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CMSC MRI Protocol Outline

Consortium of MS Centers MRI Protocol for the Diagnosis and Follow-up of MS Guidelines and Recommendations in year 2003, 2006 and 2009

Three documents were utilized: 1) Consortium of MS Centers MRI Protocol for the Diagnosis and Follow-up of MS Proposed 2009 Revised Guidelines;  2) Consortium of MS Centers MRI Protocol for the Diagnosis and Follow-up of MS June 2003;  and 3) Standardized MR Imaging Protocol for Multiple Sclerosis: Consortium of MS Centers Consensus Guidelines February 2006

The three documents reviewed for the outline varied slightly from year-to-year.  The 2003 guidelines were short and provided clinical guidelines for brain and spinal cord MRIs and time saving options and imaging sequences.

The 2006 guidelines were much more broad and included background information on dissemination in time and space, clinically isolated syndrome, the McDonald Criteria, and factors for decisions to diagnosis and treat MS.  The 2009 proposed revised guidelines pale in comparison to the 2006 document though there were consistencies such as standardized terminology.  Without the substance of the 2006 recommendations specifically in the area CIS, DIS and DIT it’s difficult to imagine 2009 as stand alone guidelines and recommendations. 

Field of strength year-to-year differences

          2003

·          1.0 Tesla recommended and .07 only recommended when patient cannot  handle closed magnet

            2006

·          If possible MRI performed at >1 Tesla to optimize image quality and tissue       contrast

            2009

·          No specific recommendation on magnet size or strength. Scans should be “good” quality, and adequate signal noise ration and resolution (slice pixel resolution             <1m x 1m)

Radiologist Report

          2003

·                    Lesion number, location, size, shape, character and qualitative assessment of brain atrophy

·                    Comparison with previous studies

·                    Interpretation and differential diagnosis

2006 (included similar language as 2003 and the below bullets)

·        Recommendations emphasize use of simple everyday language and consistency

·        Description of the findings

·        Interpretation and differential diagnosis

03 and 06 recommendations in the area of radiology reporting are similar, though 03 provided more specific guidance.

The following addition in 2006 is noted:

Key addition to the protocol: A statement could be provided regarding T2 lesions volume: mild (few lesions) moderate (multiple lesions, early or near confluent; and sever (many confluent lesions).

            Opinion/thoughts: Although 2003, 2006, and 2009s protocol all provide specific recommendations to document quantity and characteristics of lesions, this recommends generalize language such as mild, moderate, and severe. Though this is common interpretation language  – many members of our MS forum post vague language/details in the reports.

The following addition in 2006 is noted: Quantitative measure of total lesion volume and brain and spinal atrophy was considered optional due to imaging facility capability.

            Opinion/thoughts: This may explain why this is not automatic as recommended, in comparison findings and studies.

Standard year-to-year MRI protocols

Suspected MS à         Baseline evaluate:

                                    * Brain MRI recommended w/gadolinium

                                    * Spinal Cord if presenting symptoms at level of cord not resolved,                                   or if brain is non-diagnostic

                                    *Brain MRI recommended to demonstrate new disease activity

Established MS à       Baseline evaluate:

                                    * Brain MRI recommended - gadolinium OPTIONAL

                                    * Unexpected clinical worsening

                                    * Re-assessment of disease burden before starting/modifying                                            therapy

                                    * Suspicion of a secondary disease

MRI Protocol  à       Field Strength:   1.0 T or higher recommended (note 1T open ring Brain Spinal Cord     magnets have field strength of approx. .7 T and are only                         (03)                  recommended if patients cannot tolerate closed magnet

                                    Slices:   < 3 mm and no gap of plane resolution of < 1 mm for                                      brain and spinal cord. <5 mm of no gap is acceptable for brain if                                       centers are unable to acquire 3 mm slices in allotted time.

Brain  à                     1^st:  Sagittal FLAIR

Sequences                  2^nd:  Axial PD/T2

                                    3^rd:  Axial FLAIR

                                    4^th:  Gadolinium enhanced T1(if suspicious lesions on FLAIR)

Spinal Cord à            1^st:   Sagittal PD/T2

Sequences                  2^nd:  Sagittal pre-Gad T1

                                    3^rd:  Sagittal post-Gad T1

                                    4^th:  Axial post-Gad T1 through suspicious lesions

                                    5^th:  Axial T2 through suspicious lesions

MRI Protocol  à       Field Strength:   No specific Recommendation

Brain Spinal Cord    *Scans should be good quality with adequate signal noise ratio             (09)                in  pixel resolution of < 1mm x 1mm

Brain  à                     1^st:  Sagittal FLAIR

Sequences                  2^nd:  Axial FLAIR

                                    3^rd:  Axial T2

                                    4^th:  Axial T1 pre and post gadolinium

Past recommendations were to run the 4^th above enhanced T1 if suspicious lesions on FLAIR

As compared to past recommendations, Axial PD is now “optional” as is 3D IR prepared T1 gradient echo (1.0-1.5 mm thickness)

Spinal Cord à            1^st:  Cervical Cord coverage 

Sequences                  2^nd:  Sagittal T2

                                    3^rd:  Sagittal PD or STIR

                                    4^th:  Sagittal T1

Past recommendations included: Axial post-Gad T1 through suspicious lesions and Axial T2 through suspicious lesions.

Optional for spinal cord MRIs include: post gad T1, 3D IR prepared T1 gradient echo, thoracic cord and conus coverage and Gad not need be given for spinal cord MRI IF it follows a contrast brain MRI study.

Quick Reference Chart

Sources:

http://www.ajnr.org/cgi/content/full/27/2/455#T1

http://www.mscare.org/cmsc/images/pdf/mriprotocol2009.pdf

http://www.mscare.org/cmsc/images/pdf/MRIprotocol2003.pdf