Multiple Sclerosis Community

Consortium of MS Centers  
MRI Protocol for the Diagnosis and Follow-up of MS

by
Anthony Traboulsee, MD; David Li, MD; Joseph Frank, MD;
Jack Simon, MD; Patricia Coyle, MD; Jerry Wolinsky, MD; Donald Paty, MD

June 2003

I. CLINICAL GUIDELINES for Brain and Spinal Cord MRI in MS

Suspected MS:

Baseline evaluation:
• Brain MRI recommended (with gadolinium)
• Spinal Cord MRI if presenting symptoms are at the level of the spinal cord and have not
resolved, or if the Brain MRI is non-diagnostic.

Follow-up evaluation:
• Brain MRI recommended to demonstrate new disease activity


Established MS indications:

Baseline evaluation:
• Brain MRI recommended (gadolinium optional)

Follow-up of MS:
• Unexpected clinical worsening
• Re-assessment of disease burden before starting or modifying therapy
• Suspicion of a secondary diagnosis


II. MRI PROTOCOLS for Brain and Spinal Cord

Field Strength: 1.0 Tesla or higher recommended for brain or spinal cord.
(Note: 1T open ring magnets have an effective field strength of approximately 0.7 Tesla and are
only recommended when patients can not tolerate the closed magnet).

Slice Thickness: < 3mm and no gap and in plane resolution of < 1mm x 1 mm for both Brain and spinal cord. (Note: < 5mm and no gap is acceptable for Brain MRI for centers that are unable to acquire 3mm slices in the allotted time).

Scan Orientation and Coverage:
Reproducible coverage and orientation for the axial slices using the subcallosal line as a reference on an appropriate Sagittal localizer is critical for longitudinal comparisons.

Brain MRI Sequences:
1st: Sagittal FLAIR (fluid attenuating inversion recovery).
2nd: Axial PD/T2 (proton density and T2 weighted T1 usually  80ms)
3rd: Axial FLAIR
4th: Gadolinium enhanced T1 (if suspicious lesions seen on FLAIR).
Note: all 4 sequences recommended for a diagnostic MRI in suspected MS. The Sagittal FLAIR and gadolinium enhanced T1 are optional in the follow-up study for established MS.

Spinal Cord Sequences:
1st: Sagittal PD/T2
2nd: Sagittal pre-Gad T1
3rd: Sagittal post-Gad T1
4th: Axial post-Gad T1 through suspicious lesions.
5th: Axial T2 through suspicious lesions.

Gadolinium:
• The recommended dose is 0.1 mmol/kg IV
• The minimum delay after giving gadolinium is 5 minutes before acquiring the axial T1 weighted axial post contrast images.
• Gadolinium does not need to be given for a spinal cord MRI if it follows a contrast Brain MRI study.

Time saving strategies:
• Omit the axial Fast Spin Echo PD
• Only cover the corpus callosum with the Sagittal FLAIR.
• Acquire the axial FLAIR after giving gadolinium and before the axial T1 weighted axial post contrast images.

Report:
The report should use common language and be descriptive including:
• Lesion number, location, size, shape, character and a qualitative assessment of brain atrophy.
• Comparison with previous studies for new, enlarging and/or enhancing lesions and atrophy.
• Interpretation and differential diagnosis.

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

Archival and Storage:
Copies of these MRI studies should be retained permanently and be available. They should be stored in a standard format (example DICOM). It may be useful for patients to keep their own studies on portable digital media.