“Central vessel sign” on 3T FLAIR* MRI for the differentiation of multiple sclerosis from migraine

Abstract

ObjectiveThe diagnosis of multiple sclerosis (MS) presently relies on radiographic assessments of imperfect specificity. Recent data using T2* methodology for the detection of the “central vessel sign” (CVS) in MS lesions suggests this novel MRI technique may distinguish MS from other disorders. Our aim was to determine if evaluation for CVS on 3T FLAIR* MRI differentiates MS from migraine.MethodsPatients with MS or migraine and a prior brain MRI demonstrating at least two hyperintense lesions ≥3 mm were recruited. Exclusion criteria included any additional comorbidity known to cause brain MRI abnormalities. 3T MRI was performed in each participant with administration of gadopentetate dimeglumine, and FLAIR* images were generated in postprocessing. The total number of discrete ovoid lesions ≥3 mm were counted on FLAIR, per participant, and subsequently evaluated for presence of CVS on FLAIR*. An exploratory method evaluating for CVS in a maximum of 12 lesions per subject was also completed.ResultsTen participants with MS and 10 with migraine completed the study. The median percentage (quartiles) of lesions in MS participants with CVS was 84 (79, 94) compared to 22 (15, 54) in migraine (P = 0.008). In a subanalysis by brain region, in the subcortical and deep white matter, the median percentage (quartiles) of lesions in MS participants with CVS was 88 (81, 100) compared to 19 (11, 54) in migraine (P = 0.004). This difference was not identified in juxtacortical, periventricular, or infratentorial regions.InterpretationIdentification of CVS using FLAIR* on 3T MRI helps differentiate MS from migraine, particularly in the subcortical and deep white matter.

Dark Rims: Novel Sequence Enhances Diagnostic Specificity in Multiple Sclerosis

“…We noted heterogeneity of the signal change within lesions on GM-DIR, but no presence of a central vein sign that has been described in SWI and T2* techniques. 9,11,27–30 If the rim we observed was suspected to be due to opposed magnetization effect, in the future, one could optimize the GM-DIR parameters to further enhance this phenomenon.…”

“…To address this problem, prior studies have added MRI sequences to conventional MR protocols 8 , including SWI, T2*imaging 9 , and 7T field strength, 10,11 yielding interesting sequences for future studies. Recently proposed revisions to the existing MRI criteria 12 may further enhance diagnostic accuracy, still to be confirmed in larger studies.…”

The central vein sign and its clinical evaluation for the diagnosis of multiple sclerosis: a consensus statement from the North American Imaging in Multiple Sclerosis Cooperative

“…The other approach, proposed by Sati et al 34 and known as FLAIR*, uses 1 mm isotropic 3D FLAIR (for lesion detection) and 0.55 mm isotropic 3D EPI (for vein detection) sequences -both acquired in <10 min -and provides high-resolution isotropic images of the whole brain. Recent studies reported on the utility of FLAIR* at various field strengths for differentiating MS from other diseases 16,20,64 , and for improving diagnostic accuracy 31,44,48 . T2*-based imaging of the spinal cord is much more challenging, owing to factors such as the small physical dimensions of the spinal cord, strong magnetic field inhomogeneity caused by surrounding tissues (bones, soft tissues and air), and physiological motion (pulsation of cerebrospinal fluid flow, and cardiac and respiratory movement).…”

“…The 'central vein sign' (CVS) has been investigated in various neurological conditions by several groups, and evidence has accumulated that the CVS may have the ability to accurately differentiate MS from its mimics [15][16][17][18][19][20][21] . As a consequence, recent guidelines from the Magnetic Resonance Imaging in MS (MAGNIMS) group 1,4 and the Consortium of MS Centers (CMSC) task force 22 have acknowledged the potential of the CVS and its dedicated MRI acquisitions for the differential diagnosis of MS, while calling for further research before considering a possible modification of the diagnostic criteria.…”

Spring cleaning: time to rethink imaging research lines in MS?

“…The perivenular nature of MS lesion development directly influences their morphology and brain topography, so that MS lesions are generally ellipsoidal, with a characteristic pattern of distribution that follows the venous vasculature and preferentially involves certain areas of the WM (periventricular and juxtacortical) as well as the edges of the optic nerve, brainstem, and spinal cord (Figure 1). Potentially relevant for the diagnostic workup is that the “central vein sign” has been consistently described as “atypical” in small vessel disease [18, 20, 24–26] and migraine [27], and it may be a useful adjunct to traditional criteria for diagnosing MS in difficult cases [28]. Whether the proportion of perivenular lesions can be used to discriminate demyelinated MS lesions from mimicking lesions in other immunological conditions (e.g.…”