Tony Traboulsee, MD Associate Professor (Medicine/Neurology) Head, UBC MS and NMO Programs. MRI Diagnostic Red Flags

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1 Tony Traboulsee, MD Associate Professor (Medicine/Neurology) Head, UBC MS and NMO Programs MRI Diagnostic Red Flags

2 UBC MS and NMO Research Programs LEARNING OBJECTIVES By the end of this presentation, you should be able to: 1. Recognize that small white matter lesions are common in the general population. 2. Recognize that mass effect and persistent gadolinium enhancement are unusual for MS lesons. 3. Employ spinal cord imaging to assist in the diagnostic workup.

3 UBC MS and NMO Research Programs Presenter Disclosure Relationships with commercial entities (past 3 years) Advisory Boards: Biogen, Chugai, EMD Serono, MedImmune, Novartis, Roche, Sanofi Genzyme, Teva Clinical Trials steering committee member: Roche opera study Clinical Trials Principal Investigator: Biogen, Chugai, Novartis, Roche, Sanofi Genzyme Research Financial Support: EMD Serono, Novartis, Roche, Sanofi Genzyme Stocks/Shares: None t.traboulsee@ubc.ca

4 UBC MS and NMO Research Programs Mitigating Potential Bias Only generic drug names will be used. All products of relevance will be given equal weight during the presentation. The content of this presentation is under my complete control.

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6 White matter lesions are non specific on clinical MRI

7 White matter lesions are non specific on clinical MRI VASCULITIS CADASIL LYMPHOMA LYMPHOMA ADEM Chronic Hypertension Nonspecific UBO Perivascular Space

8 Corpus callosum: Sjogren s and Susac s disease

9 103 patients referred to a Colorado MS center because of an abnormal brain MRI. 11% had definite MS 70% had an alternative diagnosis

10 Differential Diagnosis of White Matter Abnormalities Filippi et al. JMRI 21: , 2005

11 Differential Diagnosis of White Matter Abnormalities Filippi et al. JMRI 21: , 2005

12 False Positive MRI UBOs Perivascular spaces

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15 Classic MS MRI Features 80% of MS patients have spinal cord lesions T2 Weighted Proton Density

16 Spinal Cord Lesions Bot et al. Radiology 223:46-56, 2002 Present in 50-90% of CDMS patients (cervical > thoracic) May be helpful when MS strongly suspected clinically but no brain lesions (5-10% CDMS) Do not occur in healthy normal subjects even in older age groups Much less common with ischemia and other neurological diseases (6%)

17 Other neurological disorders Spinal cord normal Spinal cord abnormal OND (n = 43) 39 4 MS (n = Z=-7.01, p< Bot JCJ. et al. Radiology. 2002;223:46-56

18 Typical spinal cord lesion characteristics Shape Frequency Location Pattern Swelling Gadolinium enhancement Cigar (discrete) Diffuse (PPMS) 43% of CIS patients 83% of CDMS patients Peripheral Cervical > thoracic Random Asymmetric Rare Rare

19 Spinal cord MRI is useful in the differential diagnosis MS cord lesions can be asymptomatic Spondylosis Lesions on nerve roots (carcinomatosis)

20 Advantages of Spinal Cord Imaging Spinal cord lesions are common in MS and often clinically silent. Rare in other neurologic diseases and always symptomatic Bot JCJ. et al. Radiology. 2002;223:46-56

21 Large and unusual appearing

22 MS lesions rarely have significant mass effect and persistent enhancement Baseline FLAIR Follow-up FLAIR and post contrast T1 of a glioblastoma multiforma

23 Large lesions MS Glioblastoma Abscess

24 Red Flag Lesions T1 post contrast sequences MS open ring Glioblastoma Abscess

25 Gadolinium Red Flags Persistently enhancing lesions >3 months. Meningeal enhancement.

26 Case No. 3 Jan 19 th

27 Feb 2nd

28 CNS lymphoma

29 Progressive Multifocal Leukoencephalopathy

30 Inflammatory lesion decreasing in size Feb 2006 Aug 2006 Mar 2006

31 Unusual lesions seen in NMO

32 Large spinal cord lesions MS Lesion on Sagittal T2 LESCL on Sagittal T2

33 Long extensive spinal cord lesions common in NMOSD Cord atrophy

34 Other long cord lesions: GBM

35 Other long cord lesions: syphilis

36 Other long cord lesions: multiple sclerosis

37 Dental work Hair product with iron

38 Dental Braces Axial PD andt1 post gadolinium Red Arrows = Artifact, Green Arrow Lesion?

39 Key Messages MRI is sensitive but pathologically non-specific. The clinical history is important to the interpretation. Gadolinium and serial imaging can be useful. MS Multiple Infarcts