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MS/MRI Research Group University of British Columbia, Vancouver, BC. ENS 2002 Guidelines for a standardized MRI protocol for MS. Tony Traboulsee, FRCPC (Neurology) for the CMSC work group. How should MRI be used for the management of MS patients?. “I only use MRI for diagnosis.” - PowerPoint PPT Presentation
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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.”
Dr. A. Traboulsee, UBC MS/MRI Research Group
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
Vancouver CMSC MRI GuidelinesVancouver CMSC MRI Guidelines
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
Dr. A. Traboulsee, UBC MS/MRI Research Group
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
Vancouver CMSC MRI GuidelinesVancouver CMSC MRI Guidelines
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?
Dr. A. Traboulsee, UBC MS/MRI Research Group
Vancouver CMSC MRI GuidelinesVancouver CMSC MRI Guidelines
All MRIs for MS should be done All MRIs for MS should be done according to a standardized according to a standardized protocol.protocol.
Dr. A. Traboulsee, UBC MS/MRI Research Group
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.
Dr. A. Traboulsee, UBC MS/MRI Research Group
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;
Dr. A. Traboulsee, UBC MS/MRI Research Group
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.
Vancouver CMSC MRI GuidelinesVancouver CMSC MRI Guidelines
Indications for a brain MRI:a) The initial evaluation and diagnosis of
suspected MS.b) The baseline evaluation of a patient with
definite MS.
Dr. A. Traboulsee, UBC MS/MRI Research Group
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
Dr. A. Traboulsee, UBC MS/MRI Research Group
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.
Dr. A. Traboulsee, UBC MS/MRI Research Group
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
Vancouver CMSC MRI GuidelinesVancouver CMSC MRI Guidelines
A copy of these MRI studies should be retained permanently.
Dr. A. Traboulsee, UBC MS/MRI Research Group
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.
Dr. A. Traboulsee, UBC MS/MRI Research Group
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.
Dr. A. Traboulsee, UBC MS/MRI Research Group
Acknowledgements
The development of the MRI guidelines is through the generous support of the Consortium of MS Centres (www.mscare.org)
Dr. A. Traboulsee, UBC MS/MRI Research Group
For More Information:For More Information:
Or Or
www.mscare.orgwww.mscare.org