Assessing the Reliability of the OMERACT Juvenile Idiopathic Arthritis Magnetic Resonance Scoring System for Temporomandibular Joints (JAMRIS-TMJ)

Contrast-enhanced magnetic resonance imaging (MRI) remains the most comprehensive modality to assess juvenile idiopathic arthritis (JIA)-related inflammation and osteochondral damage in the temporomandibular joints (TMJ). This study tested the reliability of a new JIA MRI scoring system for TMJ (JAMRIS-TMJ) and the impact of variations in calibration and reader specialty. Thirty-one MRI exams of bilateral TMJs were scored independently using the JAMRIS-TMJ by 20 readers consisting of radiologists and non-radiologist clinicians in three reading groups, with or without a calibrating atlas and/or tutorial. The inter-reader reliability in the multidisciplinary cohort assessed by the generalizability coefficient was 0.61–0.67 for the inflammatory and 0.66–0.74 for the damage domain. The atlas and tutorial did not improve agreement within radiologists, but improved the agreement between radiologist and non-radiologist groups. Agreements between different calibration levels were 0.02 to 0.08 lower by the generalizability coefficient compared to agreement within calibration levels; agreement between specialty groups was 0.04 to 0.10 lower than within specialty groups. Averaging two radiologists raised the reliability above 0.8 for both domains. Therefore, the reliability of JAMRIS-TMJ was moderate-to-good depending on the presence of specialty and calibration differences. The atlas and tutorial are necessary to improve reliability when the reader cohort consists of multiple specialties.

Indirect markers for length adjustment in distal biceps tendon allograft reconstruction

Chronic musculotendinous retraction, shortening and fibrosis after distal biceps tendon tears makes a primary reconstruction often difficult or even impossible. Interposition reconstruction with allograft provides a solution, however there is no consensus about appropriate intraoperative graft length adjustment. Therefore, the purpose of this study was to find a practical reference value for distal biceps tendon length adjustment. Three-dimensional surface models of healthy distal biceps tendons were created based on 85 MRI scans. The tendon length was measured from the myotendinous junction to the insertion on the bicipital tuberosity. Inter-epicondylar distance (IED) and radial head diameter (RHD) were measured on antero-posterior radiographs as a surrogate for patient size. Correlations between the tendon length and IED, RHD and patient’s height (PH) were calculated. Mean length of the external part of the distal biceps tendon was 69mm (female 64mm, male 71mm). The tendon length in mm was on average 1.1 times of the IED (mm), 3 times of the RHD (mm) and 0.4 times of PH (cm). Herewith, the tendon length could be predicted within a narrow range of +/-1cm in 84% by using IED, 82% by using RHD and 80% by using PH. Intra- and inter-reader reliabililty of IED and RHD was excellent (R2 = 0.938–0.981). The distal biceps tendon length can be best predicted within 1cm with an accuracy of 82–84% using the IED and RHD with an excellent intra- and inter-reader reliability.

Diagnostic interpretation of non-contrast qualitative MR imaging features for characterisation of uterine leiomyosarcoma

Objective: To assess the value of non-contrast MRI features for characterisation of uterine leiomyosarcoma (LMS) and differentiation from atypical benign leiomyomas Methods: This study included 57 atypical leiomyomas and 16 LMS which were referred preoperatively for management review to the specialist gynae-oncology multidisciplinary team meeting. Non-contrast MRIs were retrospectively reviewed by five independent readers (three senior, two junior) and a five-level Likert score (1-low/5-high) was assigned to each mass for likelihood of LMS. Evaluation of qualitative and quantitative MRI features was done using uni- and multi variable regression analysis. Inter reader reliability for the assessment of MRI features was calculated by using Cohen’s κ values. Results: In the univariate analysis, interruption of the endometrial interface and irregular tumour shape had the highest Odds ratios (OR) (64.00, p < 0.001 and 12.00, p = 0.002, respectively) for prediction of LMS. Likert score of the mass was significant in prediction (OR, 3.14; p < 0.001) with excellent reliability between readers (ICC 0.86; 95% CI, 0.76–0.92). The post-menopausal status, interruption of endometrial interface and thickened endometrial stripe were the most predictive independent variables in multivariable estimation of the risk of leiomyosarcoma with an accuracy of 0.88 (95%CI, 0.78–0.94). Conclusion: At any level of expertise as a radiologist reader, the loss of the normal endometrial stripe (either thickened or not seen) in a post-menopausal patient with a myometrial mass was highly likely to be LMS. Advances in knowledge: This study demonstrates the potential utility of non-contrast MRI features in characterisation of LMS over atypical leiomyomas and therefore influence on optimal management of these cases.

