Guidelines Updated for MRIs in Multiple Sclerosis

BANGKOK, THAILAND — Magnetic resonance imaging of the brain should be considered every 1–2 years for patients with a confirmed diagnosis of multiple sclerosis, with more frequent imaging if symptoms worsen unexpectedly.

“If a patient has a clinical deterioration that is out of keeping with their disease, you will want to look for a complication of treatment, such as progressive multifocal leukoencephalopathy, or a different issue, such as a stroke in an elderly patient,” said Dr. Anthony Traboulsee, who is a coauthor of updates to the MRI Protocol for the Diagnosis and Follow-Up of Multiple Sclerosis, issued by the Consortium of MS Centers.

The consortium is an international group of neurologists and radiologists, including members of the American Academy of Neurology and the American Society of Neuroradiology. It first released its imaging recommendations in 2003. The new guidelines replace previous revisions from 2006.

The goal of the document is to establish a uniform, internationally practical imaging protocol for MS patients, said Dr. Traboulsee of the University of British Columbia, Vancouver. “The whole point of developing guidelines is practicality, so that anywhere you are in the world, if you have access to MRI, you can get good imaging for your MS patients.”

The document outlines recommendations for the initial imaging procedure in patients with a clinically isolated syndrome suggestive of the disease, and for follow-up imaging in patients with a confirmed diagnosis.

Patients with a clinically isolated syndrome and suspected MS should have, at the minimum, a brain MRI with gadolinium. A spinal cord MRI may be called for if there is persistent uncertainty about the diagnosis, equivocal findings on the brain MRI, or presenting symptoms at the spinal cord level.

To make the best use of both time and money, the guidelines recommend performing as much of the imaging as possible in a single session. This allows completion of both brain and spinal imaging on a single dose of gadolinium.

The protocol recommends a slice thickness of no more than 3 mm for brain and spinal cord. Core sequences of the brain should include sagittal and axial Fluid Attenuated Inversion Recovery (FLAIR); axial T2; and axial T1 both pre- and post-gadolinium.

Renal function should always be assessed before giving gadolinium, Dr. Traboulsee said at the World Congress of Neurology. “We recommend this because there have been rare cases of poor outcomes following exposure in patients with impaired renal function.” The gadolinium dose should be a single infusion of 0.1 mmol/kg given over 30 seconds, with a minimum 5-minute delay before obtaining post-gadolinium T1 images. The FLAIR or T2 studies can be done during this delay.

The guidelines recommend two types of sequences for spinal cord, he said. “Don't just rely on the sagittal T2, but try variations like proton density or Short Tau Inversion Recovery (STIR).”

There are two indications for follow-up MRI in patients with an established diagnosis: acute clinical deterioration, which may be related to treatment reaction or the onset of a concomitant disorder, and planned reassessment.

“How often we should be doing follow-up MRIs—particularly in the early disease course—is where the challenge comes in, because there is not a perfect relationship of new lesions and disease outcome,” Dr. Traboulsee said. However, the expert panel recommended that physicians consider annual or biannual studies.

A brain MRI with gadolinium should also be performed to reassess disease before starting or modifying medical therapy.

The guidelines are available at www.mscare.org/cmsc/images/pdf/mriprotocol2009.pdf

BANGKOK, THAILAND — Magnetic resonance imaging of the brain should be considered every 1–2 years for patients with a confirmed diagnosis of multiple sclerosis, with more frequent imaging if symptoms worsen unexpectedly.

“If a patient has a clinical deterioration that is out of keeping with their disease, you will want to look for a complication of treatment, such as progressive multifocal leukoencephalopathy, or a different issue, such as a stroke in an elderly patient,” said Dr. Anthony Traboulsee, who is a coauthor of updates to the MRI Protocol for the Diagnosis and Follow-Up of Multiple Sclerosis, issued by the Consortium of MS Centers.

The consortium is an international group of neurologists and radiologists, including members of the American Academy of Neurology and the American Society of Neuroradiology. It first released its imaging recommendations in 2003. The new guidelines replace previous revisions from 2006.

The goal of the document is to establish a uniform, internationally practical imaging protocol for MS patients, said Dr. Traboulsee of the University of British Columbia, Vancouver. “The whole point of developing guidelines is practicality, so that anywhere you are in the world, if you have access to MRI, you can get good imaging for your MS patients.”

The document outlines recommendations for the initial imaging procedure in patients with a clinically isolated syndrome suggestive of the disease, and for follow-up imaging in patients with a confirmed diagnosis.

Patients with a clinically isolated syndrome and suspected MS should have, at the minimum, a brain MRI with gadolinium. A spinal cord MRI may be called for if there is persistent uncertainty about the diagnosis, equivocal findings on the brain MRI, or presenting symptoms at the spinal cord level.

