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Figures
- Fig 1.
Orientation of axial oblique sequences. Orientation of axial oblique sequences should be along the subcallosal line as indicated by the solid line. Axial sections should be ≤3 mm with no gap.
Tables
Minimum MRI Features for DIS (2 of 4 Criteria Required) 1 Infratentorial lesion 1 Juxtacortical lesion (touching the cortex) 1 Periventricular lesion (touching the ventricles) 1 Spinal cord lesion Note:—DIS indicates dissemination in space; DIT, dissemination in time.
↵a MS diagnosis requires clinical and/or MRI evidence for CNS demyelination occurring in multiple locations (DIS) and with multiple events (DIT). The MRI criteria may support the clinical diagnosis of patients with MS with typical symptoms of CNS demyelination after the exclusion of alternative diagnoses. The DIT criterion can be met on MRI with an asymptomatic contrast-enhancing lesion on T1WI sequences (first or follow-up MRI) or newly active T2WI lesions on follow-up MRI. Lesions should be at least 3-mm in diameter and asymptomatic.
Parameters Description Field strength Scans should be of good quality, with adequate SNR and resolution (in-sections, pixel resolution of ≤1 × 1 mm) Scan prescription Use the subcallosal plane to prescribe or reformat axial oblique sections (Fig 1) Coverage Whole-brain coverage Section thickness and gap ≤3 mm, No gap (for 2D acquisition or 3D reconstruction) Core sequences Anatomic 3D inversion recovery–prepared T1 gradient echo (eg, 1.0- to 1.5-mm thickness) Gadolinium single dose, 0.1 mmol/kg given for 30 secondsa 3D sagittal T2WI FLAIRb (eg, 1.0- to 1.5-mm thickness) 3D T2WI b (eg, 1.0- to 1.5-mm thickness) 2D axial DWI (≤5-mm sections, no gap) 3D FLASH (non-IR prep) postgadoliniumb (eg, 1.0- to 1.5-mm thickness) 3D series would be typically reconstructed to 3-mm thickness for display and subsequent comparison for lesion counts Optional sequences Axial proton attenuation Pre- or postgadolinium axial T1 spin-echo (for chronic black holes) SWI for identification of central vein within T2 lesions Note:—IR indicates inversion recovery.
↵a Minimum 5-minute delay before obtaining postgadolinium T1. The 3D sagittal FLAIR may be acquired immediately after contrast injection before the 3D FLASH series.
↵b If unable to perform a 3D acquisition, then perform 2D axial and sagittal FLAIR, axial fast spin-echo proton attenuation/T2, and axial post-gadolinium T1WI spin-echo at ≤3-mm section thickness.
Parameters Description Field strength Scans should be of good quality, with adequate SNR and resolution (in-section pixel resolution of ≤1 × 1 mm) Scan prescription Use the subcallosal plane to prescribe or reformat axial oblique sections (Fig 1) Coverage Whole-brain coverage Sequences 3D sagittal T2WI FLAIRa 2D axial DWI (5-mm-thick, no gap) Section thickness and gap ≤3 mm, No gap (for 2D acquisition or 3D reconstruction) ↵a If unable to perform a 3D acquisition, then perform 2D axial FLAIR at ≤3-mm section thickness.
Parameter Description Field strength Scans should be of good quality, with adequate SNR and resolution (in-section pixel resolution of ≤1 × 1 mm) Closed magnets (large bore for patients with claustrophobia) preferred Coverage Cervical cord coveragea Core sequences Sagittal T2 Sagittal proton attenuation, STIR, or PST1-IR Axial T2 through lesions Section thickness and gap Sagittal: ≤3 mm, no gap Axial: 5 mm, no gap Optional sequences Axial T2 through complete cervical cord Gadoliniumb and postgadolinium sagittal T1 Sagittal T1 Note:—PST1-IR indicates phase-sensitive T1 inversion recovery.
↵a Thoracic and conus coverage recommended if symptoms localize to this region to rule out an alternate diagnosis.
↵b Minimum 5-minute delay before obtaining postgadolinium T1. Additional gadolinium does not need to be given for a spinal cord MRI if it follows a contrast brain MRI study.
Guidelines Baseline studies for patients with a CIS and/or suspected MS Brain MRI protocol with gadolinium at baseline and Spinal cord MRI if transverse myelitis, insufficient features on brain MRI to support diagnosis, or age older than 40 years with nonspecific brain MRI findings A cervical cord MRI performed simultaneously with the brain MRI would be advantageous in the evaluation of patients with or without transverse myelitis and would reduce the number of patients requiring a subsequent MRI appointment Orbital MRI if severe optic neuritis with poor recovery Timing of a follow-up brain MRI protocol for patients with a CIS and/or suspected MS to look for evidence of dissemination in time 6–12 Months for high-risk CIS (eg, ≥2 ovoid lesions on first MRI) 12–24 Months for low-risk CIS (ie, normal brain MRI findings) and/or uncertain clinical syndrome with suspicious brain MRI features (eg, RIS) Timing of brain MRI protocol with gadolinium for patients with an established diagnosis of MS No recent prior imaging available (eg, patient with MS transferring to a new clinic) Postpartum to establish a new baseline Prior to starting or switching disease-modifying therapy Approximately 6 months after switching disease-modifying therapy to establish a new baseline on the new therapy Every 1–2 years while on disease-modifying therapy to assess subclinical disease activity Unexpected clinical deterioration or reassessment of original diagnosisa Timing of PML surveillance brain MRI protocol Every 12 months for patients negative for serum JC virus antibody Every 3–6 months for patients positive for serum JC virus antibody and ≥18 months on natalizumabb Note:—JC indicates John Cunningham; RIS, radiologic isolated syndrome.
↵a Routine spinal cord follow-up not required unless syndrome is predominately recurrent transverse myelitis.
↵b The brain MRI protocol for monitoring patients on disease modifying therapies includes the PML surveillance sequences.
Recommendations The clinical requisition for brain MRI should include Requesting the CMSC or standardized brain MRI protocol Indicating the purpose of the study Diagnostic study for CIS or MS (indicate date of symptom onset) Treatment-monitoring study (indicate if on disease-modifying therapy) PML surveillance study (indicate if high- or low-risk) Unexpected clinical decline or reassessment of diagnosis Date and location of most recent MRI study (encourage patient to bring a copy of outside images on portable media at the time of MRI appointment) The radiology report should include For a diagnostic MS study Number of gadolinium-enhancing T1 lesions (eg, 0, 1, 2, 3, 4, ≥5) Comparison with previous studies for the number of new T2 lesions (eg, 0, 1, 2, 3, 4, ≥5) The presence of juxtacortical (touching the cortex), periventricular (touching the ventricles), infratentorial, or spinal cord lesions The report should avoid a summary statement like “McDonald diagnostic criteria met” The interpretation should indicate whether findings are typical, atypical, or not consistent with MS and should provide a differential diagnosis if appropriate For a follow-up MS study Number of gadolinium-enhancing T1 lesions (eg, 0, 1, 2, 3, 4, ≥5) Comparison with previous studies for the number of new T2 lesions (eg, 0, 1, 2, 3, 4, ≥5) Qualitative assessment of Overall T2 lesion-burden severity (eg, mild, moderate, severe) Comparison with previous studies for overall worsening of T2 lesion burden and atrophy For a PML surveillance study Comparison with previous studies for new T2 lesions, hyperintense lesions on DWI Presence of PML suspicious features
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