AB0516 THE INCONSISTENCY IN THE ASSESSMENT OF SACROILIAC JOINTS MRI PERFORMED BY A BLINDED AND UNBLINDED RHEUMATOLOGISTS AND A RADIOLOGISTS AFTER AND WITHOUT SPECIAL MRI TRAINING

Background:Despite of the development the criteria for the diagnosis of axial spondyloarthritis (axSpA) the problem of late axSpA diagnostics is not resolved. The difficulties in the assessment of MRI sacroiliitis (SI) could be of the reasons of axSpA diagnostic delay.Objectives:to evaluate the inconsistency in the assessment of sacroiliac joints MRI that was performed by a blinded and unblinded rheumatologists and a radiologists.Methods:The assessment of 80 magnetic-resonance tomograms of sacroiliac joints (SIJ) was performed by 4 independent readers, one which was blinded to clinical data radiologist (BR), another radiologist was informed that the study was performed for axSpA (unblinded radiologist - UR), another 2 readers were blinded to diagnosis rheumatologists. One of the rheumatologists was trained in SIJ MRI (BTRh), another rheumatologist was not trained specially in MRI of SIJ (BURh). The study was carried out on the magnetic resonance tomography (GE Discovery MR750W 3.0T) in T1 and STIR regimens. 65 MRI were performed in pts that fulfilled the ASAS criteria for the axSpA and history of active SII (bone marrow edema) on previous SIJ MRI. According CT of SIJ 25 (38.5%) of these pts had nr-axSpA, 22 (33.8%) had SI grade II / III, in 18 (27.7%) of the pts SI grade IV was detected. 15 MRI scans were performed in healthy volunteers who did not meet the ASAS 2009 criteria at the time of the study and had no CT changes in SIJ.The number of detected by each reader cases of active SII as defined by ASAS were analyzed with the calculation of the inter-reader reliability.Results:There was found that there was inter-reader reliability between results of blinded and unblinded radiologists (73.8%) with statistical differences in the number of detected and undetected signs of SII (p <0.05).The inter-reader reliability scores between the unblinded rheumatologist and the radiologist were 97.5% and did not have statistically significant statistical differences (p≥ 0.05).And for a trained rheumatologist and a blinded untrained rheumatologist it was 53.5% and had significant statistical differences (p<0.05).The results of 4 readers SIJ MRI assessments are presented at Table 1.Table 1.The results of MRI sacroiliitis assessments performed by blinded and unblinded radiologists and rheumatologistsBRUbRBtRhBURhRevealed SII in axSpA (n = 65), n(%)44 (67.7)*64 (98.5)#62(95.4)26 (40)*Undetected SII in axSpA (n = 65), n(15)21(32.3)*1(1,5)3(4.6)39(60)*Revealed SII in controls (n = 15), n(%)2 (13.3)*3 (20) #3(20)1(6.7)*Undetected SII in controls (n=15), n(%)13(86.7)*12(80) #12(80)14(93.3)**inter-reader reliability with the results of all another reader with p<0.05. # inter-reader reliability between unblinded radiologist (UR) and blinded treated rheumatologist (BtRh) with p<0.05. BURh – blinded untreated rheumatologist. BR – blinded radiologist.Conclusion:The better agreement in inter-reader reliability in MRI of SIJ assessment was detected between unblinded radiologist and trained blinded rheumatologist. Blinded radiologist had shown lower inter-reader agreement with another specialists. The lowest of all inter-reader agreement had shown untrained blinded rheumatologist. Special MRI of SII assessment trainings for rheumatologists and radiologists are unmet need for the improvement of in-time axSpA diagnostics.Disclosure of Interests:None declared.

Role of magnetic resonance neurography in intercostal neuralgia; diagnostic utility and efficacy

