Indian Journal of Radiology and Imaging Indian Journal of Radiology and Imaging

MUSCULOSKELETAL IMAGING
Year
: 2019  |  Volume : 29  |  Issue : 4  |  Page : 386--390

Dual energy CT and research of the bone marrow edema: Comparison with MRI imaging


Luca Saba1, Massimo De Filippo2, Francesco Saba3, Federica Fellini4, Pierre-Yves Marcy1, Robert Dagan1, Philippe Voituriez1, Jacques Aelvoet1, Gérard Klotz1, Roland Bernard1, Valérie Salinesi1, Serge Agostini1,  
1 Groupe ELSAN, Department of Radiology, Clinique Les Fleurs, Avenue Frédéric Mistral, Ollioules; Groupe ELSAN, Department of Radiology, Clinique du Cap-d'Or, 1361 Avenue des Anciens Combattants Français d'Indochine, La Seyne-sur-Mer, France
2 Department of Radiology, University of Parma, Via Gramsci 21, Parma, Italy
3 University of Sassari, Via Vienna 2, Sassari, Italy
4 Department of Cardiology, St Musse Hospital, 54 Rue Henri Sainte-Claire Deville, Toulon, France

Correspondence Address:
Dr. Luca Saba
Groupe ELSAN Department of Radiology, Clinique du Cap D'Or, 1361 Avenue des Anciens Combattants Français d'Indochine, 83500 La Seyne-sur-Mer
France

Abstract

Aims: To evaluate the diagnostic accuracy of the Dual Energy Computed Tomography (DECT) in the research of the bone marrow edema. Methods and Material: The MRI images of 100 patients with episodes of articular and or bone pains with or without traumatic lesion were prospectively evaluated during a period between March 2018 and February 2019. In the presence of bone marrow edema, a DECT was performed. The measurement of the density of the bone marrow edema in the DECT was compared with healthy bone in the same patient by two operators. Result: The DECT and MRI images of 15 patients with bone marrow edema were compared. The mean of pathologic bone marrow edema was 1008.20 (Standard Deviation (SD) 23.00), for healthy bone marrow 947.53 (SD 16.42), and t = 11.75, with a statistical significance P < 0.05 (Statistical significance 95%). The agreement between the measurements of the two radiologists has a statistical significance (P < 0.05). Conclusion: The DECT presents an excellent diagnostic accuracy to detect the bone marrow edema, comparable to MRI. The utility of these recent possibilities is maximum where access to MRI is still very difficult.



How to cite this article:
Saba L, De Filippo M, Saba F, Fellini F, Marcy PY, Dagan R, Voituriez P, Aelvoet J, Klotz G, Bernard R, Salinesi V, Agostini S. Dual energy CT and research of the bone marrow edema: Comparison with MRI imaging.Indian J Radiol Imaging 2019;29:386-390


How to cite this URL:
Saba L, De Filippo M, Saba F, Fellini F, Marcy PY, Dagan R, Voituriez P, Aelvoet J, Klotz G, Bernard R, Salinesi V, Agostini S. Dual energy CT and research of the bone marrow edema: Comparison with MRI imaging. Indian J Radiol Imaging [serial online] 2019 [cited 2020 May 31 ];29:386-390
Available from: http://www.ijri.org/text.asp?2019/29/4/386/274501


Full Text



 Background



The terminology of bone marrow edema suggests that the water content of bone marrow is increased when it is T1W hypointense and T2W hyperintense.[1],[2]

Bon marrow edema is often post-traumatic or linked to a multiples causes of biomechanical alteration; it can also be generated to acute or chronic inflammation.[1],[2]

Bone marrow edema is easily identified in the magnetic resonance imaging (MRI) as a hyperintensity signal in specific sequences with fat suppression (proton density (PD) suppressed by fat or suppressed by fat T2).[1],[2],[3]

The histological findings vary based on the underlying etiology, and the presence of fibrosis or inflammatory infiltrate is frequent and often predominant.[1],[2],[4]

The detection of bone marrow edema is important because of its diagnostic and prognostic value. It indicates underlying structural damage and may modify management in patients with rheumatoid arthritis or spondyloarthropathies.[3],[4],[5],[6]

The new performance of Dual Energy CT (DECT) gives the possibility to detect the anatomical and pathological sign, not possible with the conventional CT. DECT applications can largely be divided into exploration of material-nonspecific and material-specific energy-dependent information.[7],[8],[9]

To evaluate the diagnostic accuracy of the Dual Energy Computed Tomography (DECT) in the research of the bone marrow edema.

 Methods and Material



The research was performed according to the World Medical Association Declaration of Helsinki. Informed consent was obtained from research subjects.

The MRI images of 100 patients with recent episode of articular and or bone pains, occurred until 10 days before the radiological examination (with or without traumatic lesion), were prospectively evaluated, during a period between March 2018 and February 2019. If the edema was present in the IRM images, the DECT was performed for researching CT bone marrow edema with Spectral images; written informed consents were obtained from all patients when a complementary CT was requested.

