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T2-relaxation mapping and fat fraction assessment to objectively quantify clinical activity in thyroid eye disease: an initial feasibility study


Imaging in thyroid eye disease (TED) is used to exclude other diagnoses, assess for apical crowding and plan surgery. But to quantify TED activity objectively, subjective clinical scoring assessments remain the norm. Magnetic resonance imaging (MRI) T2-relaxation times correlate with extra-ocular muscle (EOM) inflammation, but are confounded by signal from fat. We investigated whether T2-relaxation mapping in combination with fat fraction (FF) measurements could quantify disease activity in EOMs objectively. Sixty-two TED patients and six controls were enroled for coronal short tau inversion recovery (STIR), T2 multi-echo fast-spin echo and multi-echo fast-gradient echo MRI of the orbits. STIR signal intensity ratios (SIRs), T2-relaxation times and percentage FF were derived for inferior, lateral, superior and medial recti bilaterally. Twelve patients were re-scanned following immunosuppressive treatment. The results found a positive correlation for all subjects between T2 and SIR (p < 0.001), but only mean T2 differed significantly between patients and controls (p < 0.001). We measured FF in EOMs for the first time and found it greater in TED (p < 0.001). There was also a significant reduction in mean T2 after treatment, with a corresponding reduction in the clinical activity score (CAS) in almost all patients. We show that T2-relaxation times differentiate between normal and inflamed EOMs and are responsive to treatment. Combined, uniquely, with FF measurement in EOMs, an objective, quantitative marker of inflammation in TED-affected muscles could be derived. T2-relaxation times mirrored improvements in CAS after treatment, occasionally preceding them. Rarely, they diverged, suggesting limitations in the CAS as a disease burden marker.

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We would like to acknowledge Dr. Paul Meyer, Dr. Nagui Antoun, and the MRI Radiographers.


The project was supported by the Addenbrooke’s Charitable Trust and the National Institute for Health Research [Cambridge Biomedical Research Centre at the Cambridge University Hospitals NHS Foundation Trust]. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Author contributions

The team conceived of the idea for this study and all authors have contributed to the data gathering, analysis and writing.

Author information


  1. Department of Radiology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK

    • Tilak Das
    • , Andrew J. Patterson
    •  & Martin J. Graves
  2. Department of Ophthalmology, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Cambridge, UK

    • Jonathan C. P. Roos
    •  & Rachna Murthy
  3. Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK

    • Jonathan C. P. Roos
    •  & Rachna Murthy


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Conflict of interest

All authors are doctors who assess patients with thyroid eye disease either clinically or radiologically. There are no other conflict ofcompeting interests and a unified declaration form is available on request.

Ethics statement

This study was approved by the local Research Ethics Committee.


The corresponding author has the right to grant on behalf of all authors and does grant on behalf of all authors an exclusive licence on a worldwide basis to permit this article to be published.


Dr. Das serves as guarantor of this work. It is an honest, accurate and transparent account of the study being reported; no important aspects of the study have been omitted.

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Correspondence to Tilak Das.

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