To make the best use of both time and money, the guidelines recommend performing as much of the imaging as possible in a single session. This allows completion of both brain and spinal imaging on a single dose of gadolinium.

The protocol recommends a slice thickness of no more than 3 mm for brain and spinal cord. Core sequences of the brain should include sagittal and axial Fluid Attenuated Inversion Recovery (FLAIR); axial T2; and axial T1 both pre- and post-gadolinium.

Renal function should always be assessed before giving gadolinium, Dr. Traboulsee said at the World Congress of Neurology. “We recommend this because there have been rare cases of poor outcomes following exposure in patients with impaired renal function.” The gadolinium dose should be a single infusion of 0.1 mmol/kg given over 30 seconds, with a minimum 5-minute delay before obtaining post-gadolinium T1 images. The FLAIR or T2 studies can be done during this delay.

The guidelines recommend two types of sequences for spinal cord, he said. “Don't just rely on the sagittal T2, but try variations like proton density or Short Tau Inversion Recovery (STIR).”

There are two indications for follow-up MRI in patients with an established diagnosis: acute clinical deterioration, which may be related to treatment reaction or the onset of a concomitant disorder, and planned reassessment.

“How often we should be doing follow-up MRIs—particularly in the early disease course—is where the challenge comes in, because there is not a perfect relationship of new lesions and disease outcome,” Dr. Traboulsee said. However, the expert panel recommended that physicians consider annual or biannual studies.

A brain MRI with gadolinium should also be performed to reassess disease before starting or modifying medical therapy.

The guidelines are available at www.mscare.org/cmsc/images/pdf/mriprotocol2009.pdf

BANGKOK, THAILAND — Magnetic resonance imaging of the brain should be considered every 1–2 years for patients with a confirmed diagnosis of multiple sclerosis, with more frequent imaging if symptoms worsen unexpectedly.

“If a patient has a clinical deterioration that is out of keeping with their disease, you will want to look for a complication of treatment, such as progressive multifocal leukoencephalopathy, or a different issue, such as a stroke in an elderly patient,” said Dr. Anthony Traboulsee, who is a coauthor of updates to the MRI Protocol for the Diagnosis and Follow-Up of Multiple Sclerosis, issued by the Consortium of MS Centers.

The consortium is an international group of neurologists and radiologists, including members of the American Academy of Neurology and the American Society of Neuroradiology. It first released its imaging recommendations in 2003. The new guidelines replace previous revisions from 2006.

The goal of the document is to establish a uniform, internationally practical imaging protocol for MS patients, said Dr. Traboulsee of the University of British Columbia, Vancouver. “The whole point of developing guidelines is practicality, so that anywhere you are in the world, if you have access to MRI, you can get good imaging for your MS patients.”

The document outlines recommendations for the initial imaging procedure in patients with a clinically isolated syndrome suggestive of the disease, and for follow-up imaging in patients with a confirmed diagnosis.

Patients with a clinically isolated syndrome and suspected MS should have, at the minimum, a brain MRI with gadolinium. A spinal cord MRI may be called for if there is persistent uncertainty about the diagnosis, equivocal findings on the brain MRI, or presenting symptoms at the spinal cord level.

To make the best use of both time and money, the guidelines recommend performing as much of the imaging as possible in a single session. This allows completion of both brain and spinal imaging on a single dose of gadolinium.

The protocol recommends a slice thickness of no more than 3 mm for brain and spinal cord. Core sequences of the brain should include sagittal and axial Fluid Attenuated Inversion Recovery (FLAIR); axial T2; and axial T1 both pre- and post-gadolinium.

Renal function should always be assessed before giving gadolinium, Dr. Traboulsee said at the World Congress of Neurology. “We recommend this because there have been rare cases of poor outcomes following exposure in patients with impaired renal function.” The gadolinium dose should be a single infusion of 0.1 mmol/kg given over 30 seconds, with a minimum 5-minute delay before obtaining post-gadolinium T1 images. The FLAIR or T2 studies can be done during this delay.

The guidelines recommend two types of sequences for spinal cord, he said. “Don't just rely on the sagittal T2, but try variations like proton density or Short Tau Inversion Recovery (STIR).”

There are two indications for follow-up MRI in patients with an established diagnosis: acute clinical deterioration, which may be related to treatment reaction or the onset of a concomitant disorder, and planned reassessment.

“How often we should be doing follow-up MRIs—particularly in the early disease course—is where the challenge comes in, because there is not a perfect relationship of new lesions and disease outcome,” Dr. Traboulsee said. However, the expert panel recommended that physicians consider annual or biannual studies.

A brain MRI with gadolinium should also be performed to reassess disease before starting or modifying medical therapy.

The guidelines are available at www.mscare.org/cmsc/images/pdf/mriprotocol2009.pdf