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Magnetic resonance imaging with diffusion-weighted imaging in the evaluation of thyroid-associated orbitopathy: getting below the tip of the iceberg

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Abstract

Objectives

To compare extraocular muscles (EOMs) T2, post-contrast T1 (T1Gad) signal intensity ratios (SIRs) and normalized-apparent diffusion coefficient (n-ADC) values in patients with thyroid-associated orbitopathy (TAO) at different phases of activity and severity and correlate MRI modifications to clinical evolution during follow-up.

Methods

A total of 74 TAO patients were classified as active or inactive on the basis of the clinical activity score (CAS). Severity of EOM impairment was evaluated by assigning a functional score to each rectus. T2, T1Gad SIRs and n-ADC of EOMs were compared in patients with active inflammation, those with inactive disease and 26 healthy controls, and correlated with clinical scores. MRI parameter variation was correlated with clinical modifications during follow-up.

Results

All MRI parameters in TAO EOMs were significantly higher than in healthy subjects and correlated with muscle dysfunction and CAS. EOMs of active patients showed higher T2 and T1Gad SIRs than those with inactive disease. The T2 SIR and n-ADC of normally functioning TAO EOMs were higher than those of healthy controls. SIRs decreased in clinically improved and clinically stable EOMs after therapy.

Conclusions

T2 SIR, T1Gad SIR and n-ADC are objective measures of activity and severity of EOMs in TAO patients. MRI shows clinically silent muscle involvement and modifications.

Key Points

• MRI and DWI measures are objective, quantitative parameters of TAO activity and severity

• MRI and DWI measures significantly correlate with clinical scores in TAO patients

• MRI and DWI can identify clinically silent inflammation of deep orbital structures

• MRI and DWI can depict subclinical modifications during follow-up

• MRI and DWI may aid clinicians in choosing the most appropriate treatment

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Abbreviations

ADC:

apparent diffusion coefficient

CAS:

clinical activity score

CT:

computed tomography

DWI:

diffusion-weighted imaging

EOM:

extraocular muscle

MRI:

magnetic resonance imaging

n-ADC:

normalized apparent diffusion coefficient

ROI:

region of interest

SIR:

signal–intensity ratio

TAO:

thyroid-associated orbitopathy

T1Gad:

post-contrast T1

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Acknowledgments

The scientific guarantor of this publication is Letterio Salvatore Politi. The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article. The authors state that this work has not received any funding. One of the authors (A.A.) has significant statistical expertise. Institutional review board approval was obtained. Written informed consent was obtained from all subjects (patients) in this study. Methodology: prospective, observational, performed at one institution.

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Authors and Affiliations

  1. Neuroradiology Department and Neuroradiology Research Unit, San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy

    Letterio Salvatore Politi, Claudia Godi, Antonella Iadanza & Andrea Falini

  2. Università Vita-Salute San Raffaele, Milan, Italy

    Letterio Salvatore Politi, Claudia Godi, Alessandro Ambrosi & Andrea Falini

  3. Neurophthalmology Service, Ophthalmology Department, IRCCS Istituto Auxologico Italiano, Milan, Italy

    Gabriella Cammarata & Stefania Bianchi Marzoli

  4. Endocrinology Unit, Department of Internal Medicine, San Raffaele Scientific Institute, Milan, Italy

    Roberto Lanzi

Authors
  1. Letterio Salvatore Politi
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  2. Claudia Godi
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  3. Gabriella Cammarata
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  4. Alessandro Ambrosi
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Corresponding author

Correspondence to Letterio Salvatore Politi.

Electronic supplementary material

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Supplementary Figure 1

Box-plots comparing T2 SIR (A), T1Gad SIR (B) and n-ADC (C) values of healthy controls’ EOMs with those of TAO patients. EOMs of patients affected by TAO showed significantly higher T2 SIR, T1Gad SIR and n-ADC than those of healthy controls (Mann-Whitney test, p<0.001). (JPEG 15 kb)

High resolution image (TIFF 3828 kb)

Supplementary Figure 2

MRI features of a representative healthy control (A, D, G), clinically inactive TAO patient (B, E, H) and clinically active TAO patient (C, F, I) with axial Turbo Spin Echo T2 SPIR images (A, B, C), Spin Echo post-gadolinium T1 SPIR images (T1Gad, D, E, F) and ADC maps from Single-Shot Echo Planar (SSh-EPI) Diffusion Weighted Imaging (obtained with b=0-700, G, H, I). The patient with active TAO (right column) had more prominent T2 SPIR and T1Gad hyperintensity of EOMs (medial recti muscles) than the patient with inactive TAO (middle column), while in ADC maps no differences could be appreciated between the two. (JPEG 76 kb)

High resolution image (TIFF 13510 kb)

Supplementary Figure 3

Box-plots illustrating mean T2 SIR (A, D, G, J), T1Gad SIR (B, E, H, K) and n-ADC (C, F, I, L), in TAO patients with CAS reduction (A, B, C), and in TAO EOMs with motility improvement (D, E, F); a significant decrease between baseline and follow-up values was found in both cases (Wilcoxon Signed-Rank test). Interestingly, a similarly significant reduction in mean T2 SIR, T1Gad SIR and n-ADC was also observed in TAO patients with stable CAS (G, H, I) and stable EOM function (J, K, L) over time (Wilcoxon Signed-Rank test). (JPEG 68 kb)

High resolution image (TIFF 17227 kb)

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Politi, L.S., Godi, C., Cammarata, G. et al. Magnetic resonance imaging with diffusion-weighted imaging in the evaluation of thyroid-associated orbitopathy: getting below the tip of the iceberg. Eur Radiol 24, 1118–1126 (2014). https://doi.org/10.1007/s00330-014-3103-3

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  • DOI: https://doi.org/10.1007/s00330-014-3103-3

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