Guidelines from The Italian Neurological and Neuroradiological Societies for the use of magnetic resonance imaging in daily life clinical practice of multiple sclerosis patients

Abstract

MRI is highly sensitive in detecting focal white matter lesions in multiple sclerosis (MS). For this reason, it has been formally included in the diagnostic workup of patients with clinically isolated syndromes suggestive of MS, through the definition of ad hoc sets of criteria to show disease dissemination in space and time. MRI is used in virtually all clinical trials of the disease as a surrogate measure of treatment response. Several guidelines have been published to help characterizing the imaging features on conventional MR sequences of "typical" MS lesions and work has also been performed to identify "red flags" which should alert the clinicians to exclude possible alternative conditions. Despite this, the application of the available guidelines and criteria in daily life clinical practice is still limited and varies among and within countries (including Italy) due to regulatory issues and heterogeneity of MRI facilities. It is crucial for neurologists and neuroradiologists to become familiar with these criteria to improve the quality of their diagnostic assessment. In patients with established MS, the main problem is to define standard procedures for monitoring the course of the disease and treatment response. This review aims at providing daily life guidelines to clinicians for a correct application of MRI in the workup of patients suspected of having MS as well as in the monitoring of disease evolution in those with established MS. It also offers clues for the standardization of MRI studies and relative reporting to be applied at a national level.

Guidelines for the use of magnetic resonance imaging in diagnosing and monitoring the treatment of multiple sclerosis: recommendations of the Swedish Multiple Sclerosis Association and the Swedish Neuroradiological Society

“…However, there is a lack of scientific evidence to support a specific interval between follow‐up examinations. The interindividual variation in disease activity between patients with MS makes it difficult to specify a general examination frequency suitable for all cases, as reflected in the recommendations given in other available guideline documents 21, 23, 28. While we acknowledge this and would like to emphasize that the MRI frequency and timing should be adapted to the clinical situation, it is our opinion that general recommendations of MRI frequency are still valuable in the clinical care of patients.…”

“…Revisions of the guidelines will become necessary as the knowledge regarding the use of MRI in the care of individuals with MS evolves. Other important guidelines21, 23, 27, 28, 29, 30 for the current work have been taken into account and the MAGNIMS research group requires special mention 21, 23…”

MAGNIMS consensus guidelines on the use of MRI in multiple sclerosis—clinical implementation in the diagnostic process

“…76 Various guidelines have consistently recommended a standardized brain MRI protocol (Box 2). [77][78][79][80][81] This approach consists of multisequence MRI performed at a magnetic field strength of at least 1.5 T (preferably 3.0 T) with a maximum slice thickness of 3 mm and an in-plane spatial resolution of 1 × 1 mm (voxel size 3 × 1 × 1 mm), and using the pulse sequences described in Box 2. In addition, the protocol should be completed in 25-30 min.…”

“…Statements and recommendations ■ Brain MRI should be performed using a magnetic field strength of at least 1.5 T (but preferably 3.0 T), with a slice thickness of 3 mm for 2D sequences [77][78][79][80][81] Nature Reviews | Neurology a c b ■ The standardized protocol for conventional MRI in diagnostic work-up includes axial T1-weighted sequences before and after contrast, axial T2-weighted and proton-density (or T2-FLAIR) sequences, and sagittal 2D or isotropic 3D T2-FLAIR sequences [79][80][81] ■ A single dose (0.1 mmol/kg body weight) of gadolinium-based contrast medium should be used, with a minimum delay of 5 min after contrast injection 88 ■ Conventional 2D spin-echo sequences should be used to detect gadolinium-enhancing MS lesions at 1.5 T, 92 but at 3.0 T, isotropic 3D gradient-echo or fast spin-echo sequences are a potentially valuable alternative to 2D sequences 92,93 ■ Standardized image acquisition and slice positioning between baseline and follow-up are of paramount importance to establish DIT via detection of new T2 lesions 79,80 ■ DWI cannot replace contrast-enhanced T1-weighted images for differentiating between acute and chronic MS lesions 98 Standardized spinal cord MRI protocol MS affects the entire CNS, and more than 90% of patients show focal or diffuse abnormalities in the spinal cord on T2-weighted sequences (Figure 2). Spinal cord lesions are less prevalent in patients with CIS than in patients with clinically definite MS.…”

MAGNIMS consensus guidelines on the use of MRI in multiple sclerosis—establishing disease prognosis and monitoring patients

“…84,85 Accordingly, some experts have proposed that the refer ence scan should be performed 6 months after-rather than before-treatment initiation. 81,86 Follow-up measurement Gadolinium enhancing lesions are typically easier to identify than new and/or enlarged T2 lesions, and the process is also less dependent on technical factors such as scan repositioning. Furthermore, some new T2 lesions can only be visually detected after being identi fied as new gadolinium enhancing lesions, owing to their small size or their location in areas with confluent lesions.…”