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The role of MRI in the diagnosis of Multiple Sclerosis
LH is a 34 yo female with a history of relapsing remitting MS presents to the multiple sclerosis clinic for MRI follow up of disease progression.
Brice Gaudilliere, PhD (Harvard Medical School year IV)
Gillian Lieberman, MD
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–Briefly review the pathogenesis of multiple sclerosis (MS).
–Introduce the McDonald's MRI criteria for diagnosis of MS.
–Describe the typical MRI findings and disease- progression of MS.
–Discuss limits and future prospects of MRI diagnosis of MS.
Objectives
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Multiple Sclerosis1868: Jean-Martin Charcot describes the “Sclérose en Plaque” as a new disease linking clinical and postmortem findings.
MRI Pathology Luxol Fast BlueN Engl J Med. 2000 Sep 28;343(13):938-52.
4Pathogenesis of MS
Extravasating T-cells
Demyelination
N Engl J Med. 2006 Mar 2;354(9):942-55
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Disease Patterns • Relapsing remitting (RRMS)
• Secondary progressive: initial RRMS then progression.
• Primary progressive: Progression from onset with occasional plateau.
• Progressive relapsing: Progression from onset with acute relapse.
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Diagnostic criteria for MS
• POSER criteria (1980s)
Two attacks + Two separate clinical lesions=
Clinically definite MS
Two attacks + one clinical lesion + Labs findings (CSF,OCB, IgG) =
Laboratory definite MS
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Diagnostic criteria for MS• McDonald’s criteria (2001 and 2005)
• Demonstrate dissemination of clinical events in space and time.
• Demonstrate dissemination of MRI findings in space and time.
• Assigns confidence for MS vs Possible MS vs. Not MS based on clinical and MRI findings
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MRI modality of choice for MS• Conventional MRI is the most sensitive way to detect
MS lesions.
• Typical MRI lesions correlate well with histopathology: Found in periventricular region, corpus callosum, subcortical region, brainstem, optic nerve and visual pathways.
• Lesions usually not seen on CT.
• Use of contrast allows early detection of acute lesions.
• Specificity 90%, sensitivity 80%, ppv 65%. (<50yo)
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Ant. Horn of lateral ventricules
Head of Caudate nucleus
ThalamusPutamen
Ant. And post.Limb of internalcapsule
Genu of Corpus Callosum
Visual Cortex
Neuroanatomy
http://www.imaios.com/en/e-Anatomy/Brain-neuroanatomy-MR
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companion patient 1: MS lesions on MRI
N Engl J Med. 2000 Sep 28;343(13):938-52.
Hypointense lesions on T1WI Hyperintense lesions on T2WI
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Companion patient 2: Fluid attenuated Inversion Recovery (vFLAIR) allows for better visualization
of periventricular lesionsHyperintense lesions on T2WI Hyperintense lesions on T2 FLAIR
AJNR Am J Neuroradiol 2006; 27: 1165–76.
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DDx of white matter lesion
• Ischemia• Systemic lupus
erythematosus• HTLV-I• Sarcoidosis• Behcet's disease• Vasculitides
Companion patient 3: axial FLAIR
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Specific MRI findings to narrow the differential
• Review specific lesions found in MS.
• Apply McDonald’s criteria for dissemination in space and time.
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Classical MS lesions: Dawson’s fingers (Patient LH)
Sagital FLAIR (PACS, BIDMC) Axial FLAIR (PACS, BIDMC)
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Classical MS lesions : Black holes (patient LH)
T2 (PACS, BIDMC) T1 (PACS, BIDMC)
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McDonald’s MRI criteria: Three of the following are required:
At least one gadolinium-enhancing lesion or nine T2 hyperintense lesions
• At least one infratentorial lesion• At least one juxtacortical lesion• At least three periventricular lesions
Dissemination in Space
Polman CH et al. Ann Neurol. 20 Dec; 58(6): 840-6.
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Dissemination in space (Patient LH)
Sagital FLAIR (PACS, BIDMC) Sagital T2 (PACS, BIDMC)
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Detection of gadolinium enhancement at least 3 months after the onset of the initial clinical event.
Detection of a new T2 lesion
Dissemination in Time:
Polman CH et al. Ann Neurol. 20 Dec; 58(6): 840-6.
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Detection of recent MS lesions • Acute MS lesions disrupt the Blood Brain
Barrier.
• Can be seen as Gadolinium-enhancing lesions on T1-Post.
• Remain for days to months
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Detection of recent MS lesions: T1 post-contrast (Patient LH)
05/10/08 05/10/08
(PACS, BIDMC) (PACS, BIDMC)
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Dissemination in time (Patient LH)
Sagital T2 (PACS, BIDMC)
AXIALFLAIR (PACS, BIDMC)
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Limitation of traditional MRI• Many lesions seen on histopathology are missed
on MRI.
• Conversely the number and size of lesions seen is dependent on field strength and amount of contrast given.
• Although useful in following the disease, poor correlation between T1, T2, T1-post findings and clinical evolution.
AJNR Am J Neuroradiol 1998; 19: 1489-93
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Companion patient 7: Volumetric analysis
• New uses of conventional MRI: subtraction measures for disease follow up.
AJNR Am J Neuroradiol 2008; 29: 340–46.
Companion patient 7:Axial FLAIR
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Companion patient 8: Volumetric analysis
• Measures of diffuse cortical atrophy, some evidence correlating grey matter atrophy and functional impairment
Lancet Neurol 2006; 5: 158–70. Companion patient 8
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Companion patient 9: Diffuse Tensor imaging
• Diffusion MRI allowing reconstruction of axonal tracts and may provide correlation between circuitry damage and functional impairment.
NeuroImage 2005;26: 258–65.
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Acknowledgments
• Rafeeque Bhadelia, MD• Rich Rana, MD• Maria Levantakis• Larry Barbaras• Gillian Liberman, MD
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Reference• Noseworthy JH et al. N Engl J Med. 2000 Sep 28;343(13):938-52. • Frohman EM et al. N Engl J Med. 2006 Mar 2;354(9):942-55. • Islam T et al. Neurology. 2007 Jul 24;69(4):381-8.• Ge Y., AJNR Am J Neuroradiol 2006; 27: 1165–76.• Offenbacher H et al. Neurology 1993 May;43(5):905-9. • Bakshi R et al. Lancet Neurol. 2008 Jul;7(7):615-25. • Polman CH et al. Ann Neurol. 20 Dec; 58(6): 840-6.• Geurts JG et al. Lancet Neurol. 2008 Sep;7(9):841-51.• Pagani E et al. NeuroImage 2005;26: 258–65.• Duan Y et al. AJNR Am J Neuroradiol 2008; 29: 340–46• http://www.imaios.com/en/e-Anatomy/Brain-neuroanatomy-MR• http://www.nationalmssociety.org