Non-EPI-DWI for Detection, Disease Monitoring, and Clinical Decision-Making in Thyroid Eye Disease

C. Feeney; R.K. Lingam; V. Lee; F. Rahman; S. Nagendran

doi:10.3174/ajnr.A6664

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Fig 1.
Correlation between CAS and ADC and clinically meaningful group-wise comparisons of ADC and CAS in the overall cohort. Box plots demonstrate a positive Spearman rank correlation coefficient between CAS and ADC of individual EOMs (n = 368) (A) and significantly greater ADC values in CAS ≥ 3 (n = 70) (B) compared with CAS < 3 (n = 298) groups. Two asterisks indicate P < .001, 2-tailed. C, Significantly greater ADC values of all EOMs in cohort 3 compared with those in cohort 1 (P < .001) and cohort 2 (P = .03). For cohort 2, ADC values were significantly higher than those in cohort 1 (P < .001) but lower than those in cohort 3 (P = .03). Single asterisk indicates P < .05.
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Fig 2.
Patient flow chart for clinical decisions influenced by the reported activity of non-EPI-DWI scans in conjunction with CAS and clinical assessment. Whole numbers denote the number of patients. The dashed line represents the opportunity for a non-EPI-DWI-informed clinical decision. MDT indicates multidisciplinary team.
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Fig 3.
Representative examples of non-EPI-DWI of orbital EOMs in patients from each of cohorts 1, 2, and 3 alongside STIR MR imaging. A, Coronal orbital/EOM MR imaging STIR image (A₁) and a non-EPI-DWI ADC image (A₂) show mild enlargement of the extraocular muscles with mild increased signal and ADC values (right inferior rectus muscle = 590; left inferior rectus muscle = 540), labeled an inactive scan (cohort 1). STIR image (B₁) and ADC image (B₂) show moderate-to-marked enlargement of the extraocular muscles and increased signal and ADC values, notably at the right inferior and left medial recti muscles (arrows) (cohort 2). STIR image (C₁) and ADC image (C₂) show moderate-to-marked enlargement of the extraocular muscles and markedly increased signal and ADC values notably at the inferior recti muscles (arrows) (cohort 3).
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Fig 4.
ROCs for ADC values obtained in subjects with no/possible disease (cohort 1) and moderate-severe disease (cohort 3) (area under the curve = 0.737; 95% CI, 0.68–0.80; P < .001). Diagonal line represents a line of no discrimination between disease states. Arrowed number represents the ADC value.

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Table 1:

Patient characteristics (cohorts 1–3)

	No.	Cohort 1	No.	Cohort 2	No.	Cohort 3
Age at initial scan (yrs)	12	43.9	8	47.0	11	53.7
SD + range		15.4 (20.2–74.4)		12.9 (33.9–71.9)		20.8 (22.6–79.8)
n% female	12	9 (75.0%)	8	5 (62.5%)	11	8 (72.7%)
n% Afro-Caribbean	11^{^a}	1 (9.1%)	8	3 (37.5%)	11	5 (45.5%)
n% current smokers	12	4 (33.3%)	8	3 (37.5%)	11	3 (27.3%)
n% positive family history	12	4 (33.3%)	8	3 (37.5%)	11	1 (9.1%)
n% positive autoantibody^{^b}	9^{^c}	5 (55.5%)	8	4 (50.0%)	10^{^d}	10 (100.0%)
n% antithyroid medication^{^e}	12	6 (50.0%)	8	6 (75.0%)	11	11 (100.0%)
n% euthyroid^{^f}	12	6 (50.0%)	8	2 (25.0%)	11	0 (0.0%)
n% DON	12	0 (0.0%)	8	1 (12.5%)	11	4 (36.3%)
n% IV methylprednisolone	12	0 (0.0%)	8	2 (25.0%)	11	11 (100.0%)
n% second-line immunosuppression^{^g}	12	0 (0.0%)	8	0 (0.0%)	11	3 (27.3%)
n% orbital radiotherapy	12	0 (0.0%)	8	0 (0.0%)	11	7 (63.6%)
No. of scans	12	1	8	2.5	11	2.5
SD + range		0 (1.0–1.0)		0.9 (2.0–4.0)		0.8 (2.0–4.0)
Initial CAS	12	0.5	8	1.6	11	3.6
SD + range		0.5 (0.0–1.0)		0.5 (1.0–2.0)		1.1 (3.0–6.0)
CAS: 1st Follow-up	NA	NA	8	0.5	11	2.1
SD + range				0.8 (0–2)		1.9 (0–6)
Baseline ADC all EOMs	96	678	54	811	65	691
SD + range		171 (340–1141)		256 (311–1426)		208 (240–1088)
ADC all EOMs:1st Follow-up	NA	NA	52	770	63	873
SD + range				236 (340–1321)		319 (169–1585)
Time between 1st & 2nd scan (Months)	NA	NA	8	10.5	11	9.5
SD + range				3.1 (5.5–16.2)		7.8 (2.0–29.0)
Final CAS	12	NA	8	0.4	11	1.6
SD + range				0.1 (0.0–1.0)		2.0 (0.0–6.0)
Total follow-up period (Months)	12	NA	8	39.3	11	48
				27.7 (16.3–97.4)		49.3 (8.3–163.0)

Note:—NA indicates not applicable.
↵a Data unrecorded (n = 1).
↵b Either thyroid peroxidase or thyroid-stimulating hormone receptor antibody.
↵c Data missing (n = 3).
↵d Data missing (n = 1).
↵e Either carbimazole, propylthiouracil, or both.
↵f Normal thyroid function and no history of thyroid abnormalities.
↵g Mycophenolate or hydroxychloroquine. Cohort 1 = mild/possibly active (CAS 0 or 1), cohort 2 = mild-to-moderate and active (CAS 1–3), cohort 3 = moderate-to-severe and active (CAS ≥ 3).