12-month Magnetic Resonance Imaging Research Articles

Paper 38: Addition of a Lateral Extra-articular Tenodesis is Associated with Lower Quadriceps Tendon Autograft MRI Signal Intensity Two Years Following Anterior Cruciate Ligament Reconstruction in Skeletally Immature Adolescents

Objectives: In recent studies, quadriceps tendon autograft (QTA) has been shown to yield promising results in the treatment of anterior cruciate ligament (ACL) ruptures in pediatric and adolescent patients. Additionally, lateral extra-articular tenodesis (LET) has been found to reduce the risk of ACL re-tear in high-risk patients when performed concomitantly with ACL reconstruction (ACLR). The purpose of this study was to evaluate graft maturity two years after ACLR by comparing magnetic resonance imaging (MRI) signal intensity ratio (SIR) of QTA in patients that underwent a primary ACL reconstruction with a concomitant LET versus patients without a concomitant LET. Methods: After institutional review board approval, operative records of all pediatric patients ≤ 18 years old who underwent an ACLR from June 2015 to December 2021 were retrospectively reviewed. MRIs were ordered for this age cohort of patients for clinical growth plate surveillance. Patients were included if they underwent an ACLR using a QTA and had open distal femoral and proximal tibial physes. MRIs were excluded if they were external or were ordered due to a new injury. The final cohort included 28 patients: 13 without a LET (ACLR only) and 15 with a LET (ACLR+LET). Signal intensity ratio (SIR) was measured on sagittal MRI by averaging the signal at three regions of interest along the ACL graft and dividing by the signal of the insertion of the posterior cruciate ligament. Statistical analysis was performed to evaluate for differences in SIR values at 6 months, 1 year, and 2 years post-operatively in skeletally immature patients undergoing ACLR alone versus ACLR with LET. Results: A total of 43 patients had an MRI at a two-year follow-up, 28 of whom were included in the study. The mean age of the complete cohort was 12.63±3.62 years (ACLR+LET: 13.96±0.91 years vs. ACLR only: 13.51±1.19 years). There were no significant differences in SIR between groups on the 6-month MRI or the 12-month MRI. However, the average SIR of the ACLR+LET group was significantly lower than the average SIR of the ACLR-only group at the two-year post-operative time point (1.398 vs. 1.916, respectively, p=0.046). Conclusions: QTA MRI signal intensity is lower two years after surgery in patients that underwent ACLR with a LET versus ACLR alone. Lower MRI signal intensity correlates with increased graft maturity and structural integrity. These findings suggest improved graft maturation, remodeling, and structural integrity with the addition of a LET to an ACLR with QTA in skeletally immature patients. [Table: see text]

MRI Signal Intensity of Quadriceps Tendon Autograft and Hamstring Tendon Autograft 1 Year After Anterior Cruciate Ligament Reconstruction in Adolescent Athletes

Background: Hamstring tendon autograft (HTA) is a common graft choice for anterior cruciate ligament (ACL) reconstruction (ACLR) in skeletally immature patients. Recently, the use of quadriceps tendon autograft (QTA) has shown superior preliminary outcomes in this population. Purpose: To evaluate graft maturity by comparing magnetic resonance imaging (MRI) signal intensity of HTA versus QTA used in primary ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: All patients under the age of 18 years who underwent a primary ACLR by the senior authors using either an HTA or a QTA were retrospectively reviewed. A total of 70 skeletally immature patients (37 in the HTA group and 33 in the QTA group) with an available MRI at 6 and 12 months postoperatively were included. Signal intensity ratio (SIR) was measured on sagittal MRI by averaging the signal at 3 regions of interest along the ACL graft and dividing by the signal of the tibial footprint of the posterior cruciate ligament. Statistical analysis was performed to determine interrater reliability and differences between time points and groups. Results: Age, sex, and type of surgery were not associated with any differences in SIR. There was no significant difference in SIR between groups on the 6-month MRI. However, the SIR of the QTA group was significantly less than in the HTA group on the 12-month MRI (2.33 vs 2.72, respectively; P = .028). Within the HTA group, there was no significant difference in SIR at either MRI time point. In the QTA group, there was a significant decrease in SIR between the 6-month and 12-month postoperative MRI (2.70 vs 2.33, respectively; P = .045). Conclusion: These findings suggest improved graft maturation, remodeling, and structural integrity of the QTA compared with the HTA between 6 and 12 months postoperatively. This provides evidence that, at 1 year postoperatively, QTA may have a superior rate of incorporation and synovialization as compared with the HTA.

