0 TR: 2000 (ms) TE: 200 (ms) Acquisition matrix: 212 x 165 (Recon: 224) Voxel size: 0.8 x 0.8 x 0.8 (AP mm x RL mm x FH mm) FOV: 170 x 170 x 24 (AP mm x RL mm x FH mm) Num of slices: 30 Thickness: 0.8 (mm) T1W 3D Acquisition time: 01:52.5 TR: 10 (ms) TE: 4.7 (ms) Acquisition matrix: 212 x 148 (Recon: 224) Voxel size: 0.8 x 0.8 x 0.8 (AP mm x RL mm x FH mm) FOV: 170 x 170 x 24 (AP mm x RL mm x FH mm) Num of slices: 30 Thickness: 4 (mm) T2W TSE ax Acquisition time: 01:06.0 TR: 3000 (ms) TE: 80 (ms) Acquisition matrix: 416 x 295 (Recon: 560) Voxel size: x (AP mm x RL mm) FOV: 240 x 221 x 149 (AP mm x RL mm x FH mm) Num of slices: 30 Thickness: 4 (mm)

10 MATERIALS AND METHODS - Raw data were transferred to a PC workstation for postprocessing; - Positive Perilymph Images (PPI) and MR cisternographic images (T2W 3D DRIVE) were analyzed; - according to the ratio * : endolymphatic space vestibular fluid space - vestibular endolymphatic hydrops was scored as: no hydrops: ⅓ mild hydrops: > ⅓, ½ severe hydrops: > ½ * Nakashima T. Laryngoscope IMAGE ANALYSIS T2W 3D DRIVE MIP FLAIR 3D MIP FLAIR 3D - PPI

11 MATERIALS AND METHODS IMAGE ANALYSIS Endolymphatic hydrops was also defined as present (1) or not (0) if a signal void was detected: - in the cochlea; - in the semicircular canals. T2W 3D DRIVE MIP FLAIR 3D MIP FLAIR 3D - PPI

12 severe in 8 patients and mild in 5; - cochlear endolymphatic hydrops was observed in 7 out of 13 patients (53.8%); - semicircular canals endolymphatic hydrops was observed in 5 out of 13 patients (38.4 %). RESULTS HYDROPS - No adverse events due to contrast agent administration were observed; - 3 patients didn t show perilymphatic enhancement thereby they were not considered for data analysis; - vestibular endolymphatic hydrops was observed in 100% of patients and it was Patient years gender side hydrops Vestibule Cochlea Superior S. C. Lateral S. C. Posterior S. C m Sn / / / / / 2 51 m Sn severe normal signal void normal signal void 3 74 f Sn / / / / / 4 42 m Dx / / / / / 5 39 m Sn severe signal void normal normal normal 6 49 f Sn severe signal void signal void signal void signal void 7 60 f Dx mild signal void normal normal normal 8 59 f Dx severe signal void normal normal normal 9 55 f Dx severe signal void signal void signal void normal f Dx severe normal normal normal signal void m Sn severe signal void signal void signal void signal void f Sn mild normal normal signal void signal void f Dx mild normal normal normal normal f Sn severe normal signal void signal void normal f Sn mild normal normal normal normal m Dx mild signal void normal normal normal

13 RESULTS AUDIOVESTIBULAR FUNCTIONAL TESTS AIR CONDUCTED AUDIOMETRY BONE CONDUCTED AUDIOMETRY cvemps 62 db 44 db 27 db 52 db Relationship between cochlear hydrops (x-axis, grade 0 1) and air pure tone average hearing levels at 0.25, 0.5, 1, 2, 4 and 8 khz (y-axis, in db nhl). Relationship between cochlear hydrops (x-axis, grade 0 1) and bone pure tone average hearing levels at 0.25, 0.5, 1, 2 and 4 khz (y-axis, in db nhl) Relationship between vestibular hydrops and interaural difference ratio (IAD), defined as: (controlateral ear P13-n23) (affected ear p13-n23) (controlateral ear P13-n23) + (affected ear p13-n23)

14 CONCLUSION - Our study confirms that endolymphatic hydrops can be detected at 3T MR images after intratympanic contrast agent administration; - moreover, our preliminary results seem to suggest that, in patient s with Definite Ménière s disease, endolymphatic hydrops may affect more often the vestibule than cochlea or semicircular canals; - absence of a significant correlation between endolymphatic hydrops and audio-vestibular functional test confirms that endolymphatic hydrops should be considered as a histologic marker for Ménière's disease rather than being directly responsible for its symptoms.

15 G r a z i e p e r l a t t e n z i o n e salicesimone@gmail.com Institute of Advanced Biomedical Technologies (ITAB) Department of Neurosciences and Imaging "G. D'Annunzio" University of Chieti-Pescara Via dei Vestini Chieti ITALY