Objective: To evaluate the utility and efficacy of MR neurography (MRN) in the diagnostic work-up for intercostal neuralgia and to assess the treatment course and outcomes in MRN-imaged clinically suspected intercostal neuropathy cases of chronic chest and abdominal wall pain syndromes. Methods: Following a retrospective cross-sectional study, a consecutive series of patients who underwent MRN of torso for suspected intercostal neuralgia were included. Patient demographics, pain location/level/duration, previous work-up for the same indication, MRN imaging results, and MRN cost per patient were recorded. An inter-reader reliability assessment was performed on the MRN findings using Cohen’s weighted κ analysis. Post-MRN treatment choice, as well as success rates of MRN directed perineural injections and surgical management were also evaluated. Results: A total of 28 patients (mean ± SD age, 48.3 ± 18.0 years, female/male = 3.0) were included. Pain and/or numbness in the right upper quadrant were the most common complaints. The mean maximum pain level experienced was 7.4 ± 2.5 on a 1 (lowest pain level) - 10 (highest pain level) visual analog scale. The duration of pain before MRN work-up was 36.9 ± 37.9 months. The patients had seen an average of 5 ± 2.8 physicians for such syndromes. 20 (71%) patients had one or multiple other imaging studies for prior work-up. MRN identified positive intercostal nerve abnormality in 19 cases with clinical symptoms of intercostal neuralgia. From the inter-reader reliability assessment, a Cohen’s weighted κ value of 0.78 was obtained. The costs of work-up was about one-third with MRN for diagnostic purposes with less financial and psychological harm. Among the MRN-positive cases, 9/19 patients received perineural injections, of which 6 reported improvement after their first round, lasting an average of 41.1 ± 83 days. Among the nine MRN-negative cases, two received perineural injections, of which none reported improvement. Surgical management was mostly successful with a positive outcome in six out of seven operated cases (85.7%). Conclusion: MRN is useful in diagnostic algorithm of intercostal neuralgia and MRN-positive cases demonstrate favorable treatment response to perineural injections and subsequent surgical management. Advances in knowledge: The use of MRN in intercostal neuralgia is an application that has not been previously explored in the literature. This study demonstrates that MRN offers superior visualization of pathology in intercostal neuralgia and confirms that treatment directed at MRN identified neuropathy results in good outcomes while maintaining cost efficiency.

Feasibility of ultrashort echo time (UTE) T2* cartilage mapping in the hip: a pilot study

Background Ultrashort echo time (UTE) T2* is sensitive to molecular changes within the deep calcified layer of cartilage. Feasibility of its use in the hip needs to be established to determine suitability for clinical use. Purpose To establish feasibility of UTE T2* cartilage mapping in the hip and determine if differences in regional values exist. Material and Methods MRI scans with UTE T2* cartilage maps were prospectively acquired on eight hips. Hip cartilage was segmented into whole and deep layers in anterosuperior, superior, and posterosuperior regions. Quantitative UTE T2* maps were analyzed (independent one-way ANOVA) and reliability was calculated (ICC). Results UTE T2* mean values (anterosuperior, superior, posterosuperior): full femoral layer (19.55, 18.43, 16.84 ms) ( P=0.004), full acetabular layer (19.37, 17.50, 16.73 ms) ( P=0.013), deep femoral layer (18.68, 17.90, 15.74 ms) ( P=0.010), and deep acetabular layer (17.81, 16.18, 15.31 ms) ( P=0.007). Values were higher in anterosuperior compared to posterosuperior regions (mean difference; 95% confidence interval [CI]): full femur layer (2.71 ms; 95% CI 0.91–4.51: P=0.003), deep femur layer (2.94 ms; 95% CI 0.69–5.19; P=0.009), full acetabular layer (2.63 ms 95% CI 0.55–4.72; P=0.012), and deep acetabular layer (2.50 ms; 95% CI 0.69–4.30; P=0.006). Intra-reader (ICC 0.89–0.99) and inter-reader reliability (ICC 0.63–0.96) were good to excellent for the majority of cartilage layers. Conclusion UTE T2* cartilage mapping was feasible in the hip with mean values in the range of 16.84–19.55 ms in the femur and 16.73–19.37 ms in the acetabulum. Significantly higher values were present in the anterosuperior region compared to the posterosuperior region.

A Novel Fluorescence Optical Imaging Scoring System for Hand Synovitis in Rheumatoid Arthritis – validity and agreement with ultrasound

Objectives To develop and validate a new semiquantitative Fluorescence Optical Imaging (FOI) scoring system – the FOI Enhancement-Generated rheumatoid arthritis (RA) Score (FOIE-GRAS) for synovitis assessment in the hand. Methods The development of FOIE-GRAS was based on consensus of 4 experts in musculoskeletal imaging. Forty-six RA patients, eligible for treatment intensification and with ≥1 clinically swollen joint in the hands and 11 healthy controls were included. FOI, ultrasound and clinical assessment of both hands were obtained at baseline and for RA patients after 3- and 6-months’ follow-up. Twenty RA patients had an FOI rescan after 4 hours. Synovitis was scored using FOIE-GRAS and the OMERACT ultrasound synovitis scoring system. All FOI images were scored by 2 readers. Inter-scan, inter-and intra-reader reliability were determined. Furthermore, FOIE-GRAS agreement with ultrasound and responsiveness was assessed. Results FOIE-GRAS synovitis was defined as early enhancement and scores based on the degree of coverage of the specific joint region after 3 seconds (0–3). Inter-scan, intra- and inter-reader intraclass correlations coefficients (ICC) were good-excellent for all baseline scores (0.76-0.98) and moderate-to-good for change (0.65-76). The FOIE-GRAS had moderate agreement with ultrasound (ICC 0.30-0.54) for total score, a good standardized response mean (&gt;0.80), and moderate correlation with clinical joint assessment and DAS28-CRP. The median (IQR) reading time per FOI examination was 133 (109;161) seconds. Scores were significantly lower in controls 1(0;4) than RA patients 11(6;19). Conclusion The FOIE-GRAS offers a feasible and reliable assessment of synovitis in RA, with a moderate correlation with ultrasound and DAS28CRP, and good responsiveness.

