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Guidelines for a standardized MRI protocol for MS:. Rationale for Standardized MRI Applying knowledge from population studies to understanding the individual. Applying knowledge from population studies to understanding the individual. Early diagnosis- “MS” Monitoring subclinical disease

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slide2

Rationale for Standardized MRI Applying knowledge from population studies to understanding the individual

applying knowledge from population studies to understanding the individual
Applying knowledge from population studies to understanding the individual
  • Early diagnosis- “MS”
  • Monitoring subclinical disease
    • activity & extent
  • Monitoring treatment efficacy
  • Identifying factors influencing prognosis
slide4

Early “MS” (Old Terminology)

Clinical ThresholdLine

Clinically Isolated Syndrome

Relapsing MS

Clinically Definite MS

Disease Onset

Progressive Stages

Time

slide5

Early Diagnosis of MS - New Criteria

Clinically Isolated Syndrome

MS

Classic MS

slide6

Clinically Isolated Syndrome + Positive MRI

Experience and Technique Determine Result

Formal evaluation

median 7

Formal evaluation

3mm non-gapped

slices

median 13 lesions

For 5 mm /gapped slices

median reported at 5 lesions

monitoring subclinical disease

Monitoring Subclinical Disease

This is what MRI is all about!

most ms pathology is clinically silent
Most MS pathology is clinically silent
  • Disease activity by MRI is 5-10 fold greater than clinical activity
  • The reversible & irreversible accumulating BOD relatively clinically silent but may become important over time
slide11

Phase III clinical trial data

Counting enhancing (or new T2) lesions

to monitor an individualRichert et al, 2000

slide12

Advantages to standardization

of MRI

in individuals:

  • Lesion detection, characterization - early diagnosis
  • Detecting new lesions –patient management & treatment issues
  • Lesion characterization - common terminology
  • Consistent reporting & charting of findingsover time
slide13

Standardized MRI Protocol

PRESCRIPTIVE GUIDELINES

Standardized

Clinical Indications

for MRI &

follow-up

MRI

Standardized

Charting of

Disease Activity

Standardized

MRI

Acquisition

Standardized

MRI

Report

Standardized

Interpretation

of

MRI

cmsc mri guidelines meetings
CMSC MRI Guidelines Meetings
  • Organizing Committee:
    • Don Paty, Joe Frank, Pat Coyle,
    • David Li, Jack Simon, Jerry Wolinsky, Tony Traboulsee
  • Participants:
    • North American, NZ, and European
    • clinical and research MS Neurologists, Neuroradiologists and MRI Technologists
  • Representatives: RSNA,ASNR
slide15

Consensus workshop in November 2001 sponsored by the CMSC. ( 35 participants)

    • Two working groups: one for the clinical guidelines and one for the standardized MRI protocol.
  • Follow-up meeting in March 2003 to update the guidelines and protocol.(19 participants)
slide16

Objective for theclinical guidelines:

    • When should MRI be performed to diagnose and follow MS patients?
  • Objective for the MRI protocol:
    • What is a reasonable standardized clinical MRI protocol that will allow comparison between studies?
slide17
Guideline--Suspected MS

When available, a brain MRI that meets the standardized protocol should be done as part of the initial evaluation and for diagnosis

Indication for follow-up MRI in suspected MS:

To establish the diagnosis of MS by detecting silent disease disseminated in time and/or space.

slide18

Indications for spinal MRI - 1:

    • If the main presenting symptoms are at the level of the spinal cord, and have not resolved, then a spinal cord MRI and brain MRI are recommended.
  • Indications for spinal MRI - 2:
    • When the brain MRI gives equivocal results, spinal MRI provides increased specificity in patients with an abnormal brain MRI or increased sensitivity in patients with a negative brain MRI.
slide19

Guidelines in Clinically Definite MS

The baseline evaluation of a patient with established MS includes a brain MRI that meets the standardized protocol in addition to a comprehensive neurological history and examination.

In the absence of clinical indications, routine follow-up MRI (at pre-defined intervals) in established MS is not validated at this time, whether the patient is on disease modifying therapy or not.

Indications for follow-up MRI in established MS include:

Re-assessment for initiation or modification of treatment.

Unexpected clinical worsening

Suspicion of a secondary diagnosis.

If a follow-up MRI is to be done, it should be performed by the standardized MRI protocol and compared to previous studies.

slide20
Regarding the use of gadolinium:

Suspected MS – recommended.

If lesions are not seen on PD, T2 or flair sequences, then it may not be necessary to give gadolinium.

Baseline evaluation of established MS – optional.

Follow-up evaluation – optional

It was generally agreed that gadolinium provides useful additional information about new, inflammatory activity.

slide21

Standardized MRI Methodology

    • 1.0 Tesla or higher
        • < 3 mm, no gap if possible; otherwise 5 mm, no gap
sagittal flair

Sequences

Sagittal FLAIR

FLuidAttenuatedInversionRecovery

axial

Proton Density

T2

FLAIR

Sequences

Axial

*

Conventional Spin Echo or Fast (Turbo) SE

axial post gadolinium enhanced t1
Axial (Post) Gadolinium Enhanced T1
  • IV Gadolinium 0.1mmol/kg (single dose) over 30 seconds
  • Minimum delay of5 minutes before scanning
  • Pre-gadolinium axial T1 scans are optional
brain mri protocols

Sequences

Sagittal FLAIR

Recommended

Optional

Axial PD/T2

Recommended

Recommended

Axial FLAIR

Recommended

Recommended

*

Optional

Gadoliniumenhanced T1

Recommended

*Gadolinium may not be necessary if no lesions on the PD/T2 or FLAIR images

Brain MRI Protocols

Suspected MS Diagnosis

Established MSBaseline or FU

slide26

Spine

  • Slice thickness:< 3 mm, no gap
  • In plane resolution:< 1mm x 1mm
  • No additional gadolinium required if spinal cord study immediately follows Gad-enhanced brain MRI
spinal cord mri protocol

Sagittal PD/T2

Recommended

Sagittal pre-Gad T1

Recommended

Sagittal post-gad T1

Axial post-gad T1

Through suspicious lesions

Axial T2

Helpful to confirm suspicious lesions

Spinal Cord MRI Protocol

Sequences

For suspicious lesions

communication
Communication

The referring physician should indicate on the request for the standardized MRI brain and/or spinal cord protocol (in addition to appropriate clinical information) one of the following indications:

  • Suspected MS
  • Baseline evaluation of MS
  • Follow-up of MS
communication1
Communication

The radiology report should use common language and include:

  • Description of findings (lesion number, location, size, shape, character and qualitative assessment of brain atrophy)
  • Comparison with previous studies (new, enlarging and/or enhancing lesions, atrophy)
  • Interpretation and Differential diagnosis

An optional standardized reporting table may be helpful to the radiologist and neurologist.

archival storage
Archival & Storage

Copies of these MRI studies should be retained permanently and be available.

Studies should be stored in a standard format (example DICOM).

It may be useful for patients to keep their own studies on portable digital media.

slide32

CMSC MRI Guidelines

Implementation strategies

  • Presentations at local and international meetings.
  • Booth at annual meetings.
  • CME (use and interpretation training) – Web or CD based.
  • Manufacturer specific protocols.
  • Technologists web sites and newsletters.
  • Improved access to CMSC website.
  • Examples on website (lesions, subcallosal line, protocols).
  • Publications.