Tony Traboulsee, FRCPC (Neurology) for the CMSC work group for the CMSC work group ENS 2002 Guidelines for a standardized MRI protocol for MS MS/MRI Research

Tony Traboulsee, FRCPC (Neurology)Tony Traboulsee, FRCPC (Neurology) for the CMSC work groupfor the CMSC work group

ENS 2002ENS 2002Guidelines for a standardized Guidelines for a standardized

MRI protocol for MSMRI protocol for MS

MS/MRI Research Group

University of British Columbia, Vancouver, BC

How should MRI be used for the How should MRI be used for the management of MS patients?management of MS patients?

“I only use MRI for diagnosis.”

“My patients have an MRI at least once a year so that I can see how active their MS has been.”

“I order an MRI if a patient isn’t doing well on therapy and change therapies if the MRI

looks bad.”Dr. A. Traboulsee, UBC MS/MRI Research Group

Vancouver CMSC MRI GuidelinesVancouver CMSC MRI Guidelines

Problems:Problems:•Variability in frequency of MRI Variability in frequency of MRI follow-up.follow-up.

•Applying population data to the Applying population data to the individual patient to define individual patient to define treatment effect. treatment effect.

•Inconsistency in MRI protocols.Inconsistency in MRI protocols.

Dr. A. Traboulsee, UBC MS/MRI Research Group

A non-standardized MRI can be a A non-standardized MRI can be a non-informative follow-up MRI.non-informative follow-up MRI.

“Three newly appreciated small T2 hyperintensities may represent interval lesions, but their detection on today’s exam may also be technical in nature since contiguous slices are not obtained on axial imaging at this time.”


Consortium of MS Centers Consensus Meeting, Vancouver, Canada,

November 2nd-4th, 2001

CMSC MRI Protocol for the CMSC MRI Protocol for the Diagnosis and Follow-up of MSDiagnosis and Follow-up of MS


Organizing Committee:Don Paty, Joe Frank, Pat Coyle, David Li, Jack Simon, Jerry Wolinsky, T Traboulsee

Participants:Canadian, US and Europeanclinical and research MS Neurologists and Neuroradiologists


Doug ArnoldPeter CalabresiJoseph FrankDoug GraebRobert HerndonDouglas JefferyCraig JonesCiaran KeoghNancy SicotteDonald PatyErnst RadueJack SimonLael StoneTony TraboulseeJay TsurudaErnest WilloughbyGuojun Zhao

Barry ArnasonJose Cabrera-GomezBruce CohenPat CoyleVirginia DevonshireGeorge EbersStan HashimotoJohn HoogeCorree LauleThomas LeistDavid LiGeorge RiceAndrew RiddeoghJay RosenbergRandall SchapiroJoel OgerJames SimsarianJerry Wolinsky


Objectives:•What is a reasonable standardized What is a reasonable standardized clinical MRI protocol that will allow clinical MRI protocol that will allow comparison between studies?comparison between studies?

•Should routine follow-up MRI be Should routine follow-up MRI be performed after MS has been performed after MS has been diagnosed?diagnosed?



All MRIs for MS should be done All MRIs for MS should be done according to a standardized according to a standardized protocol.protocol.


Table 1: BRAIN MRI ProtocolsTable 1: BRAIN MRI Protocols

•Field Strength Field Strength >> 1.0T 1.0T•Slice thickness Slice thickness << 3mm and no gap. 3mm and no gap. •Scan orientation for the brain on the Scan orientation for the brain on the subcallosal line using 3 planes (localizer if subcallosal line using 3 planes (localizer if available).available).•In-plane pixel size should be In-plane pixel size should be << 1mm x 1mm. 1mm x 1mm.•Axial FSE PD/T2 with TE1 minimum Axial FSE PD/T2 with TE1 minimum usually < 30ms and TE2 > than 80ms.usually < 30ms and TE2 > than 80ms.


