Guidelines for a standardized MRI protocol for MS:

Slides:



Advertisements
Similar presentations
Defining suboptimal response to MS treatment: MRI outcome
Advertisements

‘How I do’ CMR in DCM Dr Sanjay Prasad, Royal Brompton Hospital London, UK. For SCMR August 2006 This presentation is posted for members of scmr as an.
ENS 2002 Guidelines for a standardized MRI protocol for MS
Study Design 121 Relapsing-remitting MS patients randomized to –Stress Management Therapy MS active treatment* 16 individual sessions conducted over 24.
Musculoskeletal Imaging Musculoskeletal diseases debilitate millions of people and are tremendous burden on health care systems worldwide. It was estimated.
DIAGNOSTIC ROLE OF STATIC AND DYNAMIC CONTRAST ENHANCED MAGNETIC RESONANCE IMAGING IN THE EVALUATION OF SOFT TISSUE TUMOURS Abstract No. IRIA
NZIMRT Conference The BasicsThe Basics  Equipment required  Clinical Indications  Patient Preparation  Sequences  Image Appearances.
Rituximab (RITUXAN) & Multiple Sclerosis
© 2014 Direct One Communications, Inc. All rights reserved. 1 New Insights into the Basic Mechanisms, Diagnosis, and Staging of Epilepsy Nicole Odom, MD.
ACT on Alzheimer’s Disease Curriculum Module VII: Disease Diagnosis.
Practice Guidelines and Consensus on Capsule Endoscopy
Practice Guidelines and Consensus on Capsule Endoscopy
Maximally-Invasive Curriculum: A Model Curriculum for Osteopathic Surgical Residencies (ACOS) India Broyles, EdD University of New England College of Osteopathic.
Alzheimer’s Assessment Assessing the Cognitive-Linguistic effects of Alzheimer’s.
An Analysis of Monthly Surveillance 3T MRI in MS patients switched from long term natalizumab to teriflunomide in a controlled, prospective study K. Edwards,
Utility of Post-Therapy Surveillance Scans in Diffuse Large B-Cell Lymphoma Thompson C et al. Proc ASCO 2013;Abstract 8504.
Idoia Corcuera-Solano, Gerard Reddy, Bradley Delman, Reade De Leacy, Dan Rettmann, Lawrence N Tanenbaum EP
© 2014 Direct One Communications, Inc. All rights reserved. 1 A New Era of Therapy in Multiple Sclerosis: Balancing the Options and Challenges Ahead Jennifer.
Sagittal FLAIR images - Stable nonenhancing hyperintensities within the pericallosal white matter and bilateral centrum semiovale, consistent with known.
RECIST Overview.
1 SCREENING. 2 Why screen? Who wants to screen? n Doctors n Labs n Hospitals n Drug companies n Public n Who doesn’t ?
Updates on Optic Neuritis Briar Sexton Neuro-ophthalmology Clinical Day Friday, November 18, 2005.
CHP400: Community Health Program-lI Mohamed M. B. Alnoor Muna M H Diab SCREENING.
MRI as a Potential Surrogate Marker in the ADCS MCI Trial
3D sequence MRI in the assessment of meniscofemoral and ligament lesions of the knee MA.Chaabouni,A.Daghfous, A.Ben Othman,L.Rezgui Marhoul Radiology departement.
Screening and its Useful Tools Thomas Songer, PhD Basic Epidemiology South Asian Cardiovascular Research Methodology Workshop.
MRI CASE Done By: Haya Al-Thuwaini Ro’aa Al-Nemer Kholoud Al-Washmi Prepared For: Dr.Halima,,
Enrollment and Monitoring Procedures for NCI Supported Clinical Trials Barry Anderson, MD, PhD Cancer Therapy Evaluation Program National Cancer Institute.
CasePerspectives: Illuminating Dark Pathways in Complex MS Cases Program Highlights Stephen Krieger, MD Associate Professor of Neurology Corinne Goldsmith.
Advisory Committee for Peripheral and Central Nervous System Drugs March 7, 2006 Question 1: 1.Has Biogen demonstrated natalizumab’s efficacy on reduced.
Clinico-Radiological Profile of Spinal Cord Multiple Sclerosis Glenn H. Roberson Bhavik N. Patel Asim K. Bag University of Alabama at Birmingham, Birmingham,
