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Magnetisation transfer imaging adds information to conventional MRIs to differentiate inflammatory from fibrotic components of small intestinal strictures in Crohn’s disease

  • Magnetic Resonance
  • Published:
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Abstract

Objectives

Identifying inflammation- or fibrosis-predominant strictures in Crohn’s disease (CD) is crucial for treatment strategies. We evaluated the additive value of magnetisation transfer (MT) to conventional MRI for differentiating CD strictures using surgical histopathology as a reference standard.

Methods

Twenty-eight consecutive CD patients who underwent MRI preoperatively were recruited. MRI parameters included T2-weighted imaging (T2WI) hyperintensity, bowel wall thickness, enhancement pattern changes over time, enhancement pattern and gain ratio in dynamic contrast-enhanced phases, and MT ratio. Correlation analysis was performed using Spearman’s rank test. Receiver operating characteristic curve analysis and Cohen’s κ were used. A model with combined MRI variables characterising intestinal strictures was proposed and validated in 14 additional CD patients.

Results

Significant correlations with histological inflammation scores were shown for wall thickness (r = 0.361, p = 0.001) and T2WI hyperintensity (r = 0.396, p < 0.001), whereas histological fibrosis scores were significantly correlated with MT ratio (r = 0.681, p < 0.001) and wall thickness (r = 0.461, p < 0.001). T2WI hyperintensity could differentiate mild from moderate-to-severe inflammation with a sensitivity of 0.871 and a specificity of 0.800. MT ratio could discriminate mild from moderate-to-severe fibrosis with a sensitivity and a specificity of 0.913 and 0.923, respectively. Combining MT ratio and T2WI hyperintensity, the MRI classification moderately agreed with the pathological stricture classification (p < 0.01, κ = 0.549). In the validation set, the diagnostic accuracy of T2WI hyperintensity and MT ratio were 86% and 89%, with good agreement between MRI and histopathological classification (p < 0.01, κ = 0.665).

Conclusions

MT ratio combined with conventional MRI improves the differentiation of fibrotic from inflammatory components of small-bowel strictures in CD patients.

Key Points

• MT ratio from magnetisation transfer imaging combined with T2WI from conventional MRI can simultaneously characterise bowel fibrosis and inflammation in adult Crohn’s disease.

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Abbreviations

CD:

Crohn’s disease

CDAI:

Crohn’s disease activity index

CI:

Confidence interval

H&E:

Haematoxylin and eosin

ICC:

Intraclass correlation coefficient

MT:

Magnetisation transfer

MTI:

Magnetisation transfer imaging

OR:

Odds ratio

SI:

Signal intensity

T1WI:

T1-weighted imaging

T2WI:

T2-weighted imaging

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Funding

This study has received funding by the National Natural Science Foundation of China (81600508, 81500501, 81770654, 81771908, 81571750, 81870451).

Author information

Author notes

  1. Zhuang-nian Fang and Xue-hua Li contributed equally to this work.

Authors and Affiliations

  1. Department of Radiology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan II Road, Guangzhou, 510080, People’s Republic of China

    Zhuang-nian Fang, Xue-hua Li, Jin-jiang Lin, Si-yun Huang, Can-hui Sun, Zi-ping Li & Shi-Ting Feng

  2. Department of Pathology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan II Road, Guangzhou, 510080, People’s Republic of China

    Qing-hua Cao

  3. Department of Gastrointestinal and Pancreatic Surgery, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan II Road, Guangzhou, 510080, People’s Republic of China

    Zhi-hui Chen

  4. Mallinckrodt Institute of Radiology, Washington University in St. Louis, 510 South Kingshighway Boulevard, St. Louis, MO, 6310, USA

    Zhong-wei Zhang

  5. Department of Gastroenterology, Hepatology and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, USA

    Florian Rieder

  6. Department of Radiology, Hospital Clínic de Barcelona, IDIBAPS, University of Barcelona, Villarroel 170, 08036, Barcelona, Barcelona, Spain

    Jordi Rimola

  7. Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, 58 Zhongshan II Road, Guangzhou, 510080, People’s Republic of China

    Min-hu Chen & Ren Mao

Authors
  1. Zhuang-nian Fang
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  8. Zhong-wei Zhang
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  13. Ren Mao
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Corresponding authors

Correspondence to Ren Mao or Shi-Ting Feng.

