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

[doublevision1]

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.

[doublevision1]

I finally posted this on Health Pages.  FYI.

[Fluffysmom]

I've printed this out.  I called the MRI department to ask if my MRIs were done under the MS Protocol, and was told that they were.

It seems clear to me from this that they were not. I have no way of telling if the used 3 mm slices and all that, but my brain MRI reports didn't give the lesion count, location, or shape.  They simply state "multiple mm sized areas of increased and abnormal water signal scattered throughout supratentorial white matter tracts.  The appearance and distribution of these lesions is far and away most consistent with multiple sclerosis."

Of course there is more than that, about a prominence of the CSF spaces about the posterior fossa at the midline.  The MRA I had called thatconsistent with a  mega cisterna magna.  Anyway, he talks about the parts that are normal, and so forth.

Were there just too many little lesions for him to count?  I wish he had described their locations, at least the ones that were "most consistent with MS".

I'll ask my MS Specialist about this; maybe I'll get the new MRIs with a 3 T machine done under the MS Protocol.  Its worth a try, anyway.  :o)

Kathy

[Sarahsmom46]

This is good info to keep on hand.  Thanks for posting it.

Julie

[OperaMBA]

A classic quote from that site....:

Ms. Dottie Pfohl: You know, in your lecture you mentioned zebra and horse.
What was that all about?

Dr. Anthony Traboulsee: Oh, the zebra and horse. There’s this old saying in
diagnostic medicine - if you hear hoofs, you should be thinking horses, not zebras.

Ms. Dottie Pfohl: Oh, got you.

Dr. Anthony Traboulsee: That means when you--if you see some white spots on
an MRI in someone with the symptoms classic for MS, you should be thinking of--you
know, MS should be the first thing that comes to your mind as opposed to some exotic
infection from deepest, darkest somewhere.

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A breath of fresh air....

[Quixotic1]

Exactly!  This is what we have needed.  Thank you, soooo much!

Now I suspect that some of this will need interpretation into plainer words.  

Anyone have questions?

Quix