Objective To explore the potential of a post-processing technique combining FLAIR and T 2 * (FLAIR*) to distinguish between lesions caused by multiple sclerosis (MS) from cerebral small vessel disease (SVD) in a clinical setting. Methods FLAIR and T 2 * head datasets acquired at 3T of 25 people with relapsing MS (pwRMS) and ten with pwSVD were used. After post-processing, FLAIR* maps were used to determine the proportion of white matter lesions (WML) showing the 'vein in lesion' sign (VIL), a characteristic histopathological feature of MS plaques. Sensitivity and specificity of MS diagnosis were examined on the basis of >45% VIL + and >60% VIL + WML, and compared with current dissemination in space (DIS) MRI criteria. Results All pwRMS had >45% VIL + WML (range 58-100%) whilst in pwSVD the proportion of VIL + WML was significantly lower (0-64%; mean 32±20%). Sensitivity based on >45% VIL + was 100% and specificity 80% whilst with >60% VIL + as the criterion, sensitivity was 96% and specificity 90%. DIS criteria had 96% sensitivity and 40% specificity.

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