Table 1: BRAIN MRI ProtocolsAcquisition Sequence Diagnostic Scan

for CISCDMS baseline

or Follow-up Scan3 plane localizer: subcallosal line Required Required

Sagittal FLAIR Required Optional

Axial FSE PD/T2 Required Required

Axial FLAIR Required Required

High contrast T1W 3D sequence Optional Optional

Gad 0.1mmol/kg over 30 seconds Required Optional

Post contrast axial SE T1W (5 minute delay)

Required Optional

CIS: clinically isolated syndrome of demyelination; CDMS: clinically definite multiple sclerosisFSE: fast spin echo; PD: proton density weighted;


Table 2a: SPINAL CORD MRI Protocol without a contrast brain study

Acquisition Sequence

Localization in 3 planes Required

Sagittal FSE PD/T2 Required

High contrast T1W 3D sequence Optional

Sagittal T1W Required

Gadolinium 0.1 – 0.3 mmol/kgover 30 seconds

If required

Post contrast Sagittal SE T1W If required

Post contrast axial SE T1W Through suspicious lesions

Axial FSE T2 Through suspicious lesions

Use phase array coil if available; Slice thickness < 3mm (< 1.5mm for 3D sequences), and no gap. In-plane pixel size should be < 1mm x 1mm; FSE: fast spin echo; PD: proton density weighted;Axial FSE PD/T2: TE1 minimum usually less than 30ms and TE2 greater than 80ms.

Table 2b: SPINAL CORD MRI Protocol following a contrast brain study (an additional bolus of gadolinium is probably not required)

Acquisition Sequence

Localization in 3 planes Required

Post contrast Sagittal SE T1W Required

Post contrast axial SE T1W Through suspicious lesion

Sagittal FSE PD/T2 Required

Axial FSE T2 Through suspicious lesions

High contrast T1W 3D sequence

Optional

Use phase array coil if available; Slice thickness < 3mm (< 1.5mm for 3D sequences), and no gap. In-plane pixel size should be < 1mm x 1mm.; FSE: fast spin echo; PD: proton density weighted;Axial FSE PD/T2: TE1 minimum usually less than 30ms and TE2 greater than 80ms.


Indications for a brain MRI:a) The initial evaluation and diagnosis of

suspected MS.b) The baseline evaluation of a patient with

definite MS.


Indications for spinal MRI:a) presenting symptoms are at the level of the

spinal cord

b) if the head MRI gives equivocal results

Vancouver CMSC MRI Guidelines

Routine follow-up MRI is not recommended


Indications for follow-up MRI include:a) unexpected clinical worsening.

b) re-assessment of T2 burden of disease for initiation of treatment.

c) suspicion of secondary diagnosis.

Vancouver CMSC MRI Guidelines - 2

The referring physician should indicate:• Suspected MS• Baseline evaluation of MS• Follow-up of MS

The radiology report should be descriptive.


Table 3: Comprehensive MS MRI ReportBRAIN MRI MRI date: MRI date: MRI date: MRI date:

Baseline Follow-up Follow-up Follow-up

With gadolinium (check)

Normal (check)

Total number of T2 lesions (> 3mm)

New T2 lesions compared to baseline

NA

Periventricular lesions

Juxtacortical lesions

Infratentorial lesions

Corpus callosum lesions

Enlarging lesions NA

Total number of enhancing lesions

Non-enhancing T1 hypointense lesions

Brain Atrophy (no, mild, moderate, severe)

Other finding


A copy of these MRI studies should be retained permanently.


Implementing the guidelines

These guidelines will be maintained on the Consortium of MS Centers website (www.mscare.org), and will be updated as MRI technology evolves and new clinical indications emerge.


Conclusions1. A standardized MRI protocol is essential for

gathering meaningful follow-up information.

2. Gadolinium provides additional information and is especially useful for a diagnostic MRI.

3. Additional evidence is required to bridge the gap between the role of serial MRI in population studies and the role for individual patient follow-up.


Acknowledgements

The development of the MRI guidelines is through the generous support of the Consortium of MS Centres (www.mscare.org)


For More Information:For More Information:

[email protected]

Or Or

www.mscare.orgwww.mscare.org

mailto:[email protected]

mailto:[email protected]

Documents

Tony Traboulsee, FRCPC (Neurology) for the CMSC work group for the CMSC work group ENS 2002 Guidelines for a standardized MRI protocol for MS MS/MRI Research