1. 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

2. 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

3. 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

4. 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

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

6. 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

8. 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

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

10. 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

11. 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

12. 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.

13. 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.

14. 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

15. 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

16. 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

17. 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

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

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

20. 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

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

22. For More Information: Or