The exclusions criteria were patient age 70Statistical analysis

We used descriptive statistical tests for nominal data such as t-Test. The statistical program used was SPSS 19 (IBM SPSS Statistics for Windows; IBM Corporation, Armonk, New York, USA). A P value less than 0.05 was considered significant.

 Result



The MRI images of 100 patients were evaluated to search bone marrow edema. Edema has been identified as “present or not present” in the MRI images.

When the edema was present, a DECT has been acquired.

The DECT and MRI images of 15 patients with bone marrow edema were compared.

Out of 15 patients, 4 were vertebral columns, 2 knees, 3 ankles, 1 foot, 4 shoulders, and 1 wrist.

Two radiologists with at least 5 years of experience in musculoskeletal radiology have prospectively examined the acquired images; the edema was “present or not present.”

Each radiologist made a measurement of the density of the pathological bone (with edema) of each patient (15 measurements each) using spectral images that enhance the concentration of water in the bone, and one on the healthy bone of the same patient as a control, for a total of 4 measurements for each patient (15 + 15 into the bone marrow edema et 15 + 15 into the healthy bone marrow).

The mean of pathologic bone marrow edema was 1008.20 (Standard Deviation (SD) 23.00), for healthy bone marrow 947.53 (SD 16.42), and t = 11.75 [Table 1].{Table 1}

The result of the 30 measurements of the pathological bone was discordant from the 30 measurements on healthy bone, with a statistical significance P < 0.05 (Statistical significance 95%).

The agreement between the measurements of the two radiologists was confirmed (P< 0.05): The mean for the first operator of pathologic bone marrow edema was 1013.13 (SD 27.79), for healthy bone marrow 948.73 (SD 19.03), and t = 6.83.

The mean for the second operator of pathologic bone marrow edema was 1003.26 (SD 16.46), for healthy bone marrow 946.33 (SD 13,90), and t = 11.11.

The positivity of MRI in sequences with fat suppression is related to the positivity of DECT, after evaluating the images that increase the bone water presence.

Subjectively, for both radiologists, MRI has superior for edema evaluating.

DECT has fewer artifacts and more details with more spatial resolution.

 Discussion



The DECT presents a high diagnostic accuracy in the research of the bone marrow edema, comparable to that of the MRI [Figure 1]A, [Figure 1]B, [Figure 1]C, [Figure 1]D and [Figure 2]A, [Figure 2]B, [Figure 2]C, [Figure 2]D.{Figure 1}

Subjectively, for both radiologists, MRI has superior for edema evaluation, but DECT has fewer artifacts and more details with more spatial resolution.

The use of DECT allows the search of additional information, such as bone marrow edema, even in patients without evident fractures.

Diseases such as algodystrophy can be visualized without the use of MRI, which is more expensive and less available [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d.{Figure 2}

We have found few studies that speak about this topic.[10],[11]

Bone marrow edema is the term given to abnormal fluid signal seen within the bone marrow on MRI. It is a nonspecific, yet important, finding usually indicating the presence of an underlying pathology.[1],[4],[5],[10],[11]

The new CT techniques developed, therefore, allow increasing the visualization of the water bone, distribution, identifying the edema.[7],[8],[9]

This novelty is extremely important above all, because until now, it was exclusively pertinent to other methods, in particular, MRI in radiology, or scintigraphy and PET-CT for nuclear medicine.[3],[4],[6],[11],[12]

The possibility of a different diagnosis through the use of DECT will allow in the future determine the modification of the diagnostic radiology indications.[7],[13]

Considering bone marrow edema, for example, it could be useful in an emergency service to search for a small no visible fracture [Figure 3]a, [Figure 3]b, [Figure 3]c, a stress fracture, algodystrophy, arthritis, or other.{Figure 3}

The utility of these recent possibilities is maximal where access to MRI is still very difficult.

MRI, more expensive and with limited access, can be used for more complex examinations, reducing to a minimum the diagnostic investigation after the acquisition of a DECT.[14]

The recent development of the DECT gives of the radiologist multiple diagnostic possibilities unknown with conventional CT.[7],[8],[9],[13],[15],[16],[17]

Dual-energy CT applications can largely be divided into exploration of material-nonspecific and material-specific energy-dependent information. Both evaluations can be qualitative or quantitative. The former includes virtual monoenergetic imaging, effective atomic map, and electron density map. The latter includes material decomposition, material labeling, and material highlighting.[7],[8],[14]

With these recent techniques, two materials with different dual-energy slopes caused by different photoelectric effects can be differentiated by using a predefined separation line.[7],[8],[15]

Spectral imaging demonstrates clear clinical benefits. Tissue characterization utilizing CT is based on several features, including lesion enhancement, patterns of enhancement, lesion outline, and/or the presence of calcium or fat within the lesion.[7],[9],[14]

DECT enhances the diagnostic performance and confidence of CT by increasing iodine contrast-to-noise ratio, decreasing metal or beam-hardening artifacts, and providing material-specific information.[15]

Radiologists should explore the various clinical benefits of DECT, an emerging technology in medical imaging.[13],[14],[15]

The main limits of this study are low diffusion of the DECT presents in the territory, the small number of patients and data, and the lack of experience regarding the possibility of the DECT.

