title: Comparison of different magnetic resonance imaging sequences for assessment of fistula-in-ano.
abstract: OBJECTIVE
  To assess agreement between different forms of T2 weighted imaging (T2WI), and post-contrast T1WI in the depiction of fistula tracts, inflammation, and internal openings with that of a reference test.
  
  
  METHODS
  Thirty-nine consecutive prospective cases were enrolled. The following sequences were used for T2WI: 2D turbo-spin-echo (2D T2 TSE); 3D T2 TSE; short tau inversion recovery (STIR); 2D T2 TSE with fat saturation performed in all patients. T1WI were either a 3D T1-weighted prepared gradient echo sequence with fat saturation or a 2D T1 fat saturation [Spectral presaturation with inversion (SPIR)]. Agreement for each sequence for determination of fistula extension, internal openings, and the presence of active inflammation was assessed separately and blindly against a reference test comprised of follow-up, surgery, endoscopic ultrasound, and assessment by an independent experienced radiologist with access to all images.
  
  
  RESULTS
  Fifty-six fistula tracts were found: 2 inter-sphincteric, 13 trans-sphincteric, and 24 with additional tracts. The best T2 weighted sequence for depiction of fistula tracts was 2D T2 TSE (Cohen's kappa = 1.0), followed by 3D T2 TSE (0.88), T2 with fat saturation (0.54), and STIR (0.19). Internal openings were best seen on 2D T2 TSE (Cohen's kappa = 0.88), followed by 3D T2 TSE (0.70), T2 with fat saturation (0.54), and STIR (0.31). Detection of inflammation showed Cohen's kappa of 0.88 with 2D T2 TSE, 0.62 with 3D T2 TSE, 0.63 with STIR, and 0.54 with T2 with fat saturation. STIR, 3D T2 TSE, and T2 with fat saturation did not make any contributions compared to 2D T2 TSE. Post-contrast 3D T1 weighted prepared gradient echo sequence with fat saturation showed better agreement in the depiction of fistulae (Cohen's kappa = 0.94), finding internal openings (Cohen's kappa = 0.97), and evaluating inflammation (Cohen's kappa = 0.94) compared to post-contrast 2D T1 fat saturation or SPIR where the corresponding figures were 0.71, 0.66, and 0.87, respectively. Comparing the best T1 and T2 sequences showed that, for best results, both sequences were necessary.
  
  
  CONCLUSIONS
  3D T1 weighted sequences were best for the depiction of internal openings and active inflammatory components, while 2D T2 TSE provided the best assessment of fistula extension.
authors.affiliation: Michael R Torkzad, 12 Reris Grange Close, Milford, Surrey, GU8 5FD, United Kingdom.
authors.forename: Michael R
authors.initials: MR
authors.lastname: Torkzad
authors.affiliation: Michael R Torkzad, 12 Reris Grange Close, Milford, Surrey, GU8 5FD, United Kingdom.
authors.forename: Håkan
authors.initials: H
authors.lastname: Ahlström
authors.affiliation: Michael R Torkzad, 12 Reris Grange Close, Milford, Surrey, GU8 5FD, United Kingdom.
authors.forename: Urban
authors.initials: U
authors.lastname: Karlbom
keywords: Diagnosis; Fistula; Magnetic resonance imaging