Exit Strategies in Natalizumab-Treated RRMS at High Risk of Progressive Multifocal Leukoencephalopathy: a Multicentre Comparison Study

The main aim of the study is to evaluate the efficacy and safety profile of ocrelizumab (OCR), rituximab (RTX), and cladribine (CLA), employed as natalizumab (NTZ) exit strategies in relapsing–remitting multiple sclerosis (RRMS) patients at high-risk for progressive multifocal leukoencephalopathy (PML). This is a multicentre, retrospective, real-world study on consecutive RRMS patients from eleven tertiary Italian MS centres, who switched from NTZ to OCR, RTX, and CLA from January 1st, 2019, to December 31st, 2019. The primary study outcomes were the annualized relapse rate (ARR) and magnetic resonance imaging (MRI) outcome. Treatment effects were estimated by the inverse probability treatment weighting (IPTW), based on propensity-score (PS) approach. Additional endpoint included confirmed disability progression (CDP) as measured by Expanded Disability Status Scale and adverse events (AEs). Patients satisfying predefined inclusion and exclusion criteria were 120; 64 switched to OCR, 36 to RTX, and 20 to CLA. Patients from the 3 groups did not show differences for baseline characteristics, also after post hoc analysis. The IPTW PS-adjusted models revealed that patients on OCR had a lower risk for ARR than patients on CLA (ExpBOCR 0.485, CI 95% 0.264–0.893, p = 0.020). This result was confirmed also for 12-month MRI activity (ExpBOCR 0.248 CI 95% 0.065–0.948, p = 0.042). No differences were found in other pairwise comparisons (OCR vs RTX and RTX vs CLA) for the investigated outcomes. AEs were similar among the 3 groups. Anti-CD20 drugs were revealed to be effective and safe options as NTZ exit strategies. All investigated DMTs showed a good safety profile.

Effects of Venous Angioplasty on Cerebral Lesions in Multiple Sclerosis: Expanded Analysis of the Brave Dreams Double-Blind, Sham-Controlled Randomized Trial

Purpose: To evaluate if jugular vein flow restoration in various venographic defects indicative of chronic cerebrospinal venous insufficiency (CCSVI) in multiple sclerosis (MS) patients can have positive effects on cerebral lesions identified using magnetic resonance imaging (MRI). Materials and Methods: The Brave Dreams trial ( ClinicalTrials.gov identifier NCT01371760) was a multicenter, randomized, parallel group, double-blind, sham-controlled trial to assess the efficacy of jugular venoplasty in MS patients with CCSVI. Between August 2012 and March 2016, 130 patients (mean age 39.9±10.6 years; 81 women) with relapsing/remitting (n=115) or secondary/progressive (n=15) MS were randomized 2:1 to venography plus angioplasty (n=86) or venography (sham; n=44). Patients and study personnel (except the interventionist) were masked to treatment assignment. MRI data acquired at 6 and 12 months after randomization were compared to the preoperative scan for new and/or >30% enlargement of T2 lesions plus new gadolinium enhancement of pre-existing lesions. The relative risks (RR) with 95% confidence interval (CI) were estimated and compared. In a post hoc assessment, venograms of patients who underwent venous angioplasty were graded as “favorable” (n=38) or “unfavorable” (n=30) for dilation according to the Giaquinta grading system by 4 investigators blinded to outcomes. These subgroups were also compared. Results: Of the 130 patients enrolled, 125 (96%) completed the 12-month MRI follow-up. Analysis showed that the likelihood of being free of new cerebral lesions at 1 year was significantly higher after venoplasty compared to the sham group (RR 1.42, 95% CI 1.00 to 2.01, p=0.032). Patients with favorable venograms had a significantly higher probability of being free of new cerebral lesions than patients with unfavorable venograms (RR 1.82, 95% CI 1.17 to 2.83, p=0.005) or patients in the sham arm (RR 1.66, 95% CI 1.16 to 2.37, p=0.005). Conclusion: Expanded analysis of the Brave Dreams data that included secondary/progressive MS patients in addition to the relapsing/remitting patients analyzed previously showed that venoplasty decreases new cerebral lesions at 1 year. Post hoc analysis confirmed the efficacy of the Giaquinta grading system in selecting patients appropriate for venoplasty who were more likely to be free from accumulation of new cerebral lesions at MRI.

The INTEGRITY Trial: Preservation of Uterine-Wall Integrity 12 Months After Transcervical Fibroid Ablation with the Sonata System.

Objective: The aim of this research was to evaluate uterine-wall integrity 12 months after transcervical fibroid ablation (TFA) of uterine fibroids with the Sonata® system (Gynesonics Inc., Redwood City, CA).Materials and Methods: INTEGRITY is a secondary analysis of the FAST-EU clinical trial, a prospective, longitudinal, multicenter single-armed trial involving women with heavy menstrual bleeding secondary to fibroids who were treated at 7 academic and community hospitals in the United Kingdom, the Netherlands, and Mexico with transcervical, intrauterine, ultrasound-guided radiofrequency ablation (the Sonata system). TFA was performed on up to 5 fibroids per subject ranging from 1–5 cm in diameter as determined by magnetic resonance imaging (MRI). All measurements and comparisons, including uterine-wall thicknesses were derived from baseline and 12-month MRI scans by an independent core MRI center. Scans were analyzed to assess preservation of uterine-wall integrity and reviewed for uterine-wall anomalies after TFA with the Sonata system.Results: Twenty-nine patients had baseline and 12-month MRI with contrast enhancement. Minimum uterine-wall thicknesses in all visible slices were >2.5 mm in diameter. No areas on MRI indicated any loss of uterine-wall integrity, compared with baseline imaging; comparison of baseline and postablation uterine-wall thicknesses revealed no significant changes.Conclusion: Transcervical fibroid ablation with the Sonata system was associated with preservation of uterine-wall integrity in this patient cohort.