Feasibility of CT-derived myocardial strain measurement in patients with advanced cardiac valve disease

To explore the feasibility of CT-derived myocardial strain measurement in patients with advanced cardiac valve disease and to compare it to strain measurements derived from transthoracic echocardiography (TTE). 43 consecutive patients with advanced cardiac valve disease and clinically indicated retrospectively gated cardiac CTs were retrospectively analyzed. The longitudinal, circumferential as well as radial systolic strain were determined in all patients utilizing a commercially available CT strain software. In 36/43 (84%) patients, CT-derived longitudinal strain was compared to speckle-tracking TTE. Pearson’s correlation coefficients as well as Bland–Altman analysis were used to compare the CT-derived strain measurements to TTE. The intra- and inter-reader-reliability of the CT-derived strain measurements were assessed by intra-class correlation coefficients (ICCs). Strain measurements were feasible in all patients. CT-derived global longitudinal strain (GLS) correlated moderately with TTE-derived GLS (r = 0.6, p < 0.001). A moderate correlation between CT-derived GLS and CT-derived left ventricular ejection fraction was found (LVEF, r = − 0.66, p = 0.036). Bland–Altman analysis showed a systematic underestimation of myocardial strain by cardiac CT compared to TTE (mean difference: − 5.8%, 95% limit of agreement between − 13.3 and 1.8%). Strain measurements showed an excellent intra- and inter-reader-reliability with an intra-reader ICC of 1.0 and an inter-reader ICC of 0.99 for GLS measurements. CT-derived myocardial strain measurements are feasible in patients with advanced cardiac valve disease. They are highly reproducible and correlate with established parameters of strain measurements. Our results encourage the implementation of CT-derived strain measurement into clinical routine.

MR imaging of the quadriceps femoris tendon: distal tear characterization and clinical significance of rupture types

Objective To characterize quadriceps femoris tendon tears on magnetic resonance (MR) imaging regarding tear extent, location, and presence of bony avulsion. Materials and methods IRB approval was obtained and informed consent was waived for this retrospective case series. Electronic medical records from all patients in our hospital system were searched for keywords: knee MR imaging, and quadriceps tendon rupture or tear. MRI studies were randomized and independently evaluated by two fellowship-trained musculoskeletal radiologists. MR imaging was used to characterize each individual quadriceps tendon as having tendinosis, tear (location, partial versus complete, size, and retraction distance), and bony avulsion. Knee radiographs were reviewed for presence or absence of bony avulsion. Descriptive statistics and inter-reader reliability (Cohen’s Kappa and Wilcoxon-signed-rank test) were calculated. Results Fifty-two patients with 53 quadriceps tears were evaluated (45 males, 7 females; mean age: 51 ± 13 years). The vastus intermedius (VI) tendon more often incurred a partial rather than a complete tear (39.6% vs. 37.7%), while the rectus femoris (RF), vastus medialis (VM), and vastus lateralis (VL) incurred complete tears more commonly (64.2–66%). Subjects with bony avulsion on radiographs had higher-grade tears of the RF, VM, and VL tears (p = 0.020–0.043) but not the VI. Most tendons tore at or immediately proximal to the patella (84.8–93.6%). Gaps in retracted torn tendons measured between 2.3 and 2.7 cm. Inter-reader reliability was substantial to almost perfect (κ = 0.624–0.953). Conclusion Quadriceps femoris tendon tears most commonly involve the RF or VL/VM layers usually in proximity to the patella. A bony avulsion correlates with a more extensive tear. Key Points • Quadriceps femoris tendon tears most commonly involve the rectus femoris or vastus lateralis/vastus medialis layers. • A rupture of the quadriceps femoris tendon usually occurs in proximity to the patella. • A bony avulsion of the patella correlates with a more extensive tear of the superficial and middle layers of the quadriceps tendon.