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Guarantor

The scientific guarantors of this publication are Ren Mao and Shi-Ting Feng.

Conflict of interest

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.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

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Institutional Review Board approval was obtained.

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• Performed at one institution

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Electronic supplementary material

ESM 1

Supplementary Table 1 MRI sequences and parameters. Supplementary Table 2 Histologic score for inflammatory and fibrotic Crohn’s disease. Supplementary Table 3 Correlation between MRI parameters and histological inflammation score. Supplementary Table 4 Correlation between MRI parameters and histological fibrosis score. Supplementary Fig. 1 Mural SI was defined as normal (equal to the SI of normal bowel walls) or hyperintense (higher than the SI of normal bowel walls) on T2WI. Coronal T2WI demonstrates high signal intensity in the thickened intestinal wall (arrow), whereas the normal bowel wall showed low-signal intensity (arrowhead). SI signal intensity, T2WI T2-weighted imaging. Supplementary Fig. 2 The enhancement pattern was classified as mucosal only (with enhancement of only the innermost wall layer), homogeneous (with the entire bowel wall showing equal enhancement), or layered (with both mucosal and serosal bowel wall layers showing enhancement and with a central band of relatively reduced enhancement). (a) Precontrast T1-weighted image showing bowel wall thickening and luminal narrowing (arrow); (b-d) Coronal postcontrast magnetic resonance images of thickened bowel walls demonstrating (b) mucosal only, (c) layered, and (d) homogeneous patterns of enhancement. Arrow = bowel serosa, arrowhead = mucosa. Supplementary Fig. 3 The enhancement progressions from 70 s to 7 min in deep layers were recorded as stability over time (e.g., homogeneous, mucosal, or layered) and progression of enhancement over time (from mucosal or layered to homogeneous). The deeper layers of the bowel wall show lower enhancement than the superficial layers at 70 s after contrast injection (a, arrow) but homogenous enhancement at 7 min (b, arrow). Supplementary Fig. 4 Axial MT imaging without (a) and with (b) MT pulse. The off-resonance prepulse had a Gaussian shape with a frequency offset of 1.2 kHz, a duration of 9984 μs, an effective flip angle of 500°, and a bandwidth of 192 Hz. MT magnetization transfer. Supplementary Fig. 5 Pairwise comparison shows a significantly higher MT ratio in moderate inflammation than in mild inflammation (p = 0.001). There are no significant differences between moderate and severe inflammation (p = 1.000) or between mild and severe inflammation (p = 0.062). Supplementary Fig. 6 Pairwise comparison shows that wall thickness is significantly lower in mild inflammation than in severe (p < 0.001) and moderate (p < 0.001) inflammation. There is no significant difference between moderate and severe inflammation (p = 1.000). Supplementary Fig. 7 Pairwise comparison shows a significantly higher MT ratio in severe fibrosis than in moderate (p = 0.005) and mild (p < 0.001) fibrosis. The MT ratio of moderate fibrosis is also significantly higher than that of mild fibrosis (p < 0.001). Supplementary Fig. 8 Pairwise comparison shows that wall thickness is significantly lower in mild fibrosis than in severe (p < 0.001) and moderate (p < 0.001) fibrosis. There is no significant difference between moderate and severe fibrosis (p = 0.167) (DOCX 41325 kb) (DOCX 41325 kb)

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Fang, Zn., Li, Xh., Lin, Jj. et al. Magnetisation transfer imaging adds information to conventional MRIs to differentiate inflammatory from fibrotic components of small intestinal strictures in Crohn’s disease. Eur Radiol 30, 1938–1947 (2020). https://doi.org/10.1007/s00330-019-06594-x

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