It is hoped that it will be offset in the years to come, going to greatly improve the diagnostic capabilities of the radiologist.

 Conclusion



The DECT presents an excellent capacity to detect the bone marrow edema, comparable to MRI.

The utility of these recent possibilities are maximum where access to MRI is still very difficult.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Manara M, Varenna M. A clinical overview of bone marrow edema. Reumatismo 2014;66:184-96.
2Sharma UK, Dhungel K, Pokhrel D, Tamang S, Parajuli NP. Magnetic resonance imaging evaluation of musculoskeletal diseases of ankle and foot. Kathmandu Univ Med J (KUMJ) 2018;16:28-34.
3Rios AM, Rosenberg ZS, Bencardino JT, Rodrigo SP, Theran SG. Bone marrow edema patterns in the ankle and hindfoot: Distinguishing MRI features. AJR Am J Roentgenol 2011;197:W720-9.
4Hayes CW, Conway WF, Daniel WW. MR imaging of bone marrow edema pattern: Transient osteoporosis, transient bone marrow edema syndrome, or osteonecrosis. Radiographics 1993;13:1001-11.
5Blum A, Roch D, Loeuille D, Louis M, Batch T, Lecocq S, et al. Bone marrow edema: Definition, diagnostic value and prognostic value. J Radiol 2009;90:1789-811.
6Takatori Y, Kokubo T, Ninomiya S, Nakamura T, Okutsu I, Kamogawa M. Transient osteoporosis of the hip: Magnetic resonance imaging. Clin Orthop 1991;271:190-4.
7Goo HW, Goo JM. Dual-energy CT: New horizon in medical imaging. Korean J Radiol 2017;18:555-69.
8Omoumi P, Verdun FR, Guggenberger R, Andreisek G, Becce F. Dual-energy CT: Basic principles, technical approaches, and applications in musculoskeletal imaging (Part 2). Semin Musculoskelet Radiol 2015;19:438-45.
9Johnson TR, Krauss B, Sedlmair M, Grasruck M, Bruder H, Morhard D, et al. Material differentiation by dual energy CT: Initial experience. Eur Radiol 2007;17:1510-7.
10Kaup M, Wichmann JL, Scholtz JE, Beeres M, Kromen W, Albrecht MH, et al. Dual-energy CT-based display of bone marrow edema in osteoporotic vertebral compression fractures: Impact on diagnostic accuracy of radiologists with varying levels of experience in correlation to MR imaging. Radiology 2016;280:510-9.
11Ali IT, Wong WD, Liang T, Khosa F, Mian M, Jalal S, et al. Clinical utility of dual-energy CT analysis of bone marrow edema in acute wrist fractures. AJR Am J Roentgenol 2018;210:842-7.
12Kon E, Ronga M, Filardo G, Farr J, Madry H, Milano G, et al. Bone marrow lesions and subchondral bone pathology of the knee. Knee Surg Sports Traumatol Arthrosc 2016;24:1797-814.
13Kivity S, Gofrit SG, Baker FA, Leibushor N, Tavor S, Lidar M, et al. Association between inflammatory back pain features, acute and structural sacroiliitis on MRI, and the diagnosis of spondyloarthritis. Clin Rheumatol 2019;38:1579-85.
14Martín Noguerol T, Luna Alcalá A, Beltrán LS, Gómez Cabrera M, Broncano Cabrero J, Vilanova JC. Advanced MR imaging techniques for differentiation of neuropathic arthropathy and osteomyelitis in the diabetic foot. Radiographics 2017;37:1161-80.
15Faby S, Kuchenbecker S, Sawall S, Simons D, Schlemmer HP, Lell M, et al. Performance of today's dual energy CT and future multi energy CT in virtual non-contrast imaging and in iodine quantification: A simulation study. Med Phys 2015;42:4349-66.
16Wang CK, Tsai JM, Chuang MT, Wang MT, Huang KY, Lin RM. Bone marrow edema in vertebral compression fractures: Detection with dual-energy CT. Radiology 2013;269:525-33.
17Pomerantz SR, Kamalian S, Zhang D, Gupta R, Rapalino O, Sahani DV, et al. Virtual monochromatic reconstruction of dual-energy unenhanced head CT at 65-75 keV maximizes image quality compared with conventional polychromatic CT. Radiology 2013;266:318-25.