1. Clinico-Radiological Profile of Spinal Cord Multiple Sclerosis Glenn H. Roberson Bhavik N. Patel Asim K. Bag University of Alabama at Birmingham, Birmingham, AL, USA

2. Glenn H. Roberson: Involved in clinical trials sponsored by Guerbet LLC & Wyeith Pharmaceuticals Bhavik N. Patel: No disclosure Asim K. Bag: Involved in clinical trials sponsored by ACRIN & Guerbet LLC

3. Introduction  Multiple sclerosis (MS) has extensive disease burden  MS affects approximately 350,000 individuals in the United States  Typically between the ages of 18 and 45 Medical Clinics of North America 2009;93:451-476

4.  Initial MRI diagnosis of MS does not include spinal cord MRI findings  Spinal cord is involved in >90% of MS patients  Asymptomatic cord lesions are found in 30% to 40% of patients  Spinal cord imaging is very important to identify disease progression in time and space Neuroimaging Clinics of North America 2009;19:81-99 Introduction

5. 1.To identify radiologic pattern of spinal cord involvement in MS 2.To correlate radiologic findings with clinical symptoms Purpose

6.  Retrospective identification of all consecutive patients with abnormal T2 signal in the spinal cord with radiologic concern for MS between 2004 and 2009  Inclusion criteria  Patients who meet the Revised McDonald MS Diagnostic Criteria were included in this study Materials & Methods: Patients

7.  Sagittal  T1  T2  STIR  T1+c  Axial  T1  T2  STIR  T1+c Materials & Methods: MRI sequences

8.  Number of lesions per patient  Involvement pattern of the cord (anterior, posterior, central and diffuse)  Location (cervical, thoracic and lumbar)  Length of lesions  Enhancement pattern Materials & Methods: Lesion Characterization

9.  Demography of the patient (age, sex and race)  Clinical presentation  Pattern of disease course Materials & Methods: Clinical Evaluation

10.  Association between lesion location and distribution with symptoms  Association between lesion load and disease course Materials & Methods

11.  544 patients were identified with spinal cord T2 abnormality with radiologic concern for MS  Only 166 patients met the Revised McDonald MS Diagnostic Criteria Results

12.  Age range: 17-75  Male:Female 1:12.9  More common in Caucasian than African- American (1.84:1) Results: Demography

13.  Sensory 42.77%  Motor 37.95 %  Gait 21.68 %  Bladder 12.65 %  No Spinal symptom 12.65 %  Lhermitte 3.01 % Results: Clinical presentations

14.  Relapsing remitting 71.68%  Secondary progressive 24.09%  Primary progressive 0%  Progressive relapsing 0%  Neuromyelitis optica 4.21% Results: Clinical Course Diagram

15.  Relapsing-remitting  Average number of lesion 2.20 (range 1 to 7)  Secondary-progressive  Average number of lesion 2.14 (range 1 to 5) Results: Lesion loads & disease course

16. 166 patients had total 340 lesions  Location  46.47% posterior  27.94% anterior  22.35% central  3.23% diffuse  Enhancement  4.4%  Lesion length  Mean 18.2 mm [range3-108 mm]  Average number of lesions per patient  2.04 Results: Lesion Characterization

17. Sagittal & Axial T2 Imaging example

18. Sagittal & Axial STIR Imaging example

19. Sagittal & Axial T2 Imaging example

20. Sagittal & Axial STIR Imaging example

21. Sagittal & Axial STIR Imaging example

22. Sagittal T1, T2 & STIR Imaging example

23. Pre- & post-contrast axial and sagittal T1 Imaging example

24.  Number of lesions in this bar diagram exceeds 340 as some of the lesions involved more than one segments  Only 7 patients had isolated thoracic spine involvement Results: Lesion Location

25.  No association between lesion location and  Sensory symptoms  Bladder symptoms  Motor symptoms Results

26.  All patients with posterior column signs, positive Romberg test and gait abnormality had posterior lesions Results

27. Source: http://en.wikipedia.org/wiki/File:Spinal_cord_tracts_-_English.svg

28.  The study is based on retrospective analysis of data  There is a component of selection bias as the study patients were identified from prior MRI Limitations

29.  Demography  Age of presentation 17-75  Predominantly in women (13:1)  Clinical Presentation  Most common presentation is sensory symptoms  Relapsing-remitting is the most common clinical course Conclusion

30.  Radiologic appearance  Cervical spinal cord is most commonly involved  Posterior spinal cord is involved most commonly  Mean lesion length is 18.2 mm  Enhancement is rare  Clinico-radiologic correlation  Posterior column signs and gait abnormality are associated with posteriorly located lesions  Average number of lesions is similar in relapsing- remitting and secondary progressive MS Conclusion

31. Thank you!