ENS 2002 Guidelines for a standardized MRI protocol for MS Tony Traboulsee, FRCPC (Neurology) for the CMSC work group 1/12 MS/MRI Research Group University of British Columbia, Vancouver, BC

How should MRI be used for the management of MS patients? “I only use MRI for diagnosis.” “My patients have an MRI at least once a year so that I can see how active their MS has been.” “I order an MRI if a patient isn’t doing well on therapy and change therapies if the MRI looks bad.” 2/12 Dr. A. Traboulsee, UBC MS/MRI Research Group

Vancouver CMSC MRI Guidelines Problems: Variability in frequency of MRI follow-up. Applying population data to the individual patient to define treatment effect. Inconsistency in MRI protocols. Dr. A. Traboulsee, UBC MS/MRI Research Group

A non-standardized MRI can be a non-informative follow-up MRI. “Three newly appreciated small T2 hyperintensities may represent interval lesions, but their detection on today’s exam may also be technical in nature since contiguous slices are not obtained on axial imaging at this time.” Caution if MRI and CSF are normal 1 – 3 MRIs required Gd lesion > 3 months after clinical attack OR New T2 or Gd lesion > 3 months after 1st MRI 2 – 3 MRIs required Positive 1st MRI AND Gd lesion > 3 months after clinical attack Negative MRI and CSF is very low risk for developing Dr. A. Traboulsee, UBC MS/MRI Research Group

CMSC MRI Protocol for the Diagnosis and Follow-up of MS Consortium of MS Centers Consensus Meeting, Vancouver, Canada, November 2nd-4th, 2001

Vancouver CMSC MRI Guidelines Organizing Committee: Don Paty, Joe Frank, Pat Coyle, David Li, Jack Simon, Jerry Wolinsky, T Traboulsee Participants: Canadian, US and European clinical and research MS Neurologists and Neuroradiologists Dr. A. Traboulsee, UBC MS/MRI Research Group

Vancouver CMSC MRI Guidelines Objectives: What is a reasonable standardized clinical MRI protocol that will allow comparison between studies? Should routine follow-up MRI be performed after MS has been diagnosed? Dr. A. Traboulsee, UBC MS/MRI Research Group

Vancouver CMSC MRI Guidelines All MRIs for MS should be done according to a standardized protocol. Dr. A. Traboulsee, UBC MS/MRI Research Group

Table 1: BRAIN MRI Protocols Field Strength > 1.0T Slice thickness < 3mm and no gap. Scan orientation for the brain on the subcallosal line using 3 planes (localizer if available). In-plane pixel size should be < 1mm x 1mm. Axial FSE PD/T2 with TE1 minimum usually < 30ms and TE2 > than 80ms. Dr. A. Traboulsee, UBC MS/MRI Research Group

Diagnostic Scan for CIS Table 1: BRAIN MRI Protocols Acquisition Sequence Diagnostic Scan for CIS CDMS baseline or Follow-up Scan 3 plane localizer: subcallosal line Required Sagittal FLAIR Optional Axial FSE PD/T2 Axial FLAIR High contrast T1W 3D sequence Gad 0.1mmol/kg over 30 seconds Post contrast axial SE T1W (5 minute delay)   CIS: clinically isolated syndrome of demyelination; CDMS: clinically definite multiple sclerosis FSE: fast spin echo; PD: proton density weighted; Dr. A. Traboulsee, UBC MS/MRI Research Group

Table 2a: SPINAL CORD MRI Protocol without a contrast brain study Acquisition Sequence   Localization in 3 planes Required Sagittal FSE PD/T2 High contrast T1W 3D sequence Optional Sagittal T1W Gadolinium 0.1 – 0.3 mmol/kg over 30 seconds If required Post contrast Sagittal SE T1W Post contrast axial SE T1W Through suspicious lesions Axial FSE T2 Use phase array coil if available; Slice thickness < 3mm (< 1.5mm for 3D sequences), and no gap. In-plane pixel size should be < 1mm x 1mm; FSE: fast spin echo; PD: proton density weighted; Axial FSE PD/T2: TE1 minimum usually less than 30ms and TE2 greater than 80ms.

Table 2b: SPINAL CORD MRI Protocol following a contrast brain study (an additional bolus of gadolinium is probably not required) Acquisition Sequence   Localization in 3 planes Required Post contrast Sagittal SE T1W Post contrast axial SE T1W Through suspicious lesion Sagittal FSE PD/T2 Axial FSE T2 Through suspicious lesions High contrast T1W 3D sequence Optional Use phase array coil if available; Slice thickness < 3mm (< 1.5mm for 3D sequences), and no gap. In-plane pixel size should be < 1mm x 1mm.; FSE: fast spin echo; PD: proton density weighted; Axial FSE PD/T2: TE1 minimum usually less than 30ms and TE2 greater than 80ms.

Vancouver CMSC MRI Guidelines Indications for a brain MRI: The initial evaluation and diagnosis of suspected MS. The baseline evaluation of a patient with definite MS. Indications for spinal MRI: presenting symptoms are at the level of the spinal cord if the head MRI gives equivocal results Dr. A. Traboulsee, UBC MS/MRI Research Group

Vancouver CMSC MRI Guidelines Indications for follow-up MRI include: unexpected clinical worsening. re-assessment of T2 burden of disease for initiation of treatment. suspicion of secondary diagnosis. Routine follow-up MRI is not recommended Dr. A. Traboulsee, UBC MS/MRI Research Group

Vancouver CMSC MRI Guidelines - 2 The referring physician should indicate: Suspected MS Baseline evaluation of MS Follow-up of MS The radiology report should be descriptive. Dr. A. Traboulsee, UBC MS/MRI Research Group

Table 3: Comprehensive MS MRI Report BRAIN MRI MRI date:   Baseline Follow-up With gadolinium (check) Normal (check) Total number of T2 lesions (> 3mm) New T2 lesions compared to baseline NA Periventricular lesions Juxtacortical lesions Infratentorial lesions Corpus callosum lesions Enlarging lesions Total number of enhancing lesions Non-enhancing T1 hypointense lesions Brain Atrophy (no, mild, moderate, severe) Other finding

Vancouver CMSC MRI Guidelines A copy of these MRI studies should be retained permanently. Dr. A. Traboulsee, UBC MS/MRI Research Group

Implementing the guidelines These guidelines will be maintained on the Consortium of MS Centers website (www.mscare.org), and will be updated as MRI technology evolves and new clinical indications emerge. Dr. A. Traboulsee, UBC MS/MRI Research Group

Conclusions A standardized MRI protocol is essential for gathering meaningful follow-up information. Gadolinium provides additional information and is especially useful for a diagnostic MRI. Additional evidence is required to bridge the gap between the role of serial MRI in population studies and the role for individual patient follow-up. Dr. A. Traboulsee, UBC MS/MRI Research Group

Acknowledgements The development of the MRI guidelines is through the generous support of the Consortium of MS Centres (www.mscare.org) Dr. A. Traboulsee, UBC MS/MRI Research Group

For More Information: trabouls@interchange.ubc.ca Or www.mscare.org