Comparison of T1 FLAIR and T1 FSE Images Andrew Allmendinger, DO Sylvie Destian, MD.
Magnetic Resonance Imaging In Young Patients With Neuro - Psychiatric SLE : A Case Series Dr. Vivek Gupta Department of Radiodiagnosis Postgraduate Institute.
Anaplastic thyroid cancer based on ATA guideline for Management of Patients with ATC. Thyroid. 2012;22: R3 이정록.
In The Name of God. Multiple Sclerosis and Normal MRI new modalities for problems solving.
European Patients’ Academy on Therapeutic Innovation Challenges in Personalised Medicine.
Carrie M. Hersh, D.O., Robert Fox, M.D.
Imaging requirements in ECST-2
Quality issues in monitoring diagnostic and treatment performance Dr
Four Known Types of MS Clinically isolated syndrome (CIS)
NEDA epoch analysis of patients with relapsing multiple sclerosis treated with ocrelizumab: Results from the OPERA I and OPERA II, phase III studies G.
Melanoma Staging an update
Clinical Audit of Head CT in Stroke Alert Cases: Role of Radiology Resident and CT Technologist Awareness in improving Head CT reporting time K Hooda,
Informed Consent, Image Recording and
Nat. Rev. Neurol. doi: /nrneurol
MRI findings in MS. A. Axial first-echo image from T2-weighted sequence demonstrates multiple bright signal abnormalities in white matter, typical for.
Ali Batouli1 Dennis Monks1 Sobia Mirza1 Michael Goldberg1
Two lesions are seen within the lateral segment of the left lobe of the liver (yellow arrows). They appear mildly hyperintense on T2 images and mildly.
Intervista a Angelo Delmonte
Figure 1 Perivenous distribution of multiple sclerosis lesions
Figure 2. A patient with multifocal nodular lesions diagnosed with CNS tuberculosis A patient with multifocal nodular lesions diagnosed with CNS tuberculosis.
Figure 4 Paradoxical immune reconstitution inflammatory syndrome
Challenges in the Diagnosis of MS: Physician and Nurse Perspectives
7.1b. Contrast coronal T1 Wtd MRI 7.1c. Contrast sagittal T1 Wtd MRI
Stephen L. Hauser, Jorge R. Oksenberg  Neuron 
Figure 4. Brain imaging and neuropathologic demonstration of Epstein-Barr virus (EBV) encephalitis in patient PT-10 Brain imaging and neuropathologic demonstration.
Figure Facial photograph during headache attack and brain and upper cervical cord MRI Facial photograph during headache attack and brain and upper cervical.
Treating to Target in MS
Figure 1 MRI, pathology, and EEG findings(A) Axial fluid-attenuated inversion recovery (FLAIR) MRI sequences of the brain showing right frontal and parietal.
In 507 follow-up images, only 1
Examples of 2 patients with lesions visible only in the DIR images and not in the T2WI TSE images. Examples of 2 patients with lesions visible only in.
Figure Postcontrast axial and coronal brain MRI in a patient with CLIPPERS treated with hydroxychloroquineT1-weighted spin echo post IV gadolinium contrast.
Figure 1 Imaging of disease onset and treatment response Repeat MRI scans including fluid-attenuated inversion recovery (FLAIR) (A) and T2 fast field echo.
Figure 1 MRI findings over time
Figure Imaging, histology/immunohistochemistry, and schematic course of treatment with corresponding clinical and radiologic disease activity Imaging,
Figure Rapid progression of lesions after natalizumab treatment(A) MRI from February Rapid progression of lesions after natalizumab treatment(A)
Figure A 57-year-old man with relapsing-remitting MS (RRMS) and new-onset ataxia A 57-year-old man with relapsing-remitting MS (RRMS) and new-onset ataxia.
Figure 4 Patient 3 MRI evolution over time
 Axial magnetic resonance imaging (MRI) of a 30 year old man with relapsing remitting multiple sclerosis (MS) showing multiple periventricular lesions:
New Provider and Reappointment Training
Presentation transcript:

Guidelines for a standardized MRI protocol for MS:

Rationale for Standardized MRI Applying knowledge from population studies to understanding the individual

Applying knowledge from population studies to understanding the individual Early diagnosis- “MS” Monitoring subclinical disease –activity & extent Monitoring treatment efficacy Identifying factors influencing prognosis

Clinical Threshold Line Clinically Definite MS Clinically Isolated Syndrome Disease Onset Early “MS” (Old Terminology) Time Relapsing MS Progressive Stages

Classic MS Clinically Isolated Syndrome MS Early Diagnosis of MS - New Criteria

For 5 mm /gapped slices median reported at 5 lesions Formal evaluation 3mm non-gapped slices median 13 lesions Formal evaluation median 7 Clinically Isolated Syndrome + Positive MRI Experience and Technique Determine Result

Monitoring Subclinical Disease This is what MRI is all about!

Most MS pathology is clinically silent Disease activity by MRI is 5-10 fold greater than clinical activity The reversible & irreversible accumulating BOD relatively clinically silent but may become important over time

Subclinical Pathological Events New + Enlarging T2 Lesion Profile

From Treatment Trials to Monitoring the Individual Patient ?

Phase III clinical trial data Counting enhancing (or new T2) lesions to monitor an individualRichert et al, 2000

Lesion detection, characterization - early diagnosis Detecting new lesions –patient management & treatment issues Lesion characterization - common terminology Consistent reporting & charting of findings over time Advantages to standardization of MRI in individuals:

Standardized MRI Acquisition Standardized Clinical Indications for MRI & follow-up MRI Standardized Interpretation of MRI Standardized Charting of Disease Activity Standardized MRI Protocol PRESCRIPTIVE GUIDELINES Standardized MRI Report

CMSC MRI Guidelines Meetings Organizing Committee: Don Paty, Joe Frank, Pat Coyle, David Li, Jack Simon, Jerry Wolinsky, Tony Traboulsee Participants: North American, NZ, and European clinical and research MS Neurologists, Neuroradiologists and MRI Technologists Representatives: RSNA,ASNR

Consensus workshop in November 2001 sponsored by the CMSC. ( 35 participants) Two working groups: one for the clinical guidelines and one for the standardized MRI protocol. Two working groups: one for the clinical guidelines and one for the standardized MRI protocol. Follow-up meeting in March 2003 to update the guidelines and protocol.(19 participants) Follow-up meeting in March 2003 to update the guidelines and protocol.(19 participants)

Objective for the MRI protocol: What is a reasonable standardized clinical MRI protocol that will allow comparison between studies? Objective for theclinical guidelines Objective for the clinical guidelines: When should MRI be performed to diagnose and follow MS patients?

Guideline--Suspected MS When available, a brain MRI that meets the standardized protocol should be done as part of the initial evaluation and for diagnosis suspected Indication for follow-up MRI in suspected MS: To establish the diagnosis of MS by detecting silent disease disseminated in time and/or space.

Indications for spinal MRI - 1: If the main presenting symptoms are at the level of the spinal cord, and have not resolved, then a spinal cord MRI and brain MRI are recommended. Indications for spinal MRI - 2: When the brain MRI gives equivocal results, spinal MRI provides increased specificity in patients with an abnormal brain MRI or increased sensitivity in patients with a negative brain MRI.

The baseline evaluation of a patient with established MS includes a brain MRI that meets the standardized protocol in addition to a comprehensive neurological history and examination. established In the absence of clinical indications, routine follow-up MRI (at pre- defined intervals) in established MS is not validated at this time, whether the patient is on disease modifying therapy or not. established Indications for follow-up MRI in established MS include: Re-assessment for initiation or modification of treatment. Unexpected clinical worsening Suspicion of a secondary diagnosis. If a follow-up MRI is to be done, it should be performed by the standardized MRI protocol and compared to previous studies. Guidelines in Clinically Definite MS

Regarding the use of gadolinium: Suspected MS – recommended. If lesions are not seen on PD, T2 or flair sequences, then it may not be necessary to give gadolinium. Baseline evaluation of established MS – optional. Follow-up evaluation – optional It was generally agreed that gadolinium provides useful additional information about new, inflammatory activity.

Standardized MRI Methodology 1.0 Tesla or higher < 3 mm, no gap if possible; otherwise 5 mm, no gap Standardized MRI Methodology 1.0 Tesla or higher < 3 mm, no gap if possible; otherwise 5 mm, no gap

Sagittal FLAIR FLuid FLuid Attenuated Attenuated Inversion Inversion Recovery Sequences

Axial Proton Density T2 FLAIRSequences Conventional Spin Echo or Fast (Turbo) SE *

Axial (Post) Gadolinium Enhanced T1  Pre-gadolinium axial T1 scans are optional n IV Gadolinium 0.1mmol/kg (single dose) over 30 seconds  Minimum delay of 5 minutes before scanning

Brain MRI Protocols Recommended Optional Recommended Established MS Baseline or FU Suspected MS Diagnosis Gadolinium enhanced T1 Axial FLAIR Axial PD/T2 Sagittal FLAIR Sequences *Gadolinium may not be necessary if no lesions on the PD/T2 or FLAIR images *

Spine  No additional gadolinium required if spinal cord study immediately follows Gad-enhanced brain MRI n Slice thickness: < 3 mm, no gap  In plane resolution: < 1mm x 1mm

Spinal Cord MRI Protocol Helpful to confirm suspicious lesions Axial T2 For suspicious lesions Through suspicious lesions Axial post-gad T1 Sagittal post-gad T1 RecommendedSagittal pre-Gad T1 RecommendedSagittal PD/T2 Sequences

The referring physician should indicate on the request for the standardized MRI brain and/or spinal cord protocol (in addition to appropriate clinical information) one of the following indications: Suspected MS Baseline evaluation of MS Follow-up of MS Communication

The radiology report should use common language and include: Description of findings (lesion number, location, size, shape, character and qualitative assessment of brain atrophy) Communication An optional standardized reporting table may be helpful to the radiologist and neurologist. Comparison with previous studies (new, enlarging and/or enhancing lesions, atrophy) Interpretation and Differential diagnosis

Standardized Reporting and Charting

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

Implementation strategies Presentations at local and international meetings.Presentations at local and international meetings. Booth at annual meetings.Booth at annual meetings. CME (use and interpretation training) – Web or CD based.CME (use and interpretation training) – Web or CD based. Manufacturer specific protocols.Manufacturer specific protocols. Technologists web sites and newsletters.Technologists web sites and newsletters. Improved access to CMSC website.Improved access to CMSC website. Examples on website (lesions, subcallosal line, protocols).Examples on website (lesions, subcallosal line, protocols). Publications.Publications. CMSC MRI Guidelines

Future The guidelines will need to be updated as new information becomes available. The guidelines will need to be updated as new information becomes available.

The guidelines have been presented at major international meetings