Diagnostic performance of multishot echo-planar imaging (RESOLVE) and non-echo-planar imaging (HASTE) diffusion-weighted imaging in cholesteatoma with an emphasis on signal intensity ratio measurement

Abstract

To evaluate the diagnostic efficacy of multishot echo-planar imaging (EPI) [RESOLVE (RS)] and non-EPI (HASTE) diffusion-weighted imaging (DWI) in detecting cholesteatoma (CHO), and to explore the role of signal intensity (SI) ratio measurements in addressing diagnostic challenges. We analyzed RS-EPI and non-EPI DWI images from 154 patients who had undergone microscopic middle ear surgery, with pathological confirmation of their diagnoses. Two radiologists, referred to as Reader A and Reader B, independently reviewed the images without prior knowledge of the outcomes. Their evaluation focused on lesion location, T1-weighted (T1W) signal characteristics, and contrast enhancement in temporal bone magnetic resonance imaging. Key parameters included lesion hyperintensity, size, SI, SI ratio, and susceptibility artifact scores across both imaging modalities. Of the patients, 62.3% (96/154) were diagnosed with CHO, whereas 37.7% (58/154) were found to have non-CHO conditions. In RS-EPI DWI, Reader A achieved 89.6% sensitivity, 79.3% specificity, 87.8% positive predictive value (PPV), and 82.1% negative predictive value (NPV). Non-EPI DWI presented similar results with sensitivities of 89.6%, specificities of 86.2%, PPVs of 91.5%, and NPVs of 83.3%. Reader B’s results for RS-EPI DWI were 82.3% sensitivity, 84.5% specificity, 89.8% PPV, and 74.2% NPV, whereas, for non-EPI DWI, they were 86.5% sensitivity, 89.7% specificity, 93.3% PPV, and 80% NPV. The interobserver agreement was excellent (RS-EPI, κ: 0.84; non-EPI, κ: 0.91). The SI ratio measurements were consistently higher in non-EPI DWI (Reader A: 2.51, Reader B: 2.46) for the CHO group compared with RS-EPI. The SI ratio cut-off (>1.98) effectively differentiated hyperintense lesions between CHO and non-CHO groups, demonstrating 82.9% sensitivity and 100% specificity, with an area under the curve of 0.901 (95% confidence interval: 0.815–0.956; P < 0.001). Susceptibility artifact scores averaged 1.18 ± 0.7 (Reader A) and 1.04 ± 0.41 (Reader B) in RS-EPI, with non-EPI DWI recording a mean score of 0. Both RS-EPI and non-EPI DWI exhibited high diagnostic accuracy for CHO. While RS-EPI DWI cannot replace non-EPI DWI, their combined use improves sensitivity. SI ratio measurement in non-EPI DWI was particularly beneficial in complex diagnostic scenarios. This study refines CHO diagnostic protocols by showcasing the diagnostic capabilities of both RS-EPI and non-EPI DWI and highlighting the utility of SI measurements as a diagnostic tool. These findings may reduce false positives and aid in more accurate treatment planning, offering substantial insights for clinicians in managing CHO.