Consortium of MS Centres Guidelines Revised Standardized MRI Protocol for the Diagnosis and Follow-up of MS David K.B. Li MD FRCPC Indianapolis, Indiana May 27, 2015 Disclosure I have received research funding from the Canadian Institute of Health Research and Multiple Sclerosis Society of Canada. I am the Director of the UBC MS/MRI Research Group which has been contracted to perform central analysis of MRI scans for therapeutic trials with Chugai, Genzyme, Hoffmann-LaRoche, EMD-Serono, Nuron Biotech, Perceptives and Sanofi-Aventis. I have acted as a consultant to Biogen-Idec, EMD-Serono, Genzyme, Novartis, Nuron Biotech, Opexa and Vertex Pharmaceuticals 1
A Standardized MRI is important for Diagnosis and Follow-up 2 years later FSE PD 5mm, 0.5 mm gap FLAIR 3mm, contiguous There are several new T 2 hyperintense lesions which are probably new interval lesions however their identification on today s study may be technical, because of differences in pulse sequence (FLAIR versus PD/T2), the use of contiguous and thinner (3 mm versus 5 mm) slices as well as different patient positioning A Standardized MRI is important for Diagnosis and Follow-up T 2 Post Gad FLAIR Post Gad T 1 Follow Up Baseline 2
Consortium of Multiple Sclerosis Centers Vancouver, BC Canada November 3-4, 2001 February 28-March 2, 2003 October 10-11, 2008 Newark, NJ, USA October 3, 2014 Goal: To develop indications and guidelines for a standardized MRI protocol in the diagnosis and follow-up of patients with MS Consortium of Multiple Sclerosis Centers http://www.mscare.org/pdf/mriprotocol2003.pdf AJNR 27:455-461, 2006 http://www.mscare.org/cmsc/images/pdf/mriprotocol2009.pdf AJNR accepted April 2015 3
Universally Vision USEFUL Helpful and Beneficial USEABLE Practical and Reasonable USED Acceptable and Adopted Standardized MRI Protocol 2015 Recommendations 4
Field Strength No specific recommendation Scans to be of good quality with adequate SNR and spatial resolution (in plane 1 mm x 1 mm) Slice thickness and gap < 3 mm, no gap Whole Brain Coverage 5
Scan orientation reproducible subcallosal line as reference 2D Sequences 2D acquisition T 2 < 3 mm slice thickness, contiguous, no gaps FLAIR FLuid Attenuated Inversion Recovery Axial Sagittal 6
3D isotropic volumetric acquisition 3D- FLAIR 3D-T2 3D- MPRAGE (IR-prep GE) 3D volumetric acquisition Isotropic, 1.0-1.5 mm slice thickness 120-150 slices/slab sagittal acquisition Moraal et al. Eur Radiol 18: 2311-2320, 2008 Sequences IV Gadolinium 0.1mmol/kg (single dose) over 30 seconds Minimum delay of 5 minutes before scanning Pre Gad T1 Post Gad T1 7
2D/3D Sagittal & Axial FLAIR 2D/3D Axial T 2 Brain MRI Post Gad 2D/3D Brain MRI 2D/3D Sagittal & Axial FLAIR 2D/3D Axial T 2 3D IR-prep GE T 1 Post Gad 2D/3D 8
Brain MRI 2D/3D Sagittal & Axial FLAIR 2D/3D Axial T 2 3D IR-prep GE T 1 Axial 2D DWI Post Gad 2D/3D Brain MRI 2D/3D Sagittal & Axial FLAIR + 2D/3D Axial T + 2 3D IR-prep GE T 1 Axial 2D DWI Post Gad 2D/3D Optional Axial PD Pre Gad 2D/3D SWI +FLAIR or T 2 may be performed during the 5 minute minimum delay after gadolinium injection before acquiring the post-gadolinium T1 9
Brain MRI 2D/3D Sagittal & Axial FLAIR + 2D/3D Axial T + 2 3D IR-prep GE T 1 Axial 2D DWI Post Gad 2D/3D Optional Axial PD* Pre Gad 2D/3D SWI *PD and T 2 may be acquired as a dual echo if acquired 2D +FLAIR or T 2 may be performed during the 5 minute minimum delay after gadolinium injection before acquiring the post-gadolinium T1 PML Surveillance 2D/3D Sagittal & Axial FLAIR 2D/3D Axial T 2 3D IR-prep GE T 1 Axial 2D DWI Post Gad 2D/3D Optional Axial PD Pre Gad 2D/3D SWI 10
Spinal Cord Proton density T2 Slice thickness: < 3 mm(sag), < 5 mm(axial), no gap In plane resolution: < 1mm x 1mm No additional gadolinium required if spinal cord study immediately follows Gad-enhanced brain MRI Spinal Cord Imaging: Pulse Sequences FSE T 2 2000/80 TR/TE FSE PD 2000/8.4 TR/TE STIR 3000/70/200 TR/TE/TI T 1 -IR mag 2400/8/400 TR/TE/TI T 1 -IR phase 2400/8/400 TR/TE/TI Poonawalla et al. Radiology 246: 258-264, 2008 11
Multiple Echo Recombined Gradient Echo (MERGE) Multi Echo Image Data Combination (MEDIC) MERGE T2w-FSE T2w-FSE MERGE T2w-FSE Martin et al. AJR 199: 157-162, 2012 Cord MRI Sagittal T 2 Sagittal PD or STIR or T 1 -PSIR Axial T 2 /T 2 * through lesions Optional Sagittal T 1 Post Gad T1 # (sag, axial) Axial T 2 /T 2 * entire cervical cord # No additional gadolinium necessary if cord examination immediately follows gadolinium enhanced brain MRI 12
Orbital MRI Fat-Sat T 2 STIR Fat-Sat Post-Gad T 1 Slice thickness: < 2 mm Coverage to include optic chiasm Orbital MRI Coronal Fat-Sat T 2 or STIR Coronal Post-Gad Fat-Sat T 1 Optional Axial/Coronal Pre-Gad Fat-Sat T 1 Axial Fat-Sat T 2 or STIR Axial Post-Gad Fat-Sat T 1 13
What have you Learned Today? The importance of a Standardized MRI examination protocol Details for Standard Brain MRI Brain MRI for PML surveillance Spinal cord (Cervical) MRI Orbital MRI 14