Myosteatosis: diagnostic significance and assessment by imaging approaches

Myosteatosis has emerged as an important concept in muscle health as it is associated with an increased risk of adverse health outcomes, a higher rate of complications, and increased mortality associated with ageing, chronic systemic and neuromuscular diseases, cancer, metabolic syndromes, degenerative events, and trauma. Myosteatosis involves ectopic infiltration of fat into skeletal muscle, and it exhibits a negative correlation with muscle mass, strength, and mobility representing a contributing factor to decreased muscle quality. While myosteatosis serves as an additional biomarker for sarcopenia, cachexia, and metabolic syndromes, it is not synonymous with sarcopenia. Myosteatosis induces proinflammatory changes that contribute to decreased muscle function, compromise mitochondrial function, and increase inflammatory response in muscles. Imaging techniques such as computed tomography (CT), particularly opportunistic abdominal CT scans, and magnetic resonance imaging (MRI) or magnetic resonance spectroscopy (MRS), have been used in both clinical practice and research. And in recent years, ultrasound has emerged as a promising bedside tool for measuring changes in muscle tissue. Various techniques, including CT-based muscle attenuation (MA) and intermuscular adipose tissue (IMAT) quantification, MRI-based proton density fat fraction (PDFF) and T1-T2 mapping, and musculoskeletal ultrasound (MSUS)-based echo intensity (EI) and shear wave elastography (SWE), are accessible in clinical practice and can be used as adjunct biomarkers of myosteatosis to assess various debilitating muscle health conditions. However, a stan¬dard definition of myosteatosis with a thorough understanding of the pathophysiological mechanisms, and a consensus in assessment methods and clinical outcomes has not yet been established. Recent developments in image acquisition and quantification have attempted to develop an appropriate muscle quality index for the assessment of myosteatosis. Additionally, emerging studies on artificial intelligence (AI) may provide further insights into quantification and automated assessment, including MRS analysis. In this review, we discuss the pathophysiological aspects of myosteatosis, all the current imaging techniques and recent advances in imaging assessment as potential biomarkers of myosteatosis, and the most common clinical conditions involved.