Changes in bone microarchitecture following kidney transplantation-Beyond bone mineral density.

Bone disease in kidney transplant recipients (KTRs) is characterized by bone mineral density (BMD) loss but bone microarchitecture changes are poorly defined. In this prospective cohort study, we evaluated bone microarchitecture using non-invasive imaging modalities; high-resolution magnetic resonance imaging (MRI), peripheral quantitative computed tomography (pQCT), dual energy X-ray absorptiometry (DXA), and the trabecular bone score (TBS) following kidney transplantation. Eleven KTRs (48.3±11.2years) underwent MRI (tibia), pQCT (radius) and DXA at baseline and 12months post-transplantation. Transiliac bone biopsies, performed at transplantation, showed 70% of patients with high/normal bone turnover. Compared with baseline, 12-month MRI showed deterioration in indices of trabecular network integrity-surface to curve ratio (S/C; -15%, P=0.03) and erosion index (EI; +19%, P=0.01). However, cortical area increased (+10.3%, P=0.04), with a non-significant increase in cortical thickness (CtTh; +7.8%, P=0.06). At 12months, parathyroid hormone values (median 10.7pmol/L) correlated with improved S/C (r=0.75, P=0.009) and EI (r=-0.71, P=0.01) while osteocalcin correlated with CtTh (r=0.72, P=0.02) and area (r=0.70, P=0.02). TBS decreased from baseline (-5.1%, P=0.01) with no significant changes in BMD or pQCT. These findings highlight a post-transplant deterioration in trabecular bone quality detected by MRI and TBS, independent of changes in BMD, underlining the potential utility of these modalities in evaluating bone microarchitecture in KTRs.

P041 - Phase 2 BOLD extension study efficacy results for siponimod (BAF312) in patients with relapsing-remitting multiple sclerosis

Background/objectives In the adaptive dose-ranging, 6- or 3-month BOLD study in patients with relapsing-remitting multiple sclerosis, once-daily siponimod (BAF312) showed dose-dependent reduction of combined unique active lesion number and annualized relapse rate (ARR); near-maximal effects were observed at 2 mg. Here, we report the efficacy findings of first 12 months of the extension (representing >18 or 15 months of total treatment). Design/methods Patients either continued on siponimod doses assigned in the core phase or were re-randomized from placebo to siponimod 10, 2, 1.25, 0.5 and 0.25 mg: 33, 29, 43, 29 and 50 patients comprised each dose group, respectively. Patients had >7 days (washout time) study drug interruption between core and extension phases to enable siponimod dose titration from 0.25 mg over the first 10 days. Magnetic resonance imaging (MRI) was performed at extension baseline, month 6 and month 12. Results 263/297 (88.6%) patients completed the core study; 184 of these (62.0%) entered the extension. The following data pertain to patients taking 10, 2, 1.25, 0.5 and 0.25 mg, respectively. 27, 25, 37, 24 and 37 patients had a 12-month MRI, and mean gadolinium-enhancing lesion numbers at extension month 12 were: 0.1, 0.5, 0.1, 0.6, 0.8 (compared with 1.7, 1.4, 1.8, 3.1, 1.3 at core study baseline, and 1.7 in placebo at month 6). Mean numbers of new/enlarged T2 lesions at extension month 12 were 0.4, 0.6, 0.2, 1.7 and 1.7, and ARRs were 0.27 (95% confidence interval, 0.14–0.52), 0.18 (0.08–0.42), 0.13 (0.06–0.28), 0.34 (0.18–0.64) and 0.33 (0.20–0.54). No new safety issues were observed. Conclusion Over the 12-month extension, MRI-assessed inflammatory lesion activity and ARRs remained low, particularly in the 1.25, 2 and 10 mg treatment groups, with no new safety concerns.

Magnetic Resonance Imaging Osteonecrosis Pattern within an Osteochondral Dowel Allograft

A 22-year-old male with a history of a previously debrided large posttraumatic osteochondral lesion of the lateral femoral condyle presented to our institution for further treatment due to persistent pain and instability. He was treated with a large cryopreserved osteochondral dowel allograft and remained clinically asymptomatic with no pain, locking, or instability at his 12-month, 18-month, and 42-month follow-up appointments. However, his 12-month magnetic resonance imaging (MRI) examination demonstrated an osteonecrosis pattern within the osseous component of the allograft. Six months later, the osteonecrosis pattern decreased in size, and 30 months later had completely resolved. The allograft was otherwise stable in appearance. The MRI appearance was most likely due to a normal maturation process of bone healing within osteochondral allograft dowel, referred to as "creeping substitution".